Clinical vignettes have been used widely to compare quality of clinical care and to assess variation in practice, but the effect of different response formats has not been extensively evaluated. Our objective was to compare three clinical vignette-based survey response formats – open-ended questionnaire (A), closed-ended (multiple-choice) questionnaire with deceptive response items mixed with correct items (B), and closed-ended questionnaire with only correct items (C) – in rheumatologists' pre-treatment assessment for tumor-necrosis-factor (TNF) blocker therapy.Study design: Prospective randomized study. Setting: Rheumatologists attending the 2004 French Society of Rheumatology meeting. Physicians were given a vignette describing the history of a fictitious woman with active rheumatoid arthritis, who was a candidate for therapy with TNF blocking agents, and then were randomized to receive questionnaire A, B, or C, each containing the same four questions but with different response formats, that asked about their pretreatment assessment. Measurements: Long (recommended items) and short (mandatory items) checklists were developed for pretreatment assessment for TNF-blocker therapy, and scores were expressed on the basis of responses to questionnaires A, B, and C as the percentage of respondents correctly choosing explicit items on these checklists. Statistical analysis: Comparison of the selected items using pairwise Chi-square tests with Bonferonni correction for variables with statistically significant differences.Data for all surveys distributed  were complete and available for analysis. The percentage of questionnaire A, B, and C respondents for whom data was correctly complete for the short checklist was 50.4%, 84.0% and 95.0%, respectively, and was 0%, 5.0% and 5.9%, respectively, for the long version. As an example, 65.8%, 85.7% and 95.8% of the respondents of A, B, and C questionnaires, respectively, correctly identified the need for tuberculin skin test (p < 0.0001).In evaluating clinical practice with use of a clinical vignette, a multiple-choice format rather than an open-ended format overestimates physician performance. The insertion of deceptive response items mixed with correct items in closed-ended (multiple-choice) questionnaire failed to avoid this overestimation. Improvement of quality of clinical practice needs quality measurements. These measurements must be accurate, valid and feasible. The advantages and disadvantages of different methods of measuring the process of care, including both the competence of the clinician and what the clinician actually does, have been well described. Methods include chart extraction, standardized patients and clinical vignettes. Substantial inaccuracies in administrative data are common, which leads to expensive data extraction and difficulty in validating data -3. CompaVignette-based surveys for physicians feature open-ended questions rather than multiple-choice questions or checklists. In this way, physicians can give a personal response to each question, which ensures that the survey captures the full range of practice variation ,12. OpenMoreover, different formats yield different answers: in one study, a closed-ended questionnaire produced results reflecting higher willingness to pay for a health care intervention, with different justifications for those evaluations than did those from an open-ended one . A publiFrom these data, we wanted to evaluate how clinical vignette-based surveys influence physician responses. Assuming that closed-ended (multiple-choice) questions for vignettes produce different responses than open-ended, leading to an overestimation of professional performance, we aimed to determine whether the influence of deceptive response items included in the closed-ended questionnaires result in a better assessment of professional performance.We conducted a prospective randomized study aimed at comparing three response modalities for a vignette-based survey: open-ended questionnaire, closed-ended questionnaire (with only correct response items) and closed-ended questionnaire with deceptive response items mixed with correct items.The survey was composed of two parts. The first part was short, identical in each questionnaire, and collected demographic characteristics and specialties of physicians. The second part was the clinical vignette.The vignette reported the history of a fictitious 50-year-old woman with active rheumatoid arthritis, a candidate for therapy with tumor necrosis factor (TNF) blocking agents. Physicians were asked to answer four questions about their pre-treatment assessment, considering that TNF-blocking treatment was planned: 1) what specific data are you searching for in this patient's history? 2) What clinical data are you personally searching for during the physical examination? 3) Which biological, radiographic or other tests do you request? 4) What other preventive measures do you take? Physicians were given these questions in one of three questionnaire formats: open-ended questionnaire (questionnaire A) [see Additional file Responses to questionnaire A were coded for comparison to those of the other two questionnaires. For each item, the response was classified as "item correctly selected"; "item incorrectly selected"; "item correctly not selected"; "item incorrectly not selected." We classified each item according to three sources: an evidence-based literature search of clinical practice concerning TNF-blocking drug management, international and national guidelines, and a French clinical tool guide on use of TNF-blocking agents elaborated by an expert panel of academic and community physicians . From thClub Rhumatismes et Inflammation (CRI), the division of the French Society of Rheumatology dedicated to musculosquelettal inflammatory diseases.During the 2004 French Society of Rheumatology meeting, rheumatologists were asked to participate in a survey concerning pretreatment assessment in cases of therapy with TNF blockers, which aimed at detecting contraindications to treatment. The survey was conducted on behalf of the Until the targeted sample size was achieved, the survey distribution was randomized, with each physician receiving only one questionnaire format . Rheumatologists were blinded to the hypothesis. Particularly, they were unaware of the existence of different response modalities, of deceptive items in questionnaire B, and that all items of questionnaire C were correct. Time to complete the survey was limited to fifteen minutes.Four interviewers were responsible for encouraging participation in the survey, explaining the official nature of the survey, checking that all the questionnaires were correctly completed in the time allowed, and checking the randomization was achieved. Participation was voluntary, and physicians' responses were kept anonymous.A chi-square test was used to compare the proportion of items selected or not in terms of the questionnaire format of each of the three questionnaires. A p < 0.05 was considered statistically significant. Pairwise chi-square tests with Bonferonni correction (corrected significant probability of 0.017) were used to compare variables with statistically significant differences. Statistical analysis involved use of SAS Release 8.2 and Splus 6.2.Sample size calculation: Three sets of 100 questionnaires – one set for each of the three questionnaires – were planned for the analysis. In fact, when considering pairwise comparisons for the response item "tuberculin skin test," with a sample size of 100 in two groups, a two-group chi-square test with a 0.017 two-sided significance level would have 80% power to detect a difference between a 65% proportion in one group and a 85% proportion in the other group. Because we expected 15% incomplete or non-analyzable questionnaires, we distributed 350 questionnaires.Of 350 questionnaires dispensed , all were completed, and all responses were eligible for further analysis. Table Although we expected 15% incomplete or non-analyzable questionnaires, we did not observe any missing data for open-ended or closed-ended questionnaires.Significant differences depending on questionnaire format were found in reporting pre-treatment assessment. Compared with the two closed-ended questionnaires, the open-ended questionnaire gave lower reporting of items correctly selected and correctly not selected Table .In terms of global results, none of the questionnaire A respondents proposed response items of the long checklist, although 5.0% and 5.9% of questionnaire B and C respondents, respectively, correctly selected all items Table .For the A, B and C questionnaires, 50.4%, 84.0% and 95.0% respondents, respectively, correctly selected all mandatory response items of the short checklist. When focusing on response items within the short checklist, questionnaires B and C did not produce differences in responses to item "order chest X-rays" also difference was observed with open- and close-ended questionnaires (p < 0.0001)  or determining blood sugar level (40.3%). None of the questionnaire A respondents spontaneously proposed these items. Questionnaire B respondents showed a tendency for a lower percentage of correctly selected items than questionnaire C respondents. The open-ended format allowed for collecting qualitative data on items that we did not propose in the close-ended questionnaires, such as "give information to the patient on potential adverse effects" or "give information to the patient on monitoring these drugs."We compared three clinical vignette-based survey response formats: an open-ended questionnaire, a closed-ended (multiple-choice) questionnaire with cued correct items and a closed-ended questionnaire with deceptive items mixed with correct items. As expected, use of a closed-ended questionnaire with cued items overestimated physicians' performance as compared with an open-ended questionnaire, given that the latter is considered as the gold standard in assessing practice ,12,24. AOur study focuses on the difficulty in evaluating the quality of physician performance for specific domains with open-ended questionnaires. Physicians may be more brief with open-ended formats and responses may be less accurate. Of the 114 questionnaire A respondents, 74.4% responded with "tuberculosis" to the "other tests" question but gave no specific description of a test or what clinical examination they would do to evaluate this tuberculosis risk. In the closed-ended format, we assumed that including deceptive items would influence respondents' answers and lower the overestimation inherent in the closed-format survey. To our knowledge, this is the first time that deceptive items have been mixed with cued items in a close-ended questionnaire. Questionnaire B respondents indeed selected fewer correct items than did questionnaire C respondents. However, these results were very different from those obtained with the open-ended questionnaire (A), which are probably closer to reality.The influence of framing questionnaire items remains crucial for clinical practice evaluation. This bias in response acquiescence has been reported from study of two versions of a training satisfaction questionnaire randomly distributed to medical residents; in one, half the items were stated positively and half negatively, and in the other, all items were stated positively. Results showed a significant effect of positive versus negative framing .In conclusion, even if closed-ended questionnaires may provide more accurate data in clinical practice evaluation, general open-question format has value in such evaluation. Strategies for generating quantitative and qualitative data from open-ended questionnaires, associated or not with closed-ended questionnaires, facilitating survey analysis, are very likely interesting to develop to improve physician performance evaluation .This study was support by an educational grant from Wyeth Pharmaceuticals. The pharmaceutical company has paid for the 3-day employment of the 4 Ipsos interviewers. Ipsos is an independent company focused on survey-based research. The authors did not receive money from the pharmaceutical company.TP participated in the design of the study, carried out the survey, participated in the elaboration of the clinical vignettes and drafted the manuscript. CS performed the statistical analysis. XM and FL participated in the elaboration of the clinical vignettes and especially the formulation of the correct and deceptive items. PD participated in the design of the study and its coordination. PR conceived of the study, and participated in its design and coordination. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1472-6963/9/128/prepubQuestionnaire A. Vignette reporting history of a fictitious 50-year-old woman with active rheumatoid arthritis, candidate for therapy with tumor necrosis factor (TNF) blocking agents, with an open-ended questionnaire about pre-treatment assessment.Click here for fileQuestionnaire B. Vignette reporting history of a fictitious 50-year-old woman with active rheumatoid arthritis, candidate for therapy with tumor necrosis factor (TNF) blocking agents, with a closed-ended (multiple-choice) questionnaire about pre-treatment assessment containing deceptive response items mixed with correct items.Click here for fileQuestionnaire C. Vignette reporting history of a fictitious 50-year-old woman with active rheumatoid arthritis, candidate for therapy with tumor necrosis factor (TNF) blocking agents, with a closed-ended (multiple-choice) questionnaire about pre-treatment assessment containing only correct items.Click here for file


