Allium cepa roots as a model system. The activity of CDK genes modulated by auxin and cytokinin during cell division, elongation, and endoreduplication process is explained in this research work. To study the significance of auxin and cytokinin in the management of cell division and endoreduplication process in plant meristematic cells at molecular level endoreduplication was developed in root tips of  Allium cepa by giving colchicine treatment. There were inhibition of vegetative growth, formation of c-tumor at root tip, and development of endoreduplicated cells after colchicine treatment. This c-tumor was further treated with NAA and BAP to reinitiate vegetative growth in roots. BAP gave positive response in reinitiation of vegetative growth of roots from center of c-tumor. However, NAA gave negative response in reinitiation of vegetative growth of roots from c-tumor. Further, CDKs gene expression analysis from normal, endoreduplicated, and phytohormone (NAA or BAP) treated root tip was done and remarkable changes in transcription level of CDK genes in normal, endoreduplicated, and phytohormones treated cells were observed.Molecular mechanism regulated by auxin and cytokinin during endoreduplication, cell division, and elongation process is studied by using  Endoreduplication cycle is believed to be the switch between cell proliferation and cell differentiation during the developmental stages . The tim Allium cepa were taken as experimental model to study regulation of cell cycle and endoreduplication at molecular level. This plant is an ideal model system for investigating the relationship between cell division and endoreduplication process, as root tips and intercalary meristems of monocotyledons grow fundamentally linear and growth occurs in a well-defined region. In such a linear system, by adopting the cellular view, an organs growth can be determined at a steady-state rate. Allium cepa roots were used to study plant cell proliferation and endoreduplication at molecular level due to its relatively simple structure and distinct regions of meristem, elongation, and mature zones. When cells leave the meristematic zone, they enter the elongation zone. Here, they no longer divide but continue to elongate, resulting in a rapid increase in length as a function of position. Basal to the elongation zone, cells are of constant size and considered mature. After maturation they undergo differentiation  as listed in Primers used in quantification of the relative level of transcripts of CDKs genes were selected from the reprint of Miao et al.  CDKA;1  [tubulinSupplementary data Figure 10: shows changes in morphology of Allium cepa root growth after colchicine, NAA and BAP treatment. Allium cepa root grown in distilled water for 120h showed normal thin root. When young root (24h old) of Allium cepa was exogenously treated with NAA for 120h, C-tumor formation and inhibition in growth of root was observed. When young root was exogenously treated with BAP it showed faster and normal growth of root. When young root was treated with colchicine for 120h, c-tumor formation was observed. This colchicine treated root when treated with NAA for 120h showed no change in growth of root. But colchicine treated root when treated with BAP for 120h showed increase in growth of root.Supplementary data Figure: 11Shows changes in length of Allium cepa roots after exogenous colchicine and NAA treatment.Supplementary data Figure: 12Shows changes in length of Allium cepa roots after exogenous colchicine and BAP treatment.Click here for additional data file.


Rapidly proliferating tumors attempt to meet the demands for nucleotide biosynthesis by up-regulating folate pathways that provide the building blocks for pyrimidine and purine biosynthesis. Reduced folates are carriers of one carbon units required for the synthesis of purines, thymidylate and methionine, derived from serine, glycine and formate. As folate metabolism plays a key role in cell proliferation, the folate-requiring enzymes dihydrofolate reductase and thymidylate synthase have long been key targets for treatment of cancer. Recent studies show that the mitochondrial folate enzymes are also critical, in that they enable mitochondria to produce additional one carbon units for purine synthesis to allow for rapid growth. In transformed cells, methylene tetrahydrofolate dehydrogenase MTHFD2 is often reactivated and expressed along with other members of the serine synthesis, one carbon (folate) metabolism and glycine cleavage system, allowing for enhanced production of purines, ATP and NADPH, fueling cell proliferation . More reUsing gene expression arrays, we have shown that overexpression of mitochondrial enzymes, particularly MTHFD2, is associated with both high proliferation rates and cMYC overexpression ; this keThe New Twist. It has recently been shown that MTHFD2 can have an impact on proliferation independent of its enzymatic activity . In thes


Objective. To describe selected biochemical and hematological parameters  in petrol station attendants in Mansoura city. Methods. This is a comparative cross-sectional study. The exposed group included 102 petrol station attendants. They were compared to a matched group of healthy 102 male service and office workers at the Faculty of Medicine, Mansoura University. The results of blood picture, liver enzymes, and kidney functions were compared between both groups. Results. Mean Red Blood Cells (RBCs) count, hemoglobin level, and Hematocrit (HCT) level were significantly lower in petrol station attendants than the comparison group. All other blood picture parameters showed nonsignificant difference between both groups. Liver enzymes, renal functions, serum albumin, and total protein showed statistically nonsignificant difference between both groups except for alanine aminotransferase (ALT) which was significantly higher in petrol station attendants. Conclusions. Some laboratory parameters among petrol station attendants showed changes that could be attributed to workplace exposure and should be given attention at preemployment and periodic medical examination. Petrol (or gasoline) is a mixture of volatile hydrocarbons, while diesel fuel is a distillate of petroleum which contains paraffins, alkenes, and aromatics .Fuel (petrol and diesel) filling station attendants (FFSAs) are exposed to a mixture of hydrocarbons in fuel vapours during dispensing fuel and to the gases from vehicular exhaust . In fillCertain people have a greater risk of exposure to gasoline vapors; these include filling station workers, service station attendants, drivers of gasoline trucks, and refinery workers. The volatile nature of petrol products makes them readily available in the atmosphere any time it is dispensed, especially at petrol filling stations and depots .Many of the harmful effects seen after exposure to gasoline are due to the individual chemicals in the gasoline mixture, such as benzene, lead, and oxygenates. Breathing small amounts of gasoline vapors can lead to nose and throat irritation, headaches, dizziness, nausea, vomiting, confusion, and breathing difficulties. Some effects of skin contact with gasoline include rash, redness, and swelling. Allergic reactions (hypersensitivity) have been reported but these are rare occurrence , 6. The Occupational diseases in gasoline filling workers have been recognized for many years and affect workers in different ways; such diseases are still problems in all parts of the world. The numbers of such work-related diseases in developing countries are much higher in reality than the numbers that are reported. The numbers of cases and types of occupational diseases are increasing in both developing and industrialized countries .To the best of the authors' knowledge no past studies have investigated the laboratory profile of petrol station attendants as a result of their workplace occupational exposure in Egypt.The objective of this study was to describe selected biochemical and hematological parameters  in petrol station attendants in Mansoura city.A comparative cross-sectional study was conducted upon petrol station attendants at Mansoura city during the period from January 1, 2015, to March 31, 2015.Google Earth.” The study included 102 out of 112 petrol station attendants