Staphylococcus aureus (CA-MRSA) infections among young people without healthcare-associated risk factors have emerged during the past decade. Reported prevalence rates of CA-MRSA vary widely among studies, largely because of the different definitions employed and different settings in which the studies have been performed. Although the majority of CA-MRSA infections are mild skin and soft tissue infections, severe life-threatening cases have been reported. CA-MRSA infections have mostly been associated with staphylococcal strains bearing the staphylococcal cassette chromosome mec type IV element and Panton-Valentine leukocidin genes. These strains are more frequently susceptible to a variety of non-beta-lactam antibiotics. Clinicians must be aware of the wide spectrum of disease caused by CA-MRSA. Continued emergence of MRSA in the community is a public health problem, and therefore warrants increased vigilance in the diagnosis and management of suspected and confirmed staphylococcal infections.Community-acquired methicillin-resistant  Staphylococcus aureus (MRSA) is an important cause of nosocomial infections worldwide. However, the epidemiology of MRSA is changing as the isolation of MRSA is no longer limited to hospitalized patients or persons with predisposing risk factors.[Methicillin-resistant  factors. Outbreak factors.–4 CA-MRSReported prevalence rates of CA-MRSA vary widely among studies, in part because of the use of different definitions to distinguish between CA-MRSA and HA-MRSA, but also because of the different settings in which studies have been performed. It should be noted that relatively few studies have been conducted among randomly selected healthy members of the community. Most studies have been based on hospitalized patients or patients upon admission to the hospital, which has probably resulted in an overestimation of the ‘true’ prevalence of CA-MRSA.No consensus definition for CA-MRSA exists. In February 2005, the Centers for Infectious Disease Control and Prevention defined CA-MRSA infection as identification of MRSA in a patient with signs and symptoms of infection, either in the outpatient setting or within 48 hours after admission to a hospital, with no history of MRSA infection or colonization, no history of admission to a hospital or a nursing home during the previous year, and no history of dialysis, surgery, permanent indwelling catheters, or medical devices that pass through the skin to the body.[CA-MRSA is distinct from HA-MRSA both genetically and phenotypically. Methicillin resistance, signifying resistance to all beta-lactam antibiotics, is mediated by the mecA gene which codes for the penicillin-binding protein PBP2A. The mecA gene is located on a genetic island called the staphylococcal cassette chromosome mec (SCCmec), and differences in SCCmec are used to categorize MRSA. HA-MRSA strains carry SCCmec types I to III, whereas CA-MRSA strains carry SCCmec IV and the more recently isolated SCCmec V; HA-MRSA tends to be multiresistant, whereas CA-MRSA tends to be susceptible to narrow-spectrum non-beta-lactams such as clindamycin, trimethoprim-sulfamethoxazole (TMP-SMX), and tetracyclines.7S. aureus (MSSA) or HA-MRSA. Furthermore, unlike HA-MRSA, which is considered an opportunistic pathogen, CA-MRSA causes infection in healthy, predominantly young hosts who have no predisposing comorbidities.[Another distinguishing genetic feature of CA-MRSA is that a high percentage of strains carry genes for Panton-Valentine leukocidin (PVL), an exotoxin that is lethal to leukocytes. Genes for PVL are largely absent from HA-MRSA strains. PVL, perhaps in combination with other exotoxins, appears to be responsible for the enhanced pathogenicity of CA-MRSA strains and instrumental in producing necrotic skin lesions and necrotizing pneumonia. Severe invasive disease, such as necrotizing pneumonia and necrotizing fasciitis, appears to be more common with CA-MRSA than methicillin-sensitive bidities.Perhaps the most remarkable feature of the CA-MRSA genotype is its evolutionary success, resulting in its rapid worldwide clonal emergence. The small SCCmec IV allele seems to carry little fitness cost, allowing CA-MRSA to thrive and spread readily outside the hospital environment, unlike HA-MRSA strains which require the hospital milieu for sustained survival. CA-MRSA strains were first reported in the 1980s, and were responsible for an outbreak of infection in intravenous drug users in North America. Later ouS. aureus isolates; the proportion had increased from 2% in 1999 to 8% in 2003. Of all MRSA isolates, 62% represented community-acquired infection. The proportion of community-acquired isolates increased from 41.7% in 1999 to 66.6% in 2002.[et al. studied the genotypes of MRSA from Riyadh and found that CA-MRSA strains harbored the SCCmec type IV element and the PVL genes.[S. aureus further recorded in another study from King Fahd Hospital of the University revealed that between 2001 and 2008, both the percentage of CA-MRSA isolates as well as the overall number of CA-MRSA isolates increased. By 2008, of all MRSA isolates, 73% represented community-acquired infection and the prevalence of CA-MRSA infections increased from 9.9 per 10 000 admissions in 2001 to 67 per 10 000 admissions in 2008.[As in other countries, the prevalence of CA-MRSA has increased in Saudi Arabia in the past 10 years, and CA-MRSA infections in healthy individuals without established risk factors have now been documented in the community in Saudi Arabia. The first CA-MRSA infections were reported from King Fahd Hospital of the university in the Eastern Province and with in 2002. Moussa eVL genes. The chan in 2008.Of concern is the recent report of severe cases of invasive infections and sepsis among children caused by CA-MRSA from King Saud Hospital of the university. Between January 2005 and March 2008, five (6%) previously healthy children with invasive CA-MRSA infections were identified from 80 children with community-onset MRSA infections.The spectrum of clinical infections caused by CA-MRSA is similar to that caused by MSSA2 but cle12SSTIs, specifically furuncles, carbuncles, abscesses, and cellulitis, are the most frequently reported clinical manifestations. MRSA skiS. aureus is an important pathogen to consider in patients with intracranial complications of sinusitis such as epidural or subdural abscesses.[Head and neck CA-MRSA infections such as cervical lymphadenitis, otitis externa, otitis media with otorrhea, or acute mastoiditis and retropharyngeal abscess are also being encountered with increasing frequency.17 The rebscesses.Less commonly, CA-MRSA has been associated with severe and invasive staphylococcal infections in the community, including necrotizing pneumonia and empyema, sepsis syndrome, musculoskeletal infections including pyomyositis and osteomyelitis, necrotizing fasciitis, purpura fulminans, and disseminated infections with septic emboli.1220 Inva12S. aureus infections in the community. Clinicians should obtain appropriate material for bacterial culture follow-up on the results of susceptibility testing of all S. aureus isolates, and recommend surgical drainage of infections when feasible. The primary treatment modality of skin and soft tissue abscesses is incision and drainage. One study demonstrated that with lesions smaller than 5 cm in diameter, outcomes are favorable with incision and drainage alone.[To avoid clinical complications, clinicians should now consider MRSA as a potential pathogen in patients with suspected ge alone.Streptococcus pyogenes cannot be ruled out, some experts do not recommend treating empirically with TMP-SMX or doxycycline monotherapy because of reported streptococcal resistance to these antibiotics. Some researchers suggest a combination of clindamycin with either TMP-SMX or tetracycline.[in vitro, but are erythromycin-resistant. If inducible resistance is present, there is a potential for treatment failure with clindamycin, despite the culture and sensitivity report indicating susceptibility. Antibiotics should be adjusted once culture results are known. Patients treated on an outpatient basis should be clearly instructed to report promptly if they develop systemic symptoms or worsening local symptoms or if their symptoms do not improve within 48 hours.Unlike HA-MRSA, most CA-MRSA isolates are susceptible to several antimicrobial agents. In cases of CA-MRSA infection not requiring hospitalization but for which antibiotics are deemed necessary, oral antibiotics such as TMP-SMX, doxycycline, and clindamycin may be appropriate. The combacycline. Clindamyacycline. Strains For patients with invasive infections that may have been caused by CA-MRSA, vancomycin, teicoplanin, tigecycline, and linezolid represent appropriate empirical therapeutic options.21CA-MRSA outbreaks have been controlled with strategies focusing on wound care and containment, enhanced hygiene, and regular cleaning of frequently touched environmental surfaces. Persons with active infections should be restricted from certain activities such as contact sports and daycare if their wound drainage cannot be contained. Local health authorities should be informed of suspected outbreaks, and additional related cases should also receive adequate treatment. Patient education regarding the nature of the disease, its spread, and the possibility of recurrence is important. Providing antibiotic prophylaxis to family members is currently not recommended, and administering decolonization regimens to whole families has not been studied, but may need to be used in specific circumstances.CA-MRSA has emerged as an important infection in the community. The rate of CA-MRSA infection is rapidly increasing and has become a threat to the community and to persons with unknown risk factors. Appropriate adjustment of treatment regimens and enforcement of better hygiene practices should prevent further evolution and spread of these highly adapted infectious agents.