Depression and diabetes are two highly prevalent and co-occurring health problems. Web-based, diabetes-specific cognitive behavioral therapy (CBT) depression treatment is effective in diabetes patients, and has the potential to be cost effective and to have large reach. A remaining question is whether the effectiveness differs between patients with seriously impaired mental health and patients with less severe mental health problems.To test whether the effectiveness of an eight-lesson Web-based, diabetes-specific CBT for depression, with minimal therapist support, differs in patients with or without diagnosed major depressive disorder (MDD), diagnosed anxiety disorder, or elevated diabetes-specific emotional distress (DM-distress).We used data of 255 patients with diabetes with elevated depression scores, who were recruited via an open access website for participation in a randomized controlled trial, conducted in 2008–2009, comparing a diabetes-specific, Web-based, therapist-supported CBT with a 12-week waiting-list control group. We performed secondary analyses on these data to study whether MDD or anxiety disorder (measured using a telephone-administered diagnostic interview) and elevated DM-distress (online self-reported) are effect modifiers in the treatment of depressive symptoms (online self-reported) with Web-based diabetes-specific CBT.MDD, anxiety disorder, and elevated DM-distress were not significant effect modifiers in the treatment of self-assessed depressive symptoms with Web-based diabetes-specific CBT.This Web-based diabetes-specific CBT depression treatment is suitable for use in patients with severe mental health problems and those with a less severe clinical profile.International Standard Randomized Controlled Trial Number (ISRCTN): 24874457; http://www.controlled-trials.com/ISRCTN24874457 (Archived by WebCite at http://www.webcitation.org/63hwdviYr) With an estimated world prevalence of 285 million people, diabetes mellitus has reached epidemic levels globally . Affectid = –0.58, 95% CI, –0.77 to –0.39), compared with pharmacologic treatment  or collaborative care  . Ex0 see  [1 Patients could individually sign up for participation in the study through an open access study website. Written informed consent was obtained by mail and included information on the study, permission for anonymous data use, and permission to contact the patient’s general practitioner and treating diabetes physician for obtaining data on diabetes. After having signed the informed consent, patients were invited to fill out the baseline assessment through a personal online questionnaire, and they received a telephone-administered diagnostic interview.Individual randomization by computer was used to assign participants to either the experimental or control condition, at an individual level, using a 1:1 allocation ratio. Due to the nature of the study (waiting-list controlled) it was not possible to blind patients to treatment allocation. The sample size was calculated based on the expected difference in the primary outcome variable . Based on a statistical power of 80%, with an alpha of .05, we required 100 participants in each group to be able to detect differences with an effect size of 0.35. The design of the RCT on the effectiveness of the Web-based diabetes-specific depression intervention has been described in more detail elsewhere . Data ofParticipants assigned to the intervention group individually attended the online course, based on the principles of CBT. The intervention DbG.nl (www.diabetergestemd.nl) was developed by the VU University Medical Center in collaboration with the Trimbos Institute. DbG.nl was based on the effective Web-based CBT depression intervention Color Your Life , the IntPatients attended nonanonymously, so having multiple identities was not possible. Coaches only knew patients’ names, and all personal data were omitted after the patients’ medical data were obtained from their treating physician (to which the patients consented) and the participant completed or withdrew from the course. Coaches were blinded to treatment allocation of participants.P ≥ .05) [Baseline characteristics of our study sample were self-reported as part of the online assessment. Previous analyses confirmed successful randomization: intervention and control groups did not statistically significantly differ regarding demographic or clinical characteristics at baseline  . Of thosDepressive symptoms were self-assessed online with the Dutch version of the CES-D. The CES-D is a validated self-report screening instrument that measures the frequency with which participants have experienced specific depressive symptoms within the preceding week. The questionnaire contains 20 items assessed on a 4-point Likert scale. The total score can range from 0 to 60, where higher scores indicate more depressive symptoms. In Dutch samples, a cut-off point of 16 or higher is generally accepted to indicate clinical depression .Based on our research questions, we selected the following three potential effect modifiers: MDD (yes/no), anxiety disorder (yes/no), and high versus low level of DM-distress.Diagnostic and Statistical Manual of Mental Disorders, 4th edition. The WHO CIDI-auto is a computerized version of the WHO CIDI, a qualified substitution of the face-to-face interview [To diagnose MDD and anxiety disorder, the Dutch, we administered by telephone the computerized version of the World Health Organization Composite International Diagnostic Interview (WHO CIDI-auto), a fully structured psychiatric diagnostic interview that assesses diagnostic criteria of mental disorders according to the nterview . Since q DM-distress was measured using the Dutch-validated Problem Areas in Diabetes scale (PAID), which was self-assessed online . We compTo test effect modification, the course of depressive symptoms at baseline, posttreatment, and 1-month follow-up between the intervention and control groups was compared for each potential effect modifier. We performed generalized estimating equation (GEE) analyses using 3-way interaction terms  to examine whether having an MDD (yes/no) diagnosis, anxiety disorder (yes/no) diagnosis, and elevated DM-distress (PAID ≥40/<40) were significant effect modifiers in the treatment effect. All analyses were corrected for baseline depression scores to gain insight into the relative degree of change, and for time between baseline measurement and postmeasurement. Also, all potential effect modifiers were examined on baseline differences for all of the measured sociodemographic and clinical variables, and all analyses were corrected for these differences.P < .001), attrition was not completely at random. We therefore imputed missing data using the state-of-the-art multiple imputation technique with Stata 10.0 software . Multiple imputation minimally alters variance of data and thus provides best estimates of true data [ In the RCT data, overall study attrition was 32% at postassessment and 35% at 1-month follow-up. Since study attrition was higher in noncompleters of the course at the 1-month follow-up than in completers of the course  and a lower percentage used antidepressant medication . MDD patients reported higher baseline symptoms of depression, with a mean (SD) CES-D of 30 (7) versus 26 (7), P < .001, and higher levels of DM-distress, mean (SD) PAID 42 (20) versus 37 (17), P = .02. About a third of the total study sample  had an anxiety disorder diagnosed. Patients with an anxiety disorder diagnosis had higher baseline depressive symptoms, with a mean (SD) CES-D of 31 (8) versus 27 (7), P < .001, and DM-distress, mean (SD) PAID 48 (18) versus 36 (18), P < .001, and did not differ significantly on any sociodemographic variable.As shown in P < .001; were likelier to be female ; had higher baseline depression scores of mean (SD) CES-D 31 (7) vs 26 (6), P < .001; and were more likely to have an anxiety disorder  than those without elevated DM-distress.Half of our study sample  had elevated DM-distress. The patients with elevated DM-distress were younger, with a mean (SD) age of 47 (3) versus 53 (12), P = .49) was not a significant effect modifier in the treatment effect on depressive symptoms   . This isP = .92), was not a significant effect modifier in the treatment effect on depressive symptoms  for patients with or without MDD, (2) for patients with or without an anxiety disorder, and (3) for patients with or without elevated DM-distress? Secondary analyses from an RCT comparing Web-based diabetes-specific depression treatment versus a waiting-list control in patients with type 1 and type 2 diabetes with comorbid depression show that a diagnosis of MDD or anxiety disorder, or reporting high DM-distress does not significantly modify the effect of Web-based diabetes-specific CBT depression treatment. These findings thus suggest that there is no reason to exclude patients with more severe depression or anxiety from participating in what is often considered a first line of treatment for patients with mild depression, following a stepped-care approach . When reInterestingly, roughly half of the participating diabetes patients with comorbid depression reported high disease-specific distress, which was found not to be an effect modifier. This suggests that DbG.nl is suitable for patients with and without high diabetes-related distress. In a future study, comparing the diabetes-specific intervention with a generic Web-based depression intervention on effectiveness and attractiveness from the patient’s perspective would be of great importance.In interpreting the results of our study, we should acknowledge several strengths and limitations of the study. The most important strengths are the design of the study, being an RCT, and the innovative character of the study. This is the first study that tested the effectiveness of Web-based, diabetes-specific depression treatment in different subgroups of patients. Moreover, we administered a diagnostic interview and used validated instruments for measuring depressive symptoms and DM-distress.An important limitation that needs mentioning is that examining the effect modification was not the primary aim of our RCT. Therefore, this study was not powered to detect significant differences in effect between patients with and without MDD, anxiety disorder, and elevated DM-distress. Yet, due to the relatively large sample size of the study, we had substantial subgroups of patients to compare . We were unable to test whether specifically MDD was more difficult to treat when patients had comorbid anxiety, but instead examined the effect modification in the full sample of subclinically depressed and MDD patients. Since in our study sample a substantial group had both MDD and anxiety disorder, this stresses the importance of testing the effect modification of anxiety disorder in a sample of diabetes patients with MDD.Regarding external validity of our results, we should take into account that our sample consisted largely of white, relatively well-controlled diabetes patients, including only a few less-educated people  and patients older than 65 years . Considering the increased prevalence of diabetes in ethnic populations, older people, and those with lower social economic status, further research is warranted to test the effectiveness of our program in more diverse populations. We also observed that only a few of the participants with MDD had recurrent depression, even though MDD has been shown to be more recurrent in diabetes patients . PerhapsFindings from this study provide the first evidence to suggest that Web-based diabetes-specific depression treatment is effective in patients with mild to more severe depression, with or without comorbid anxiety disorder. Information on differential effects of Web-based therapy is vital to make evidence-based recommendations regarding indication, referral, and reimbursement of the intervention.The Web-based, diabetes-specific depression treatment seems to have high usability because it can serve as an intervention for both subclinical and clinical depression in diabetes patients. Given its Web-based administration, this diabetes-specific depression treatment has the potential to reach large patient populations and to be cost effective.


