Organ transplantation is the main alternative to the loss of vital organ function from various diseases. However, to avoid graft rejection, transplant patients are treated with immunosuppressive drugs that have adverse side effects. A new emerging approach to reduce the administration of immunosuppressive drugs is to co-treat patients with cell therapy using regulatory cells. In our laboratory, as part of a European project, we plan to test the safety of tolerogenic dendritic cell (TolDC) therapy in kidney transplant patients. In this mini-review, we provide a brief summary of the major protocols used to derive human TolDC, and then focus on the granulocyte macrophage-TolDC generated by our own team. Proof of safety of TolDC therapy in the clinic has already been demonstrated in patients with diabetes. However, in transplantation, DC therapy will be associated with the administration of immunosuppressive drugs, and interactions between drugs and DC are possible. Finally, we will discuss the issue of DC origin, as we believe that administration of autologous TolDC is more appropriate, as demonstrated by our experiments in animal models. Dendritic cells (DC) are potent antigen-presenting cells with dual functions; they can be either immunogenic or tolerogenic in nature. Several protocols of human DC generation have been described and both types of DC have clinical applications. Immunogenic DC are used in patients with cancer to reduce tumor development . Tolerogin vitro, to obtain TolDC with specific features [et al. showed that VitD3-DC generated from the monocytes of healthy volunteers or patients with relapsing remitting multiple sclerosis have similar properties; a semi-mature phenotype, an anti-inflammatory profile and a low capacity to induce allogeneic T cell proliferation [in vitro with lipopolysaccharide (LPS). Such cells are described as alternatively activated DC [In the literature, several protocols have been described for the generation of human TolDC. In these studies, TolDC have been derived from monocytes (MoDC) using the cytokines granulocyte macrophage colony-stimulating factor (GM-CSF) and IL-4. However, as described for tolerogenic bone marrow-derived DC (BMDC) in animal models, different drugs or cytokines could be added to GM-CSF/IL-4 culture to manipulate human DC features . Among tfeatures -5. More feration . Furtherferation . In paraferation . Prior tferation . In ordevated DC ,10 and ivated DC . Other mvated DC .+ cells in mice [a.By contrast to Dex-DC and VitD3-DC, rapamycin-treated DC (Rapa-DC) express CD83 and CD86 markers and produce low amounts of IL-10 and high levels of IL-12p40/p70, characteristics of a mature DC phenotype . Further in mice a.+ T cells [+ T cells [b. Unfortunately, another property of IL-10-producing DC is a decreased trafficking of these cells to the lymph nodes. The chemokine CCR7 participates in the migration of DC to the lymph nodes, and generating mouse DC with IL-10 down-regulates their expression of CCR7 and impairs their in vivo homing to lymph nodes [et al. showed that injection of DC co-expressing IL-10 and CCR7 induced a significant prolongation of graft survival. However, DC expressing either IL-10 only or CCR7 only had no effect [Another important molecule used to generate tolerogenic DC is IL-10. Two protocols have been used and lead to the differentiation of different types of TolDC depending on whether IL-10 is present from the initiation of culture or added at the end. In fact, DC generated with IL-10 added at the end of culture have an immature phenotype and display resistance to maturation stimuli ,16. Thes T cells  in an an T cells . More re T cells . The aut T cells . Another T cells . A key c T cells ,21b. Unfph nodes . In a moo effect .c, mesenchymal stem cells [d or regulatory macrophages [e. Clinical trials in transplantation using mesenchymal stem cells and regulatory macrophages have already been performed.Alternative protocols to generate tolerogenic antigen-presenting cells have been described by other teams, with the resulting cells being referred to as myeloid-derived suppressor cells c, mesencem cells ,26d or rrophages e. ClinicFrom the studies described in this section, some TolDC were generated using a clinical grade protocol prior to an application in the clinic ,8,11,13.in vivo or an induction of tolerance in transplant models [in vivo injection [in vitro[Over the last few years, we have generated and characterized tolerogenic BMDC in rats, mice and non-human primates. In these different models, injection of tolerogenic BMDC leads to a reduced immune response t models -31. Basenjection . In para[in vitro. Human GTo set up this protocol, we tested methods of monocyte selection. The most common method to obtain monocytes is to positively select CD14-positive cells using microbeads. Another possibility is to enrich monocytes from peripheral blood by elutriation. This purification technique is based on the separation of cells according to their size and density . The latlow CD80low CD86low CD40low with less than 2% contamination with T cells, B cells or natural killer cells. This immature phenotype of human TolDC is in accordance with the findings of our previous studies in rats, mice and non-human primates [in vitro function  of human GM-TolDC was similar to that of tolerogenic BMDC described in animal models [in vitro features of animal TolDC, whose efficacy has been proven in vivo, with those obtained in humans, is encouraging for their potential use in the clinic.In summary, GM-TolDC were more than 90% MHC-IIprimates -30. Furtprimates , human Gl models -30. The in vivo were detected in DC-treated volunteers [Whereas clinical trials using immunogenic DC to treat cancer have been developed over the last 15 years , TolDC tlunteers ,38. Morelunteers . Controllunteers . Furtheret al., manuscript in preparation). Similar experiments using the two other IS or the combination of both IS associated or not with DC therapy are on-going. These studies should identify any potential side effects of DC therapy on the IS treatment used in the clinic.As part of a European project, we plan to test the safety of autologous monocyte-derived TolDC in patients who have had a kidney transplant. To avoid graft rejection, transplant patients receive life-long immunosuppressive drugs (IS). That means that in this clinical trial, TolDC will be injected into patients receiving three IS commonly used in transplantation: tacrolimus, mycophenolate mofetil (MMF) and prednisolone. However, as summarized in Table Others parameters related to DC injections should be considered before doing a clinical trial, such as the time of cell product injection, the numbers of DC injected, and also the number of injections as well as the route of administration. Regarding this last parameter, experiments performed in mice have shown that intravenous injection of Dex/LPS-treated BMDC prolongs cardiac transplant survival whereas subcutaneous injection of the same Dex/LPS-treated BMDC does not increase graft survival . Our preThe clinical trials described in the previous section of this review either have already been performed or are on-going in autoimmune diseases. In transplantation, another parameter has to be taken into consideration; this is the question of whether TolDC should be derived from the donor or from the recipient. Most of the studies described in rodents have been performed using donor TolDC or recipient TolDC loaded with donor peptides and administrated one week or more before transplantation . In thisFirstly and very importantly, the risk of donor sensitization due to the presence of a slight contaminant cell product or the destruction of the injected cells by non-self recognition cannot be excluded using donor TolDC therapy ; we hypoin vivo injection. Even if administration of donor TolDC induces tolerance to a transplant, donor TolDC are unable to directly regulate an immune response in vivo[+ cells from the graft are present in the spleen of the recipient 3 to 5 days after transplantation. Stainings performed in the spleens of these animals suggest that the donor cells interact with the injected TolDC. Moreover, depletion of graft passenger leukocytes from the donor organ before transplantation prevents any effect of the autologous TolDC injection . These results validate the hypothesis that injected autologous un-pulsed TolDC are able to migrate to the spleen where they capture and process the donor antigen from graft passenger leukocytes  leading to antigen-specific graft acceptance [Secondly, as regards the efficacy of the cells, some studies performed recently in mice by Morelli’s group demonstrated that injected donor DC die quickly after e in vivo. In thise in vivo. We belie in vivo. Studiese in vivo,63. Furtceptance .As demonstrated by the clinical trial in patients with diabetes , the useHuman leukapheresis samples were collected from healthy donors following institutional-approved protocols . All animal experiments were performed under specific pathogen-free conditions in accordance with the European Union Guidelines and in compliance with the ethical rules of the INSERM.aCamilla Macedo; bGiada Amodio; cNatasa Obermajer; dMartin Hoogduijn and Elke Eggenhofer; eJames Hutchinson and Paloma Riquelme participated in The One Study Workshop 2012 and described Rapa-DC, DC10, myeloid-derived suppressor cells, mesenchymal stem cells and regulatory macrophages respectively in other mini-reviews.BMDC: Bone-marrow derived dendritic cells; CD: Cluster of differentiation; DC: Dendritic cells; Dex: Dexamethasone; GM-CSF: Granulocyte macrophage colony-stimulating factor; IFN-γ: Interferon gamma; Ig: Immunoglobulin; ILT: Ig-like transcript; IS: Immunosuppressive drugs; LPS: Lipopolysaccharide; MHC: Major histocompatibility complex; MoDC: Monocyte derived DC; MMF: Mycophenolate Mofetil; Rapa: Rapamycin; RPMI: Roswell Park Memorial Institute; TolDC: Tolerogenic DC; VitD3: Vitamin D3.The authors declare that they have no competing interests.AM participated in the design of the study and drafted the manuscript. EV helped to draft the manuscript. LBD carried out the cell culture and the different assays. MCC conceived the study, participated in its design and coordination, revised and gave the final approval of the manuscript. All the authors read and approved the final manuscript.