with a response rate of 91%, recruited from 6 stations with the largest workforce (more than 5 workers) and agreed to participate in the study. All attendants are males working either in fuelling service for 24 hours/day for three days in one week and for four days in the next week in an alternating pattern or in car maintenance and wash and oiling services for 8 hours/day from 9 a.m. to 5 p.m.There are 14 petrol stations in Mansoura city and neighborhood as detected by “The petrol station attendants were interviewed and a blood sample was taken at the administrative office at each station at 10 a.m. where their workload at this time is relatively light.The group comprised 102 male service and office workers at the Faculty of Medicine, Mansoura University, comparable to petrol station attendants in most of the variables except for the risk of exposure to petrol. They represent 89.5% of all male service and office workers. They were interviewed and examined at the department of public health and community medicine during the work day.Ethical Consideration. Approvals of the studied petrol stations, Faculty of Medicine authorities, and the research ethics committee were obtained. An informed verbal consent of study subjects to participate voluntarily in the study with a full right to withdraw, as they were willing to make a health check for free, was obtained with assurance of confidentiality and anonymity of the data.Interview: a questionnaire was used to collect the following information: sociodemographic and occupational profile of workers; usage of personal protective equipment and reasons for nonusage; general health status; and respiratory complaints.Laboratory investigation: a 5 mL blood sample was taken from each participant through venipuncture which was then divided into the following:There is two mL blood collected in a plastic tube containing ethylenediaminetetraacetic acid (EDTA) for complete blood picture.There is three mL blood collected in a dry plastic tube for kidney function tests  and liver function tests , serum albumin, and total protein). The sample was allowed to clot naturally to separate the serum for analysis and was stored upright at room temperature until it was transported to the laboratory for analysis. In the laboratory, each sample was centrifuged and stored in the freezer at −70°C until being processed.Each participant was subjected to the following:Data Analysis. Data were entered and statistically analyzed using the Statistical Package for Social Sciences (SPSS) version 17. The cut-off points for different parameters were defined according to the laboratory standard defined by the manufacturer of the kits. Qualitative data were described as numbers and percentages. Chi-square (χ2) test was used for comparison between groups. Quantitative data were described as means (standard deviation (SD)) or medians, as appropriate. They were tested for normality by Kolmogorov-Smirnov test. In the normally distributed variables, independent sample t-test was used, while in nonnormally distributed variables, Mann Whitney test was used for comparison between groups. “p value ≤ 0.05” was considered to be statistically significant.Petrol station attendants matched the comparison group in all sociodemographic and occupational profile items except for the median duration of smoking which was longer in petrol station attendants .Mean RBCs count, hemoglobin level and the percent anemic, and HCT level were significantly lower in petrol station attendants than the comparison group. All other blood picture parameters showed nonsignificant difference between both groups .Liver enzymes, renal functions, serum albumin, and total protein  showed statistically nonsignificant difference between both groups except for ALT which was significantly higher in petrol station attendants .Both groups neither had health insurance, worn personal protective equipment (PPE) due to their unavailability nor had preemployment or periodic examination. Among petrol station attendants, one (1%) complained of headache and vertigo, one (1%) complained of morning cough and shortness of breath, and two (2%) complained of skin itch, redness, and rash (data are not shown in tables).The association between exposure to benzene or benzene-containing mixtures and certain types of blood disorders has been shown in epidemiological studies in different countries , 10. BenThe results of the study showed that the mean hemoglobin level and RBCs count of petrol station attendants were significantly lower than those of the comparison group while mean white blood cells (WBCs) and platelets counts were higher among petrol station attendants with nonsignificant difference between both groups. Similarly, in hematological assessment of gasoline exposure among petrol filling workers in Baghdad, their mean hemoglobin level, WBCs, and RBCs counts were significantly lower than those of comparison group .In this study, mean HCT value was significantly lower in petrol station attendants than comparison group while mean corpuscular volume (MCV), mean corpuscular hemoglobin (MCH), and mean corpuscular hemoglobin concentration (MCHC) were similar in both groups with statistically nonsignificant difference between them. Previous studies did not detect decreased blood cell counts on routine monitoring of workers exposed to low level of benzene , 14.Liquefied petroleum gas- (LPG-) exposed workers of Gaza governorates were found to have significantly higher values of RBC, hemoglobin, HCT, MCH, MCHC, and platelets than comparison group while the mean WBCs count was significantly lower. This study showed a significant effect of LPG exposure on the haematological parameters of LPG workers compared to comparison group . Their rIn the study, the median values of ALT and AST were higher among petrol station attendants than the comparison group where ALT showed significant difference between them while AST showed nonsignificant difference. Similarly, the mean values of serum AST and ALT were significantly higher among LPG workers of Gaza governorates  compared with controls   showed tThis study showed that serum uric acid, urea, and creatinine levels were higher among petrol station attendants than comparison group however statistically nonsignificant. Similarly, serum levels of urea and creatinine were shown to be significantly elevated in gasoline filling workers in Sulaimani City, Kurdistan, more than comparison group, though these values are still within the highest accepted normal ranges . Also, tThis study showed lower mean values of serum albumin and total protein among petrol station attendants than comparison group with statistically nonsignificant difference between them. In Sulaimani City, Kurdistan, total plasma protein levels were not significantly changed in gasoline filling station workers compared to nonexposed subjects, while plasma albumin levels were significantly elevated in workers more than comparison group .Fuel products are mixtures of aliphatic and aromatic hydrocarbons mostly related to gasoline; most of them are toxic to many organ systems including the kidney , 25, whiIn this study, 1% of petrol station attendants complained of headache and vertigo, morning cough, and shortness of breath, and 2% complained of skin itch, redness, and rash. The results of the study of workers at filling and distribution stations of LPG of Gaza governorates showed significantly higher rates of nearly all health status items in LPG workers than comparison group, especially experiencing headache or fatigue in work, eye itches, redness, pain, skin itches, redness and rash, and respiratory complaints, such as fatigue during climbing stairs, repeated sneezing during working hours, shortness of breath in poorly ventilated room, and shortness of breath in the workplace .Studies in different settings showed similar results to that of Gaza Strip, especially concerning health complaints related to respiratory system , 30. TheThe frequency of general health and respiratory complaints among petrol station attendants in our study is low despite the nonuse of PPE at work and this could be attributed to the outdoor location of petrol stations together with the enclosed system for fuelling vehicles that could minimize exposure to benzene.