Quorum sensing is a cell density-dependent signaling phenomenon used by bacteria for coordination of population-wide phenotypes, such as expression of virulence genes, antibiotic resistance and biofilm formation. Lately, disruption of bacterial communication has emerged as an anti-virulence strategy with enormous therapeutic potential given the increasing incidences of drug resistance in pathogenic bacteria. The quorum quenching therapeutic approach promises a lower risk of resistance development, since interference with virulence generally does not affect the growth and fitness of the bacteria and, hence, does not exert an associated selection pressure for drug-resistant strains. With better understanding of bacterial communication networks and mechanisms, many quorum quenching methods have been developed against various clinically significant bacterial pathogens. In particular, Gram-negative bacteria are an important group of pathogens, because, collectively, they are responsible for the majority of hospital-acquired infections. Here, we discuss the current understanding of existing quorum sensing mechanisms and present important inhibitory strategies that have been developed against this group of pathogenic bacteria. Vibrio fischeri, almost four decades ago ), 3-hydroxytridecan-4-one (cholera autoinducer-1 [CAI-1]), cis-11-methyl-2-dodecenoic acid  and autoinducer-3 (AI-3). The PQS pathway exists in P. aeruginosa and the operon, pqsABCDE, controls the initial production of the PQS precursor, 2-heptyl-4(1H)-hydroxyquinoline (HHQ), followed by a subsequent oxidative hydroxylation reaction by PqsH at the 3′ carbon position to convert HHQ to PQS amino-benzenesulfonamide, termed LED209, was able to attenuate expression of QseC-associated genes to reduce virulence in EHEC strains [et al. also described the use of isolimonic acid and ichangin as potent inhibitors of Type III secretion systems (TTSS) and biofilm formation in a QseC- and QseA-dependent manner [E. coli quorum sensing. Using Melia dubia seed extracts, Ravichandiran et al. found that the crude content was able to reduce biofilm and swarming motility in uropathogenic E. coli (UPEC) by targeting the SdiA-mediated quorum sensing pathway [et al. were one of the first groups to report the inhibitory effects of brominated furanones on bacterial species [E. coli by means of a comparative gene expression study. The objective of investigation, however, focused on the AI-2-mediated pathway, and it was suggested that furanones can also alter AI-2 signaling post-transcriptionally to downregulate biofilm formation and motility phenotypes [AI-3 related quorum sensing inhibition in  strains . More ret manner . In addi pathway . Notably pathway . Biofilm pathway . In othe species . Later, enotypes .K. pneumoniae, A. baumannii and Enterobacter spp. collectively accounted for more than 13 percent of hospital-acquired infections in the two-year period of 2009 to 2010 [vis-à-vis quorum inhibitions). Studies related to K. pneumoniae, A. baumannii and Enterobacter spp. have been limited, and the methods developed are unlikely to be useful for complete attenuation of quorum sensing in these bacteria. For example, Derakhshan et al. were the only group to show that essential oil from cumin seeds reduced biofilm formation in K. pneumoniae. From scanning electron microscopy images, it was evident that the capsular layer of K. pneumoniae was affected, possibly accounting for the observed two-fold decrease in biofilm formation [According to a report by the Centers for Disease Control and Prevention,  to 2010 . Moreove to 2010 ,138. Givormation . HoweverEnterobacter spp., Reis Ponce et al. have found that AiiA lactonase lowered cell numbers during early biofilm formation by Enterobacter cloacae [et al. in an anti-biofouling study, which showed that Enterobacter microbial populations were reduced by half in treated membrane bioreactors (MBRs) [A. baumannii, disruption of quorum sensing has been limited to the use of non-native AHLs and antagonists containing aromatic acyl groups [d-AHLs were also strong antagonists of the AbaR receptor, with increased potency against L-AHLs analogues, although d-AHLs are predicted to be less effective against LuxR-type receptors. In any case, the antagonists identified were successful in inhibiting AHL-mediated quorum sensing and its subsequent surface motility and biofilm formation. Most recently, Saroj et al. also found that streptomycin at sub-inhibitory concentrations is able to inhibit quorum sensing in A. baumannii [abaI and A1S_0112, resulting in the corresponding decrease in 3-oxo-C12-HSL production. It was proposed that streptomycin could act as an antagonist of AbaR and prevent positive feedback activation of abaI by functional 3-oxo-C12-HSL-AbaR complexes. In addition to this study, several others have also showed that sub-inhibitory concentrations of antibiotics can positively or negatively modulate quorum sensing, in contrast to bactericidal effects observed at high concentrations: tobramycin was found to induce biofilm formation in E. coli and P. aeruginosa when applied at concentrations three-fold below the minimal inhibitory concentration (MIC) [In the case of  cloacae . The effs (MBRs) . Proteoml groups . Interesaumannii . Streptoon (MIC) . It has on (MIC) . Such a K. pneumoniae, A. baumannii and Enterobacter spp. are still rather limited. The current lack of quorum inhibitors for clinically significant Gram-negative pathogens is a mounting concern, especially with the continued evolution of resistance mechanisms and the prevalence of MDR strains. When “last resort” drugs, such as colistin and tigecycline lose their efficacies, there will be even less treatment options available against MDR species. Fortunately, at least for the moment, we may not have to look beyond existing strategies, as many Gram-negative pathogens share similar quorum sensing mechanisms. Generic pathways and methods can be exploited and used against affiliated species. As mentioned, MTAN inhibitors were able to disrupt DPD formation and prevent AI-2 synthesis in E. coli strains. Since the AI-2 biosynthetic pathway is conserved in many bacterial species, inhibition of AI-2 production can target bacteria with the existing quorum sensing system [et al. using FabI mutants, and the group have further shown that triclosan at low concentrations successfully inhibited FabI by almost 50 percent [In spite of the above-mentioned examples, studies related to quorum inhibition of g system . In addig system . Currentg system . Alterna percent . It is pAnabaena sp. is promiscuous and is able to degrade AHLs ranging from four to 14 carbons in acyl chain length. In addition, the enzyme does not discriminate against any particular substitution group on the acyl chain, suggesting a probable involvement in broad range signal interference within a complex microbial community [Rhodococcus erythropolis is a distinct example, where AHLs with acyl chain lengths ranging from six to 14 carbons can be inactivated [et al. described an engineered GKL lactonase from Geobacillus kaustophilus with enhanced catalytic activity against AHLs ranging from six to 12 carbons in acyl chain length [kcat/KM) against longer chained AHLs and a newly acquired C4-HSL activity (the wild-type enzyme had no detectable lactonase activity against C4-HSL). The improved lactonase was identified through directed evolution methods, illustrating the utility of this approach for engineering novel substrate specificities into existing quorum quenching enzyme scaffolds. The authors also demonstrated the translational potential of the study by using the engineered quorum-quenching lactonase to disrupt biofilm formation in A. baumannii  were able to profiteer from inhibition-sensitive subtypes when the quorum regulated product was secreted into the extracellular milieu (“public goods”). More importantly, mutual sharing in this case does not necessarily lead to a selective advantage for “cooperators”, and the enrichment of resistant subtypes can be mitigated. Nevertheless, quorum-quenching efficiency will be compromised when resistant subtypes are present in the treatment population. On the other hand, if the quorum regulated product is intracellular (“private goods”), inhibition of quorum sensing could favorably select for resistant subtypes, as the “products” generally cannot be shared [An anti-virulence approach represents an anticipated solution to PDR bacterial infections, yet such optimism has to be periodically reviewed and tempered with caution. Recently, Defoirdt re genes . In retrsettings . Certainsettings . Similarsettings . The emeeighbors . Taking e shared . EssentiA. baumannii, K. pneumoniae and the Enterobacter species. Along with the studies on quorum inhibition, there is also concern about bacterial resistance against anti-virulence methods. In fact, there is increasing evidence of quorum quenching treatments leading to a rise in resistant bacterial phenotypes. Further studies are necessary to determine the molecular mechanisms of mutations that confer the resistant bacterial phenotypes and if the selection of such mutations is by chance and would confer advantages in fitness. Nevertheless, future studies in the therapeutic development of anti-virulence strategies should proceed with care and caution to avoid the undesired fate currently associated with antibiotic development.Research efforts in the past few decades have contributed significantly to the understanding of the mechanisms of bacterial communication. Due to the rapid occurrence of antibiotic resistance, recent focus was placed on inhibitory studies to address the therapeutic potential for the healthcare industry. Disruption of quorum sensing is widely regarded as an attractive anti-virulence approach, as this strategy is non-bactericidal and, therefore, would not generate the unwanted selective pressure for resistance. A variety of quorum disruption strategies (with varied success) against pathogenic bacteria have been described, including the inhibition of quorum molecule synthesis, accumulation and detection. Gram-negative bacteria represent a significant group of human pathogens, as they are responsible for a majority of hospital-acquired infections. Despite successful efforts against some of the more common pathogens, there remain a number of less-studied (and understood) bacterial pathogens waiting for effective therapeutic intervention: there have been limited reports on quorum sensing disruption in pathogens, such as