The aim of the present study was to investigate whether a previously shown survival benefit resulting from routine early invasive management of unselected patients with acute non-ST-segment elevation myocardial infarction (NSTEMI) may differ according to smoking status and age.Post-hoc analysis of a prospective observational cohort study of consecutive patients admitted for NSTEMI in 2003  and 2006 . A strategy for transfer to a high-volume invasive center and routine early invasive management was implemented in 2005. Patients were subdivided into current smokers and non-smokers (including ex-smokers) on admission.The one-year mortality rate of smokers was reduced from 37% in the CS to 6% in the IS (p < 0.001), and from 30% to 23% for non-smokers (p = 0.18). Non-smokers were considerably older than smokers . The percentage of smokers who underwent revascularization (angioplasty or coronary artery bypass grafting) within 7 days increased from 9% in the CS to 53% in the IS (p < 0.001). The corresponding numbers for non-smokers were 5% and 27% (p < 0.001). There was no interaction between strategy and age (p = 0.25), as opposed to a significant interaction between strategy and smoking status (p = 0.024). Current smoking was an independent predictor of one-year mortality .The treatment effect of an early invasive strategy in unselected patients with NSTEMI was more pronounced among smokers than non-smokers. The benefit for smokers was not entirely explained by differences in baseline confounders, such as their younger age. Early invasive management of non-ST-segment elevation myocardial infarction (NSTEMI) has been shown, when contrasted with a conservative treatment approach, to improve clinical outcome . WhetherDetails on the study design and methodology are published elsewhere . In brieA diagnosis of AMI was, in the case of both cohorts, made in the presence of typical symptoms and elevated troponin T greater than a cutoff level of ≥ 0.1 μg/L. According to the electrocardiographic findings, AMI was sub-classified into ST-segment elevation myocardial infarction (STEMI) and NSTEMI. Current smokers included those who had smoked within the last three months. Non-smokers were defined as never-smokers and ex-smokers who had stopped more than three months prior to admission. Data on smoking cessation was not collected due to the fact that informed consent was required in order to undergo one-year follow-up on morbidity and medication. This, however, could only be obtained in 55% of the study group due to limitations such as patient refusal, old age, dementia and geographical factors. Baseline risk evaluation for both cohorts included the Global Registry of Acute Coronary Events (GRACE) risk score for 6-month mortality  age 71 [62-77] vs. 83 [74-88] years, p < 0.001). The corresponding figures for smokers were 58 (50-70) vs. 63 (59-78) years (p = 0.035). Similar age-differences were observed in the CS.Non-smokers in the IS who had revascularization within 7 days were significantly younger than those not undergoing this treatment  in the IS between smokers and non-smokers .Data on medical treatment during hospitalization are provided in Table The main finding of this study is that smokers with NSTEMI benefit the most from an early invasive treatment strategy, and that the treatment effect seems independent of age. For all-cause mortality the interaction term between current smoker and strategy was significant, implying that the effect of an invasive strategy was significantly different between smokers and non-smokers. In this unselected population one-year mortality for smokers decreased from 37% in the CS to 6% in the IS. Half of the fatal events among smokers in the CS occurred within 7 days. Such a profound reduction in early mortality could not be demonstrated among the non-smokers, where the increased use of early invasive management was less pronounced. In spite of the favorable findings among smokers undergoing early invasive treatment, current smoking was still an independent predictor of one-year mortality.Several studies and registries of patients with NSTE-ACS have compared the outcome of smokers vs. non-smokers in order to evaluate the possible existence of a "smoker's paradox" ,8-10. ThMost studies on the prognostic impact of smoking in acute coronary syndromes have compared younger smokers with older non-smokers, and, in part, ex-smokers ,9,11-13.Smokers were considerably younger and more likely to undergo early revascularization than non-smokers. It could therefore be argued that the favorable effect of an invasive strategy in the younger subgroup of smokers can be explained solely by this difference in age and the lower proportion of early revascularization in non-smokers. However, we found no interaction between strategy and age, as opposed to a significant interaction between strategy and smoking status at admission. Accordingly, the survival benefit of an invasive strategy in our study seems independent of age. This is consistent with previous findings from randomized trials. In the RITA 3 trial  patientsAnother potential confounding factor is the different concomitant medical therapy given to each cohort. It should be emphasized that there were no changes in the recommendations for adjunctive medical treatment from the first to the second cohort. In spite of this, we observed a non-significant tendency for more statin usage among smokers in the IS than in the CS. Statin and aspirin use during hospitalization were associated with a lower hazard ratio for mortality (model 1), but when included in the adjusted analysis, such treatment had no influence on the interaction between smoking and treatment strategy.The present study is a post-hoc analysis of a prospective observational cohort study including all patients with NSTEMI admitted to our hospital. This unselected study population is representative of Norwegian patients with NSTEMI in general, as opposed to patients included in randomized trials with various inclusion and exclusion criteria. On the other hand, due to the observational and nonrandomized design, our findings may have been influenced by unidentified confounders. In light of the relatively modest population size, potential differences between the groups might not be statistically significant because of type 2 errors. Due to the same reason it did not seem appropriate to stratify age groups. Data on important confounding factors during follow-up, such as secondary medical prophylaxis and smoking cessation after discharge were not available. According to observations made in studies of smoking cessation in patients with coronary heart disease, an apparent affect on mortality is not seen until after 2-4 years -18. In rUnselected smokers with NSTEMI represent a subset of patients who receive particular clinical benefit from an early invasive strategy. This benefit seems to be independent of age.ACE-I: angiotensin converting enzyme inhibitor; AMI: acute myocardial infarction; ARB: angiotensin-II receptor blocker; CABG: coronary artery bypass grafting; CI: confidence interval; CS: conservative strategy cohort; DES: drug-eluting stent; GRACE: global registry of acute coronary events; HR: hazard ratio; IS: invasive strategy cohort; LVSD: left ventricular systolic dysfunction; NSTE-ACS: non-ST-segment elevation acute coronary syndrome; NSTEMI: non-ST-segment elevation myocardial infarction; PCI: percutaneous coronary intervention; STEMI: ST-segment elevation myocardial infarction.The authors declare that they have no competing interests.This study was conceived and designed by EA, KE, JJ and JEO. EA, KE and JEO acquired the data. EA, KE, JR, JJ and JEO analyzed and interpreted the data. EA and JR conducted the statistical analysis. EA, JJ and JEO drafted the original version of the manuscript. EA, KE, JR, JJ and JEO revised the manuscript critically for important intellectual content. All authors have read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2261/10/59/prepub


N-terminal protease (A) gene from cyanobactin synthetase gene clusters, in a set of diverse cyanobacteria from our culture collection  CC). Homologues of this gene were found in Microcystis and Rivularia strains, and for the first time in Cuspidothrix, Phormidium and Sphaerospermopsis strains. Phylogenetic relationships inferred from available A-gene sequences, including those obtained in this work, revealed two new groups of phylotypes, harboring Phormidium, Sphaerospermopsis and Rivularia LEGE isolates. Thus, this study shows that, using underexplored cyanobacterial strains, it is still possible to expand the known genetic diversity of genes involved in cyanobactin biosynthesis.Cyanobactins are a recently recognized group of ribosomal cyclic peptides produced by cyanobacteria, which have been studied because of their interesting biological activities. Here, we have used a PCR-based approach to detect the  Cyanobacteria are one of the preferred microbial sources in the search of novel bioactive compounds due to the great structural diversity of their secondary metabolites ,2. MolecN-C terminal cyclized), most are additionally decorated with diverse posttranslational modifications, such as heterocyclization, isoprenylation or N-methylation, making this group of compounds one of the largest classes of diverse peptides  and [KF008255-KF008266], respectively see also .et al. [Phylogenetic studies of A-genes and 16S rRNA genes from the different cyanobacterial strains were performed. The putative A-gene sequences obtained in this study were independently submitted as the queries in a BLASTn search in order to confirm their identity. Since portions of the A- and G-genes are homologous, some of the sequences corresponded to the G-gene and were discarded. Cyanobactin A-gene sequences previously reported for cyanobacteria were also retrieved from the same database, as well as their respective 16S rRNA gene sequences (whenever available). Shih et al.  searchesMEGA 5.05 was used to perform the phylogenetic analyses. Multiple sequence alignments were obtained using the MUSCLE algorithm . To compN-terminal protease (A) genes seems to be an effective strategy to screen for cyanobacterial strains that may produce novel cyanobactins. Using this approach, two novel putative cyanobactin groups (Clades III and V, Phylogenetic analysis of cyanobactin


Torenia spps.) have made it notable as a model plant on the frontier of genetic engineering aimed at studying ornamental characteristics and pest control in horticultural ecosystems. The remarkable advantage of torenia over other ornamental plant species is the availability of an easy and high-efficiency transformation system for it. Unfortunately, most of the current torenia research is still not very widespread, because this species has not become prominent as an alternative to other successful model plants such as Arabidopsis, snapdragon and petunia. However, nowadays, a more global view using not only a few selected models but also several additional species are required for creating innovative ornamental traits and studying horticultural ecosystems. We therefore introduce and discuss recent research on torenia, the family Scrophulariaceae, for secondary metabolite bioengineering, in which global insights into horticulture, agriculture and ecology have been advanced. Floral traits, in torenia particularly floral color, have been extensively studied by manipulating the flavonoid biosynthetic pathways in flower organs. Plant aroma, including volatile terpenoids, has also been genetically modulated in order to understand the complicated nature of multi-trophic interactions that affect the behavior of predators and pollinators in the ecosystem. Torenia would accordingly be of great use for investigating both the variation in ornamental plants and the infochemical-mediated interactions with arthropods.Advances in research in the past few years on the ornamental plant torenia ( Torenia  ) . In addidagascar . There adagascar . Many hyately 5% . The shoately 5% , similarin vitro system for observing the guidance of pollen tubes using the naked embryo sac  and sesquiterpenes , as well as a trans-volatile [(E)-β-ocimene] -2-carene, α-terpinene, p-cymene and limonene], abolished the supporting effect of the trans-volatile embedded in the natural HIPVs. Transgenic torenia thus provides an intriguing tritrophic system, as predator attraction was enhanced only when non-flowering plants were infested , which is involved in phytoalexin biosynthesis, was resistant to a necrotrophic fungus, Botrytis cinerea, unlike the wild-type progenitors [Metabolic engineering of torenia also demonstrated the abilities of plants to resist fungi and arthropod herbivores. genitors . CollectIn summary, recent advances in torenia research have made this ornamental plant notable for genetic engineering aimed at studying both flower characteristics  and pestCHS: Chalcone synthase; CRES-T: Chimeric REpressor gene-silencing technology; DFR: Dihydroflavonol 4-reductase; HIPVs: Herbivore-induced plant volatiles; RNAi: RNA interference; VIGS: Virus-induced-gene-silencing.The authors declare no competing interests.MN and GA conceived the study and drafted the early version of the manuscript. TS and TN commented on the manuscript, revised the text and structure, and outlined it several times together with MN and GA. All authors read and approved the final manuscript.MN’s research focuses on the elucidation of the molecular mechanisms that control flower pigmentation and genetic engineering of novel colored flowers. TS is currently working on behavioral responses of pest herbivores and their natural enemies to herbivore-induced plant volatiles. TN’s research interest is focused on molecular breeding of ornamental flowers. His research interests include plant secondary metabolism, floral morphology and molecular engineering. GA’s research focuses on molecular ecology of plant-insect interactions mediated via volatiles. He has intensively studied mechanisms of resistance to arthropod herbivores.