To investigate factors influencing the adoption of kangaroo mother care in different contexts. We searched PubMed, Embase, Scopus, Web of Science and the World Health Organization’s regional databases, for studies on “kangaroo mother care” or “kangaroo care” or “skin-to-skin care” from 1 January 1960 to 19 August 2015, without language restrictions. We included programmatic reports and hand-searched references of published reviews and articles. Two independent reviewers screened articles and extracted data on carers, health system characteristics and contextual factors. We developed a conceptual model to analyse the integration of kangaroo mother care in health systems.We screened 2875 studies and included 112 studies that contained qualitative data on implementation. Kangaroo mother care was applied in different ways in different contexts. The studies show that there are several barriers to implementing kangaroo mother care, including the need for time, social support, medical care and family acceptance. Barriers within health systems included organization, financing and service delivery. In the broad context, cultural norms influenced perceptions and the success of adoption.Kangaroo mother care is a complex intervention that is behaviour driven and includes multiple elements. Success of implementation requires high user engagement and stakeholder involvement. Future research includes designing and testing models of specific interventions to improve uptake. Complications of preterm birth are the leading cause of death among newborns.To understand factors influencing adoption of kangaroo mother care in different contexts, we did a systematic review. We created a narrative analysis of the articles and reports identified, guided by a conceptual frameworkWe searched PubMed, Embase, Web of Science, Scopus, African Index Medicus (AIM), Latin American and Caribbean Health Sciences Literature (LILACS), Index Medicus for the Eastern Mediterranean Region (IMEMR), Index Medicus for the South-East Asian Region (IMSEAR) and Western Pacific Region Index Medicus (WPRIM) without language restrictions, from 1 January 1960 to 19 August 2015 using the search terms “kangaroo mother care” or “kangaroo care” or “skin-to-skin care.” We excluded studies without human subjects or without primary data collection. We screened studies for inclusion if they discussed barriers to kangaroo mother care implementation or enablers for successful implementation. Our population of interest included mothers, newborns or mother-newborn dyads who had practiced kangaroo mother care, and health-care providers, health facilities, communities and health systems that have implemented such care. We hand-searched the reference lists of published systematic reviews and references of the included articles. To search the grey literature for unpublished studies, we explored programmatic reports and requested data from programmes implementing kangaroo mother care.Two reviewers independently extracted data from identified articles using standardized forms to identify potential determinants of kangaroo mother care uptake, including data on knowledge, attitudes and practices. Reviewers compared their results to reach consensus and ties were broken by a third party. To assess study quality, we evaluated each study in five quality domains: selection bias, appropriateness of data collection, appropriateness of data analysis, generalizability and ethical considerations.A deductive approach was used to fit the outputs of the analysis to the elements of the conceptual framework and explore emerging themes.Themes were explored at each level of implementation . We examined the interactions between implementers and described health system characteristics that could influence the uptake of kangaroo mother care.Of the 2875 papers identified, we included 112 studies with qualitative data on barriers to and enablers of kangaroo mother care . Most of–,–,–The narrative synthesis of the studies showed that the burden of death and disability of newborns was acknowledged as an important problem.The included studies revealed that kangaroo mother care is a complex intervention with several possible components – skin-to-skin contact, breastfeeding, early discharge and follow-up . The inc–,–,,–,,,,The promotion of skin-to-skin contact for as long as possible once the newborn was stabilized emerged as a common theme in several studies.,,The complexity of kangaroo mother care and lack of a standardized operational definition makes it challenging to implement. Implementation of kangaroo mother care can be considered at three levels: (i) mothers, fathers and families; (ii) health-care workers; and (iii) facilities. The location of facilities and the resources available determine whether kangaroo mother care takes place in the health facility or at home.,,,,Mothers, fathers and families were usually the primary caregivers of preterm newborns and involved in decision-making and practice of care.We identified six major themes concerning barriers and enablers for implementation of kangaroo mother care: (i) buy-in and bonding; (ii) social support; (iii) time; (iv) medical concerns; (v) access and (vi) context .,Buy-in and bonding refer to the acceptance of kangaroo mother care, belief in the benefits of such care to mothers and preterm or low birthweight infants and reported perceptions of bonding. Fear, stigma and/or anxiety about having a preterm infant impaired the care process. Mothers felt shame or guilt for having a preterm infant,,,,,,Positive perceptions of the potential benefits of kangaroo mother care for caregivers and for newborns among mothers, fathers and families promoted uptake. Studies used words such as relaxed, calm, happy, natural, instinctive and safe to describe the bonding process that mothers and fathers reported during and after kangaroo mother care.,–,,,,,,,,,,,,,,,,,,A lack of belief in kangaroo mother care and limited knowledge of such care restricted its uptake among health-care workers.,,,,,Social support refers to assistance received from other people to perform kangaroo mother care. While practicing kangaroo mother care, both mothers and fathers did not feel supported by their families or communities.,When institutional leadership did not prioritize kangaroo mother care, health-care workers were less motivated to practice or teach it,,,,,,,,,The time needed to provide kangaroo mother care was a potential barrier for mothers, fathers and families, due to responsibilities at home and work and time needed for commuting, preventing them from devoting the time needed for continuous and extended kangaroo mother care.One study showed that uptake of kangaroo mother care increased with expansion of visiting hours at health facilities.,,,,,,Clinical conditions of the mother and/or newborn may prevent kangaroo mother care from occurring. The medical effects of delivery for mothers, including fatigue, depression and postpartum pain, especially after a caesarean section, can reduce uptake of kangaroo mother care.,,,,,,While parents believed that kangaroo mother care was less costly than incubator care,,,,,,,Without uniform knowledge and protocols within a facility, health-care workers were uncomfortable promoting kangaroo mother care.,,,Sociocultural context and sociocultural constructs of gender and roles of parents in childcare, men in the household and other family members influenced uptake.http://www.who.int/volumes/94/2/15-157818) for full details of the included studies.Please refer to the supplementary ,The core components of kangaroo mother care are skin-to-skin contact and feeding support. Additional features such as the frequency and location of early-discharge and follow-up depend on the context.,,The stresses and stigma associated with having a preterm infant can hinder buy-in and support from parents and families for practicing kangaroo mother care. This problem is compounded by a lack of knowledge about kangaroo mother care among parents, families and health-care workers. Clear articulation of the benefits of kangaroo mother care for mothers and for newborns, creation of a community among parents, caregivers and health-care workers and engagement of fathers in childcare can help overcome these barriers. Collaboration among health-care workers, with shared goals and team commitments, partnering inexperienced nurses with nurses experienced in kangaroo mother care can also help.There are substantial barriers to kangaroo mother care within health systems, especially financing and service delivery. Dedicated financing for kangaroo mother care is critical for it to be seriously considered and implemented. Funding should consider creation of suitable environments , reducing burden of transport costs to mothers, home visits by community health workers and training parents to perform kangaroo mother care as independently as possible. Financing should be augmented with policies, guidelines, role definitions , education (in service and pre-service) and monitoring systems that are suitably tailored for different settings (including in the community).,Logistic issues, such as time for travel and kangaroo mother care, can be challenging but could be partly overcome by incorporating targeted assistance and support and extension of visiting times. Buy-in from policy-makers is critical to promote kangaroo mother care, especially through policies like maternity and paternity leave.We may not have captured all the programmatic reports and data available. In particular, most of the studies included in our review were published from regions with low neonatal mortality. This limits the generalizability of our findings.Prolonged skin-to-skin care demands time and energy from mothers recovering from labour and carers who may have other obligations. Many women are not aware of kangaroo mother care; health workers have not been trained or, if trained, do not promote such care. Kangaroo mother care may not be socially acceptable or even conflict with traditional customs. There is lack of standardization on who should receive kangaroo mother care and the presence of admissions criteria in neonatal units.Kangaroo mother care should be practiced more systematically and consistently to enhance adoptionKMC: kangaroo mother care.