Obesity, hypertension, and high cholesterol are risk factors for cardiovascular disease, which accounts for approximately 20% of deaths in Washington State. For most states, self-reports from the Behavioral Risk Factor Surveillance System (BRFSS) provide the primary source of information on these risk factors. The objective of this study was to compare prevalence estimates of self-reported obesity, hypertension, and high cholesterol with examination-based measures of obesity, hypertension, and high-risk lipid profiles.During 2006–2007, the Washington Adult Health Survey (WAHS) included self-reported and examination-based measures of a random sample of 672 Washington State residents aged 25 years or older. We compared WAHS examination-based measures with self-reported measures from WAHS and the 2007 Washington BRFSS (WA-BRFSS).P < .001). Prevalence estimates of hypertension based on self-reports from WA-BRFSS  and WAHS  were similar to the examination-based estimate . Prevalence estimates of high cholesterol based on self-reports from WA-BRFSS  and WAHS  were similar; both were lower than the examination-based WAHS estimate of high-risk lipid profiles  (P < .001).The estimated prevalence of obesity from WA-BRFSS  was lower than estimates derived from WAHS physical measurements  (Self-reported heights and weights underestimate the prevalence of obesity. The prevalence of self-reported high cholesterol is significantly lower than the prevalence of high-risk lipid profiles. Periodic examination-based measurement provides perspective on routinely collected self-reports. Medscape, LLC is pleased to provide online continuing medical education (CME) for this journal article, allowing clinicians the opportunity to earn CME credit.This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education through the joint sponsorship of Medscape, LLC and Preventing Chronic Disease. Medscape, LLC is accredited by the ACCME to provide continuing medical education for physicians. AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.Medscape, LLC designates this Journal-based CME activity for a maximum of 1 www.medscape.org/journal/pcd (4) view/print certificate.All other clinicians completing this activity will be issued a certificate of participation. To participate in this journal CME activity: (1) review the learning objectives and author disclosures; (2) study the education content; (3) take the post-test with a 70% minimum passing score and complete the evaluation at Release date: June 20, 2012; Expiration date: June 20, 2013Upon completion of this activity, participants will be able to:Compare self-report and examination-based data regarding obesityCompare self-report and examination-based data regarding hypertensionCompare self-report and examination-based data regarding hyperlipidemiaDistinguish factors associated with undiagnosed hyperlipidemiaCME EDITORPreventing Chronic Disease. Disclosure: Ellen Taratus has disclosed no relevant financial relationships.Ellen Taratus, Editor, CME AUTHORCharles P. Vega, MD, Health Sciences Clinical Professor; Residency Director, Department of Family Medicine, University of California, Irvine. Disclosure: Charles P. Vega, MD has disclosed no relevant financial relationships.AUTHORS AND CREDENTIALSDisclosures: Juliet Van Eenwyk, PhD; Lillian Bensley, PhD; Eric M. Ossiander, PhD; Karen Krueger, MBA, MN have disclosed no relevant financial relationships.Affiliations: Juliet Van Eenwyk, PhD; Lillian Bensley, PhD; Eric M. Ossiander, PhD; Karen Krueger, MBA, MN, Washington State Department of Health, Olympia, Washington.Obesity, hypertension, and high cholesterol are well-established as risk factors for cardiovascular disease. They are targets for public health efforts to reduce illness and death from ischemic heart disease and stroke, which account for about one-fifth of deaths in Washington State and in the United States . AlthougA few studies have compared self-reports and examination-based measures of risk factors for cardiovascular disease. These studies generally show that self-reports underestimate obesity prevalence -7. StudiWe were unable to identify studies that compare self-reported high cholesterol with measures of high-risk lipid profiles; high-risk profiles are those that identify people who take medication to regulate blood cholesterol or have abnormal values for any cholesterol component or for triglycerides. Although medical science has advanced in understanding the roles of cholesterol components and triglycerides in the development of cardiovascular disease, researchers have not assessed how high-risk lipid profiles compare with self-reported high cholesterol.The objective of this study was to compare prevalence estimates of self-reported obesity, hypertension, and high cholesterol with examination-based measures of obesity, hypertension, and high-risk lipid profiles.The Washington State Department of Health designed the Washington Adult Health Survey (WAHS) primarily to estimate the statewide prevalence of hypertension and high-risk lipid profiles and to determine whether these differed for people living in households that have an annual income of less than $35,000 compared with households that have higher incomes. WAHS used a 3-stage stratified cluster design, randomly selecting block groups stratified by median household income , housing units in block groups, and 1 adult aged 25 or older in each housing unit. WAHS included adults who spoke English or Spanish, lived in the sampled residence at least half the year, and were their own legal guardians. WAHS excluded pregnant women and people who had hemophilia or were being treated for cancer.Field personnel included nurses and interviewers. Study procedures took place in participants’ homes. The first home visit included recruitment; informed consent; and directions for fasting, completing self-administered questionnaires, and having containers of prescription medications available at the next visit. The second visit included interviews on medical conditions, collection of fasting blood samples, physical measurements, and review of prescription medication containers. The interviews included asking participants, “Have you taken any prescription medicine in the past 30 days?” For those answering yes, the nurse said, “I would like to look at the medicine containers or packages to record what they are. Do you have your medicines available?” Participants received a $45 Visa debit card and information about their blood pressure, blood glucose and lipids, and body mass index (BMI). Data were collected from August 2006 to November 2007. Of 1,534 people determined to be eligible, 672 participated in WAHS, a participation rate of 44%. The Council of American Survey Research Organizations (CASRO) response rate , which aWe also used self-reported data from the 2007 Washington State (WA) BRFSS , excludi2 or more, overweight as BMI of 25 kg/m2 to less than 30 kg/m2, and neither overweight nor obese as BMI of less than 25 kg/m2. The WAHS examination-based measure of obesity was computed from measured heights and weights following protocols adapted from NHANES  determined levels of total cholesterol; high-density lipoprotein (HDL) and low-density lipoprotein (LDL) cholesterol; and triglycerides. Very low-density lipoprotein (VLDL) cholesterol was calculated for participants with triglycerides of 400 mg/dL or less by subtracting HDL and LDL values from total cholesterol. Abnormal lipid values were defined as total cholesterol of 240 mg/dL or more, LDL cholesterol of 160 mg/dL or more, VLDL cholesterol of 40 mg/dL or more, HDL cholesterol of less than 40 mg/dL for men and less than 50 mg/dL for women, or triglycerides of 200 mg/dL or more.Because lipid values measured on 1 occasion are not sufficient for clinical diagnosis, this study used a range of definitions reflecting levels of diagnostic certainty to estimate the prevalence of high-risk lipid profiles among WAHS participants. Categories are mutually exclusive so that participants classified at higher levels of certainty are not considered for lower levels. Participants were classified as having definite high-risk lipid profiles if the nurse recorded that they were taking medications to control blood cholesterol. They were classified as having probable high-risk lipid profiles if they had at least 1 abnormal lipid value. Participants who had at least 1 borderline lipid value  or reported using medication or diet change to lower cholesterol were classified as possible high-risk lipid profile. Participants who reported that a health care provider said they had high blood cholesterol on at least 1 occasion were classified as probable no. Participants who reported none of the above were classified as definite no. Participants classified with definite or probable high-risk lipid profiles were coded as having high-risk lipid profiles.This study coded WAHS and WA-BRFSS participants as self-reporting high cholesterol if they answered yes to “Have you ever had your blood cholesterol checked?” and “Have you ever been told by a doctor or other health professional that your blood cholesterol level was high?”; participants were coded as not self-reporting high cholesterol if they answered yes to the first and no to the second question. We excluded from this comparison participants who said they had not had their cholesterol checked.This study coded WAHS participants as having possible undiagnosed hypertension if they did not report ever being told by a health care provider that they had high blood pressure, were not on medications used only to control blood pressure, and had measured systolic blood pressure of 140 mm Hg or more or diastolic blood pressure of 90 mm Hg or more. They were coded as having possible undiagnosed high-risk lipid profiles if they did not report ever being told that they had high cholesterol (including those never tested), were not on medications used to control cholesterol, and had at least 1 abnormal lipid value.z tests to compare WAHS and WA-BRFSS data and generalized estimating equations to conduct tests of paired comparisons between WAHS self-reported and examination-based findings. We used Wald χ2 tests to test demographic differences in sample characteristics between WAHS and WA-BRFSS. All analyses accounted for the sample designs and used design weights based on probability of selection and poststratification weights based on the age and sex distributions of the Washington State population. Statistical significance was set at P < .05.This study provides prevalence estimates and 95% confidence intervals (CIs) for obesity, hypertension, high cholesterol, and high-risk lipid profiles. Missing WAHS data for individual items ranged from none to 11%, and 28% of participants had missing data on at least 1 item used in the analyses. To minimize bias, because missingness may not have been random and may have been associated with exposure or outcome or both, we used multiple imputation to impute values for missing WAHS data . This prWAHS did not measure self-reported obesity. This study conducted a Poisson regression to ensure that