Recent evidence indicates that osteoarthritis (OA) may be a systemic disease since mesenchymal stem cells (MSCs) from OA patients express type X collagen, a marker of late stage chondrocyte hypertrophy . We recently showed that the expression of type X collagen was suppressed when MSCs from OA patients were cultured on nitrogen (N)-rich plasma polymer layers, which we call "PPE:N"  of N.®), were also investigated for comparison.In the present study, we examined the expression of type X collagen in fetal bovine growth plate chondrocytes (containing hypertrophic chondrocytes) cultured on PPE:N. We also studied the effect of PPE:N on the expression of matrix molecules such as type II collagen and aggrecan, as well as on proteases  and molecules implicated in cell division (cyclin B2). Two other culture surfaces, "hydrophilic" polystyrene  and nitrogen-containing cation polystyrene (PrimariaResults showed that type X collagen mRNA levels were suppressed when cultured for 4 days on PPE:N, suggesting that type X collagen is regulated similarly in hypertrophic chondrocytes and in human MSCs from OA patients. However, the levels of type X collagen mRNA almost returned to control value after 20 days in culture on these surfaces. Culture on the various surfaces had no significant effects on type II collagen, aggrecan, MMP-13, and cyclin B2 mRNA levels.Hypertrophy is diminished by culturing growth plate chondrocytes on nitrogen-rich surfaces, a mechanism that is beneficial for MSC chondrogenesis. Furthermore, one major advantage of such "intelligent surfaces" over recombinant growth factors for tissue engineering and cartilage repair is potentially large cost-saving. Endochondral ossification involves the expression of type X collagen, a marker of chondrocyte hypertrophy -3. RecenEndochondral ossification begins during long bone formation in the embryo . After bnitrogen-rich plasma-polymerized ethylene" (PPE:N), is able to inhibit hypertrophy as well as osteogenesis in committed human MSCs from OA patients  values are capable of suppressing type X collagen mRNA in growth plate chondrocytes, with no significant effects on type II collagen, aggrecan, MMP-13 and cyclin B2 mRNA levels. The similarity in type X collagen suppression by PPE:N in hypertrophic growth plate chondrocytes and in human MSCs from OA patients raises the question of whether similar mechanisms are involved. However, contrary to what was observed in MSCs in which PPE:N reduced type X collagen for long time in culture , PPE:N wlsewhere ,29, we alsewhere , and vaclsewhere , both caFinally, although gene expression data may suggest an influence of the nitrogen-rich surfaces on the hypertrophic phenotype, mineralization was not addressed in the present study. It is commonly believed that type X collagen is involved in controlling the later stages of endochondral bone formation -3. In thType X collagen expression was reduced, at least transiently, by nitrogen rich surfaces in both growth plate chondrocytes as well as in MSCs from OA patients, which is beneficial to chondrogenesis. As "intelligent" surfaces, PPE:N coatings therefore represent a potentially advantageous cell-culture substrate with beneficial effects for cartilage and intervertebral disc repair. However, further studies are necessary to better understand the nature of specific functional groups, such as primary amines, on gene expression and cell phenotype: this information will be important in tissue engineering applications that require the use of such "intelligent" surfaces.2H4: ethylene; DMEM: Dulbecco's modified Eagle's medium; FBS: Fetal bovine serum; MMP: matrix metalloproteinase; MSC: Mesenchymal stem cell; N: Nitrogen; OA: Osteoarthritis; PPPE:N: N-doped plasma-polymerized ethylene; PS: Polystyrene; RT-PCR: Reverse transcriptase-Polymerase chain reaction; SCCM: standard cubic centimeters per minute; SLM: standard liters per minute; XPS: X-ray photoelectron spectroscopyBOPP: biaxially oriented polypropylene; CThe authors declare that they have no competing interests.AP participated in the interpretation of the results, drafted the Introduction and the Discussion with FM, and revised the final version of the article. CND carried out experiments with stem cells, participated to RT-PCR experiments, and drafted the section on stem cell isolation and culture. PLGL prepared the surfaces and helped to draft the method section on surface preparation. DS participated to cell isolation and RT-PCR analysis. MRW critically revised the manuscript. JA participated in the design of the study and performed the statistical analysis. FW conceived the study and drafted the Introduction and the Discussion with AP. All authors read and approved the final manuscript.


Objectives: The aims were to analyze whether the levels of self-reported bruxism and anxiety associate among otherwise healthy subjects, and to investigate the independent effects of anxiety and stress experience on the probability of self-reported bruxism. Study Design: As part of a study on irregular shift work, a questionnaire was mailed to all employees of the Finnish Broadcasting Company with irregular shift work (number of subjects: n=750) and to an equal number of randomly selected employees in the same company with regular eight-hour daytime work. Results: The response rates were 82.3% (56.6 % men) and 34.3 % (46.7 % men), respectively. Among the 874 respondents, those aware of more frequent bruxism reported significantly more severe anxiety (p<0.001). Adjusted by age and gender, frequent bruxers were more than two times more likely to report severe stress  and anxiety  than non-or-mild bruxers. Conclusions: Present findings suggest that self-reported bruxism and psychological states such as anxiety or stress may be related in working age subjects. Key words:Bruxism, self-report, anxiety, stress, adult. In psychologically healthy adult populations  the relationship of anxious mood and bruxism has remained inconsistent -10. HoweSleep bruxism has been shown to be part of complex arousal response of the central nervous system, which occurs during changes in sleep depth and is accompanied by, among others, body movements, increased heart rate, respiratory changes, and muscle activities -14. SincRecent studies performed on multiprofessional media personnel, who could be considered as under sustained pressure at work due to irregular shifts, intense on-going technological changes, deadlines, and demands involved in direct broadcasting, suggest that subjectively conceptualized awareness of bruxism  may reveal, among others, perceived stress  and dissAs part of comprehensive study on the effects of irregular shift work on health and work performance, a questionnaire was mailed in 2003 to all employees of the Finnish Broadcasting Company with irregular shift work  and to an equal number of randomly selected employees in the same company with regular eight-hour daytime work (42.4 % men) -9. The wBased on the survey data described above, the following variables were included in the present study (n=874):a) Demographic data: gender, age, work type.b) Bruxism: self-assessed awareness and frequency of tooth clenching or grinding with a five-point scale . Subjects reporting bruxism ‘often’ or ‘continually’ were categorized as ‘frequent bruxers’, those reporting bruxism ‘sometimes’ as ‘moderate bruxers’, and the rest as ‘non-or-mild bruxers’. ‘Bruxism’ is used as general term throughout the manuscript, unless stated otherwise.c) Anxiety: the 10-item subscale of the Symptom Checklist-90 (SCL-90-R) . The fivd) Stress  : level o-Statistical methodsThe data were cross-tabulated and the χ2 test was used to study associations between categorical variables. The Jonckheer-Terpstra test (a non-parametric trend test) was used to assess whether the severity of bruxism and anxiety were correlated. Multinomial logistic regression model was used to analyze the independent effects of the psychological variables on the probability of moderate and frequent bruxism. The reference category was non-or-mild bru-xism. Variables for the multivariate analyses were categorized as follows: age (in years), gender , irregular shift work , severe stress , anxiety  . The mulThe mean anxiety score for the study population was 0.47 (SD 0.42). Subjects aware of more frequent bru-xism tended to report significantly more severe anxiety, and a clear-cut difference was seen in the anxiety scores between severe bruxists and non-or-mild bru-xists p<0.001). Also, those reporting frequent bruxism had an anxiety score clearly above the Finnish norm for community subjects  and valid . In the present study, anxiety was measured using the SCL-90-R, which has been reliability and validity tested among adults in Finland . The meaBy definition, bruxism events may occur while asleep or awake, although it seems that these two entities do not share their correlates . Awake bThe present findings corroborate the few existing studies on the relationship of reported bruxism and anxiety among adult populations -10. WithThe present findings suggest that self-reported bruxism and psychological states such as anxiety or stress may be related in working age subjects.