Envenomings by snakebites and scorpion stings impose a high burden worldwide and result in considerable social and economic impact . It is eBothrops AV (main one), Crotalus AV, Bothrops-Crotalus AV, Bothrops-Lachesis AV, and Micrurus AV. For scorpion stings, there are two types of AVs available in Brazil: Tityus scorpion AV and a polyvalent AV against Loxosceles and Phoneutria spiders and the Tityus scorpion. In Brazil, the Ministry of Health implemented the National Program for Snakebites Control in 1986, extended to other poisonous animals in 1988. Since then, antivenom (AV) production has been standardized and all the AV production from the three national laboratories  was acquired by the Ministry of Health for distribution free of charge to patients. Five types of snake AVs are currently available: In 2013, 27,181 and 78,091 cases of snakebites and scorpion stings were reported by the Brazilian Ministry of Health, respectively . The higseringueiros) [Most of the information regarding snakebites in the Brazilian Amazon is based on surveillance data or hospital medical records. Community surveys were conducted with forest-dwelling Indigenous people and rubber tappers (gueiros) , and inhgueiros) . Snakebigueiros) –12, strogueiros) –11,13 angueiros) ,7 were tgueiros) ,10–12. Lgueiros) ,12,13. Cgueiros) –8,10,11.Bothrops snakebites are the most commonly recorded, accounting for around 80% of all cases [Lachesis accidents predominated in the case series from Cruzeiro do Sul (Acre) (51.3%), followed by Bothrops and Bothriopsis (38%). However, the authors highlight a possible confounding factor in snake identification by the local population since both Bothrops atrox and Lachesis muta receive the same popular name “surucucu” in certain Amazonian areas [ll cases ,12,13. Lan areas .Tityus obscurus, especially in the state of Pará, which can result in serious and fatal accidents [Scorpion stings in the Amazon are mostly caused by ccidents ,15. A veccidents .Major species responsible for snakebites and scorpion stings in the Brazilian Amazon are presented in Figs Rede de Ofidismo e Escorpionismo da Amazônia-ROdA) emerged from researchers at the Butantan Institute and the Tropical Medicine Foundation Dr. Heitor Vieira Dourado.Despite important efforts carried out during the past decades in Brazil to understand and control the problem of snakebite and scorpion sting envenomings, important gaps remain for the fulfillment of these goals, particularly in the Amazon region. A workshop was held in Manaus, Amazonas, in 2013 with representatives of Health Departments of Amazonian states, AV producers, universities, reference hospitals, and the Ministry of Health to identify research bottlenecks. A proposal to create the research network Snakebite and Scorpionism Network in the Amazon , which are not always available in these remote settings. In addition, training of multidisciplinary teams is not always appropriate for indigenous health services regarding AV administration, side effect management, and case monitoring and surveillance.Assess disease burden through population- and hospital-based field studies in remote areas;Seek innovation in the network for efficient distribution of immunobiologicals, especially interaction with other networks such as those providing vaccines;Integrate different sectors  for articulation of common strategies to be pursued with other ministries ;Review the skills of professionals assisting injured patients in areas without infrastructure and doctors according to international guidelines .Recommendations:Bothrops venom [Currently, AV immunoglobulins are the only treatment available for snakebites and scorpion stings envenomings. The WHO List of Essential Medicines includes them in the basic package of health care in affected countries. There is an urgent need to ensure availability of effective AVs and to improve their manufacture regulation. However, the possible interspecific venom variation associated with the geographical distribution of snakes may affect the effectiveness of therapeutic AVs against the Amazon ps venom ,18.Bothrops atrox, the main cause of snakebites in the Amazon. Efficacy of Brazilian AVs against venom from some Amazon Bothrops species has been investigated [Bothrops AV showed neutralization of B. atrox venom major toxins [Tityus serrulatus antigen, whereas T. obscurus is the most prevalent scorpion in the Amazonian region. However, some evidence suggests toxicity variation resulting from the diversity of T. obscurus venom in different Amazon areas [Current AV production methods, based on studies conducted in the 1980s, need updating in light of new technologies. Antivenom recommendations are based on experimental studies of cross-neutralization between specific venoms and AVs [stigated . Bothropr toxins ,22. Scoron areas . Thus, nA major concern relates to the failure in AV distribution. Antivenoms are usually available in the municipal hospitals, as opposed to being distributed to peripheral health clinics. The lack of adequate cold chain impairs AV distribution to rural areas. Also, inadequate storage and transportation may result in loss of material. Freeze-dried AVs are available and one of the national producers (Butantan Institute) has been working to provide both liquid and freeze-dried products.Revise toxicity of snake venoms, including proteomics, as well as the potential for AV neutralization against major venom activities;Bothrops atrox and Tityus obscurus venoms in these pools. Experimental studies should indicate the need for inclusion of new venoms, the new product needs to be validated by clinical and epidemiological data;Study seroneutralization in experimental models to support the venom pool used to immunize animals for AV production, considering the absence of Perform stability studies of liquid AVs considering the Amazonian environmental conditions. Decisions on AV distribution, either liquid or freeze-dried products, should be based on careful and detailed analysis of the epidemiology of snakebites, the prevailing conditions, and health facilities available;Study the mechanisms of venom action for different populations of snakes and scorpions in the Amazon (inter- and intra-species variations);Study supporting action or herbal drugs with specific activity on certain venom components to enable complementary or alternative treatments.Recommendations:Although clinical research related to venomous animal injuries has increased, most publications are based on case reports and lack methodological rigor. Moreover, outcome definitions, such as severity ranking criteria, were empirically established, making the results even less generalizable. Clinical research from hospital-based studies  and community observational studies  are needed.Bothrops  and defining objective criteria for recommending AV dosage;Identification of the species responsible for snakebites in the Amazon requires the establishment of a gold standard method and determination of levels of antigenemia, preferably by means of rapid diagnostic tests;Evaluate phase IV studies for adverse reactions (from three Brazilian manufacters) under AV pharmacovigilance;Submit phase II/III protocols simutaneously to assess feasibility of comparative studies on efficacy and safety;Plan training in Good Clinical Practices, as well as establish a link to the National Clinical Research Network (RNPC) from Teaching Hospitals;Inform the regulatory agencies about the limitations and peculiarities of research involving animal envenomings, paying clarification and consultation to the National Human Reseach Ethics Council and the National Regulatory Agency.Recommendations:Early adverse reactions (EAR) to AV therapy are expected events of varied frequency according to the type of AV used and individual hypersensitivity to heterologous proteins. Clinically, patients may present urticaria, itching, tachycardia, nausea, vomiting, abdominal colic, bronchospasm, hypotension, and angioedema. Over time, both the frequency and severity of early reactions have decreased due to the improvement of the AV purification process in Brazil. Frequency of delayed reactions (serum sickness) seems to be lower than EAR, but the true frequency is unknown. AV pharmacovigilance has been implemented, but reliable efficacy and safety data are still lacking.There are no accurate predictive factors for side effects occurrence and preventing them is not always possible, even with the use of premedication containing corticosteroids and/or antihistamines. Existing studies do not include controls for the intervening variables and samples are of insufficient size, limiting the validity of the results .Perform multicenter phase IV studies, identifying sentinel hospitals for monitoring cases for both early and late reactions.Recommendations:Despite the high incidence of injuries from venomous animals, there is a lack of systematic professional training on diagnosis, specific therapy, and clinical management of complications. Thus, AV misuse is not infrequent, either in quantity (number of ampoules administered) or the specific AV. Current training programs seek to link medical knowledge with the snakes’ and scorpions’ biology and surveillance. However, this approach often does not reflect the need for professional diagnosis algorithms and coherent and responsive medical management. Thus, adherence to