the difference between prevalence estimates of obesity based on physical measurements in WAHS and self-reports in WA-BRFSS was not due to demographic differences between the 2 samples. This analysis estimated a prevalence ratio for obesity in WAHS compared with WA-BRFSS, controlling for sex, age, race/ethnicity, education, annual household income, marital status, and household size. These analyses used the unimputed WAHS data because they required a combined WAHS and WA-BRFSS data set, and multiple imputation was not conducted for WA-BRFSS. Similar analyses compared self-reported hypertension and high cholesterol prevalence estimates from WAHS and WA-BRFSS.We also developed density plots to depict the distributions of measured heights and weights in WAHS and self-reported values in WA-BRFSS.Distributions by sex, age, income, marital status, and household size were similar in the weighted WAHS and WA-BRFSS samples. The samples differed in distributions by race/ethnicity and education .z = 4.17, P < .001)  . ControlWAHS examination-based measurement of height and weight resulted in shorter heights and heavier weights , and higz = 2.52, P = .01), neither estimate differed significantly from the WAHS primary (29.4%) or secondary (31.1%) examination-based estimate. The higher prevalence estimate for self-reported hypertension in WAHS compared with WA-BRFSS persisted after controlling for demographic factors: the prevalence ratio for self-reported hypertension adjusted for demographic factors in WAHS compared with WA-BRFSS was 1.2 .Although prevalence estimates of hypertension derived from self-reports in WAHS (33.4%) and WA-BRFSS (28.1%)  were sigApproximately 1 in 20  WAHS participants had possible undiagnosed hypertension. The sensitivity and specificity of self-reports compared with examination-based hypertension were 78%  and 85% , respectively.z = 1.13, P = .26) . Controlling for demographic differences did not change the similarity of the WAHS and WA-BRFSS estimates based on self-reports: the prevalence ratio for self-reported high cholesterol adjusted for demographic factors in WAHS compared with WA-BRFSS was 1.1 . Approximately half  of participants had either borderline or high total cholesterol or were on cholesterol-lowering medication; approximately two-fifths self-reported high cholesterol; and about one-third had measured high cholesterol or were on cholesterol-lowering medication , so that the estimate of participants who self-reported high cholesterol was between the estimate for high cholesterol and the estimate for borderline or high cholesterol combined. Self-reported prevalence estimates of high cholesterol in WAHS (41.8%) and WA-BRFSS (38.3%) were similar (P = .26) . Both esz = 2.45, P = .01) and participants who did not graduate from college  were more likely than college graduates   to have possible undiagnosed high-risk lipid profiles.This study identified 28.1%  of WAHS participants who had possible undiagnosed high-risk lipid profiles, including 18.1%  who reported having their cholesterol tested and 10.1%  who reported never having been tested. Hispanic participants  were more likely than non-Hispanic participants   and participants who did not graduate from college (compared with college graduates) were significantly more likely to have possible undiagnosed high-risk lipid profiles. These groups were also less likely to report having had their cholesterol checked in the 2007 WA-BRFSS. Thus, the WA-BRFSS may have limited value in identifying both the proportion of the population with high-risk lipid profiles and subgroups at higher risk than the general population.Of WAHS participants who had possible undiagnosed high-risk lipid profiles and who said they had been tested, approximately half had low HDL cholesterol as the only abnormal lipid. They could have accurately answered no to the question on high cholesterol even if they were aware of their HDL status. Other reasons for discrepancies among self-reported and examination-based hypertension, high cholesterol, or high-risk lipid profiles include anomalous readings in WAHS, recently developed conditions, incorrect recall, and control of the condition through behavioral approaches, such as physical activity or diet. One study of cholesterol recall reported that 89% of participants accurately remembered their risk category  for periods of 1 to 6 months when they were consistently counseled by providers who used these categories and the same categories were reflected in the recall measure . InformaAlthough differences in education and race/ethnicity between the WAHS and WA-BRFSS samples potentially limit the validity of our comparisons, findings persisted when we controlled for demographic factors. The low response rate also potentially limits the validity of this study. However, several recent reviews found little relationship between response rates and the amount of nonresponse bias. The range of response rates in the studies in those reviews was approximately 25% to 85% –22. The As the role of individual components of cholesterol and triglycerides in identifying people at high risk for cardiovascular disease becomes more established, the BRFSS question measuring high cholesterol may be less helpful in identifying people at high risk for cardiovascular disease. Research into how physicians explain lipid values to patients; how patients hear, interpret, and recall these messages; and how study participants interpret survey questions on blood lipids may aid in developing questions that facilitate accurate self-reporting of high-risk lipid profiles. Periodic examination-based measurement provides perspective on routinely collected self-reports.


Conflicting information exists regarding the association between hsCRP and the progression of early stages of atherosclerosis. The purpose of the study was to investigate the association of high sensitiviy c-reactive protein (hsCRP) along with major cardiovascular (CV) risk factors on early carotid atherosclerosis progression in a large, population-based cohort study.The study cohort included 839 young adults  enrolled in Bogalusa Heart Study, who in 2001-2002 attended baseline examination with measurements of CV risk factors. Progression of carotid artery intima-media thickness (IMT) was assessed during a mean follow-up of 2.4 years.Carotid artery IMT progression rates were as follows: composite carotid artery = 9.2 ± 52 μm/y, common carotid artery = 0.0 ± 51 μm/y, carotid bulb = 8.8 ± 103 μm/y, and internal carotid artery = 18.9 ± 81 μm/y. Elevated baseline hsCRP, reflecting an inflammatory state, showed independent association with composite carotid artery IMT progression. Increased age, systolic blood pressure, fasting glucose, LDL cholesterol, and current smoking were other risk associates of carotid artery IMT progression in young adults, indicating an underlying burden on the CV system by multiple risk factors.In this population-based study, we observed independent categorical association of increased hsCRP with carotid artery IMT progression in young adults. This study underlines the importance of assesssing hsCRP levels along with smoking and traditional CV risk factor profiles in asymptomatic young adults. Carotid artery intima-media thickness (IMT), as assessed noninvasively by ultrasonography, is a useful measure of preclinical atherosclerosis and has been found to predict future risk for myocardial infarction, stroke, and death from coronary heart disease. A change in carotid artery IMT over time has been validated as a vascular marker of the progression of atherosclerosis . Such loAs part of the Bogalusa Heart Study, a biracial (black-white) community based epidemiological study of the early natural history of cardiovascular (CV) disease, the present study examines the relationships of baseline traditional CV risk factors and hsCRP to carotid artery IMT progression in asymptomatic younger adults by race and sex.The Bogalusa Heart Study is a long-term epidemiologic study of the early natural history of arteriosclerosis in children and young adults from a semirural, biethnic  community in Bogalusa, Louisiana . This reStandardized protocols were used by trained examiners . Height Subjects were instructed to fast for 12 hours before screening, and compliance was determined by interview on the morning of examination. Plasma glucose was measured by a glucose oxidase method as part of the multiple chemistry profile (SMA20) in the multichannel Olympus Au-5000 Analyzer . A radioimmunoassay kit was used to measure plasma insulin . Serum cholesterol and triglycerides were determined enzymatically on the Hitachi 902 Automatic Analyzer . Serum lipoprotein cholesterols were analyzed by a combination of heparin-calcium precipitation and agar-agarose gel electrophoresis procedures. Plasma high sensitivity c-reactive protein (CRP) was measured by latex particle-enhanced immunoturbidimetric assay on the Hitachi 902 Automatic Analyzer. Urinary albumin excretion was assessed on a morning spot urine sample using an enzyme-linked immunosorbent assay kit . The laboratory is being monitored by a surveillance program of the Centers for Disease Control and Prevention, Atlanta, Ga. Intraclass correlation coefficients, a measure of reproducibility of the entire process from blood collection to data processing, between the blind duplicate values (n = 103) were 0.98 for total cholesterol, 0.99 for high-density lipoprotein (HDL) cholesterol, and 0.98 for glucose.Trained sonographers performed ultrasound examinations using the Toshiba Ultrasound instruments  with 7.5-MHz linear array transducers. B-mode images were recorded at the common catotid, carotid bulb (bifurcation), and internal carotid arteries bilaterally according to previously developed protocols for the Atherosclerosis Risk in Communities study . Images All data analyses were performed using SPSS software . Insulin, triglycerides and urinary albumin-creatinine ratio were log-transformed to improve the normality of distribution; however, their mean values in original scales are presented for description. Differences in mean values of study variables between race-sex groups were tested by analysis of covariance models. Cardiovascular risk factors and carotid artery IMT at each survey were described by mean ± SD values and contrasted by paired t-test or McNemar test. The impact of the correlates on composite carotid artery IMT progression was examined by stepwise linear regression model in the total sample. Composite carotid artery IMT progression was adjusted for the baseline (2001-2002 survey) composite carotid artery IMT and the risk model included baseline age, gender, race, systolic and diastolic blood pressures, waist-height ratio, fasting glucose, serum low-density lipoprotein (LDL) cholesterol, HDL cholesterol, fasting triglycerides, high-sensitivity c-reactive protein ≥ 2 mg/l and smoking status with a p-value criteria of < 0.05.Table Carotid IMT measurements and progression rates were presented in Tables Baseline CV risk correlates of the composite carotid artery IMT progression are presented in Table