The diagnosis of prosthetic valve endocarditis is challenging. The gold standard for prosthetic valve endocarditis diagnosis is trans-esophageal echocardiography. However, trans-esophageal echocardiography may result in negative findings or yield images difficult to differentiate from thrombus in patients with prosthetic valve endocarditis. Combined computed tomography and fluorodeoxyglucose positron emission tomography is a potentially promising diagnostic tool for several infectious conditions and it has also been employed in patients with prosthetic valve endocarditis but data are still scant.Pseudomonas aeruginosa, Staphylococcus epidermidis and Staphylococcus lugdunensis, respectively; and 3 late-onset cases in the remaining 3 patients with isolation in the blood of Streptococcus bovis, Candida albicans and P. aeruginosa, respectively. Initial trans-esophageal echocardiography was negative in all the patients, while fluorodeoxyglucose positron emission tomography showed images suspicious for prosthetic valve endocarditis. In 4 out of 6 patients valve replacement was done with histology confirming the prosthetic valve endocarditis diagnosis. After an adequate course of antibiotic therapy fluorodeoxyglucose positron emission tomography showed resolution of prosthetic valve endocarditis in all the patients.We reviewed the charts of 6 patients with prosthetic aortic valves evaluated for suspicion of prosthetic valve endocarditis, at two different hospital, over a 3-year period. We found 3 patients with early-onset PVE cases and blood cultures yielding Our experience confirms the potential role of fluoroseoxyglucose positron emission tomography in the diagnosis and follow-up of prosthetic valve endocarditis. The ageing population with prolonged life expectancy and the improvement of surgical procedures determines that a greater number of patients may live with prosthetic valve and/or implantable cardiac devices ,2. ProstThe gold standard for diagnosis of PVE is trans-oesophageal echocardiography (TEE); however TEE can be non conclusive or falsely negative in the initial phases of the disease and it should be repeated if initially negative . MoreovePositron emission tomography (PET) and computed tomography (CT), are routinely used for the diagnosis and follow up of malignancies, based on the increased glycolytic rate in malignant cells. Similarly, many infective and inflammatory conditions can be imaged with PET due to the increased uptake of  F-FluoroDespite this promising rationale, the current literature on the role of CT/FDG-PET in the diagnosis of PVE is scant and mostly based on case reports. Here we report a case series of PVEs with initial negative echocardiography in whom the PVE diagnosis was achieved using CT/FDG-PET.3 and C-reactive protein 17.13 mg/dL. The patient underwent transthoracic echocardiography (TTE) followed by TEE and signs of infection were excluded. He was treated with clindamycin and meropenem for 3 weeks with resolution of fever.A 42-year-old male patient with a history of previous intravenous drug abuse and osteosynthesis implant on the left femur in 2004, was admitted to our hospital in February 2010 for persistent fever. One month before admission, he underwent major heart surgery with graft replacement of aortic valve, aortic root and ascending aorta . On admission, his physical examination was unremarkable with exception of fever. Chest X-ray was negative, blood tests showed white-blood cells (WBC) count of 10.420 cells/mmPseudomonas aeruginosa strain susceptible to all tested antibiotics. Because of the high clinical suspicion of PVE, a CT/FDG-PET was performed, and revealed a focal uptake, of aortic valve and ascending aorta consistent with infection with maximal standardized uptake value (SUVmax) of 3.5  on the mechanic aortic valve. Combination antifungal therapy with liposomal amphotericin B plus caspofungin was started and the patient underwent emergency mechanical aortic valve replacement. Intra-operatory findings and histological examination were consistent with PVE. The physical exploration and the laboratory findings at 6-month follow-up are unremarkable, both TTE/TEE and CT/FDG-PET tested negative as well.At admission, TEE excluded cardiac involvement and treatment with fluconazole was started again. Despite adequate therapy and clinical response, blood cultures (+14 days) still yielded a fluconazole susceptible A 71-year-old was admitted on September 2012 to a medical ward for persistence of fever despite an empirical antibiotic course. His medical history revealed a composite replacement of the aortic root and valve with Bentall procedure for an ascending aortic aneurysm with aortic insufficiency in October 2010.Streptococcus bovis and a treatment with ceftriaxone was initiated with resolution of fever. One week later TEE revealed good prosthetic valve function without vegetation or other signs of PVE. However, due to the high suspicion of endocarditis a CT/FDG-PET was performed at the end of the second week of treatment showing uptake on aortic valve graft (SUVmax = 3.8) and upper pole of spleen (SUVmax = 7.4). Three weeks later, despite the appropriate antimicrobial treatment, the patient developed clinical signs of cardiac failure, thus a new TEE was performed revealing a small peri-prosthetic mass (7 mm) suggestive for an abscess formation. This feature was confirmed by a new CT/FDG-PET demonstrating higher focal uptake (SUVmax = 4.2). The patient underwent a surgical valve and Bentall prosthesis replacement. Intraoperative findings and histological examination confirmed PVE diagnosis. At 1 year follow-up the patient is symptom-free and in good clinical condition, no further evidence of an infectious process has been found by TTE/TEE and CT/FDG-PET.On admission, there were no signs of vegetation and no abscess formation at TTE. After antibiotics discontinuation, blood cultures yielded A 46-year-old man was admitted on November 2011 to our hospital for remittent fever. He had a medical history of severe aortic stenosis underwent mechanical prosthesis replacement fifteen years before and re-operated in 2010 for valve dysfunction with a Bentall procedure. A month before admission he had been successfully treated as outpatient with a short antibiotic course with levofloxacin for a community-acquired pneumonia.Pseudomonas aeruginosa; TEE was negative and CT of aorta did not show leak, defects or peri-prosthetic collections. The patient was started on a 4 week-regimen with meropenem and ciprofloxacin, with favourable clinical course and discharge home. One month later, he was re-admitted for fever relapse. A P. aeruginosa strain with the same susceptibility pattern of the prior isolate was again isolated from the blood cultures. TEE was unremarkable, but CT/FDG-PET showed high uptake on lateral and anterior prosthetic wall (SUV = 10) and peri-valve tissue (SUV = 6).At admission, blood cultures yielded ceftazidime and piperacillin resistant Surgical treatment was deemed unfeasible for the high patient EUROscore . Antimicrobial treatment with meropenem and ciprofloxacin was maintained for 4 weeks and then switched to suppressive life-long therapy with ciprofloxacin. The patient remained symptom-free and a CT/FDG-PET performed one year later showed a 50% reduction of focal uptake.Staphylococcus epidermidis with negative TEE.A 59-year-old man was admitted to our hospital for an ileocolic artery thrombosis and fever in January 2012. His past medical records revealed an aortic biological prosthestic valve replacement for severe stenosis in October 2011, complicated in the post-operative period by a bloodstream infection due to methicillin-resistant On admission TEE revealed a good valve function and no sign of vegetation. However, due to the persistence of low grade fever a CT/FDG-PET was performed showing a high uptake on the annulus of the aortic prosthetic valve (SUVmax = 10). He was started on daptomycin, oxacillin and rifampin and surgical valve replacement was scheduled. A preoperative TEE showed a 12.7 mm valve vegetation as well as surgical and histological findings confirmed the diagnosis of infective endocarditis. After a total 6 weeks of antibiotic therapy the patient was discharged, at 6-month follow-up the patient is free from disease, as confirmed by a new TTE and CT/FDG-PET.A 80-year-old woman was admitted for fever, hypotension and confusion in March 2012. She had a history of aortic valve replacement with biological prosthesis and double coronary artery by-pass in April 2011.Staphylococcus lugdunensis. The patient was started on oxacillin with resolution of fever. The diagnostic work-up, including TEE and CT-angiogram of the aorta, was negative for PVE; whereas CT/FDG-PET revealed a diffuse uptake on prosthetic valve (SUVmax 4.2). Two weeks after hospital admission a new TEE showed a peri-valve tissue abscess with aortic vegetation. Surgical treatment was considered at high risk, thus the patient continued on antimicrobial treatment without recurrence of fever and improvement of general conditions. After 6 week of treatment a new CT/FDG-PET confirmed a reduction of the focal uptake. The patient was discharged on long-term antibiotic therapy, at 6-month follow-up she is free from symptoms.At admission, blood cultures yielded a We described six patients with aortic prosthetic valve and high clinical suspicion of PVE. In all of them the TEE was firstly negative, and only in two the TEE became further positive. In all cases CT/FDG-PET showed a high uptake on the peri-prosthetic valve level. The diagnosis of PVE was then confirmed by histology in all the 4 patients who underwent surgery. In the remaining 2 patients in whom the surgery was deemed as unfeasible, a reduction of the uptake on the prosthetic valve was documented by follow-up with CT/FDG-PET under long-term antibiotic therapy Table .The major Duke’s criteria include positive blood cultures and evidence of cardiac involvement at TTE/TEE both for native and prosthetic endocarditis. However this indication, targeting TEE as the gold standard for instrumental diagnosis, could be disappointing in PVE. In fact, its performance may be sub-optimal for detecting the classical features of endocarditis such as vegetation because the damage due to biofilm-producing microorganisms may be localized at the level of valve annulus or peri-valve tissue resulting in leakage ,18. In aConversely, CT/FDG-PET owing its ability to demonstrate the metabolic activity of organs and tissues may allow earlier diagnosis, as in our cases. Another advantage of CT/FDG-PET is the possibility to quantify the standardized uptake value (SUV), this can be useful to assess the amount and extension of local infection. Additionally, CT/FDG-PET shows concomitantly the presence of secondary infection foci such as embolisms and/or metastatic infections. This tool is of pivotal value either for establishing the timing of surgery in those patients with brain embolisms, either for deciding the duration of antimicrobial therapy . Indeed,Although literature data is mainly based on case reports or small case series, like ours, the possible role of nuclear medicine tools in the diagnosis of infective endocarditis continues to be hypothesized . Thus, tIn conclusion, CT/FDG-PET is a novel useful tool for early diagnosis of occult infectious processes, including PVE. The most consistent hypothesis is that this method is able to offer some diagnostic elements (such as a metabolic active process) earlier than TEE, allowing earlier diagnosis. However, its actual sensitivity and specificity for native and prosthetic valve endocarditis, as well as for other infections (e.g. cardiac implantable electronic devices), still have to be validated in larger prospective studies.Written informed consents were obtained from all of the patients in this case series for publication of this Case Report and any accompanying images. Copies of the written consents are available for review by the Editor-in-Chief of this journal.PVE: Prosthetic valve endocarditis; TEE: Trans-esophageal echocardiography; CT: Computed tomography; FDG-PET: Fluorodeoxyglucose positron emission tomography; CT/FDG-PET: Combined computed tomography and fluorodeoxyglucose positron emission tomography; SE: Sensitivity; SP: Specificity; SUV: Standardized uptake value; TTE: Trans-thoracic echocardiography.The authors declare that they have no competing interests.MB, FT, RB, CN, PGS, FC, PV, SF, MG LR and GF have made substantial contributions to conception and acquisition of data; MB, MG, FT, PV, PGS, CR, RB and CN have been involved in drafting the manuscript and revising it critically. All authors gave final approval for publication.