medical training and courses in this area has been a major challenge. Furthermore, there is a high turnover of health professionals in small Amazon cities. Although communication technologies that greatly facilitate knowledge dissemination have proliferated in the area, these are still barely harnessed. The use of electronic media for training professionals in the management of envenomations is increasing and may be an alternative to classroom courses.Investments in training should cover all health professionals, including nurses who are critical to initial management of the patient and follow up of possible complications;Update systematically all relevant diagnosis and treatment guidelines;Encourage the use of technological resources for communication and other electronic media used in training programs and distance learning;Include the topic in the undergraduate curriculum of health professionals with regionalized approaches to issues involving venomous animals;Design new post-graduate and other courses, as well as interaction between graduate programs to increase the critical mass of professionals and researchers involved;Inplement non-formal education activities for science communication, particularly aimed at school audiences.Recommendations:Traditionally, institutions producing AVs get animals caught from nature that are kept in vivariums and used to obtain venoms. However, environmental legislation restricts the collection and transport of wild animals. There is a requirement to establish specific policies to capture animals, and captive breeding is not done satisfactorily.Field work is not limited to animal collection; it also includes studies of behavioral patterns such as diet, reproduction, and activities to establish phylogeny patterns for identifying risk factors of the envenomings. Increased knowledge on biodiversity of Amazon animals has applications on their use and species conservation. Zoological collections of invertebrates are also informative regarding their geographical distribution and diversity.Lachesis snakes and transport to vivariums of laboratories producing AVs;Establish partnerships for capture of Lachesis reproduction in captivity, which should be led by professionals familiar with their conditions both in nature and supportive maintenance environment;Guide Follow shared Standard Operating Procedures (SOPs) for the collections of venomous animals in order to facilitate exchange of information.Recommendations:In addition to all the above recommendations, the group highlights the importance of international cooperative efforts towards the control of these neglected health problems through international partnerships, namely with other Amazonian countries.


Saccharomyces cerevisiae strains having a broad range of substrate utilization, rapid substrate consumption, and conversion to ethanol, as well as good tolerance to inhibitory conditions are ideal for cost-competitive ethanol production from lignocellulose. A major drawback to directly design S. cerevisiae tolerance to inhibitory conditions of lignocellulosic ethanol production processes is the lack of knowledge about basic aspects of its cellular signaling network in response to stress. Here, we highlight the inhibitory conditions found in ethanol production processes, the targeted cellular functions, the key contributions of integrated -omics analysis to reveal cellular stress responses according to these inhibitors, and current status on design-based engineering of tolerant and efficient S. cerevisiae strains for ethanol production from lignocellulose. Saccharomyces cerevisiae. There is also much interest in the use of lignocellulose as a feedstock for future production of ethanol, since this source is much more abundant and, most important, it does not compete with food for supplies  and 2-furaldehyde  are formed from thermal oxidation of hexoses and pentoses during pretreatment  and changes in mitochondrial genome   are more sensible to thermal stress  upon being exposed to environmental changes , antioxidant enzymes , molecular chaperones and their cofactors , and the TFs , among others  and the heat-shock elements (HSE) targeted by both RIM15 and MSN2/4, and HSF1 and MSN2/4, respectively  and UV radiation, has been used for long time to generate populations with a set of mutations from which the useful ones are selected from experiments with the desired environmental pressure. This method has been used in combination with cellular shorting procedures to analyze thousands of phenotypes and came up with the most desired one -ATPase gene, PMA1, in laboratory strains increased ethanol production by around 30% respect to the laboratory strain S288C and by 10% compared to industrial strains  as the dominant mutation which provided increased tolerance to elevated concentrations of glucose and ethanol, as well as improved ethanol production  resulted in the selection of strains capable to convert spruce hydrolyzates into ethanol with high efficiency , NRG1 , and GDH1 (a NADPH-dependent glutamate dehydrogenase), play an important role in the tolerance to these hydrolyzates  enzyme and TPO1 coding for the polyamine transport protein (Kim et al., ERG28, HMG1, MCR1, ERG5, and ERG7 (Endo et al., Tolerance to phenolics can be tackled by the expression of extracellular heterologous laccases (Lee et al., S. cerevisiae strains (Yona et al., HCM1 and the protease RRT12 reproduced a significant fraction of the thermotolerant phenotype in the parental strain. A similar result was found in thermotolerant yeast strains isolated from ALE experiments to 39.5°C (Caspeta et al., HCM1 gene was found. Since duplication of ChIII was lost in evolved strains, this suggests that chromosomal duplications are a temporal solution to stress (Yona et al., Adaptive laboratory evolution has been successful for selecting thermotolerant S. cerevisiae populations showed segmental duplications only. In these strains, a nonsense mutation of ERG3 proportionated 80% of the thermotolerant phenotype (Caspeta et al., Adaptive laboratory evolution experiments have also used to generate tolerance to high pH, which induced the duplication of chromosome number five (Yona et al., S. cerevisiae resistant to very high gravity fermentations, elevated temperature, and high glucose concentrations (Hou, GPD2 encoding glycerol 3-phosphate dehydrogenase subjected to three rounds of genome shuffling, a population of strains producing lower amounts of glycerol and improved tolerance to ethanol and high osmolality were able to be selected (Tao et al., Genome-shuffling technology was used to improve yeast performance in high gravity fermentations (Liu et al., ons Hou, . In mutaS. cerevisiae strains able to cope with inhibitory conditions while keeping proper catalytic functions for raw material conversion to ethanol. Major inhibitory conditions found in the unit operations required for the conversion processes include the accumulation of toxic chemicals generated during lignocellulose pretreatment and sugar fermentation, the high temperature that accompanied simultaneous saccharification and fermentation, and the very high osmolality and elevated solids loadings at the beginning of the fermentation. Since unification of these unit operations is desirable to reduce production costs and energy utilization, it can be expected that yeast cells will be simultaneously exposed to most of these inhibitory conditions.One of the major challenges for economic conversion of lignocellulose to fuel ethanol is to generate robust Since cellular macromolecules and metabolism have evolved to sustain optimal growth rates at the prevailed natural conditions, mainly preserving genetic information and proteins/membrane functional structures, the generation of complex tolerant phenotypes for the ethanol industry will be further generated on the bases of the functions targeted by the stressors. The summarized results altogether show that major targets include cellular membrane, redox and ionic potentials, and energy metabolism, as well as protein structure – the latter of apparently minor relevance.To establish metabolic engineering strategies for increasing yeast tolerance, it is suggested to consider the route and regulation of molecular responses following sensing, signal transduction, signal integration, and execution of cellular functions in response to environmental stresses. Results from systems biology and -omics analyses, as well as from traditional data mining, point out the relevance of the cross-regulation between the routes of yeast responses according to the different types of stress. This is part of the elasticity of cellular stress-signaling network, which is advantageous during evolutionary adaptation and in the generation of resistance to the multiple stresses found in ethanol production process.In summary, the multiple technologies for the generation of numerous mutations, high-throughput screening, acceleration of cells adaptation and selection, laboratory evolution and engineering of TFs, and the new tools for controlling gene expression are accelerating the accumulation of basic information of CSRs, and the generation of yeast cells with desirable processing characteristics including better performance in the inhibitory conditions found in lignocellulosic ethanol production processes.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.