Candida fungaemia from candidaemia because of their different antifungal susceptibilities. The aims of this study were to investigate the clinical characteristics of non-Candida fungaemia and identify the clinical factors that differentiate it from candidaemia.The incidence of fungaemia has been increasing worldwide. It is important to distinguish non-Candida fungaemia in Kyoto University Hospital from 2004 to 2009.We investigated the clinical manifestations and mortality of non-Candida yeasts (10.0%), including 6 episodes with Cryptococcus neoformans, 4 with Trichosporon asahii, and 1 with Kodamaea ohmeri, in addition to 99 episodes of candidaemia (90.0%). The presence of collagen disease  or renal replacement therapy  was significantly more common in non-Candida fungaemia patients than in candidaemia patients. Prior colonisation by the species may be a predictor of non-Candida fungaemia. Non-Candida fungaemia had a higher mortality than candidaemia .There were 110 episodes of fungaemia during the study period. There were 11 renal replacement therapy episodes of fungaemia due to non-Candida species frequently cause fungaemia, we should also be aware of non-Candida yeasts because of their high mortality, particularly among high-risk patients, such as those with collagen disease and those under renal replacement therapy. Prior colonisation by the causative organisms may be an important predictor of non-Candida fungaemia.Although  Candida species are the leading cause of yeast fungaemia. However, as the fungaemia patient population has changed, several types of rare yeasts have become recognised pathogens, particularly in nosocomial settings, and have increased in clinical importance , prior bacteraemia , renal replacement therapy , corticosteroid therapy , and higher SOFA score . In the multivariate analysis, independent risk factors associated with non-Candida fungaemia included collagen disease  and renal replacement therapy .The risk factors in patients with yeast fungaemia are shown in Table Candida yeasts, which are clinically less common than Candida species, have been associated with life-threatening infections in immunocompromised individuals. Although the importance of these opportunistic yeasts is recognised, little is known about their epidemiology [Candida yeasts was less common than candidaemia, but it still accounted for a significant proportion of all fungaemia episodes (10.0%). This incidence was similar to the rate of fluconazole-resistant Candida among candidaemia in our hospital (8.0%). The incidence of non-Candida fungaemia was slightly higher than in previous reports, which have reported rates of 3-6% [C. neoformans in this study because of its different susceptibility profile to antifungal agents compared to Candida species. Cryptococcus species are resistant to echinocandins [Non-emiology . In this of 3-6% ,3. One pocandins . HoweverCandida fungaemia, one or more co-morbidities were identified in all patients, but none had a solid malignancy. Several factors, including chronic kidney disease, prior bacteraemia, renal replacement therapy, corticosteroid therapy, higher SOFA score, and 30-day mortality, were significantly over-represented in non-Candida fungaemia. However, independent risk factors associated with non-Candida fungaemia only included collagen disease and renal replacement therapy. Other significant risk factors for non-Candida fungaemia in the univariate analysis might have confounded these associations. Although colonisation by Candida species at multiple sites in the body is commonly recognised as a major risk factor for invasive candidiasis in critically ill patients, Candida colonisation occurs primarily in immunocompromised patients [Candida fungaemia patients. This finding is intriguing and may be an important clue for predicting the occurrence of non-Candida fungaemia.Among patients with non-patients . In thisCandida fungaemia was significantly associated with 30-day mortality in the univariate analysis but was not an independent predictor in the multivariate analysis. Although this factor could be a confounding variable, the mortality of non-Candida fungaemia was higher than that of candidaemia (54.5% versus 21.2%). This high mortality rate is consistent with previous reports [et al. reported that patients with non-Candida fungaemia and patients with candidaemia had similar illness severities [Candida fungaemia (P = 0.02), although this difference was not significant in the multivariate analysis. Another explanation for this discrepancy is that the clinical intervention by infectious disease physicians contributed to the low mortality of candidaemia in our hospital [Non- reports -10. The hospital .Candida yeasts; thus, treatment options are limited, and the appropriate therapy can be left untried [T. asahii fungaemia (75%). However, the rate of appropriate therapy was similarly low between non-Candida fungaemia and candidaemia when appropriate therapy was defined as treatment with agents at a low MIC within 24 hours (data not shown). These findings suggest that other factors  might contribute to the high mortality of non-Candida fungaemia.Inappropriate therapy is a significant predictor of mortality in fungaemia ,10,16-19 untried . InitialCandida fungaemia. However, this study had several limitations. The most important limitation was the small sample size of non-Candida fungaemia patients because of low incidence. In addition, other rare opportunistic yeasts  were not detected in this study. Second, due to the retrospective nature of the study, we did not identify the focus or cause of infection in some cases; therefore, we could not address the application of appropriate therapy in all non-Candida fungaemia patients. Furthermore, we could not carry out molecular species identification. Finally, this study only evaluated the crude mortality of patients with fungaemia. The development of national databases and well-defined multicentre studies are needed to resolve these limitations.Our results reveal important insights into the epidemiology of non-Candida fungaemia is a rare cause of yeast fungaemia, it should receive more attention because of its high mortality, particularly among high-risk patients, such as those with collagen disease and those under renal replacement therapy. Prior colonisation by causative organisms may be an important predictor of non-Candida fungaemia.In conclusion, although non-The authors declare that they have no competing interests.MY conceived the study, participated in its design, reviewed the medical records, performed the statistical analysis, and drafted the manuscript. ST and SI participated in the design of the study, coordination, and manuscript preparation. GH, YM, AM, and MN participated in manuscript preparation. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2334/13/247/prepub


Summary: Genome-wide association studies and re-sequencing projects are revealing an increasing number of disease-associated SNPs, a large fraction of which are non-coding. Although they could have relevance for disease susceptibility and progression, the lack of information about regulatory regions impedes the assessment of their functionality. Here we present a web server, ChroMoS (Chromatin Modified SNPs), which combines genetic and epigenetic data with the goal of facilitating SNPs' classification, prioritization and prediction of their functional consequences. ChroMoS uses a large database of SNPs and chromatin states, but allows a user to provide his/her own genetic information. Based on the SNP classification and interactive prioritization, a user can compute the functional impact of multiple SNPs using two prediction tools, one for differential analysis of transcription factor binding (sTRAP) and another for SNPs with potential impact on binding of miRNAs (MicroSNiPer).Availability: Web server, ChroMoS, is freely available at http://epicenter.immunbio.mpg.de/services/chromos.Contact:barenboim@ie-freiburg.mpg.de or manke@ie-freiburg.mpg.de The majority of SNPs from genome-wide association studies (GWAS) and resequencing projects are located in non-coding regions. This impedes the assessment of SNPs' functional effect and disease mechanisms. Handling this plethora of data requires an automated SNP prioritization for initial analysis being followed by more focused functional analysis downstream. In concurrent efforts, epigenetics studies have resulted in many publicly available ChIP-Seq profiles. Here we introduce a web server, ChroMoS, which combines genetic and epigenetic data and facilitates SNP classification and prioritization. This integration is achieved through a large database of GWAS results and chromatin annotations, or through direct upload of user-defined data in standardized file formats. Using this data, SNPs can be classified as belonging to various functional categories, such as enhancer or promoter, and prioritized for further analysis. The relationships between SNPs and epigenetic categories were demonstrated by Ernst and colleagues showing that disease-associated SNPs were significantly more likely to be positioned within strong enhancer segments than neutral dbSNP variants. ChroMoS is also integrated with two prediction algorithms, sTRAP and MicroSNiPer, to assess the functional consequences of regulatory SNPs for some transcriptional and post-transcriptional mechanisms, respectively.ChroMoS was developed using Perl, PHP and JavaScript. It has a PHP-based web interface and MySQL database as the backend. Perl CGI module runs on Apache 2 web server. ChroMoS is platform-independent and compatible with all major web browsers.http://compbio.mit.edu/ENCODE_chromatin_states/ , rs713875 is assigned to a strong enhancer state, pointing to its possible relevance in regulatory mechanism.P-values, and those with increased binding get a positive log-ratio.After SNP selection, the user can directly run the sTRAP algorithm (If it is suspected that the SNP might be involved in post-transcriptional regulation, the results can be directly transferred to the MicroSNiPer web server (To the best of our knowledge, currently there is only one web server, HaploReg , for exp