In this large community population, we identified the association of baseline traditional CV risks and hsCRP to carotid artery IMT progression in young adults (24- to 43-year old) over a 2.4-year period. The major finding was that in addition to increase in baseline age, systolic blood pressure, glucose, LDL cholesterol and the prevalence of current smoking, increase in the prevalence of baseline hsCRP ≥ 2 mg/l were associated with the composite carotid artery IMT progression independent of other traditional CV risks. An earlier report from the Bogalusa Heart Study demonstrated that smoking was the most consistent predictor of carotid artery IMT progression in 336 young men and women, who were screened in both 1995-1996 and 2000-2001 surveys, during an average follow-up of 5.8 years [A number of other large, prospective, and population-based cohort studies have investigated the association between hsCRP and carotid artery IMT progression. The INVADE (intervention project of cerebrovascular events and dementia in the community of Ebersberg) study  have fouThe role of hsCRP as an acute phase reactant on the progression of early atherosclerosis has not been clarified in detail. High-sensitivity CRP levels might express the inflammatory activity of the atherosclerotic lesion, but hsCRP has been suggested to promote endothelial dysfunction and progression of atherosclerotic lesions in the early stages, and become more pronounced in advanced stages with an important role in plaque vulnerability, rapid progression of plaques, and thrombotic complications -20. ConsAs might be expected, this study identified baseline predictors of longitudinal carotid artery IMT progression, it is an association study and it is subject to selection bias. CRP is produced in the liver and its concentration is increased by infections that show no relationship to atherosclerosis, as well as by malignancy. Intima-media thickening reflects early atherosclerotic change as well as vessel remodeling. The number of subjects with plaques was insufficient to investigate associations with more advanced atherosclerosis in our population. Restricting measurements of IMT to the common carotid artery segment has been justified in other studies by greater reproducibility of measurements from this site and the difficulty in obtaining measurements from the bifurcation or the internal carotid artery in some populations. In the present study, 87% of all subjects had valid IMT measurements from all segments. Protocols that involve additional segments have several advantages . First, Some methodologic limitations must be taken into account in the interpretation of results. The rate of progression over a 2.4-year period is relatively short and combined with measurement errors, which could be related in part to two different ultrasound machine recordings between surveys, may be responsible for the inability to detect a significant progression of IMT in the common carotid artery segment. Nevertheless, we have identified associations between traditional CV risk factors, hsCRP and composite carotid artery IMT in cross sectional studies in this population. Longer-term follow-up should increase the power to detect other associations and reveal race and gender differences.In a prospective, population-based study, we observed independent categorical association of increased hsCRP and multiple conventional risk factors including smoking with carotid artery IMT progression in young adults. This study underlines the importance of assesssing CV risk factor profiles and hsCRP level in young adults. These observations demonstrate that risk factors are associated with the progression of subclinical atherosclerosis even in young individuals who are at low risk for cardiac events. These observations reflect on the CV risk burden over time by risk factors including inflammation and smoking.hsCRP: high sensitivity c-reactive protein; CV: cardiovascular; IMT: intima-media thickness; LDL: low-density lipoprotein cholesterol; BMI: body mass index; HDL: high-density lipoprotein cholesterol; INVADE: intervention project of cerebrovascular events and dementia in the community of; Ebersberg; CIMT: carotid artery intima-media thickness.The authors declare that they have no competing interests.All authors read and approved the final manuscript. AT: Participated in its design and coordination and drafted the manuscript. RK: Involved in drafting the manuscript and revising it critically for important intellectual content. DT: Involved in drafting the manuscript and revising it critically for important intellectual content. WC: Have made substantial contributions to conception and design, acquisition of data, analysis and interpretation of data, and have given final approval of the version to be published. SS: Have made substantial contributions to conception and design, acquisition of data, analysis and interpretation of data, and have given final approval of the version to be published. JHX Have made substantial contributions to conception and design, acquisition of data, analysis and interpretation of data, and have given final approval of the version to be published. AA: Involved in drafting the manuscript and revising it critically for important intellectual content. GSB: Have made substantial contributions to conception and design, acquisition of data, analysis and interpretation of data, and have given final approval of the version to be published.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2261/11/78/prepub


Users can utilize the SOAP services implemented in Perl directly via WSDL file at http://soap.g-language.org/kbws.wsdl (RPC Encoded) and http://soap.g-language.org/kbws_dl.wsdl .The availability of bioinformatics web-based services is rapidly proliferating, for their interoperability and ease of use. The next challenge is in the integration of these services in the form of workflows, and several projects are already underway, standardizing the syntax, semantics, and user interfaces. In order to deploy the advantages of web services with locally installed tools, here we describe a collection of proxy client tools for 42 major bioinformatics web services in the form of European Molecular Biology Open Software Suite (EMBOSS) UNIX command-line tools. EMBOSS provides sophisticated means for discoverability and interoperability for hundreds of tools, and our package, named the Keio Bioinformatics Web Service (KBWS), adds functionalities of local and multiple alignment of sequences, phylogenetic analyses, and prediction of cellular localization of proteins and RNA secondary structures. This software implemented in C is available under GPL from  With more than 1700 services listed in the BioCatalogue at the time of this writing . Severaltfm command), discoverable (with wossname command), and interoperable. Advantages of the EMBOSS platform also includes a unified sequence data retrieval system with Universal Sequence Address (USA) as well as the availability of many front-end user interfaces, such as JEMBOSS [While the advent of web-based services is expected to proliferate further especially in light of the introduction of next-generation sequencers and their huge masses of data , local t JEMBOSS , SoapLab JEMBOSS , wEMBOSS JEMBOSS , and EMB JEMBOSS .kblast, and therefore there is a total of 42 tools accessing 44 services. List of supported web services in KBWS is shown in Table KBWS is composed of two parts: a proxy web server providing SOAP service wrapper to bioinformatics web services, and UNIX command-line clients in the form of EMBOSS tools that access the proxy web server. By making the clients access the proxy server instead of the original service providers, the clients can be lightweight. Therefore, same client tool can be used without update or maintenance even the original service providers change their formats, and KBWS can utilize bioinformatics web-based services provided in any protocol  of any versions . This prhttp://www.g-language.org/kbws/ and GitHub repository http://github.com/cory-ko/KBWS. Detailed documentation for each of the tools are available through the EMBOSS tfm  command, and tools can be searched and discovered with wossname utility. As an EMBOSS package, KBWS can be utilized with graphical user interfaces through JEMBOSS and wEMBOSS, and browser-based access with EMBOSS Explorer is also available at our website (http://soap.g-language.org/kbws/emboss_explorer/).Each of the 42 UNIX command-line clients accesses a unique bioinformatics web service through KBWS proxy. These tools are implemented as EMBASSY package in C programming language with gSOAP Toolkit , and arekblast), extracting the list of IDs (sed and uniq), aligning the sequences with MUSCLE (kmuscle), extracting a certain region from the alignment , and generating its sequence logo (kweblogo). Output from this workflow is shown in Figure http://soap.g-language.org/kbws/embossrc.The following set of commands comprises a workflow for generating a sequence logo image for a set of amino acid sequences of FOXP2 , using B# search similar sequence in Swiss-Prot database using BLAST% kblast swissprot:FOXP2_HUMAN -d swissprot -format k1 -eval 1e-50 -outfile kblast.out# extract ID list from BLAST report% sed 's/^\(.*\)\.-9/swissp# multiple sequence alignment using MUSCLE% kmuscle @match_list.out -outfile kmuscle.fasta# Extract a region from the alignment% extractalign -regions '420-430' kmuscle.fasta -outseq extractalign.fasta# Generation of sequence logos using WebLogo% kweblogo extractalign.fastahttp://www.myexperiment.org/) website as Taverna workflow (http://www.myexperiment.org/users/1938/workflows).Other example workflows are available at myExperiment (http://www.g-language.org/wiki/kbws/.Sample codes written by Perl, Ruby, Python and Java are also available at KBWS provides 42 web-based services as an EMBOSS package. EMBOSS is already widely used in numerous laboratories, and therefore users can readily integrate web-based services with their EMBOSS tools and UNIX commands using KBWS. Moreover, KBWS adds the advantages of web-based services to the many functionalities of EMBOSS, especially for tools like BLAST search that require large regularly updated databases that are difficult to be installed and maintained with EMBOSS in traditional manner. KBWS also does not require any external software or data for installation except for EMBOSS. As an EMBOSS package, KBWS is well-documented and can take advantage of the documentations and discovery tools, and can be used from rich clients such as JEMBOSS, wEMBOSS, and EMBOSS Explorer.ACD: Ajax Command Definitions; CGI: Common Gateway Interface; EMBOSS: European Molecular Biology Open Software Suite; KBWS: Keio Bioinformatics Web Service; REST: Representational State Transfer; USA: Universal Sequence Address; WSDL: Web Service Description Language.The authors declare that they have no competing interests.KO developed the software, KA conceived of the project, and KO and KA designed the software and drafted the manuscript. MT supervised the project. All authors have read and approved the final manuscript.