A commentary onUnraveling 50-year-old clues linking neurodegeneration and cancer to cycad toxins: are microRNAs common mediators?by Spencer, P., Fry, R. C., and Kisby, G. E. (2012). Front. Gene. 3:192. doi: 10.3389/fgene.2012.00192ALS-PDC is primarily if not exclusively an environmental disease: no gene mutations identified in related neurodegenerative disorders are found in Guam and Kii-Japan cases, and disease rates have steadily declined in the three affected populations. Emigrants from Guam may develop ALS-PDC years or decades later, but disease risk is absent in their offspring who were born and live abroad. Conversely, Filipino and other immigrants who adopt the Chamorro lifestyle on Guam may acquire the disease.As ALS-PDC declined during the twentieth century, the disease changed its clinical face from ALS in the first third of life, to PD in the second, and D in the third, a pattern consistent with a dose-related response to an environmental exposure that waned with modernization. With this hypothesis, those with the highest dose of the putative environmental factor develop fatal ALS  relatively shortly after exposure; those with intermediate doses survive with amyotrophy long enough to develop atypical parkinsonism; those with low doses reach old age and display dementia, while others with the lowest exposure have subclinical neurofibrillary disease reminiscent of early aging. Other features of ALS-PDC variably include loss of olfaction, retinal pigment epitheliopathy, and atypical skin cytology.Cycas spp.) was used to heal skin lesions  and as a tonic (Kii). On Guam, processed cycad seed was a Chamorro staple, and the cycad seed-eating flying fox (Pteropus sp.) that bioaccumulates the cycad-derived neurotoxin β-N-methylamino-L-alanine (L-BMAA) was a delicacy.The most plausible but unproven trigger decades before the disease surfaces in clinical form is exposure to certain plant-derived neurotoxins in food or medicine, or both. The raw seed of the neurotoxic cycad plant  methylazoxymethanol (MAM), a potent genotoxin, carcinogen and developmental neurotoxin that is stored in the plant as an inactive β-glucoside, the concentration of which in cycad flour correlates significantly with incidence rates for ALS and PD in males and females on Guam, unlike the concentration of (b) L-BMAA, a weak excitotoxic amino acid that is taken up by brain tissue and possibly undergoes proteogenesis, resulting in misfolded proteins; daily oral dosing of macaques with L-BMAA for up to 3 months induces a L-dopa-responsive, non-progressive motorsystem disorder with non-excitotoxic cortical and spinal motor neuron pathology. Both L-BMAA and MAM are metabolized to formaldehyde, an established genotoxic agent and human carcinogen.The Western Pacific amyotrophic lateral sclerosis and parkinsonism-dementia complex (ALS-PDC) has been described as a Rosetta Stone that bears the essential clue to understanding the etiopathogenesis of related neurodegenerative diseases. The three clinical forms  have a single pathology , just as the Rosetta Stone is inscribed with three distinct scripts bearing a common message. As recently discussed  DNA damage, promutagenic lesions that induce uncontrolled mitoses (tumorigenesis) in mouse epithelial tissues and widespread degeneration in the developing murine brain. O6-mG lesions are clearly responsible for the MAM-induced neuronal loss because the pathology is greater in mice that lack the DNA-repair enzyme O6-mG methyltransferase (Mgmt−/−) and reduced or absent in mice that overexpress MGMT , this can persist in the brain because some DNA-repair mechanisms are weakly expressed in post-mitotic cells. MAM-induces Mgmt−/− mice, an animal model of the young adult human brain, develop persistent brain O6-mG DNA lesions following a single dose of MAM. In the days following MAM treatment, these DNA lesions modulate key brain cell-signaling pathways that are also perturbed in human neurological disease, notably Alzheimer's disease, Parkinson's disease, and inherited and sporadic forms of ALS. Pathway analysis of MAM-modulated genes that are anchored to DNA damage reveals links with human cancer, genetic disorders, and skin and hair development  trigger ALS-PDC, the results of recent biochemical and systems biology studies, coupled with the absence of known mutations in related neurodegenerative disorders, encourage further efforts to examine the molecular and cellular actions of MAM and L-BMAA. These studies not only highlight the response of the brain to unrepaired DNA damage-induced by a genotoxin  as a potential initiator of a neurodegenerative process, they also provide a foundation for understanding whether such effects can lead to persistent changes at the protein level , including the erroneous incorporation of foreign amino acids, a subject of recent interest. The ability of MAM to perturb synuclein and several other classes of brain proteins  is consistent with this hypothesis (Kisby et al.,


The Global Plan to Stop TB estimates funding required in low- and middle-income countries to achieve TB control targets set by the Stop TB Partnership within the context of the Millennium Development Goals. We estimate the contribution and impact of Global Fund investments under various scenarios of allocations across interventions and regions.Using Global Plan assumptions on expected cases and mortality, we estimate treatment costs and mortality impact for diagnosis and treatment for drug-sensitive and multidrug-resistant TB (MDR-TB), including antiretroviral treatment (ART) during DOTS for HIV-co-infected patients, for four country groups, overall and for the Global Fund investments. In 2015, China and India account for 24% of funding need, Eastern Europe and Central Asia (EECA) for 33%, sub-Saharan Africa (SSA) for 20%, and other low- and middle-income countries for 24%. Scale-up of MDR-TB treatment, especially in EECA, drives an increasing global TB funding need – an essential investment to contain the mortality burden associated with MDR-TB and future disease costs. Funding needs rise fastest in SSA, reflecting increasing coverage need of improved TB/HIV management, which saves most lives per dollar spent in the short term. The Global Fund is expected to finance 8–12% of Global Plan implementation costs annually. Lives saved through Global Fund TB support within the available funding envelope could increase 37% if allocations shifted from current regional demand patterns to a prioritized scale-up of improved TB/HIV treatment and secondly DOTS, both mainly in Africa − with EECA region, which has disproportionately high per-patient costs, funded from alternative resources.These findings, alongside country funding gaps, domestic funding and implementation capacity and equity considerations, should inform strategies and policies for international donors, national governments and disease control programs to implement a more optimal investment approach focusing on highest-impact populations and interventions. The Global Plan to Stop TB for 2011 to 2015 , developed by the Stop TB Partnership with major inputs from the World Health Organization (WHO), sets out the level of tuberculosis (TB) interventions and funding that National TB Control Programs (NTPs) will need to reach Millennium Development Goal (MDG) 6 TB targets and the related targets set by the Stop TB Partnership for 2015 (see next section). The Plan’s cost projections are based on estimates of TB disease and deaths, intervention targets and service implementation costs for low- and middle-income countries (LMIC) Between 2003 and 2011, NTPs that had received funding from the Global Fund had provided treatment to 8.6 million people with sputum smear-positive TB The Global Fund fosters a demand-driven model of co-funding NTPs. Demand is moderated by the technical support provided to countries by international health agencies when developing proposals to request funds, followed by an independent technical expert review of these proposals on soundness and local appropriateness of interventions and programs. By 2010, this grant making model had resulted in an investment pattern among countries in line with their overall share in burden, for each of the three diseases Based on control priorities identified by technical agencies such as the WHO, the Global Fund regularly updates its guidance to countries on effective interventions it will finance. The Global Fund Strategy 2012–2016 which commits to scaling-up TB interventions according to the Global Plan The overall goal of the Global Plan to Stop TB is to achieve the MDG and Stop TB partnership targets set for 2015 Millennium Development Goals (set for 2015):TB in the Goal 6: Combat HIV/AIDS, malaria and other diseasesTarget 6c: Halt and begin to reverse the incidence of malaria and other major diseases;Indicator 6.9: Incidence, prevalence and death rates associated with TB;Indicator 6.10: Proportion of TB cases detected and cured under DOTS.Stop TB Partnership targets (set for 2015 and 2050)By 2015: Reduce prevalence and death rates by 50%, compared with their levels in 1990;By 2050: Eliminate TB as a public health problem, defined as a global incidence of active TB of less than one case per 1 million population per year.Specific Global Plan targets for 2015, according to the