Background: Social anxiety disorder (SAD) is characterized by distorted self-views. The goal of this study was to examine whether mindfulness-based stress reduction (MBSR) alters behavioral and brain measures of negative and positive self-views. Methods: Fifty-six adult patients with generalized SAD were randomly assigned to MBSR or a comparison aerobic exercise (AE) program. A self-referential encoding task was administered at baseline and post-intervention to examine changes in behavioral and neural responses in the self-referential brain network during functional magnetic resonance imaging. Patients were cued to decide whether positive and negative social trait adjectives were self-descriptive or in upper case font. Results: Behaviorally, compared to AE, MBSR produced greater decreases in negative self-views, and equivalent increases in positive self-views. Neurally, during negative self versus case, compared to AE, MBSR led to increased brain responses in the posterior cingulate cortex (PCC). There were no differential changes for positive self versus case. Secondary analyses showed that changes in endorsement of negative and positive self-views were associated with decreased social anxiety symptom severity for MBSR, but not AE. Additionally, MBSR-related increases in dorsomedial prefrontal cortex (DMPFC) activity during negative self-view versus case were associated with decreased social anxiety related disability and increased mindfulness. Analysis of neural temporal dynamics revealed MBSR-related changes in the timing of neural responses in the DMPFC and PCC for negative self-view versus case. Conclusion: These findings suggest that MBSR attenuates maladaptive habitual self-views by facilitating automatic  recruitment of cognitive and attention regulation neural networks. This highlights potentially important links between self-referential and cognitive-attention regulation systems and suggests that MBSR may enhance more adaptive social self-referential processes in patients with SAD. Self-views can powerfully influence how a person thinks, feels, and behaves, particularly in social contexts. The relationship of self-views to social functioning is especially salient in the clinical context of social anxiety disorder (SAD). Cognitive models of social anxiety , including the ventromedial prefrontal cortex (VMPFC), dorsomedial prefrontal cortex (DMPFC), and posterior cingulate cortex/precuneus  that are fundamental features of social anxiety.The goal of the present study was to investigate the differential effects of MBSR versus an active control condition [aerobic exercise (AE) stress reduction] on the neural bases of self-referential processing in patients with generalized SAD in the context of a RCT. MBSR cultivates a non-judgmental, pliable present-moment awareness that decreases habitual patterns of evaluation and reactivity, and increases psychological flexibility. In patients with SAD, MBSR is associated with reduced symptoms of anxiety, depression and self-deprecation, and increased quality of life and functionality  self-focus  or AE . Patients randomized to MBSR and AE did not differ in current or past Axis-I comorbidity, current Global Assessment of Functioning or Clinical Global Impression, and past psychotherapy or past pharmacotherapy Table .Patients were recruited through web-based community listings and referrals from mental health providers. After passing a telephone screening, potential participants were administered the ADIS-IV-L  of MBSR teaching experience.To match the individual and group components of MSBR, participants in the 8-week AE intervention were provided a 2-month gym membership and were required to complete weekly at least two individual AE sessions and one group AE session (other than meditation or yoga).ps > 0.51) on word frequency  and number of letters , as well as on arousal  and valence  based on the nine-point Self-Assessment Manikin rating system  included five blocks. Each block consisted of fixation, question (either “Describes ME?” or “UPPER case?”), and five adjectives of the same valence presented one at a time for 3 s each  to 3  for situations during the past week. Ratings are summed for a total LSAS-SR score (range = 0–144). The LSAS-SR has reliability and construct validity  contrast. Head movement was minimized using a bite bar and padding. During a single run, 226 volumes  were obtained . A high-resolution anatomical scan was acquired using a fast spin-echo spoiled grass pulse sequence .3 isotropic Gaussian spatial smoothing, high-pass filtering (0.011 Hz), linear detrending, and conversion into percentage change in each voxel. No volumes demonstrated motion in the x, y, or z directions in excess of ±0.8 mm. There was no stimulus-correlated motion, as assessed by correlations between condition-specific reference functions and x, y, z motion correction parameters .Analysis of functional neuroimages (AFNI) software Cox,  was usedMultiple-regression was implemented with AFNI 3dDeconvolve and included baseline parameters to remove mean, linear, and quadratic trends, and motion-related variance in the BOLD signal. Regressors for the negative self, negative case, positive self, and positive case were convolved with the gamma variate model Cohen,  of the ht-tests was conducted to examine average BOLD responses in masks for each of the three cortical midline SRN regions . The a priori rectangular region-of-interest masks were defined by a meta-analysis of 27 neuroimaging studies .t-tests to examine within-group changes pre-to-post-MBSR and AE, separately, on negative and positive self-views. We used AlphaSim, a Monte Carlo simulation bootstrapping program in the AFNI library, to protect against false positive cluster detection  provided protection against false positive cluster detection at p < 0.01.We also conducted whole-brain ts > 4.05, ps < 0.001), SAD-related disability , and increases in mindfulness . However, there were no between-group differences in pre-to-post change . A full account of the treatment-related self-reported changes in clinical and well-being measures has been published elsewhere  between the MCSDS and baseline SRET negative self-endorsement, SRET positive self-endorsement, social anxiety symptom severity (LSAS), SAD-related disability (SDS), and mindfulness skills (Kentucky Inventory of Mindfulness Skills). There was also no relationship between the MC and the same measures at post-intervention .To rule out the possibility of a social desirability response bias on self-report measures, we examined the relationship of the MCSDS and the clinical variables listed in Table negative social traits, a 2 Group  × 2 Time  repeated-measures ANOVA yielded no main effect of group (p > 0.25), a main effect of time , a main effect of time . Follow-up paired t-tests revealed increases in positive self-endorsement from pre-to-post-MBSR .For self-endorsement of To confirm that the SRET task induced activation of the cortical midline SRN, we examined BOLD responses for negative and positive self-views, separately, across all patients at baseline. There was evidence of robust activations in VMPFC, DMPFC, and PCC regions for the contrasts of negative self versus case and positive self versus case Figure .a priori ROIs  for the contrasts of negative self (versus case) and positive self (versus case), separately.We conducted a 2 Group  × 2 Time  repeated-measures ANOVA of BOLD responses in each of the three SRN p > 0.14) or group (p > 0.89), but there was a significant interaction of group by time . For the PCC, there were no main effects of time (p > 0.82) or group (p > 0.17), and a significant interaction of group by time  in the VMPFC, DMPFC, and PCC.There were no main or interaction effects  from pre-to-post-MBSR , but not AE . Increase in self-endorsement of positive self-views was associated with decrease in social anxiety symptom severity from pre-to-post-MBSR , but not from pre-to-post-AE . There was no relationship with mindfulness (KIMS).For behavioral responses, decrease in self-endorsement of negative self (versus case), increases in DMPFC activity were associated with (a) decreased social anxiety related disability (SDS) from pre-to-post-MBSR  and (b) increased mindfulness (KIMS) in MBSR . For the contrast of self-endorsement of positive self (versus case), decreases in DMPFC activity were associated with increased mindfulness (KIMS) in MBSR .For the contrast of self-endorsement of negative self (versus case) in the MBSR group, we conducted a 2 Group  × 2 Time  × 10 TRs (ten 1.5 s TRs or brain volume acquisitions) repeated-measures ANOVA with Greenhouse–Geisser correction on BOLD responses for each of the three SRN brain regions.For the contrast of p > 0.18). However, there was a group by time interaction .In the VMPFC, there were no three- or two-way interactions . However, there was an interaction of group by time  in ventromedial, left ventrolateral, and bilateral dorsolateral PFC, PCC/precuneus, left inferior parietal lobule, and left posterior superior temporal gyrus (Table positive self (versus case) yielded BOLD signal increases in anterior and posterior ventromedial, dorsomedial, right ventrolateral, and left anterior dorsolateral PFC, as well as subcortical uncus. For AE, a paired t-test revealed no significant pre-to-post BOLD signal increases for negative self (versus case), and increased responses in only the left mid-insula for positive self , impacted behavioral and neural indicators of self-views in unmedicated adult patients with generalized SAD.Clinically, both MBSR and AE significantly reduced social anxiety symptoms and disability, and enhanced mindfulness skills. Previous studies have shown similar MBSR-related improvements in patients with SAD  which was related to reduction in social anxiety symptom severity. Interestingly, increased mindfulness was not associated with changes in self-views. These findings suggest that chronically distorted social self-views in patients with SAD are modified during MSBR and that more adaptive self-views are related to clinical symptom improvement. Prior studies have also observed MBSR-related enhancement of more adaptive social self-views in patients with SAD , we examined self-endorsement and neural responses during positive and negative self-views. Behaviorally, MBSR and AE yielded significant self-endorsement decreases in negative and increases in positive self-views. However, compared to AE, MBSR resulted in (a) greater reduction in self-endorsement of Several mindfulness skills are trained in MBSR. One specific mindfulness skill that may modify self-views is decentering. This refers to non-identification with thoughts and beliefs, and active disengagement from ruminative self-evaluations and judgments  characterized by MBSR-related increased responses in the PCC and DMPFC. Examination of BOLD signal time series data showed greater recruitment of DMPFC and PCC activity in the middle portion of each 15 s block during negative self-processing from pre-to-post-MBSR. There was no significant effect of positive self (versus case). Thus, in alignment with our predictions, we did find increased attention-related PCC/precuneus response following MBSR, but did not find decreased BOLD response in more conceptual and cognitive control brain regions, as hypothesized, in the VMPFC and DMPFC.Neurally, the manipulation check of the SRET task Interestingly, recent research in developmental cognitive neuroscience suggests that SRN activation during self-reflection is considered a sign of healthy cognitive functioning and reflects the ability to sustain internal self-focused attention – an important component of self-regulation. In contrast, low levels of SRN activation have been identified as a risk factor for the development of psychological disorders and impaired social functioning  and increased mindfulness. Increased DMPFC during negative self-processing was also related to decreases in SAD-related disability. The MBSR-related increases in DMPFC activity during negative self-processing may be related to greater ability to greater recruitment of cognitive control mechanisms that regulate habitual patterns of emotional reactivity and attention allocation. This pattern of results highlights the importance of investigating both BOLD signal magnitude and timing, as well as their relationship to individual difference measures in order to elucidate how MBSR might enhance adaptive self-focus, increase psychological flexibility and reduce clinical dysfunction.The psychological functions instantiated in DMPFC and PCC that are recruited during the SRET following MBSR training might reveal the features of SAD that are specifically amenable to change with mindfulness meditation training. In general, increased SRN activation in this clinical context may reflect a greater engagement in the external stimulus  without shifting to habitual automatic avoidance which is a hallmark feature of anxiety disorder. This psychological change may be a foundation for the adaptive changes in self-views as well as clinical and social functioning observed in this study.negative self (versus case) following MBSR may reflect increased ability to monitor present-moment experience and a concomitant reduction in prepotent cognitive biases, including attend to followed by distract away attention biases, negative interpretations, and distorted self-evaluations. Additionally, phasic increases in DMPFC may also reflect transient increases in spontaneous  cognitive reappraisal of emotional reactivity to negative self-views. Recent models suggest that enhanced MBSR-related psychological flexibility, for example, mindful coping with perceived stressors, involves the process of disengaging and withdrawing