Gender discrimination and inequality in health professional education (HPE) affect students and faculty and hinder production of the robust health workforces needed to meet health and development goals, yet HPE reformers pay scant attention to these gender barriers. Gender equality must be a core value and professional practice competency for all actors in HPE and health employment systems.Peer-review and non-peer-review literature previously identified in a review of the literature identified interventions to counter gender discrimination and inequality in HPE and tertiary education systems in North America and the Caribbean; West, East, and Southern Africa; Asia; the Middle East and North Africa; Europe; Australia; and South America. An assessment considered 51 interventions addressing sexual harassment (18), caregiver discrimination (27), and gender equality (6). Reviewers with expertise in gender and health system strengthening rated and ranked interventions according to six gender-transformative criteria.Thirteen interventions were considered to have transformational potential to address gender-related obstacles to entry, retention, career progression, and graduation in HPE, when implemented in core sets of interventions. The review identified one set with potential to counter sexual harassment in HPE and two sets to counter caregiver discrimination. Gender centers and equal employment opportunity units are structural interventions that can address multiple forms of gender discrimination and inequality.The paper’s broad aim is to encourage HPE leaders to make gender-transformative reforms in the current way of doing business and commit to themselves to countering gender discrimination and inequality. Interventions to counter gender discrimination should be seen as integral parts of institutional and instructional reforms and essential investments to scale up quality HPE and recruit and retain health workers in the systems that educate and employ them. Implementation challenges spanning financial, informational, and cultural barriers need consideration. The application of core sets of interventions and a strong learning agenda should be part of ongoing HPE reform efforts. With the Sustainable Development Goals (SDGs), the global community sees greater than ever consensus about the crucial role that the health workforce plays in realizing goals to achieve universal health coverage , 2. QualOutdated, fragmented, and content-oriented curricula that produce graduates with narrow contextual understanding and insufficient knowledge, skills, and competencies to understand social and other determinants of health and diseasePoor teamwork and inadequate collaboration within and across health professional cadresEpisodic encounters with patient illnesses rather than continuous and holistic health careA predominant hospital orientation at the expense of primary careAn imbalance between health workforces and health needsWeak leadership in improving health system performanceIn 2010, the independent Commission on Education of Health Professionals for the 21st Century (henceforth “the independent Commission”) released a comprehensive report on HPE. The Commission’s report spurred a growing movement for HPE reform in many regions, including Africa, Asia, and the Americas . The repThe independent Commission’s report also mentions persistent gender stratification of professional status as a systemic deficiency and puts forth as one of its proposed reforms the need to pay particular attention to ensuring equal opportunities through more flexible working arrangements and career paths that accommodate temporary breaks, actively addressing gender discrimination and subordination . Yet genGender discrimination—whether culturally, socially, or structurally driven—is sometimes evident in health worker education and employment systems and sometimes so normative as to be invisible. Where gender discrimination and inequality exist, they can hinder production of the robust and competent health workforces needed to achieve health and development goals, by subjecting students and faculty to gender-based exclusions or restrictions and diminishing access and opportunities. As systemic problems that stem from (among other things) institutional cultures, norms, and policies, gender discrimination and inequality should be addressed in HPE reforms.To date, however, the HPE reform movement has paid scant attention to gender discrimination toward and among students and faculty. The new SDGs include a standalone goal that aims for achieving gender equality and empowering all women and girls, including a target to end all forms of discrimination against all women and girls . This giAs the independent Commission’s report emphasizes, a key outcome of educational reform should be transformative learning , which cThis paper summarizes the findings of an expert review that sought to assess interventions to combat gender discrimination and inequality in HPE settings and rank them according to whether they counter two broad types of gender discrimination in transformative ways: discrimination based on pregnancy and on family responsibilities  and sexual harassment. We also discuss challenges to implementing the identified interventions, recommendations for addressing the challenges, and implications for HPE reform.The global literature on gender and human resources for health (HRH) has demonstrated that gender discrimination and inequality are key barriers to entry, reentry, and retention in employment systems, especially for female health workers –6. The cFor HPE students, gender discrimination and inequalities are apparent at different points throughout educational careers, from admission to career track designation to graduation. At the outset of the educational continuum, cultural and gender norms and stereotypes related to childbearing and childrearing can discourage girls and women from pursuing HPE training and scholarship opportunities . Once stIn higher-education systems as a whole, insufficient and sometimes insecure living conditions can limit female students’ ability to safely access university facilities and further contribute to decisions to drop out . Sexual For faculty, gender discrimination and associated inequalities often relate to conditions that structurally disadvantage members of one sex  in the academic system, such as requiring training that involves travel in order to obtain promotions . An acadSexual harassment of faculty members can also affect career advancement. For example, Nigerian female academic staff reported that their refusal of university officials’ sexual advances led to exclusion from promotion and other benefits . This tyThe following sections describe our review of interventions to counter caregiver discrimination and sexual harassment in high- and low-resource school-based settings.A panel of experts with expertise in gender and health system strengthening reviewed and rated 52 distinct school-related interventions to address sexual harassment and caregiver discrimination in high- and low-resource settings Fig. .Fig. 1StNorth America and the Caribbean, 33 (38 %)West, East, and Southern Africa, 32 (36.8 %)Asia, 10 (11.5 %)Middle East and North Africa, 5 (5.75 %)Europe, 4 (4.6 %)Australia, 2 (2.3 %)South America, 1 (1.2 %)There were 87 distinct educational institutions/organizations/programs that were included in the literature review, most of which were universities. Of the 87 institutions, the geographical breakdown was:Interventions that had been previously identified in a review of 379 articles from peer-review and non-peer-review literature on HPE and general tertiary education  providedpotential to counter gender discrimination and inequality by applying the six gender-transformative criteria in Table Most interventions lacked the type of evaluation data related to inputs, processes, and outcomes that would allow the reviewers to determine their effectiveness, feasibility, or sustainability. Thus, reviewers rated the interventions’ For interventions targeting the two types of discrimination , each reviewer was assigned a weight based on the reviewer’s area of expertise, with assigned weights totaling 100 %. For each of the 51 practices, reviewers rated interventions applying the six criteria, with 0 representing “No” and 1 representing “Yes.” The researchers then derived a weighted average for each intervention. The expert panel decided that an intervention had at least some gender-transformative potential if its weighted average was 0.5 or above. To rank interventions, one that had a 0.5 rating would be ranked higher than one with a 0 rating. Interventions were ranked by taking inventory of the reviewers’ ratings using these critical