Several conservative  treatments exist for secondary lymphedema. The optimal treatment is unknown. We examined the effectiveness of conservative treatments for secondary lymphedema, as well as harms related to these treatments.®, EMBASE®, Cochrane Central Register of Controlled Trials®, AMED, and CINAHL from 1990 to January 19, 2010. We obtained English- and non-English-language randomized controlled trials or observational studies (with comparison groups) that reported primary effectiveness data on conservative treatments for secondary lymphedema. For English-language studies, we extracted data in tabular form and summarized the tables descriptively. For non-English-language studies, we summarized the results descriptively and discussed similarities with the English-language studies.We searched MEDLINEThirty-six English-language and eight non-English-language studies were included in the review. Most of these studies involved upper-limb lymphedema secondary to breast cancer. Despite lymphedema's chronicity, lengths of follow-up in most studies were under 6 months. Many trial reports contained inadequate descriptions of randomization, blinding, and methods to assess harms. Most observational studies did not control for confounding. Many studies showed that active treatments reduced the size of lymphatic limbs, although extensive between-study heterogeneity in areas such as treatment comparisons and protocols, and outcome measures, prevented us from assessing whether any one treatment was superior. This heterogeneity also precluded us from statistically pooling results. Harms were rare (< 1% incidence) and mostly minor .The literature contains no evidence to suggest the most effective treatment for secondary lymphedema. Harms are few and unlikely to cause major clinical problems. Secondary lymphedema (SE) is an acquired condition resulting from disease, trauma, or an iatrogenic process such as surgery or radiation that damages the lymphatic system ,2. CliniWusheria Bancrofti. In the United States (U.S.), the most common cause of SE is treatment for malignancy  [http://www.shlnews.org/?p=67.Globally, the major cause of SE is lymphatic filariasis resulting from infection with the nematode diation) , especiadiation) . The litSeveral types of conservative therapy exist to treat SE. Compression techniques, including multilayer bandaging, and pressure garments are thought to restore hydrostatic pressure and improve lymph flow in affected limbs . Manual Mechanical treatments for SE include intermittent pneumatic compression (IPC) devices and low-level laser therapy (LLLT). IPC devices are pneumatic cuffs connected to pumps that mimic the naturally occurring muscle pump effect of muscles contracting around peripheral lymphatics . LLLT emhttp://www.cms.gov/determinationprocess/downloads/id66aTA.pdf. The technology report served as background material for a Medicare Evidence Development & Coverage Advisory Committee (MEDCAC) Meeting held in November 2009. One purpose of the meeting was to discuss the available evidence for treatment methods in SE.This systematic review is based on a peer-reviewed technology report  commissiThis review addresses two key questions:1. How effective are conservative treatments for SE in pediatric or adult populations who developed SE following any type of illness except filariasis infection?2. What harms are associated with conservative treatments for SE?®, EMBASE®, Cochrane Central Register of Controlled Trials®, AMED, and CINAHL from 1990 to January 19, 2010. We exploded the subject heading 'lymphedema' and searched it as a textword ('lymphedema' or 'lymphoedema'). The complete literature search strategy is depicted in Additional file We searched MEDLINEWe included studies provided they were randomized controlled trials (RCTs) or observational studies with comparison groups . We also included studies of pediatric and adult patients who received treatment for SE following any form of illness except filariasis infection. We excluded case series, case reports, narrative and systematic reviews, editorials, comments, letters, opinion pieces, abstracts, conference proceedings, and animal experiments. We also excluded studies involving pharmacologic or surgical treatments for SE.Trained raters independently applied the inclusion and exclusion criteria to the articles retrieved in the literature search. The criteria were applied at three levels of screening: I-title and abstract first review; II-title and abstract second review; III-full text. We extracted data from articles that passed full text screening. Raters managed the screening process electronically using standardized screening forms and Distiller SR systematic review software .Two raters independently assessed the quality of the extracted English-language articles. Raters used the eight-point Jadad scale for RCTs ,18 and tIssues of methodological quality often preclude the inclusion of observational studies in systematic reviews. However, observational studies may be included to help overcome evidence gaps in RCTs, especially in the assessment of harms .A meta analysis was infeasible because the extracted studies exhibited substantial clinical and methodological heterogeneity. Therefore, we used a descriptive approach to answer the key questions. This approach involved extracting English-language data into tables and developing written summaries of the English and non-English evidence.For English-language articles, we extracted data on study design, type of treatment, sample size, cause of SE, definition of SE, study inclusion/exclusion criteria, and outcome data. While we did not extract data from the non-English articles, we summarized the main contents of these articles in writing and compared them to the extracted English-language articles.The McMaster University Evidence-based Practice Centre researched and wrote the initial technology report under contract with the AHRQ, which gave us permission to publish this manuscript. The AHRQ and CMS had no role in the literature search, data analysis, study conduct, manuscript preparation, or interpretation of results.Figure Of the 36 English-language studies, 30 were RCTs -41,43-50The major quality issues with the RCTs were inadequate description of randomization processes in about half the studies, no reports of double blinding in a majority of the studies, and no discussion of methods to assess harms in most studies.For the observational studies, the major quality issue was related to confounding. Four of the six studies ,54-56 diThirty-two of 36 English-language studies included participants with lymphedema secondary to breast cancer -52,54,55Intervals between study participants' completion of cancer treatment and recruitment into the extracted studies varied considerably, e.g., 3 to 6 weeks , at leasFollow-up periods varied considerably between studies, with little relation between follow-up length, study type, or intervention. Many studies ended immediately after the treatment regimen, although five studies followed patients for up to 1 year ,51,53,54Several RCTs did not clearly label treatments as 'comparator' or 'experimental' . For thIn the observational studies, comparators included IPC, compression garment, MLD, or no active treatment -56.Many RCTs measured outcomes using limb volume or circumference ,34,36,40For the observational studies, outcomes included limb volume -53,55,56Two RCTs showed IPC had benefits over CDT or self-massage ,49. ThreSix RCTs used some form of massage-based therapy as the study treatment. Of these, only one suggested benefits in the massage group . Other sIn three studies of laser treatment, laser was superior to exercise , sham laAuthors reported conflicting dieting results. One study showed no improvement with low fat or low caloric diets , while aPoor quality trials were more likely to suggest treatment benefits in experimental groups. Two RCTs involving IPC reported significantly more reductions in arm circumference when compared to MLD  or laserThe six observational studies examined a mixed group of treatments and found equivocal results: ultrasound was no different than IPC in reducing arm circumference , modifieSome studies showed a loss of benefit by the end of the follow-up period. One observational study of elastic sleeve versus IPC found that both groups had returned to baseline levels within 4 to 12 weeks post-treatment . AnotherConsidering the chronicity of SE, very few studies had long-term follow-ups. Eight of 36 studies reported outcomes at 6 months or more, with benefits shown to last for up to 1 year in some cases, usually with concomitant use of maintenance therapy .Harms were sporadically reported in the extracted studies. Only 17 of 30 RCTs reported harms ,43-47,49Some studies mentioned specific harms from therapy. These harms were rare, occurring in less than 1% of patients. Harms included infection, dermatitis ,38, arm Only two studies compared harms between treatments. In an RCT evaluating bandages, subjects getting high-pressure bandages reported more pain and discomfort than subjects getting low pressure bandages, although the harms were measured using an invalidated scale . A similNo studies reported on factors that may increase the risk of harms associated with treatment.We included eight non-English-language studies. All eight studies were observational and involved breast cancer survivors with upper limb SE. Sample sizes ranged from 30 ,58 to 44Three studies examined single modality treatments: self-administered MLD versus an unspecified comparator, with improved arm function in the MLD group ; MLD delThree studies investigated multi-modal treatments: multi-layer bandaging and MLD versus simplified bandaging and MLD, with larger decreases in edema occurring in the simplified bandaging group ; MLD, IPTwo studies examined whether the time of treatment initiation affected outcomes. The first study compared treatment initiated within 1 year of breast cancer surgery to initiation within 1 or 2 years. Treatment in both groups was a combination of MLD, IPC, bandage, and exercise. Faster reduction of arm swelling was observed in the group with earlier treatment initiation . ConversThe non-English-language studies mirrored the high degree of heterogeneity observed in the English-language studies, e.g., different treatment combinations, varying lengths of follow-up. This heterogeneity prevented us from drawing clear conclusions to answer the key questions. The non-English articles did not contain substantive new information to supplement or alter our English-language findings.Most extracted studies were conducted in persons with a history of breast cancer. One must be prudent before generalizing these studies' results to persons with other conditions.Many studies showed that most active treatments reduced the size of lymphatic limbs, although extensive study heterogeneity in areas such as length of follow-up, treatment protocols, comparators, and outcome measures prevented us from assessing whether any one treatment was superior. The extracted studies did not contain reports of treatment benefits in any subgroup of patients.Harms were reported in a small number of studies. These harms were rare and mild, and unlikely to be major clinical issues.The methodological quality of the extracted studies was generally 