from automatic negative appraisals into a transitory metacognitive state that attenuates semantic evaluations and enhances positive cognitive reappraisal  following MBSR in adults with SAD has been reported previously , and attention regulation  increases in use of cognitive reappraisal  and increases in cognitive reappraisal self-efficacy . As noted above, repeated social fear exposure during regular visits to the gym facility may also be related to the changes in self-esteem and associations with social anxiety symptoms, cognitive reappraisal, and self-views.With regard to the effect of AE, there was clear evidence of enhanced positive and reduced negative self-views, albeit less than MBSR, as well as similar AE and MBSR improvement in clinical symptoms and mindfulness skills. What is less clear, however, is what psychological and neural mechanisms are modulated by AE that account for these changes. Given the completely different pattern of pre-to-post-AE and MBSR SRN ROIs Figures  and 7 anThe most important implications of this study are that MBSR can modulate self-views in ways that are clearly detectable via self-report and brain networks, especially for negative self-views, and that the self-report and neural changes are related to important indicators of social anxiety symptom severity and disability. Furthermore, this study highlights that MBSR-related increases in the SRN may be an important first step in re-establishing adaptive self-views and social functioning in patients with SAD.The present study compared MBSR to AE, another active control stress reduction training intervention. One disparity is that while MBSR involves learning new mindfulness skills, AE does not. Also, in future studies, adding a no training waitlist control group could be useful to examine habituation to the SRET task. Nonetheless, the significant group by time interactions of self-endorsement ratings and BOLD responses only for negative self-views indicate meaningful differential changes from pre-to-post-MBSR versus AE. The SRET task implemented here used experimenter-selected positive and negative social trait adjectives selected for their relevance to SAD. Use of participant-generated  stimuli may result in more robust brain-behavioral responses in patients with SAD and perhaps larger differential effects of MBSR versus AE. The duration of each word stimulus was only 3 s. Use of longer stimulus durations will allow for examination of differences in self-focused attention, and rumination, as well as temporal features of BOLD responses in the SRN. This study only used single adjectives as stimuli. Future studies could explore adding non-verbal cues associated with positive and negative  self-views. The present study used binary yes/no responses for the target condition (self-descriptive) and control condition (upper case letters). Future studies will benefit from using a continuous rating scale to obtain more refined measurement of how self-descriptive a target social trait is perceived to be.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Conclusion. LP diet reduced the development of MAG and prolactin secretion which compromised milk production and pups growth. Moreover, this diet enhanced the store of lipid to glycogen ratio and suggests a higher risk of fatty liver development.Some metabolic alterations were evaluated in Wistar rats which received control or low-protein  diets, from the pregnancy until the end of lactation: control non-lactating (CNL), lactating (CL), low-protein non-lactating (LPNL) and lactating (LPL) groups. Despite the increased food intake by LPL dams, both LP groups reduced protein intake and final body mass was lower in LPL. Higher serum glucose occurred in both LP groups. Lactation induced lower insulin and glucagon levels, but these were reduced by LP diet. Prolactin levels rose in lactating, but were impaired in LPL, followed by losses of mammary gland (MAG) mass and, a fall in serum leptin in lactating dams. Lipid content also reduced in MAG and gonadal white adipose tissue of lactating and, in LPL, contributed to a decreased daily milk production, and consequent impairment of body mass gain by LPL pups. Liver mass, lipid content and ATP-citrate enzyme activity were increased by lactation, but malic enzyme and lipid: glycogen ratio elevated only in LPL.  Triacylm to TAG . Lactation comprises a catabolic mode of adipose tissue metabolism, with markedly reduced fatty acid synthesis/esterification and low-lipoprotein lipase activity , 6. By c2 or ketones (ketoacetate and β-hydroxybutyrate), which are released into the blood for use elsewhere in the body, or esterifying fatty acids to TAG and phospholipids, which are then secreted into the blood as lipoproteins including very low density lipoproteins (VLDL). In lactation, several mechanisms promote the oxidation of fatty acids in the liver [The liver has a more complex role in lipid metabolism than adipose or mammary tissue, taken up NEFA from the blood and either oxidizing them to COhe liver , which ahe liver . Despitehe liver . The phyhe liver , 12.According to Choi et al. , the intIn our laboratory, we observed low-protein dams on the 14th day of lactation lower serum insulin levels and this study showed that the maternal metabolic adaptation to hypoinsulinaemia resulted in higher insulin sensitivity, enhanced carcass fat deposition, hyperleptinaemia, and hypophagia . The aimThe experiment was formally approved by the institutional ethical committee and followed the COBEA guidelines  adopted by Mato Grosso Federal University (UFMT) . Female Spontaneous delivery took place the 22nd day of pregnancy and after which, at 3 days of age, large litters were reduced to eight pups, ensuring a standard litter size per mother, that were weighed three times a week until the end of experimental period. Lactating and non-lactating rats were divided in four groups and evaluated from the first day until the 18th day of lactation, as follows: control non-lactating (CNL) and lactating (CL), low-protein non-lactating (LPNL), and lactating (LPL), with free access to food and water. The control non-lactating and low-protein non-lactating groups were formed by virgin rats. They were kept under standard lighting conditions (12 h light/dark cycle) at a 24 ± 1°C of temperature. Food intake was evaluated at same times of animal weighting. Milk production in each group was estimated as described by do Carmo et al.  as the d2 and the blood was collected after decapitation. Serum was obtained by centrifugation and aliquots were stored at −80°C. Serum glucose was measured by the glucose oxidase method , total protein by the biuret modified method [At the end of the experimental period (18th day of lactation) the rats were euthanized with COd method . Serum hGonadal white adipose tissue (GON), liver, mammary gland (MAG), and carcass (CARC) were quickly removed after euthanasia for fresh weight determination (g) and kept at −80°C until its use for dosages. Liver fragments were excised to determination of glycogen content . The fatn−1· min−1. Protein concentration was determined as described by Lowry [Hepatic enzymes activities were measured by the following methods: glucose-6-phosphate dehydrogenase (G6PDH) was assayed as described by Lee , malic eby Lowry .t test was used to compare two groups. P < .05 indicated statistical significance. All statistical comparisons were done using the Statistics Software Package .Results were expressed as mean ± SEM for the number of rats indicated. Levene's test for homogeneity of variances was initially used to determine whether data complied with the assumptions of parametric analysis of variance. When necessary, data were log-transformed to correct for variance in heterogeneity or nonnormality. All data were subsequently analyzed by two-way ANOVA  followed by Tukey-HSD test for individual differences among groups. Different superscript letters were employed to mark statistical differences. Student's Absolute food intake was similar in low-protein lactating dams compared to controls, but the increases were found in both LPL and LPNL when normalizing it by percentage of body mass. Protein intake was reduced in absolute and relative terms in low-protein groups. By the end of experimental period, LPL group significantly reduced the final body mass . Serum protein concentration was significantly lower in LPL, but albumin levels were reduced in both low-protein groups (LPNL and LPL). In an opposite way, serum glucose values of these rats were higher than the controls .  Lactation lowered serum insulin and glucagon levels, markedly in LPL dams, being that we found insulinemia 3.5 times lower than in CL. On the other hand, low-protein diet reduced both insulin and glucagon levels when compared to controls. And, although the lowest ratios of insulin/glucose and insulin/glucagon in lactating groups  the low-protein diet reduced the insulin/glucose ratio. Lactation induced rise in serum prolactin levels in both LPL and CL, but it was impaired in low-protein dams and, a fall in serum leptin levels was observed in both control and low-protein lactating dams .By this period, LPL dams lost some relative mass of mammary glands, whereas control dams retained their MAG weights. Lipid content also reduced in MAG of control and low-protein rats . Daily mOther lipid-providing tissue such as GON was reduced in both lactating groups (LPL and CL) .Despite the highest initial body mass and relative food intake observed, the lactating low-protein dams reached the lowest values of final body mass and decrease of serum albumin concentration was observed in low-protein animals. This is a well-described consequence of scarce nitrogen stores for milk-protein synthesis in low-protein malnourishment , 8, 28. According to Dewey , a suitaSerum prolactin was 70% lower in low-protein dams, endowing the low MAG weight observed and putting the impaired milk production on a pituitary/hormonal level. Recent studies demonstrated that the actions of prolactin are not confined to the mammary gland , but conLactation half end is characterized by decreased insulinemia and leptinemia. These low insulin and leptin levels in lactating rats are associated to catabolic processes releasing fatty acids from the adipose tissue, towards to the liver. In lactating low-protein dams the insulinemia reduced in 2-thirds as compared to control lactating, prompting to a higher release of fatty acids. According to Sipols et al. , low insWe found increased serum glucose levels and reduced insulinemia in low-protein groups, especially in lactating dams. Moreover, in low-protein lactating rats the insulin/glucagon ratio was 46% lower than in control. As described, a higher fatty acid mobilization from depots is usually observed during lactation, to provide fatty acids towards the mammary gland and other tissues , 6. The Both lactating groups exhibited increased mass and lipid content in the liver. Accumulation of fats in the liver during early, but not in late lactation, is usually verified and seldom impairs its functions . The stoAdditionally, lactation strongly increased the liver lipogenic enzymes in lactating dams, as compared to non-lactating females, especially malic enzyme that elevated only in low-protein dams. Hormonal and nutritional conditions that modify liver lipogenic enzymes activities are described , 36, witPrevious works with this model of protein deficiency in pregnancy and lactation have stated permanent changes in expression of liver enzymes involved in glucose homeostasis , 41, incIn this study we observed that low-protein diet during lactation decreased the development of mammary gland and prolactin secretion which resulted in lower milk production and impaired pups growth. Lactation enhanced liver mass, lipid content and lipogenic enzymes activities. Moreover, this diet enhanced the store of lipid to glycogen ratio and suggests a higher risk of fatty liver development.