criteria .The reviewers met to discuss the ranking process and final rankings. During these meetings, they refined their application of the six gender-transformative criteria, developed recommendations about core sets of interventions, and developed cross-cutting recommendations related to countering the two types of discrimination.Of the 51 interventions reviewed, 13 interventions were identified as having significant stand-alone transformative potential in terms of the transformative criteria  policy mandates a sexual harassment advisory and disciplinary committee, yet an assessment found that not only were many managers unaware of the policy but committee members’ workloads made trainings on the policy difficult to schedule and implement .The lack of awareness of grievance procedures , along with inadequate individual and institutional training, can contribute to anemic use of grievance procedures in settings where sexual harassment is normative.Most policies explicitly prohibit retaliation against victims who report sexual harassment, but flawed grievance procedures and prevailing environments of intimidation or impunity can render anti-retaliation policies ineffective.Fear of retribution and lack of accountability discourage many victims of sexual harassment from using grievance procedures –28. AsseAlthough many HPE and other higher-education institutions included in the review had implemented one or more of the interventions in the core set to counter sexual harassment, the review identified a number of challenges:Given the possibility of culturally normative and unregulated sexual harassment in HPE settings, grievance procedures are an important intervention. To address the identified challenges, grievance procedures should pay special attention to confidentiality, guidance for documenting and reporting, clearly outline consequences for the perpetration of sexual harassment and retaliation, avoid an inadvertent chilling effect on reporting that may result from an overemphasis on false reporting, and take concrete action to both decrease and eliminate fear of retribution. Equally important, strategies must be implemented and enforced through strong institutional leadership, vigilant oversight, and timely follow-up and resolution.The reviewers also identified two core sets of interventions for students and faculty to counter caregiver discrimination Table . PracticAdverse consequences—or fear thereof—are a significant barrier associated with some interventions. For example, faculty who opt for reduced duty leave or flexible training programs may experience resentment from colleagues. Moreover, HPE faculty may not always take advantage of interventions for fear that others will perceive them as uncommitted or that their careers will be negatively affected.Work-life integration is a key concern for many current and prospective HPE faculty (both women and men) . InstituFamilies and communities may resist some of the changes required to address discrimination based on caregiver responsibilities, because the interventions challenge longstanding gender norms, expectations, and divisions of labor. Girls and women who go to school likely need a reduced workload at home, potentially adding to their families’ workload.Interventions to counter discrimination based on caregiver responsibilities also face implementation challenges, although these, too, can be met by strong HPE leadership commitment:Communication of policy and education of faculty and students, as well as ongoing public support of faculty who use such flexible policies, is key to preventing adverse consequences. A complementary strategy is to proactively plan for pregnancy coverage and flexible scheduling.HPE planners must also anticipate the different levels of resistance that may arise in recruitment and retention efforts and deliberately mobilize communities around reducing women’s and girls’ housework, preventing early marriage and pregnancy and sharing responsibility for caregiving. This implies a long-term, multidimensional, and multisectoral strategy to keep girls in school from the primary through tertiary levels. This might include provision of reproductive health services (including family planning) through HPE institutions.Develop gender equality, equal opportunity, or affirmative action policiesEngage in awareness raising and information sharingServe advocacy and accountability functionsConduct gender sensitization workshops or sexual harassment training for women and menConduct research and university assessmentsProvide financial assistance to female studentsOffer mentoring and faculty career and leadership programs to womenIn addition to selecting the core sets of interventions targeting sexual harassment and caregiver discrimination, the reviewers identified gender centers and equal employment opportunity units as having significant gender-transformative potential. These are institutional structures that advocate for, coordinate, oversee, implement, and evaluate multilevel strategies. These entities generally work to:The last two objectives are examples of special measures to counter systemic structural discrimination and promote substantive equality , or one with a more diverse range of expertise, would likely strengthen future reviews.A comprehensive HPE reform agenda aiming to produce a robust and competent health workforce should consider core sets of interventions to counter gender discrimination and inequality—even when discrimination is not overtly recognized by perpetrators or victims. Female health workers already constitute a large proportion of many countries’ health workforces , and there is a growing focus on the role of women in the health workforce in the emerging human resources for health agenda . Failureall the gender-transformative interventions identified by the reviewers, the “core sets” provide a basis for establishing priorities and taking steps to counter gender discrimination. Potential implementation challenges spanning financial, informational, and cultural barriers need to be considered, however. Financing considerations are particularly relevant when interventions entail restructuring physical resources and human resources arrangements  or require human resources .The review findings can serve as a basis for evidence-based decisionmaking in planning and implementing appropriate gender-transformative interventions. The review demonstrated that interventions can address some of the gender-related obstacles to entry, retention, career progression, and graduation in HPE, in particular those related to sexual harassment and caregiver discrimination. Although many HPE institutions may not have the resources to implement Merely offering interventions does not guarantee that interventions are used or that equal opportunities and gender equality in HPE will result. Ensuring that the institutional community and especially the intended beneficiaries are aware of, committed to, and actually use the interventions is equally important. However, because many of the interventions challenge social and institutional norms and cultural stereotypes, some community members (inside or outside the institution) may resist their implementation. Increasing the actual use of new policies or procedures requires information and advocacy, anticipating potential resistance, providing incentives, and ensuring that HPE leaders are accountable for work-life integration and the speedy and effective handling of sexual harassment so that institutional efforts actually prevent and end impunity for discriminatory organizational structures and behaviors.What are some implications for HPE reform? First, gender-transformational HPE reform will in some cases entail both institutional and instructional changes  sometimeunethical professional conduct, as well as a human rights violation. For example, the problem of quid pro quo sexual harassment  stakeholders—to make gender-transformative changes in the current way of doing business and commit themselves to countering gender discrimination and inequality in HPE. These affect the functioning, quality, outputs, and outcomes of health professional education. Gender-transformative HPE reforms that eliminate impunity for sexual harassment, promote and protect the educational and labor rights of students and faculty, and develop student and faculty understanding of professional ethics will require changes in mindsets, institutional cultures, and leadership capability and the reframing of health workers as change agents committed to gender equality in often inequitable systems. Greater focus on the application of the core sets of interventions identified in this paper and a strong learning agenda should be part of ongoing HPE reform efforts.