'fair'. The authors of some studies omitted the reporting of fundamental elements of their research, such as the blinding of outcome assessors. Quality did not generally affect our interpretation of answers to the key questions.Treatment protocols should be clearly described in published RCT reports . If researchers believe a priori that important subgroup effects are possible, then the study should be powered to detect effects in these subgroups. Since a multiplicity of outcomes exists in SE research, researchers should develop a short list of preferred study outcomes. This will facilitate between-study comparisons and help make meta analyses feasible.Experimental and comparator treatments must be clearly labeled and the comparator should be a standard treatment regimen for SE. Although sham treatments  may satisfy minimum regulatory requirements for showing effectiveness, the clinical utility of a novel treatment is best demonstrated against an accepted standard treatment. Maintenance therapies, where used, should be clearly described by study authors. Blinding of study participants, clinicians, and healthcare professionals who administer treatment may not be possible due to the nature of the therapies; however, at a minimum, researchers should blind outcome assessors to treatment.To avoid the publication of ambiguous trial reports, study authors should use existing quality scales -19,65 anMost of the extracted studies involved SE to the upper extremities. Few studies involved lower limb SE, despite its high incidence from cancer treatment . More RCAnother issue concerns whether treatment for the condition preceding SE would affect outcomes of conservative therapy for SE. For example, would patients treated with radiation therapy for breast cancer respond better to MLD than patients treated with lymphadenectomy? Research into this area could provide evidence to guide selection of SE therapy.Scientists have conducted a great deal of research into the treatment of SE. However, the literature contains no evidence to suggest the most effective treatment. Harms from treatment are minor and likely to have little clinical impact. The field of research into treating SE is open to advancement and we hope this review will guide future research in the area.The authors declare that they have no competing interests.All authors participated in the conception and design of the study. MO and ID summarized the extracted data. MO wrote the manuscript with contributions from all authors. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2407/12/6/prepubMethods S1. Literature search strategies.Click here for file


Medicago truncatula is a leading model species and substantial molecular, genetic, genomics, proteomics, and metabolomics resources have been developed for this species to facilitate the study of legume biology. Currently, over 60 proteomics studies of M. truncatula have been published. Many of these have focused upon the unique symbiosis formed between legumes and nitrogen fixing rhizobia bacteria, while others have focused on seed development and the specialized proteomes of distinct tissues/organs. These include the characterization of sub-cellular organelle proteomes such as nuclei and mitochondria, as well as proteins distributed in plasma or microsomal membranes from various tissues. The isolation of sub-cellular proteins typically requires a series of steps that are labor-intensive. Thus, efficient protocols for sub-cellular fractionation, purification, and enrichment are necessary for each cellular compartment. In addition, protein extraction, solubilization, separation, and digestion prior to mass spectral identification are important to enhance the detection of low abundance proteins and to increase the overall detectable proportion of the sub-cellular proteome. This review summarizes the sub-cellular proteomics studies in M. truncatula. Proteomics has become an important research tool to study complex biological systems in the post-genomics era, and the large-scale, systematic analysis of tissue and organelle specific proteins provides a more direct view of cellular processes not available through the measurement of DNA. Proteomics can provide insight on the specialized biochemistry of distinct tissues, protein localization, protein–protein interactions, enzymatic complexes, protein-metabolite complexes, post-translational modifications, and cellular signaling . There aProgress in the area of proteomics has relied heavily on the development of analytical tools for the sensitive, selective, and high-throughput studies of protein analytes . MS has 6–109 copies per cell  has been utilized as a model legume because of its small diploid genome compared to other legumes which have large, complex polyploidy genomes . Several of the global proteomics approaches for protein characterization from different tissues/organs of M. truncatula were based on 2-DE and MS -glucose pyrophosphorylase, vacuolar ATPase, photosystem II reaction center protein D1, and mitochondrial porin. A total of 179 peptides from 143 different proteins were identified using nano LC-MS/MS analysis of one-dimensional SDS-PAGE in-gel digests obtained from the seed nuclear proteome at 12 days after pollination (dap) which marks the switch to seed filling. Identified proteins were associated with roles in biogenesis of ribosomal subunits or nucleocytoplasmic trafficking. The results showed that 12-dap seeds accumulated ribosomal proteins in preparation for protein synthesis activity prior to seed filling. Other identified proteins were related to chromatin structure, transcription, RNA maturation, silencing, and transport to regulate gene expression and seed development.The plant nucleus is of great interest because it contains the genomic content and is the critical site of transcription and replication in eukaryote cells. M. truncatula mitochondrial fractions from root cell suspension cultures using Percoll gradient ultracentrifugation. The mitochondrial proteome of M. truncatula was characterized using 2-DE IEF/Tricine SDS-PAGE and 2-DE blue-native (BN)/Tricine SDS-PAGE. A total of 144 proteins were identified by 2-DE IEF/SDS-PAGE and 51 proteins were identified on the 2-DE BN/SDS-PAGE. The identified proteins were related to oxidative phosphorylation (OXPHOS), pyruvate decarboxylation and citric acid cycle, amino acid degradation, and ATP synthesis. The M. truncatula 2-DE mitochondrial proteome maps revealed similarities to the one from Arabidopsis. However, the abundance of complex II was increased in M. truncatula compared to Arabidopsis, which indicates increased citric acid cycle activity in M. truncatula mitochondria. Highly abundant prohibitin complexes were also present in the mitochondrial proteome of M. truncatula.Mitochondria are semiautonomous organelles involved in energy metabolism. They are also involved in many other cellular functions including amino acid and nucleotide metabolism, synthesis of cofactors, and photosynthesis. The majority of mitochondrial proteins involved in different metabolic processes are encoded by nuclear DNA, translated in the cytosol, and imported into mitochondria. M. truncatula leaf apoplast were analyzed using 2-DE separation coupled with MALDI-TOF/TOF MS identifications  and ionically bound (IB) proteins of ications . The apoMedicago cell suspension cultures. These included M. truncatula 2HA, M. truncatula sickle, and M. sativa cell lines. The authors suggest that cell suspension cultures provide an effective method to obtain representative apoplastic proteins without damaging the plant and potentially little or no sample contamination with cytoplasmic proteins. The M. truncatula cell culture secretome was isolated using a two-step centrifugation process. A total of 26 proteins were identified in the cultures derived from M. truncatula using SDS-PAGE and MALDI-TOF/TOF MS. Among the identified proteins, three secreted proteases including a subtilisin-like serine protease, aspartyl protease, and a serine carboxypeptidase were identified and detected only in M. truncatula cell cultures and not in the other Medicago cell cultures. Twelve putative defense response proteins including four chitinases, a peroxidase, three thaumatin-like PR5 proteins, PR1a, PR4a, and a prehevein-like protein were also identified from M. truncatula secretome. The authors conclude that all the identified cell culture secreted proteins are part of the classical or non-classical secretion pathways and have not been reported in other M. truncatula tissues. Therefore, they further conclude that cell culture secreted proteins are a good approximation of the appoplastic proteins of Medicago spp.Extracellular and secreted proteins (cumulatively referred to as the secretome) serve important roles in intercellular communication, development, and defense. Many secreted proteins are found in the apoplast. However, isolating proteins from apoplast is challenging and often contaminated with intracellular proteins as noted above. To circumvent intracellular contamination and to better understand apoplast protein composition, M. truncatula due to the importance of this model legume in studying plant–microbe interactions; especially symbiosis. Microsomal proteins were separated using 2-DE, and three different extraction methods were compared for preparing microsomal proteins. The extraction methods were based on phenol, acetone, and a chloroform/methanol mixture. A total of 440 microsomal proteins were visualized using analytical, silver stained 2-DE. Ninety-six proteins from 115 Coomassie stained micropreparative 2-DE protein spots were identified following in-gel digestion, MALDI-TOF MS peptide mass fingerprinting, and M. truncatula clustered EST database searches. This search method led to an increase in the percentage of successfully identified proteins to 83%. The M. truncatula membrane proteomics and a catalog of membrane proteins useful to future studies of these important cellular components.Plant membranes are key in maintaining homeostasis and in the transport/storage of cellular materials. They are also important in the perception and transduction of signals that enable effective communication with the cell’s surroundings. M. truncatula and provided an extensive analysis of their structure, lipid composition, and protein content. In the process, the authors identified 270 proteins associated with M. truncatula lipid rafts. The contamination of the plasma membranes was evaluated through the measurement of azide-sensitive ATPase activity for mitochondria and nitrate-sensitive ATPase for tonoplasts. The major proteins found were related to signaling, transport proteins, redox proteins, cytoskeleton, trafficking, and protein stability. The authors conclude that the lipid rafts contain a complete plasma membrane redox system important for stress mediation and defense, and contain a large number of receptor-like protein kinases (RLKs) that re-enforce the hypothesis that plant lipid rafts are part of the signaling network similar to animals.Glomus intraradices) inoculated or non-inoculated M. truncatula roots. Thirty-six 2-DE protein spots were differently accumulated where 15 proteins were induced, three were up-regulated, and 18 were down-regulated compared to 2-DE protein spots from non-inoculated roots. Among them, 25 spots