Vegan diet has been associated with lower risk of cardiovascular diseases and mortality, partly due to its effects on serum lipid profiles. Lipid profiles  have not been fully elucidated either in pre and postmenopausal vegans or in ovo-lacto vegetarians. This study aimed to compare lipid profiles among vegans, ovo-lacto vegetarians and omnivores.Demographic data and lipid profiles were obtained from the 2002 Taiwanese Survey on Hypertension, Hyperglycemia and Hyperlipidemia. Multivariate linear regression analysis was used to examine factors significantly and independently associated with different categories of veganism and to estimate the β value of lipid profiles in the dietary types.A total of 2397 premenopausal and 1154 postmenopausal participants who did not receive lipid lowering drugs were enrolled. Premenopausal vegans had significantly lower HDL-C and higher TG, LDL-C/HDL-C, total cholesterol (TC)/HDL-C and TG/HDL-C compared with omnivores. For postmenopausal women, vegans had lower TC while ovo-lacto vegetarians were observed with low HDL-C when compared with omnivores. Multivariate linear regression analyses showed that vegan and ovo-lacto vegetarian diets decreased HDL-C levels in premenopausal women . There were significant associations between lower LDL-C and ovo-lacto vegetarian diets  and also between TG and vegan diet , compared with omnivorous diet. Post-menopausal women reported to have consumed either a vegan or an ovo-lacto vegetarian diet were at the risk of having low HDL-C unlike those that consumed omnivorous diets . There were no significant changes in LDL-C in both pre and postmenopausal vegans.Vegan diet was associated with reduced HDL-C level. Because of its effects on lowering HDL-C and LDL-C, ovo-lacto vegetarian diet may be more appropriate for premenopausal women. The incidence of cardiovascular disease is higher in postmenopausal women than in age-matched men and premenopausal women -3. ThereVegetarian diets have experienced an increase in popularity . A low-fA considerable number of Taiwanese populations consume vegetarian diets due to philosophical or health concerns rather than solely religious beliefs as indicated by the increasing numbers of restaurants in cities . Local TSubjects were recruited from the 2002 Taiwanese Survey on Hypertension, Hyperglycemia, and Hyperlipidemia (TwSHHH) database. The survey was approved, performed and provided by the National Health Research Institutes and Bureau of Health Promotion. All subjects were given written consent prior to the study. The national-wide survey was designed to evaluate the prevalence, awareness, treatment and control of hypertension, hyperglycemia, and hyperlipidemia. Study participants were randomly selected from a subsample of the National Health Interview Survey (NHIS) conducted by the National Health Research Institutes and Bureau of Health Promotion, Taiwan in 2001. The NHIS applied a multi-staged, stratified, clustered and random sampling during the study. Details of the study design and characteristics of the study population have previously been described ,18.Summarily, 6592 households were selected from 1648 communities with approximately 26658 non-institutionalized residents ≧of 15 years of age. Because of financial burden of biomarker screening, one-half of the communities (824 communities with 3296 households and 10292 residents) in each stratum were randomly selected from the TwSHHH. Subjects were excluded if they had received lipid-lowering drugs. Finally, 3551 women completed the interviews, physical exams and lipid profile measurements.Information on socio-demographic characteristics, such as sex, age, anthropometric, physical activity, lifestyle, menopausal status, dietary habits, physician-diagnosed diseases, and medical history were obtained through household interviews. Physical examinations were made by well-trained nurses using standardized protocols.Hip circumference (HC) was measured at the level of the greater trochanter with an anthropometric tape. Waist circumference (WC) was measured midway between the iliac crest and the last rib. Waist to hip ratio (WHR) was computed as the ratio of WC (in centimeter) to hip (in centimeters). Because body weights were not measured during the TwSHHH survey, obesity was defined as WHR ≥ 0.85 . ExercisDiabetic individuals were defined as those with fasting plasma glucose ≥126 mg/dl , and/or Adherents to vegan diet excluded egg, milk, meat, poultry, seafood and by-products of animal slaughter for more than 1 year. Ovo-lacto vegetarian diet was defined as diets in which adherents completely excluded meat and fish from their diet, but included dairy and egg products for more than 1 year; otherwise, they were considered as omnivores. An organic food diet was defined as that for which subjects consumed at least 50% of total food intake as organic food, and had been on the diet for at least one year prior to the study.p value <0.05 was considered statistically significant.Data analysis was conducted using the SAS software package, version 9.2 . Continuous data were expressed as means and standard deviation. Analysis of variance was used to compare the mean difference of demographic data, biochemical measurements and anthropometric indices among vegans, ovo-lacto vegetarians and omnivores. Multiple linear regressions were used to estimate the effects of the diets on lipid profiles. A In total, 2397 premenopausal and 1154 postmenopausal women were enrolled. The baseline descriptive characteristics of each dietary group of premenopausal women are presented in Table About 5.5% of the postmenopausal women lived on vegan diet Table . Vegans After adjusting for potential confounders, vegan and ovo-lacto vegetarian diets had significant effects on HDL-C   and HDL-C (-8 mg/dl) in healthy premenopausal women, and increase in serum TG (16 mg/dl) . In a hoIn the present study, significant associations were found between vegetarian diets and lipids profiles in premenopausal than postmenopausal women. To our knowledge, no study has assessed the effects of diets on serum lipid profiles in free-living, pre and postmenopausal women. Many factors, such as lifestyle, exercises, medication and co-morbidities that may influence lipid measurements were adjusted to reduce confounding and to increase the validity of the results. There were several limitations in this study. First, TwSHHH was a cross-sectional study that may have limited the causal inference. Second, the questionnaires did not contain amount of diet and the recommended daily dietary intake. Because the results could have been affected by the quantity of diets consumed by participants, it was difficult to fully clarify the relationship between vegetarian diets and cardio-metabolic profiles. Third, a potential self-selection effect may have had an impact on our results because of certain health concerns. We reduced the confounding by adjusting hormone replacement therapy, age, organic food consumption and exercise.Vegan and ovo-lacto vegetarian diets resulted in a significant decrease in the levels of HDL-C in pre- and postmenopausal women. Lower levels of LDL-C as registered in premenopausal women could minimize possible cardiovascular disease risks attributed to lower levels of HDL-C. Ovo-lacto vegetarian diet may be more appropriate for premenopausal women. The present results cannot directly address biologic and nutritional mechanisms underlying findings; further studies should investigate such mechanisms.HC: Hip circumference; HDL-C: High density lipoprotein-cholesterol; LDL-C: Low density lipoprotein-cholesterol; NHIS: National Health Interview Survey; TC: Total cholesterol; TG: Triglyceride; TwSHHH: The Taiwanese Survey on Prevalence of Hyperglycemia, Hyperlipidemia, and Hypertension; WC: Waist circumference; WHR: Waist to hip ratio.The authors declare that they have no competing interests.YPL and YWH designed the study and revised the draft. HCC, PCK and CCH extracted and analyzed data. ZHJ, YCC and CCL interpreted data and wrote the draft. LYL and ONN provided conceptual input and contributed to the final manuscript. All authors read and provided feedback on the draft versions of the article. All the authors have read and approved the final version.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1472-6874/14/55/prepub


Objectives. Biofeedback (BFB) is an established intervention in the rehabilitation of headache and other pain disorders. Little is known about this treatment option for fibromyalgia syndrome (FMS). The aim of the present review is to integrate and critically evaluate the evidence regarding the efficacy of biofeedback for FMS. Methods. We conducted a literature search using Pubmed, clinicaltrials.gov , Cochrane Central Register of Controlled Trials, PsycINFO, SCOPUS, and manual searches. The effect size estimates were calculated using a random-effects model. Results. The literature search produced 123 unique citations. One hundred sixteen records were excluded. The meta-analysis included seven studies (321 patients) on EEG-Biofeedback and EMG-Biofeedback. In comparison to control groups, biofeedback (BFB) significantly reduced pain intensity with a large effect size . Subgroup analyses revealed that only EMG-BFB and not EEG-BFB significantly reduced pain intensity in comparison to control groups . BFB did not reduce sleep problems, depression, fatigue, or health-related quality of life in comparison to a control group. Discussion. The interpretation of the results is limited because of a lack of studies on the long-term effects of EMG-BFB in FMS. Further research should focus on the long-term efficacy of BFB in fibromyalgia and on the identification of predictors of treatment response. Fibromyalgia (FMS) is a chronic pain syndrome. The key symptoms of FMS are widespread pain, disturbed sleep, fatigue, and depressed mood , 2. FMS Recent reviews on the efficacy of psychological interventions for fibromyalgia have reached contradictory conclusions. Thieme and Gracely  and Glomhttp://nccam.nih.gov/health/whatiscam/). A scheduled review on CAM-therapies in FMS will include biofeedback . Biofeedback (BFB) is a very popular intervention alone or within cognitive-behavioural or multidisciplinary pain treatments. Biofeedback is a procedure in which patients' bodily responses such as muscle tension, heart rate, or skin temperature are monitored and reported to the patient through an auditory or visual modality. Various biofeedback modalities are used, electromyographic feedback (EMG-FB) being the most common for treatment of fibromyalgia. In EMG-FB, patients learn to control and to alleviate their muscle tension. Biofeedback is often called a “psychophysiological intervention,” although its change mechanisms are more psychological than physiological: it has been repeatedly demonstrated that the effectiveness of EMG biofeedback is mediated by cognitive changes, such as increases in self-efficacy and coping strategies induced through biofeedback training, rather than primarily by learned physiological control  AND “Fibromyalgia”[Mesh] AND  OR clinical trials[MeSH Terms] OR clinical trial[Publication Type] OR random*[Title/Abstract] OR random allocation[MeSH Terms] OR therapeutic use[MeSH Subheading]). The search keywords for clinicaltrials.gov, Cochrane Central Register of Controlled Trials, PsycINFO, and SCOPUS were as follows: .No language restrictions were applied. Only fully published articles were reviewed. In addition, reference sections of original studies, systematic reviews, and evidence-based guidelines on the management of FMS were screened manually. Two authors  independently screened the titles and abstracts of potentially eligible studies identified by the aforementioned search strategy. The full-text articles were then examined independently by two authors  to determine whether they met the inclusion criteria.Two authors  independently extracted the data using standard extraction forms. Discrepancies were identified, and consensus was achieved by discussion. Where outcomes, means, or standard deviations were missing, attempts were made to obtain these data by contacting trial authors. Additional data were provided by three authors see .Data for study settings, participants, exclusion criteria, interventions, cotherapies, attendance rates, reported side effects, and outcomes sought are listed in To assess the internal validity of each eligible RCT, authors  working independently determined whether the randomization, concealment of allocation, blinding of outcome assessors, and data analysis were adequate and whether intention-to-treat analysis was performed. Exclusion of patients with inflammatory diseases and psychiatric comorbidities was also assessed. The exclusion of these patients has