major components of the plan, include:DOTS: 6.9 million cases diagnosed, notified and treated according to the DOTS approach, in 2015 alone , with 90% of drug-susceptible cases cured .TB/HIV: Expand the enrolment of HIV-coinfected TB patients on ART, such that by 2015 all HIV-positive TB patients – estimated at almost 1 million people in 2009– are enrolled on ART. This target compares to 140,000 actual ART enrolments per year as (an estimated 37% of need) of mid-2010.MDR-TB: Diagnosis and treatment of 270,000 MDR-TB patients in 2015, i.e. 61% of estimated total MDR-TB cases in 2008, with 100% of confirmed cases treated according to international guidelines and an increase in the treatment success rate of confirmed MDR-TB from the 2009 baseline of 60% to ≥75% by 2015 These targets have been based on a situation analysis of actual progress in service delivery that NTPs made over 2006–2010. Absolute numbers of treatments corresponding to these targets, with a gradual scale-up from 2011 to 2015, are based on WHO country estimates of the current burden of drug-susceptible, MDR-TB and TB/HIV cases, projected forward to 2015 in a log-linear model fitted to the 2005–2009 observed trend The corresponding funding requirements are an overall US$ 47 billion over 2011 to 2015, including almost US$ 37 million for implementation and almost US$ 10 billion for research and development. Specific funding requirements include:DOTS: US$ 22.6 billionMDR-TB: US$ 7.1 billionTB/HIV: US$ 2.8 billion.In 2011, more than 40 countries reported to have used the WHO’s TB planning and budgeting tool We use Global Plan projections of anticipated numbers of TB cases that will be detected in DOTS programs led by NTPs in the period 2011 to 2015, and WHO estimates of TB cases in 2010 as a baseline We used WHO country trend estimates, based on notification and treatment outcome data reported annually by NTPs, to project expected TB cases in the different patient categories of DOTS, MDR-TB and TB/HIV care, and feasible numbers of these detected and treated in each country in the Global Plan To explore different allocation scenarios, we divided countries into four groups with distinct epidemiological and TB burden characteristics, namely:China and India, which together account for about a third of all incident TB cases worldwide Eastern Europe and Central Asia (EECA), where the prevalence of MDR-TB among TB cases is highest;sub-Saharan Africa (SSA), where prevalence and impact of TB/HIV is highest;all other low- and middle-income countries .Funding needs are based on country-specific needs and targets as determined in the Global Plan, which also estimated the per-person cost of DOTS, MDR-TB, and treatment and care for HIV-co-infected TB patients, including ART for the duration of DOTS treatment, in each group of countries Table 1.Lives saved were estimated using case fatality rates with and without treatment for each category of patients. We chose a no-treatment counterfactual for all three treatment categories, to validly compare these interventions for their full potential health benefit. The global average case fatality rates were derived from published studies and systematic reviews identified through a PubMed search, up to December 2011 Against a counterfactual of no treatment, every DOTS treatment of a drug-susceptible HIV-uninfected case is assumed to avert 0.33 deaths Uncertainty ranges in lives saved were estimated to reflect the wide variation among countries and populations in case fatality rates, which is apparent from published research studies, and from treatment outcomes reported by NTPs Projections of TB program expenditures funded by the Global Fund were based on 2010 donor pledges and projected income of US$11.7 billion for the replenishment period 2011 to 2013. Using the regional distribution of Global Fund disbursements from 2007 to 2009 Scenario A), we assumed that these regional allocation patterns are maintained from 2011 to 2015. Base-case projections furthermore assumed that, within each region, Global Fund investments would be allocated to DOTS, MDR-TB treatment and ART in proportion to their respective funding needs according to the Global Plan. Scenario B then considers the effect of re-allocating TB investments among regions and interventions to maximize lives saved by Global Fund financing. For comparison, a Scenario C explores what would happen if the Global Fund’s policy were to first exclusively finance DOTS with concurrent ART for HIV-coinfected TB patients, and next MDR-TB treatment, before contributing to DOTS for HIV-negative TB patients – as under the Global Plan, treatment of HIV-coinfected TB patients and MDR-TB both require a more rapid funding increase than does DOTS From 2007 to 2009, 32% of Global Fund TB disbursements were in sub-Saharan Africa, 16% in India and China, 17% in EECA, and 34% in other LMIC . For theMycobacterium (M.) tuberculosis infection Overall Global Plan targets for LMIC in 2015 China and India , reflecting mainly increasing treatments among HIV-coinfected patients . MDR-TB Among regions, about 800,000 lives  will be saved in each of China and India, sub-Saharan Africa and other low- and middle-income countries. Only about one-tenth as many lives will be saved in EECA, with fewer patients than China & India or sub-Saharan Africa. Nevertheless, this region needs most funding because of its large proportion of MDR-TB treatments, and the high per-patient cost for both drug-susceptible TB and MDR-TB . The larBased on 2010 donor pledges and projected income, and assuming the continuation of recent TB/HIV/malaria funding allocation patterns, Global Fund TB investments will increase from US$387 million in 2010 to $779 million in 2012, and then fall to US$662 million in 2015 . The peaIn 2010, the Global Fund’s total TB expenditures of $387 million covered 7.7% of DOTS, MDR, and TB/HIV funding need in LMIC . This coScenario A, regional TB investments are aligned with the regional distribution in total need  – underscoring the importance of continued co-financing by the Global Fund and other donors.If low- and middle-income countries maintain their share of financing dedicated to TB control in line with GDP growth, domestic funding will amount to US$6.5 billion annually by 2015, based on GDP projections from the International Monetary Fund (IMF) Model projections show that the Global Fund could potentially increase the health impact of its TB investments, if allocations prioritized Africa and TB/HIV (Scenario B). Of all regions, Africa has the highest immediate return on TB investment, because of its high prevalence of TB/HIV co-infection, and relatively low per-patient costs. An increased donor focus on sub-Saharan Africa is also reasonable given the rapid rise in TB funding need from 2010 to 2015, of 82% . This policy would, however, reduce lives saved compared to the base-case, because the high per-patient cost for MDR-TB treatment compared to DOTS, and the high per-patient costs in eastern Europe and Central Asia, the region with most MDR-TB, reduce the total number of treatments affordable for the given amount of total funding. Affordability of TB control globally will critically depend on the ability in EECA to improve NTP effectiveness and efficiency (for both DOTS and MDR-TB), by transitioning from the current hospital-centered service delivery per capita GDP by 72% and 50%, respectively, from 2010 to 2015. Considering their projected 60% increase in TB funding need over this period, the expected economic growth would enable maintaining or increasing domestic contributions relative to GDP – currently below those in other regions . These will depend on co-investment by other donors and national governments, who may or may not shift contributions to non-Global Fund priority TB interventions also considered cost-effective according to WHO benchmarks Despite these limitations, the projections illustrate how for given investments, the immediate mortality impact is determined by the balance in allocations between TB/HIV management mainly in Africa, with high return for low cost, and MDR-TB management mainly in EECA, with lowest return for highest cost. The future efficiency and effectiveness of TB treatment in high-cost region EECA will critically determine worldwide costs. In the short term, most lives will be saved through TB/HIV co-infection control in Africa. Investing in MDR-TB diagnosis and care, using the highly effective new technologies for diagnosis of TB and rifampicin-resistant TB, is needed to prevent MDR-TB, reduce substantial future costs of managing MDR-TB, and to reduce risk of unaffordability of TB control in longer-term. For the Global Fund, improved allocative efficiency of investments through proactive approaches that ‘inform demand’ would result in greater numbers of lives saved than might be with the prevailing funding model of responding to country demand. While an investment approach that fosters value for money improves allocative efficiency and aggregate health impact, two key considerations of the Global Fund’s 2012−2016 Strategy Table S1Grouping of countries into regions. Abbreviations: I&C: India and China; EE & CA: EECA; Other L&MIC: other low and middle-income countries; SSA: sub-Saharan Africa.(DOCX)Click here for additional data file.