were identified with MALDI-TOF MS peptide mass fingerprinting. Most of the identified proteins had not been associated with AM symbiosis previously via proteomics, transcriptomics, nor or suppressive subtractive hybridization which illustrated the potential of direct proteomics. Nineteen of the 25 mycorrhiza-responsive proteins were found to be not regulated by phosphate supply further suggesting that these proteins could serve as markers for AM symbiosis.The sub-cellular proteomes of membrane-associated protein modifications in response to arbuscular mycorrhizal (AM) symbiosis have also been studied . This ea+, Mg2+-ATPase sensitivity assays. Pyrophosphatase, inosine diphosphatase, nicotinamide adenine dinucleotide (NADH)-cytochrome c reductase insensitive to antimycin A and cytochrome c oxidase were used for markers for tonoplast, golgi, endoplasmic reticulum, and mitochondria respectively. In this study, the authors used two-dimensional LC-MS/MS or gelC-LC-MS/MS for protein separation and identification as opposed to the 2-DE method used in their earlier report which allowed for the identification of a larger number of proteins  and a predicted glycosylphosphatidylinositol-anchored blue copper-binding protein (MtBcp1). The role of these proteins in AM symbiosis remains to be investigated.proteins . CompariM. truncatula and the corresponding Rhizobia bacterium Sinorhizobium meliloti were investigated using 2-DE and LC-MS/MS  and two-dimensional LC-MS/MS. Western blot analyses were performed using antibodies against NifDK as a marker for bacteroid contamination. A quantitative analysis of plant and bacteroid responses to drought stress was also performed using one-dimensional-LC-MS/MS. The larger identified functional protein classes were involved in protein synthesis and degradation, amino acid metabolism, and glycolytic pathway and TCA cycle. The other functional groups comprised proteins involved in redox state control, defense against biotic and abiotic stress, and signaling processes in nitrogen-fixing nodules. In the quantitative study, the authors found the relative content of five nodule proteins such as Met synthase, SuSy, Asn synthetase (AS), Lb, and the transcriptional eukaryotic elongation factor-2 (eEF-2) decreased following water deficit compared to those from control nodules. The data confirm the role of SuSy and identified four new enzymes involved in drought stress.Pisum sativum). Another challenge was the identification of a whole set of proteins with diverse chemical properties. The structures of non-photosynthetic plastids are important because they are associated with nitrogen-assimilation, starch, and lipid synthesis. Plastids are also involved in connecting individual organelles during symbiotic nitrogen fixation. In this article, the authors provide an impressive comparison of the M. truncatula root plastid proteome relative to the proteomes of amyloplasts, chloroplasts, and proplastids. The authors conclude that the functional distribution of the M. truncatula root plastids proteome mainly resemble that of wheat endosperm amyloplasts and tobacco proplastids, but are markedly different from chloroplasts.Arabidopsis and rice, research using M. truncatula as a model system is increasing with the bulk of these efforts focused upon plant–microbe interactions and symbiosis. The current M. truncatula sub-cellular proteomics literature reveals nuclear proteome contains specific proteins involved in signaling and gene regulation; whereas the mitochondrial and chloroplast proteomes revealed protein fractions implicated in energy production, either in electron transport or in ATP production. Additional studies on the apoplast or secreted proteomes revealed predominantly defense related and cell wall modifying proteins. Substantial effort has also been focused on M. truncatula membranes during mutualism with AM symbiosis and many of the identified proteins had not been associated with AM symbiosis previously thereby providing additional compositional information relative to this important plant–fungal interaction. Legumes are unique in their ability to form unique symbiotic relationships with soil rhizobia in the fixation of nitrogen. Identified proteins in the M. truncatula rhizobia symbiosome membranes are critical for transport, energy, metabolic processes, nodule formation, signaling, pathogen response, and protein destination. These results provide novel insight into the exchange of nutrients and plant–rhizobia communication.Sub-cellular proteomics, the analysis of proteins purified from a cell compartment, has emerged as a promising method to better understand the spatial segregation of cellular processes and organelle function. A growing number of studies of plant proteomics have been reported on elucidating the protein functions and dynamics of plant sub-cellular compartments. Although more extensive sub-cellular proteomics literature exists for M. truncatula sub-cellular identified proteins is still quite modest relative to the number of proteins expected to be present and relative to other plant species such as Arabidopsis and rice. More comprehensive sub-cellular proteomics analyses; especially related to symbiosis, are expected to be even more informative. The accurate characterization of the proteome in different sub-cellular locations also remains a challenging task dependent on the successful isolation of purified organelles. The extent of error associated with the interpretation of protein sub-cellular localization is often due to inevitable contamination from other sub-cellular components. Accurate methods to detect and quantify proteins in mixtures are necessary to assess the purity of sub-cellular purification. Although the analysis of marker enzymes based on organelle specific antibodies and the microscopic detection of sub-organelle fractions are still useful to determine the purity, the accuracy is low and varies considerably. However, the combination of 2-DE profiling, MS-based measurements, and the use of genomic data can be useful for comparing protein identities and abundances among samples. In addition to developments in sub-cellular isolation methods, advances in bioinformatics are still needed to enable large-scale comparison and correlation of large datasets from various sub-cellular proteomics studies to better describe complex biological system.Overall the number of 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.


Mayeul Collot and Jean-Maurice Mallet were not included in the author byline. They should be listed as the eighth and ninth authors, respectively. Both Mayeul Collot and Jean-Maurice Mallet are affiliated with Ecole Normale Supérieure CNRS, Departement de Chimie, Paris, France. The contributions of Mayeul Collot are as follows: contributed reagents/materials/analysis tools and performed the experiments. The contributions of Jean-Maurice Mallet are as follows: conceived and designed the experiments.


The majority of the global population cannot afford existing asthma pharmacotherapy. Physical training as an airway anti-inflammatory therapy for asthma could potentially be a non-invasive, easily available, affordable, and healthy treatment modality. However, effects of physical training on airway inflammation in asthma are currently inconclusive. The main objective of this review is to summarize the effects of physical training on airway inflammation in asthmatics.A peer reviewed search was applied to Medline, Embase, Web of Science, Cochrane, and DARE databases. We included all observational epidemiological research studies and RCTs. Studies evaluating at least one marker of airway inflammation in asthmatics after a period of physical training were selected. Data extraction was performed in a blinded fashion. We decided a priori to avoid pooling of the data in anticipation of heterogeneity of the studies, specifically heterogeneity of airway inflammatory markers studied as outcome measures.From the initial 2635 studies; 23 studies (16 RCTs and 7 prospective cohort studies) were included. Study sizes were generally small (median sample size = 30). There was a reduction in C-reactive protein, malondialdehyde, nitric oxide, sputum cell counts and IgE in asthmatics with physical training. Mixed results were observed after training for fractional excretion of nitric oxide and bronchial hyperresponsiveness. The data was not pooled owing to significant heterogeneity between studies, and a funnel plot tests for publication bias were not performed because there were less than 10 studies for almost all outcome measures. Physical training intervention type, duration, intensity, frequency, primary outcome measures, methods of assessing outcome measures, and study designs were heterogeneous.Due to reporting issues, lack of information and heterogeneity there was no definite conclusion; however, some findings suggest physical training may reduce airway inflammation in asthmatics. Asthma is a multifactorial disease with genetic, environmental and inflammatory components in its etiology. The principal pathophysiology of asthma is chronic inflammation of the lower respiratory tract . PharmacPhysical exercise training is thought to be beneficial in asthma management, at least in children, but it has not been extensively studied . There aTo the best of our knowledge, there exists no systematic review to date focusing on the effects of physical training on airway inflammation in asthmatics. A Cochrane review published in 2012 summarized the effects of physical training on asthma and included only randomized controlled trials (RCTs) . The objA separate protocol for this review was not previously published.Studies were identified by searching electronic databases, and scanning reference lists of articles. The search was applied to Medline (1948 – 2012), Embase (1947 – 2012), and adapted for Web of Science (1898 – 2012) including SCI-EX (Science citation index Expanded), SCPCI-S (Conference Proceedings Citation Index – Science), and SPCI-SSH (Conference Proceedings Citation Index). It was also adopted for Cochrane (CENTRAL), and DARE (Database of Abstract of Reviews of Effectiveness), and the Cochrane Database of Systematic Reviews (Cochrane Reviews). These databases were searched for published studies that included physical training program in asthmatics. Variants of key words such as “Physical Education and Training”, “physical activity”, “physical training” were used. The search was run on April 19th, 2012. As we planned to investigate both humans and animal models, the search was not restricted to human subjects. No language or region restrictions were applied. The search was peer-reviewed by a librarian at The Ottawa Hospital, Ottawa, Canada.The following search strategy was applied to Medline and Embase :(exp Asthma/ OR asthma.tw) AND .tw) AND (inflammation or inflammatory).tw or Inflammation/ or exp Inflammation Mediators/or bronchial biopsy.mp or Cell Count/ or Sputum/ or Adenosine Monophosphate/ or Methacholine Chloride/ or Histamine/ or tumstatin.mp or Basement Membrane/ or Collagen/ or Collagen Type IV/ or Immunoglobulin E/ or T-Lymphocytes, Regulatory/ or eicosanoids/ or leukotrienes/ or prostaglandins/ or thromboxanes/ or cytokines/ or chemokines/ or interleukin-8/ or platelet factor 4/ or interferons/ or interferon type i/ or interferon-gamma/ or interleukins/ or interleukin-1/ or interleukin-2/ or interleukin-3/ or interleukin-4/ or interleukin-5/ or interleukin-6/ or interleukin-7/ or interleukin-9/ or interleukin-11/ or interleukin-12/ or interleukin-13/ or interleukin-15/ or interleukin-16/ or interleukin-17/ or interleukin-18/ or lymphokines/ or leukocyte migration-inhibitory factors/ or macrophage-activating factors/ or transforming growth factor beta/ or tumor necrosis factors/ or tumor necrosis factor-alpha/ or endothelial growth factors/ or fibroblast growth factors/ or platelet-derived growth factor/ or tolloid-like metalloproteinases/ or transforming growth factors/ or cells/ or antigen-presenting cells/ or granulocytes/ or basophils/ or eosinophils/ or neutrophils/ or leukocytes, mononuclear/ or cytokine-induced killer cells/ or killer cells, lymphokine-activated/ or monocytes, activated killer/ or t-lymphocytes, cytotoxic/ or lymphocytes/ or killer cells, natural/ or lymphocyte subsets/ or t-lymphocyte subsets/ or t-lymphocytes/ or cd4-positive t-lymphocytes/ or cd8-positive t-lymphocytes/ or natural killer t-cells/ or monocytes/ or fibroblasts/ or mast cells/ or epithelial cells/ or goblet cells/ or phagocytes/ or histiocytes/ or Nitric Oxide/ or lung inflammation.mp or Th2 Cells/ or Bronchoalveolar Lavage Fluid/ or airway inflammation.mp. or Bronchial Hyperreactivity/).A scoping search revealed few studies in this area pertaining to either humans or animal models of asthma; therefore, we decided to investigate this question for both animal models and human asthmatic subjects of all age groups (the former published separately ). For thThe search was applied to each database and the results were combined. Duplicate articles were removed. For the first search stage, two authors (V.L. and A.B.) independently scanned the titles and abstracts for selecting studies. At the first stage, studies were included if insufficient information was available to reliably exclude them. For the second stage, the full text of each study was obtained, and both authors independently applied the inclusion and exclusion criteria blinded to author and publication data. Studies meeting the inclusion/exclusion criteria were included for data extraction. Finally, the reference lists of all studies from stage 2 were reviewed to ensure that all relevant studies were considered. If there were any disagreements as to whether an article should be included or excluded, a third reviewer (S.P.) was called upon to reach a consensus. Human studies were used for this review, and animal asthma model studies were set aside for a separate review .Data extraction forms were created and piloted on six articles obtained from the initial scoping search. The data extraction forms were then modified to facilitate extraction of the relevant data. The data was extracted independently by two authors (V.L. and A.B.) blinded to the study authors, and publication date. Any disagreements were resolved by consensus after reviewing the study. The accuracy of the information was not verified with the authors of the original studies. Studies where the data was represented in graphical format only, or if there was insufficient raw numerical data to perform meta-analysis, study authors were contacted -25; we sThe following data was extracted from each of the included studies if available: study design, characteristics of subjects , physical training intervention/s , control intervention (if any), list of markers of airway inflammation, and the change in the evaluated markers of airway inflammation with physical training.To determine the validity of the included trials one author (A.B.) applied the Cochrane risk of bias tool to RCTs  and the We anticipated heterogeneity in studies in the primary outcome measures, methods of assessing outcome measures, and study designs. It is difficult to interpret pooled or summary measures in the presence of significant heterogeneity . We deciWe grouped the studies measuring similar markers of airway inflammation as outcome measures creating forrest plots for their mean differences to aid visual interpretation of effect estimates. We converted medians to means where the data appeared normally distributed in the graphs. Using appropriate formulae, we converted interquartile ranges, measures of variation, and 95% confidence intervals to standard deviations where the data appeared normally distributed .Though many studies reported on exercise-induced bronchoconstriction, this outcome was measured in a myriad of different ways hence the results were described only qualitatively.It is unknown if there was any selective reporting bias, as protocols for individual studies were not widely available. Funnel plots were not performed because, except EIB, there were less than ten studies reporting on any single outcome . Though Data analysis was performed using the software Comprehensive Meta-Analysis version 2.0. .The initial search yielded a total of 2635 citations. Twenty-five potentially eligible studies were selected in stage 1 based on titles and abstracts; inter-reviewer agreement was 100%. In stage 2, full texts of these 25 articles were reviewed; twelve studies were excluded for reasons stated in Figure Additional file We determined study-level and outcome-level risk of bias Tables  and 2. EMultiple studies with same outcome measure C - reactive protein (CRP)Three studies reported serum C-reactive protein (CRP) . All three studies demonstrated significantly decreased CRP mean estimates with physical exercise. Manual conversion of graphically presented data in two studies  did not accurately reflect the original findings and hence, we chose not to depict the CRP data graphically in this paper.A single study reported on the reactive oxygen species malondialdehyde (MDA) and total plasma nitric oxide (NO), as well as the antioxidants serum superoxide dismutase (SOD), and glutathione peroxidase (GHS-Px) . The NO A single study reported on sputum cell counts and found decreased total cells and eosinophils in asthmatics post-training, but there was no change in sputum macrophages, neutrophils, lymphocytes, epithelial cells, squamous cells, goblet cells, or ciliated cells .One study reported a decrease in serum IgE and in mite-specific IgE in the physically trained group. However, it must be noted that, the study was performed from February to March and there was also a significant decrease in these values in the control group. This raises the question of whether the IgE reduction was due to the subjects spending more time outside with less exposure to dust mites .Gunay et al. studied serum endothelin-1, matrix metalloproteinase-9, MDA and urine leukotriene E4 (LTE4) in asthmatics on pharmacologic therapy in comparison to those on pharmacologic therapy and exercise training. Serum endothelin-1 was decreased in the group allocated to pharmacologic therapy and exercise only; however, the urine LTE4, MDA and serum matrix metalloproteinase-9 decreased to the same extent in both the groups .A single study reported on adiponectin and leptin in asthmatics after one year of training . AdiponeFractional excretion of nitric oxide (FeNO) Four studies reported fractional excretion of nitric oxide (FeNO) shown in Figure Bronchial hyperresponsiveness to methacholine or histamineEight studies reported on bronchial hyperresponsiveness to either methacholine or histamine ,44,46,51Exercise-induced bronchoconstriction (EIB) The effect of training on exercise-induced bronchoconstriction was reported in thirteen studies . The criteria for exercise-induced bronchoconstriction varied between studies with some relying on peak expiratory flow analysis, and the exercise test protocols used to measure EIB also varied. Eight of these studies showed decreased EIB post-training but many of these results are marred by serious methodological flaws including relatively reduced ventilator stress at the post-training test owing to improvements in fitness during the training period, possible use of β2 agonists pre-testing, and the possible role of medication changes during the training period that could have contributed to a reduction in EIB .Only one study reported on serum eosinophils and there was no difference between controls and the trained group . The samOne study reported on exhaled breath condensate of cysteinly leukotrienes and found no change post training .Physical exercise has multi-faceted benefits in health and disease ,62 and iPhysical exercise does seem to have beneficial effects on reducing airway inflammation as shown by reduction in CRP ,57,60. CThe results from single studies do demonstrate that there is a signal for reduction in airway inflammation in response to physical training; however, we cannot conclude the benefits based upon the data from single studies. Nevertheless, the effects on reactive oxygen species after physical training are important: there is reduction in malondialdehyde (MDA) and total plasma nitric oxide (NO), no further increase in SOD beyond that seen with ICS alone, and increase in GSH-Px with the combination of ICS and exercise . SimilarMultiple studies have evaluated fractional excretion of Nitric Oxide (FeNO) Figure A, bronchFinally, the method of diagnosis of asthma was not uniform in all the studies which could introduce selection bias , thereby limiting the conclusions that could be drawn. In addition, reporting was not uniform across studies, especially e.g. asthma diagnosis, asthma medications, asthma severity and control. Finally, different markers of airway inflammation were used in different studies, leading to few studies reporting on any single outcome. Most importantly, physical training intervention(s)  and control intervention(s) were heterogeneous across studies. These issues combined to limit the strength of our conclusions.Effectiveness of physical exercise on airway inflammation is yet unproven. There is, however, some evidence to suggest that physical exercise may reduce inflammation in an asthmatic airway. Should such evidence emerge in future research, physical exercise may well prove to be an affordable, accessible, healthy, non-invasive, and enjoyable asthma management strategy. We urgently need to design studies to understand if this non-pharmacological adjunctive strategy can effectively decrease airway inflammation, control symptoms of asthma, and be safely administered in the community.No competing interests for any author.SP had full access to the data and takes full responsibility for the integrity of the data and the accuracy of the data analysis, contributed to the concept, design, implementation, statistical analysis, interpretation and writing. VL contributed to the data management, statistical analysis, interpretation and writing. AB contributed to the data management, statistical analysis, interpretation and writing. LT contributed to the data analysis, interpretation and writing. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2466/13/38/prepubSummary of included studies. This file provides details of the studies included in this systematic review including the number of subjects, mode of asthma diagnosis, asthma severity and control, current asthma pharmacotherapy, study design, training intervention , control intervention and outcome measures.Click here for filePRISMA Checklist.Click here for file