an impact on the interpretation of the study results: since these comorbidities are very frequent in FMS the validity of the study results might be limited to a rather small group of FMS patients.Another author (Julia Anna Glombiewski) checked the treatment settings, the means of referral to the RCT, and the demographic data of the study samples to assess whether study samples were representative  see .g. We used Cohen's categories [g > 0.2–0.5 = small effect size, g > 0.5–0.8 = medium effect size, and g > 0.8 = large effect size.Data entry (performed by Winfried Häuser) was checked by another author (Kathrin Bernardy). Discrepancies were resolved by consensus. Meta-analyses were conducted using RevMan Analysis software (RevMan 5.1) of the Cochrane Collaboration. Standardized mean differences (SMD) were calculated using means and standard deviations or change scores for each intervention. Examination of the combined results was performed using a random-effects model (inverse variance method), because this model is more conservative than the fixed-effects model and incorporates both within-study and between-study variances. The SMD used in Cochrane reviews is the effect size known as Hedges' (adjusted) tegories  to evaluI2 statistic, with I² values over 50% indicating strong heterogeneity.Heterogeneity was tested using the P < 0.05 as the criterion for significance [Potential publication bias  was investigated using the Egger test, in which the standardized effect size  is regressed on precision (inverse of standard error) . The intificance .Subgroup Analysis. Provided that at least two studies were available, subgroup analyses were prespecified for type of BFB. These subgroup analyses were also used to examine potential sources of clinical heterogeneity.After removing duplicates, the literature search produced 150 unique citations. Through screening, 143 records were excluded. Seven full-text articles were assessed for eligibility, and none were excluded. These seven studies were included in the meta-analysis see .Study characteristics are described in Patient characteristics are summarized in The number of sessions varied between 6 and 22 sessions. The length of sessions was not always exactly reported and varied between 30 minutes and 3 hours. The attendance rates were not reported in most of the included studies. Three studies included EEG-BFB see . KravitzFour studies offered EMG-BFB see . In the In four studies the controls received Sham Biofeedback . Other control groups received attention-placebo treatment, a serotonin-reuptake inhibitor, and treatment as usual. The most frequently used instrument for the outcome measures pain, sleep, and fatigue was a visual analogue scale (VAS) see . Sleep wFour studies performed follow-ups between 1 week and 6 months.Most studies were of poor methodological quality see . In all g) for all outcome measures (“Pre-post” and “Pre-follow-up” for uncontrolled effect sizes and “Controlled” and “Follow-up controlled” for controlled effect sizes) are presented in The effect sizes , I2) was still above 50% after subgroup analysis.There was substantial heterogeneity for all computed effect sizes see . The hetPublication Bias. Begg's and Egger's tests indicated a publication bias. Egger's intercept was −5.2 (P two tailed = 0.07), and Begg's Kendall-tau without continuity correction was −13.0 (P two-tailed = 0.05).This first meta-analysis of the efficacy of biofeedback in fibromyalgia found that EMG-BFB was effective for a (short-term) reduction of pain intensity in fibromyalgia patients with a large effect size. The sample was representative of the FMS population. The methodological quality of most of the included studies was poor, limiting the credibility of the results of this meta-analysis.This result is promising; however, the long-term effects of EMG-BFB on pain intensity are unclear due to the small number of studies that included follow-up assessments. Although significant, the pre-post effect is based on a small number of quite heterogeneous studies. Neither EEG nor EMG biofeedback was effective in comparison to control groups at reducing depression, sleep problems, and fatigue or at increasing health-related quality of life. Considering the complexity of FMS psychopathology, it is questionable whether short-term pain reduction alone leads to significant change for better. Long-term data and more studies including a variety of outcome measures  are needOur findings are noteworthy because no other meta-analysis on psychological or multicomponent treatments of fibromyalgia has reported comparably large effects on pain intensity , 41. ThuThe role of BFB treatment in the context of other treatments for FMS is important to consider. There is an important difference between the BFB treatment of chronic headache and BFB treatment of chronic low back pain; with chronic headache, BFB can be the sole therapy, while with chronic back pain BFB should be combined with other modalities. In FMS, BFB should also not be delivered as monotherapy. First, FMS is a complex syndrome, and its many symptoms are not addressed comprehensively by BFB. Second, there are other effective treatment options for FMS, such as aerobic exercise therapy –48 or phA strength of our study is a thorough literature search, which resulted in the identification of additional relevant studies on biofeedback compared to previous reviews on psychological treatments for FMS. Additional strengths are the inclusion only of RCTs and the computation of controlled effect sizes for several different outcome measures, as recommended by IMMPACT . The stuOne limitation of meta-analyses in general is the fact that a meta-analysis is strongly influenced by factors such as study selection criteria, the quality of the included studies, and expectancy effects . HoweverAdverse events are rarely assessed in behavioral research. In two of three studies that reported adverse events, up to 74% of patients reported side effects. Thus, we strongly recommend a systematic assessment of side effects in further BFB research and treatment. Additionally, we suggest assessing responder rates (defined as 30% pain intensity reduction) as a primary outcome .Based on the results on pain intensity reduction, we recommend incorporating EMG-BFB into psychological or multidisciplinary fibromyalgia treatment programs.Further research should focus on the long-term efficacy of BFB in FMS. Experimental research has shown low heart rate and high skin conductance levels in FMS patients as a reaction to stress ; these fFinally, it is important to identify moderators  and predictors of treatment response as well as mechanisms of change. Any future trials should address the deficiencies noted in the quality assessment.


Objectives. There are limited clinical data revealing the relationship between mitral annular calcification (MAC) and systemic inflammation. The goal of the present study was to compare high-sensitivity C-reactive protein (hs-CRP) levels in patients with and without MAC and investigate the relationship between MAC and hs-CRP. Methods. One hundred patients with MAC who underwent transthoracic echocardiography (TTE) and 100 age-matched controls without MAC who underwent TTE were included in our study. Hs-CRP levels were compared between groups. Results. Prevalence of female gender, hypertension, and coronary artery disease were significantly higher in the MAC group than in the control group . On multivariate analysis, age, gender, and coronary artery disease were the only independent predictors of MAC. The levels of hs-CRP were higher in the MAC group than in the control group . This increase in hs-CRP levels in the MAC group persisted in patients without hypertension, coronary artery disease, and in male patients when compared to the control group. Conclusions. Our study demonstrated that hs-CRP, which is a sensitive marker of systemic inflammation, increased in patients with MAC. Mitral annular calcification (MAC) represents a chronic and degenerative calcification of the surrounding fibrous support of the mitral valve. This process is a common finding on echocardiographic examination and progresses with advanced age . Althoug2 or serum creatinine >1.0 mg/dL [Participants were recruited from patients admitted to cardiology department of our hospital. One hundred consecutive patients in whom a diagnosis of MAC was made by transthoracic echocardiography (MAC group) and 100 consecutive age-matched patients without MAC (control group) were included in our cross-sectional study. Patients were excluded if they had rheumatic heart disease, congestive heart failure, cardiomyopathy, prosthetic valves, renal failure (estimated glomerular filtration ratio (eGFR) below 90 mL/min/1.73 m.0 mg/dL ), activeComplete 2-dimensional transthoracic and doppler colour flow measurements were performed in all patients with the 4-MHz transducer of a Phillips ATL 5000 HD . The echocardiographic diagnosis of MAC was made by 2-dimensional and M-mode transthoracic echocardiography. On 2-dimensional echocardiography, the diagnosis included an intense echo-producing structure located at the junction of the atrioventricular groove and posterior mitral valve leaflet on the parasternal long-axis, apical 4-chamber, or parasternal short-axis views . On M-moAll patients' demographic parameters were recorded and cardiac risk factors were determined: coronary artery disease (CAD) .t tests for continuous variables. Multivariate binary logistic regression analysis was performed to determine which clinical variables would independently predict the development of MAC. MAC entered into model as a dependent variable. Results were presented as odds ratios and 95% confidence intervals. Multiple linear regression analysis was used to examine the effect of clinical variables on hs-CRP levels. Hs-CRP level entered into model as a dependent variable . Continuous variables were presented as means ± SD and categorical variables as percentages. Differences between study groups in baseline characteristics were assessed with the use of two-sided Fisher's exact tests and chi-square tests for categorical variables and Student's variable . ResultsP = 0.01), female gender  and coronary artery disease  as the independent variables significantly associated with MAC , hypertension , coronary artery disease , hypercholesterolemia , and smoking  were all independently associated with the levels of hs-CRP. The adjusted R2 value was 0.38 for this model.Serum hs-CRP levels in the MAC and control groups were summarized in Mitral annular calcification (MAC) is a chronic process involving fibrosis and calcification of the mitral valve support ring and commonly observed on echocardiograms. Generally, this process is regarded benign although it is thought to produce significant regurgitation and/or stenosis in rare circumstances . ConsistAlthough a number of hypotheses have been proposed to elucidate the ectopic deposition of calcium on cardiac structures , 19, theWhen the literature is reviewed, MAC is observed more in patients who have atherosclerotic risk factors such as CAD and HT , 12, 26.It is well known that MAC is more common in females . In our The association of coronary artery disease and hypertension with MAC, as noted in the present study, is consistent with the findings of previous studies –33. In aFindings of our study are partly consistent with the results of the Cardiovascular Health Study which found an association between MAC and hs-CRP levels . HoweverThis study has several limitations. One of which was the cross-sectional design. Although cross-sectional studies can measure association, they are not strong enough to prove causality. It would have been ideal to have obtained serial echocardiograms and hs-CRP levels in our study patients to prove causality. Because our sample size was relatively small, this study may not be representative of the general population or populations from community-based. In addition, our study population consisted of predominantly elderly patients who might have higher hs-CRP levels than younger patients because of aging or nonspecific etiologies. Lastly, we did not assess the severity of MAC. Further study is needed to examine the relationship between systemic biomarkers of inflammation and valvular and/or annular calcification.Our study demonstrated that hs-CRP, which is a sensitive marker of systemic inflammation, increased in patients with MAC. This increase in hs-CRP levels in the MAC group persisted in patients without hypertension, coronary artery disease, and in male patients when compared to the control group. There is a need for studies which are designed to present the significance of the relationship of MAC with inflammatory process and its clinical importance.