Maternal exposures to traffic-related air pollution have been associated with adverse pregnancy outcomes. Exposures to traffic-related air pollutants are strongly influenced by time spent near traffic. However, little is known about women’s travel activities during pregnancy and whether questionnaire-based data can provide reliable information on travel patterns during pregnancy.Examine women’s in-vehicle travel behavior during pregnancy and examine the difference in travel data collected by questionnaire and global positioning system (GPS) and their potential for exposure error.We measured work-related travel patterns in 56 pregnant women using a questionnaire and one-week GPS tracking three times during pregnancy . We compared self-reported activities with GPS-derived trip distance and duration, and examined potentially influential factors that may contribute to differences. We also described in-vehicle travel behavior by pregnancy periods and influences of demographic and personal factors on daily travel times. Finally, we estimated personal exposure to particle-bound polycyclic aromatic hydrocarbon (PB-PAH) and examined the magnitude of exposure misclassification using self-reported vs. GPS travel data.Subjects overestimated both trip duration and trip distance compared to the GPS data. We observed moderately high correlations between self-reported and GPS-recorded travel distance . Better agreement was observed between the GPS and the self-reported travel time for home to work trips (r = 0.77) than work to home trips (r = 0.64). The subjects on average spent 69 and 93 minutes traveling in vehicles daily based on the GPS and self-reported data, respectively. Longer daily travel time was observed among participants in early pregnancy, and during certain pregnancy periods in women with higher education attainment, higher income, and no children. When comparing self-reported vs. GPS data, we found that estimated personal exposure to PB-PAH did not differ remarkably at the population level, but the difference was large at an individual level.Self-reported home-to-work data overestimated both trip duration and trip distance compared to GPS data. Significant differences in PAH exposure estimates were observed at individual level using self-reported vs. GPS data, which has important implications in air pollution epidemiological studies. There is a growing concern about the health impact of traffic-related air pollution on pregnancy outcomes -4. LivinExposures to traffic-related pollutants are strongly influenced by time spent near traffic emission sources . Concentrations of ultrafine particles and volatile organic compounds can be up to ten times higher in vehicles than in ambient outdoor environments -16. It hBecause of the potentially high air pollutant exposures in transit environments, it is essential to understand pregnant women’s travel behaviors for more accurate exposure assessment. However, few time-activity studies have focused on pregnant women, and little is known about travel behavior during pregnancy. The National Human Activity Patterns Survey (NHAPS) (the largest time-activity study in the U.S.) collected over 9,300 time-activity surveys but did not address pregnancy status . A numbeConventional methods for time-location collections (e.g. self-reported paper diary and telephone interview) have several major limitations, including omission of short trips and inaccurate reporting of trip duration ,28. GlobThe objectives of this paper are to examine the in-vehicle work-related travel behavior of pregnant women at different stages of pregnancy , examine the difference in travel time collected by two instruments (i.e. questionnaire and GPS tracking), investigate influential factors contributing to the difference of travel time, and examine potential exposure error in estimating personal particle-bound polycyclic aromatic hydrocarbon (PB-PAH) using the two instruments collecting travel data. PAH has been linked to adverse health effects, including adverse birth outcomes  and alleWe recruited 92 pregnant women before 20 weeks of gestation at two hospitals  in South Los Angeles County and Orange County, California in 2009–2010. Women were recruited mainly through brochures and flyers at the hospitals and a few subjects (N = 5) through word of mouth from other subjects. Eligibility criteria included age 18 years or older, nonsmoker, and low-risk pregnancy . For the present data analysis of work-related commuting and exposure, we included 56 subjects who worked during pregnancy. Gestational age was calculated based on a combination of self-reported and doctor diagnosed date. Twenty-eight out of 92 subjects participated in a personal PB-PAH exposure assessment study .We found that subjects overestimated both trip duration and trip distance compared to GPS data. Higher correlation was observed for trip distance than trip duration between self-reported and GPS data. Longer daily travel time was observed among participants in early pregnancy, and during certain pregnancy periods in women with higher education attainment, higher income, and no children. Comparing self-reported vs. GPS data, the estimation of personal exposure to PB-PAH did not differ markedly at the population level, but the difference was large at an individual level, which has significant implications in air pollution epidemiological studies. Finally, we found that subject compliance could be a critical issue when relying on GPS alone to collect weekly or longer term time-activity data.Written informed consent was obtained from the participants for the publication of this report.GPS: Portable global positioning system.The authors declare that they have no competing interests.JW is the PI of this study. JW conceptualized and designed the study, conducted data analyses, and drafted the manuscript. CJ conducted the GPS modeling work and helped with data analysis. GJ recruited human subjects and administered questionnaire interviews and GPS tracking for the majority of the subjects. AD helped to administer questionnaire interviews and GPS tracking for some subjects and helped transfer the paper-based interview data to an electronic database. SB helped with the mixed effects model development and manuscript writing. DB and RD helped conceptualize the study and provided important intellectual content for the manuscript. All authors assisted in the interpretation of results and contributed towards the final version of the manuscript. All authors read and approved the final manuscript.Selected questions on socio-demographic status and travel behavior in pregnant women.Click here for fileWeb-based estimate of trip duration and models to estimate GPS-based travel time.Click here for file


Of the known intelligently-operating systems, the majority can undoubtedly be classed as being of biological origin. One of the notable differences between biological and artificial systems is the important fact that biological materials consist mostly of chiral molecules. While most biochemical processes routinely discriminate chiral molecules, differentiation between chiral molecules in artificial systems is currently one of the challenging subjects in the field of molecular recognition. Therefore, one of the important challenges for intelligent man-made sensors is to prepare a sensing system that can discriminate chiral molecules. Because intermolecular interactions and detection at surfaces are respectively parts of supramolecular chemistry and interfacial science, chiral sensing based on supramolecular and interfacial concepts is a significant topic. In this review, we briefly summarize recent advances in these fields, including supramolecular hosts for color detection on chiral sensing, indicator-displacement assays, kinetic resolution in supramolecular reactions with analyses by mass spectrometry, use of chiral shape-defined polymers, such as dynamic helical polymers, molecular imprinting, thin films on surfaces of devices such as QCM, functional electrodes, FET, and SPR, the combined technique of magnetic resonance imaging and immunoassay, and chiral detection using scanning tunneling microscopy and cantilever technology. In addition, we will discuss novel concepts in recent research including the use of achiral reagents for chiral sensing with NMR, and mechanical control of chiral sensing. The importance of integration of chiral sensing systems with rapidly developing nanotechnology and nanomaterials is also emphasized. Often only one enantiomer of a chiral drug exhibits useful therapeutic effects while use of others may entail the risk of serious detrimental effects, so administration of single enantiomer drugs is recommended over the racemic alternative which has typically been used until fairly recently . Th. Thcis-tne phase . Upon cone phase . Similarin water . They alin water .trans-1, 2-diaminocyclohexane resulting in an enantioselectivity factor of 1.24.Structurally well designed polymers show enhanced optical properties that can be used for sensitive detection of chiral guests. For example, Pu and coworkers synthesized dendrimers containing a 1,1′-binaphthyl core and cross-conjugated phenylene dendrons . The flul-DOPA . The synthetic hydrogel displays a greenish color based on the porous structure, which can be hypochromically shifted to a blue color upon addition of l-DOPA. Binding of l-DOPA to the imprinted gel induces shrinking of the gel resulting in a change of color. In contrast, d-DOPA does not cause a color change because of its weak binding to the imprinted gel. Similarly imprinted polymers have been used for chiral sensing. Levon and coworkers used a self-assembled monolayer (SAM) polymerized on an electrode surface 2+  by combined methods of LB and SAM (II/OsIII redox pair with an oxidation rate ratio of 1.8 between (S)- and (R)-enantiomers. Nakanishi, Osaka, and coworkers prepared SAM structures of homocysteine (Hcy) on a Au(111) surface for chiral recognition of DOPA through electrochemical detection using cyclic voltammometry (CV). Oxidation reaction depended significantly on the combination of Hcy and DOPA. Oxidation reaction proceeds for d-DOPA at l-Hcy SAM and l-DOPA at d-Hcy, while DOPA is hardly oxidized with the homochiral combination (d-Hcy+d-DOPA or l-Hcy+l-DOPA). For example, the l-Hcy SAM facilitates permeation of d-DOPA to the electrode surface but suppresses permeation of l-DOPA, resulting in selective electrochemical detection on d-DOPA . Wi. Wi3]2+ n d-DOPA . They aln d-DOPA  was monideposits . ElectroR)-methyl lactate . A. AR) andet al. [d-leucine are always greater than those of l-leucine at all the surface pressure ranges investigated, indicating that the monolayer of cholesteryl-substituted cyclen has a stronger interaction with d-leucine. Interestingly, enatioselective binding of valine to the same monolayer is highly affected by surface pressure. The binding constant values of l-valine are smaller than those of d-valine at low surface pressure but exceed them at 22–23 mN m−1. This means that chiral recognition in the monolayers of cholesteryl-substituted cyclen with valine changes from the d- to l-form upon compression. This is a clear example of tuning of chiral discrimination by bulk mechanical force. The latter experimental results are a very unusual example in chiral sensing, because we can freely tune chiral selectivity just by changing the compression state of the monolayer. Actually, molecular compression was done using a film balance machine, but the same concept can, in theory, be reproduced by film compression by our hands. Therefore, this system can be regarded as hand-tuned chiral sensing, which is a part of our new concept hand-operated nanotechnology [As demonstrated experimentally ,109 and et al. , and chiet al. . Unlike et al. ,119. Recet al. . The octchnology .5.Chiral sensing is one of the most challenging targets in analytical chemistry due to the necessity for differentiation of very slight differences in molecular structure. At the same time, this target is very important for future technology because most important chiral substances are bio-related molecules and their sensing contributes to biology, biotechnology, and pharmacy. Chiral sensing processes consist of two processes, molecular sensing and signal transduction. If we more closely consider intelligent chiral sensors, inclusion of concepts on nanotechnology and nanomaterials becomes more important –125. Alt