Non-sinonasal neuroendocrine carcinomas (NSNECs) of the head and neck are considered an unfrequent clinico-pathological entity. Combined modality treatment represents an established therapeutic option for undifferentiated forms where distant metastasis is a common pattern of failure.We report on a case of NSNEC treated with sequential chemo-radiation consisting of 6 cycles of cisplatin and etoposide followed by loco-regional radiation to the head and neck and simultaneous prophylactic cranial irradiation to prevent from intracranial spread, delivered with helical tomotherapy with the 'hippocampal avoidance' technique in order to reduce neuro-cognitive late effects.One year after the end of the whole combined modality approach, the patient achieved complete remission, with no treatment-related sub-acute and late effects.The present report highlights the importance of multidisciplinary management for NSNECs of the head and neck, as the possibility to achieve substantial cure rates with mild side effects with modern radiotherapy techniques. Tumours of neuroendocrine differentiation arising within the head and neck region are considered an extremely rare clinico-pathological entity . They ha18 F-deoxyglucose- CT-positron emission tomography (CT-PET scan) was performed showing focal uptake within the oropharynx and left neck . Intermediate CT and PET restaging was performed after 3 PE cycles, with the evidence of the persistent thickening and uptake within the tongue base. The patient underwent a new biopsy of the nasopharynx and base of the tongue with no tumour observed. The chemotherapy program was completed with mild acute toxicity . A re-evaluation with functional and anatomic imaging (CT-PET scan) was carried out at the end of the CT program: complete remission (CR) was achieved. Thirty days after, the patients was planned to receive consolidation head and neck region radiation and PCI delivered with the TomoTherapy Hi-Art II system  with the HA technique, as reported by Gondi et al. [3 ≤ 20%) and HAVs (maximum dose 25.2 Gy and V20 ≤ 20%) were adapted from Gondi et al. [A 53 years old caucasian man was referred to our Institution Hospital due to the sudden appearance of a right latero-cervical enlarged lymphnode with no symptoms complained. He had a previous medical history of childhood tonsillectomy, appendectomy, acute bacterial epididymitis and asymptomatic hepatitis A infection. He was a non-smoker and had a low-moderate alcohol intake at meals. Physical examination of the neck region showed a 3-cm hard and fixed adenopathy close to the posterior belly of the right digastric muscle. He underwent, at first, a pharyngo-laryngoscopy procedure that revealed a macroscopic tongue tonsil hypertrophy. A total body CT-scan demonstrated two enlarged lymphnodes (35 and 12 mm in diameter) in the right upper neck between the sub-mandibular group (level Ib) and the upper anterior jugular group (level IIA) according to Robbins classification with an adjunctive level IIA left node (15 mm in diameter) ; thickeni et al.   the 2-year rate of DM if compared to local therapy alone  [p = 0.23). CT did not prevent from LF (p = 0.91); however half of the patients with LF did not achieve complete remission (CR) after induction CT. Thereby, some general conclusions might be drawn. Surgical approaches should be limited to well-differentiated neuroendocrine carcinoma histological subtypes , as it is for other body districts. Combined modality treatment consisting of chemotherapy and local radiotherapy should be strongly considered for moderately and poorly differentiated NSNECs. The preferable timing of the CT-RT combination is the sequential approach. Even if concurrent chemo-radiation has reached satisfactory evidence over sequential chemo-radiation in SCLC, induction CT and subsequent consolidation RT for complete or very good partial responders might be considered an efficient and less toxic approach for NSNECs, since concomitant CT-RT has not proven to improve early complete response rate, local control or survival [NSNECs of the head and neck region are widely uncommon and therefore clinical and therapeutic informations are scanty. In addition, the issue is beclouded by the slenderness of the published literature  and by the heterogeneity of the histological sub-types and anatomical sites of presentation of the medical cases described. However some informative studies are available. To our knowledge, the largest case series of NSNECs published is the one by the MD Anderson Cancer Center: 23 patients were treated between 1984 and 2001  [nalysis) . Radiatisurvival ,17. The survival ,19. PCI,survival . The hypsurvival ,23. At lWritten informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.The authors declare that they have no competing interests.PF, GN, FM, DC, PS, PC, MR LP, GG: provided medical assistance to the patients and defined the treatment approach; PC, PC, VCB: contributed in the treatment planning; PC: provided pathological specimens; PF, GN, DC, VCB, MP: contributed in the acquisition, analysis, interpretation of data; PF, GN: drafted the manuscript; ST, FO, UR: contributed in the critical revision; UR: gave final revision and approval. All authors read and approved the final manuscript.


Neuropeptide Y (NPY), which is widely expressed in both the central and peripheral nervous systems, has an important role in a variety of biological fields. In this study, we analyzed the distribution of NPY polymorphisms in dampness-phlegm pattern and non-dampness-phlegm pattern in elderly Korean subjects with cerebral infarction (CI). A total of 1.097 subjects  participated in this study. Genotyping for five SNPs  was conducted by primer extension. The results were statistically analyzed for genetic association of NPY-polymorphisms with normal versus dampness-phlegm pattern or non-dampness-phlegm pattern subjects. Among the five SNPs tested, the T allele of C-399T has a negative association with the dampness-phlegm pattern and is marked by a decrease in serum cholesterol levels. Furthermore, serum cholesterol levels were significantly higher in dampness-phlegm pattern patients than in non-dampness-phlegm pattern patients.In this study, for the first time, the association of NPY polymorphisms with pattern identification (PI) of traditional Korean medicine (TKM) was analyzed in a large CI patient population. Neuropeptide Y (NPY), first identified in mammalian brains in the 1980s, is a neuropeptide consisting of 36 amino acids  that exhThe NPY gene, located at chromosome 7p15.1, has twenty-five polymorphisms in its promoter region and seven within its exons (NT_007819.17). The L7P SNP has been associated with type 2 diabetes mellitus, alcoholism, and obesity –22. AnotTraditional Korean medicine (TKM), which is similar to traditional Chinese medicine (TCM), categorizes stroke into internal disease symptoms. Pattern identification (PI) is a diagnostic system that entails a comprehensive analysis of symptoms and signs, with implications for determining the cause, nature, and location of the illness; the patient's physical condition; the patient's treatment , 28. Go In this study, we analyzed the distribution of NPY polymorphisms in dampness-phlegm pattern and non-dampness-phlegm pattern in elderly Korean subjects.Patients with cerebral infarction (CI) were admitted into twelve Korean oriental medical hospitals participating in this study: Kyung Hee Oriental Medical Center (Seoul), Kyung Hee East-West Neo Medical Center (Seoul), Dong Guk International Hospital (Kyunggi-do), Kyung Won Oriental Medical Hospitals (Seoul and Incheon), Dong Seo Oriental Medical Hospital (Seoul), Dae Jeon Oriental Medical Hospital (Daejeon), Dong Sin Oriental Medical Hospital (Gwangju and Jeollanam-do), Won Kwang Oriental Medical Hospital (Jeollabuk-do), Woo Suk Oriental Medical Hospital (Jeollabuk-do), and Sang Ji Oriental Medical Hospital (Gangwon-do). CI was confirmed by magnetic resonance imaging (MRI) or magnetic resonance angiography (MRA). After obtaining informed consent from all subjects, clinical data were collected, and syndromes were differentiated classified using “stroke PI case report form.” PI diagnosis of each patient was determined by two expert TKM doctors, and subjects receiving differing opinions from two doctors were excluded . PatientN = 198) or non-dampness-phlegm pattern (N = 401) participated in this study. The general characteristics of normal subjects and CI patients are shown in Supplemental Table 1 . This study was approved by the Institutional Review Boards of the Korean institute of Oriental Medicine and by each of the Oriental Medical Hospitals.Normal subjects were recruited from Dae Jeon Oriental Medical Hospital and Won Kwang Oriental Medical Hospital, and stroke status was confirmed by MRI. Subjects with a history of stroke, TIA, diabetes, hyperlipidemia and heart disease were excluded. Four hundred ninety-eight normal subjects and five hundred ninety-nine CI patients classified as having dampness-phlegm pattern . The promoter region (2 kb) and all exons of the NPY gene were sequenced in 24 Korean genomic DNA samples using an ABI PRISM 3700 DNA analyzer . Primer sets used in the amplification and sequencing analyses were designed on the basis of the reference genome sequence for NPY (NC_000007). Information concerning the primers for the amplification and sequencing of the NPY gene is shown in Supplemental Table 2.Genotyping of SNPs in all subjects was conducted using the SNaPshot multiplex system  according to the manufacturer's protocol. Primer and NPY SNP genotyping probe sequences are shown in Supplemental Table 3. D′| and r2, were evaluated to measure LD between all pairs of loci . The ratio of subjects with T allele in the dampness-phlegm pattern group (45.96%) is also smaller than in the normal (53.25%) and non-dampness-phlegm pattern groups (56.0%) . In contrast, subjects with T allele of C5325T at exon 3 exhibited significantly more dampness-phlegm pattern than normal and non-dampness-phlegm pattern in the dominant model.P = 0.0111 and P = 0.0186, resp.). Conversely, triglycerides were slightly increased in the dominant model. PI is the basic system for diagnosis of patients in TKM, and it entails a systematic analysis of the patient's physical condition with implications for determination of the cause, nature, location, and treatment of the illness. The PI can lead TKM doctors to provide their patients with individualized treatment, thereby increasing the effectiveness of TKM and minimizing its adverse effects. In Korea, several questionnaires for the standardization of PI have been developed, the recent establishment of five standard PI subtypes for stroke: fire heat pattern, dampness-phlegm pattern, blood stasis pattern, Yin deficiency pattern and Qi deficiency pattern , 36. AmoIn the current study, we examined the association of the dampness-phlegm pattern of stroke with five SNPs of the NPY gene among Korean CI patients and found that the C-399T SNP was negatively associated with dampness-phlegm pattern (OR = 0.663) . NPY, which is widely expressed in both the central and peripheral nervous systems, has an important role in the hypothalamic regulation of energy balance by stimulating food intake and favoring energy storage through increased lipoprotein lipase activity in white adipose tissue . Many groups have studied the association of NPY polymorphisms with obesity and/or serum lipid levels. Karvonen et al.  reportedPlasma NPY level is positively correlated with total cholesterol and LDL-cholesterol levels , and ourIn this study, for the first time, the association of NPY polymorphisms with PI of TKM was analyzed in a large CI patient population. Among the five SNPs, the T allele of C-399T has a negative association with dampness-phlegm pattern by decreased levels of serum cholesterol, which were significantly higher in dampness-phlegm pattern patients compared with non-dampness-phlegm pattern patients. It is clear that the findings of this study should be interpreted within the context of its limitations. Our findings are not appropriate for extrapolation to the general population. The observed associations, therefore, will require further confirmation in other subject groups.Supplementary Table 1: This summary is the general characteristics of normal subjects and CI patients. The results are shown that waist circumference and waist hip ratio were significantly higher in patients than normal subjects. In serum, fasting blood sugar also increased in patients.Supplementary Table 2: This information is concerning the primers for the amplification and sequencing of the NPY gene.Supplementary Table 3: Primer and NPY SNP genotyping probe sequences.Click here for additional data file.