TotheEditor: In this investigation, we found evidence for the apparent effects that a new variant of the rabbit hemorrhagic disease virus (RHDV) is having on native wild European rabbit (Oryctolagus cuniculus) populations on the Iberian Peninsula, and how this virus could threaten the conservation of endangered predators.Historically, European rabbits were extremely abundant on the Iberian Peninsula, which is in their native range. However, during the 20th century, the number of rabbits on the peninsula has declined >90%, mainly because of diseases , and unlike the classical form of RHDV, it kills rabbits as young as 11 days of age and rabbits that have been vaccinated against classic RHDV . The lynx relies on rabbits for survival, because they represent >85% of the lynx’s diet .The European rabbit is a multifunctional keystone species of the Iberian Mediterranean ecosystem, where it serves as prey for >30 predatory animals, alters plant species composition and vegetation structure through grazing and seed dispersal, its excrement and urine have an effect on soil fertility and plant growth and provide feeding resources for invertebrates, and its burrows provide shelter for different species , panel DThe situation described exemplifies how emerging diseases can affect biodiversity conservation. It also highlights the importance of using wildlife monitoring schemes as detection tools for monitoring the impact of stochastic factors, such as the variant RHDV, on wildlife populations. Urgent management actions, designed within an Iberian rabbit conservation strategy that relies on a multidisciplinary framework, are needed to ensure the conservation of this keystone member of the Iberian Peninsula ecosystem and that of rabbit-reliant predators.


Myelodysplastic syndromes (MDS) are hematopoietic stem cell disorders characterized by dysplastic, ineffective, clonal and neoplastic hematopoiesis. MDS represent a complex hematological problem: differences in disease presentation, progression and outcome have necessitated the use of classification systems to improve diagnosis, prognostication, and treatment selection. However, since a single biological or genetic reliable diagnostic marker has not yet been discovered for MDS, quantitative and qualitative dysplastic morphological alterations of bone marrow precursors and peripheral blood cells are still fundamental for diagnostic classification. In this paper, World Health Organization (WHO) classification refinements and current minimal diagnostic criteria proposed by expert panels are highlighted, and related problematic issues are discussed. The recommendations should facilitate diagnostic and prognostic evaluations in MDS and selection of patients for new effective targeted therapies. Although, in the future, morphology should be supplemented with new molecular techniques, the morphological approach, at least for the moment, is still the cornerstone for the diagnosis and classification of these disorders. Myelodysplastic syndromes (MDS) are clonal hematopoietic stem cell disorders characterized by dysplastic, ineffective and neoplastic hematopoiesis. The risk of evolution to acute myeloid leukemia (AML) is variable, and the clinical outcome is greatly heterogeneous. Therefore, MDS constitute a complex hematological problem that gives rise to difficulties in diagnosis and therapeutic decision-making.In this review the meaning of morphology in MDS is examined; World Health Organization (WHO) classification refinements and current minimal morphological criteria for defining dysplastic involvement are highlighted, and several problematic issues are discussed.Currently, the reference classification of MDS is still the WHO classification, published in 2001 and updated in 2008.10The suspicion of MDS arises on the basis of an abnormal blood count with evidence of different combinations of anemia, neutropenia, and thrombocytopenia in an appropriate clinical setting. Anemia is often macrocytic, associated with a significantly reduced reticulocyte count. Obviously, all causes of reactive cytopenia/dysplasia should be excluded as well as other clonal stem cell disorders and congenital abnormalities . The minBCR-ABL1 negative, juvenile myelomonocytic leukemia (JMML) and refractory anemia with ring sideroblasts associated with marked thrombocytosis (RARS-T), which is still a provisional entity.16On the basis of the proportion of peripheral blood and bone marrow blasts, defined by a morphological examination, two broad categories of MDS are recognized: forms with <2% peripheral blood blasts and <5% bone marrow blasts (lower risk subtypes), including refractory cytopenias with unilineage dysplasia (RCUD), refractory anemia with ring sideroblasts (RARS), refractory cytopenia with multilineage dysplasia (RCMD), myelodysplastic syndrome-unclassified (MDS-U) and MDS associated with isolated del(5q), and forms characterized by at least 2% peripheral blood blasts and/or at least 5% bone marrow blasts (higher risk subtypes), including refractory anemia with excess blasts-1 (RAEB-1) and RAEB-2 . ChronicThe diagnosis of MDS is mainly based on morphological findings of peripheral blood and bone marrow.Peripheral blood and bone marrow specimens should be collected before any definitive therapy. No case of MDS should be reclassified while the patient is on growth factor therapy. Since prolonged exposure to anticoagulants can cause artifacts, the slides for the assessment of dysplasia should be made from freshly obtained specimens. On bone marrow aspirate smears and/or biopsy touch preparations, MGG or similar staining and iron staining could possibly, but not necessarily, be supplemented by cytochemical dyes to identify bone marrow cells and maturation stages: myeloperoxidase and Sudan black detect myeloid cells by staining cytoplasmic granular contents and better identify Auer rods, periodic acid-Schiff detects lymphocytic cells and certain abnormal erythroid cells by staining cytoplasmic glycogen, esterases distinguish myelocytic from monocytic maturation stages. On bone marrow aspirates, the cellularity should be enough to perform a 500 cells differential count, whereas, on peripheral blood smears, a differential count of 200-cell leukocyte is recommended. The blood and marrow smears should be examined for the percentages of blasts, dysplastic cells and ring sideroblasts. At least 100 erythroblasts, 100 granulocytic cells, and 30 megakaryocytes should be evaluated.6An increase of blast cells has to be considered as a sign of myelodysplasia. An International Working Group on Morphology of MDS (IWGM-MDS) of hematopathologists and hematologists, in order to improve diagnostic accuracy, agreed on some recommendations for the definition and enumeration of blasts.24Blasts have variable size, ovoid or irregularly outlined nuclei with loose chromatin pattern and variable number of nucleoli, basophilic cytoplasm, with the absence of an evident Golgi zone. They are defined as granular or agranular and may contain Auer rods, whose presence allows the automatic diagnosis of RAEB-2. Myeloblasts showing strongly basophilic cytoplasm could be misinterpreted as immature erythroid precursors. Erythroid precursors, however, have relatively mature clumped chromatin and are often larger than myeloblasts at early stages. Granular blasts should be distinguished from normal or dysplastic promyelocytes. Promyelocytes are usually characterized by a well recognizable Golgi zone; dysplastic promyelocytes, however, are often hyper- or hypogranulated and may present a less evident Golgi area than normal promyelocytes .It is worth noting that in the forms with recurrent cytogenetic abnormalities, such as t, inv(16)(p13.1q22) or t and t the diagnosis of AML should be made even with fewer than 20% bone marrow blasts. These forms are considered clinical-pathological-genetic entities with peculiar features.The IWGM-MDS also defined the different maturation stages of monocytic cells.The precise recognition and quantification of dysplasia is critical for a correct application of the WHO classification for the following main reasons: WHO proposal introduced uni- versus multilineage dysplasia as a diagnostic criterion in MDS with fewer than 5% bone marrow blasts, increasing the prognostic value of the classification;29The dysplastic abnormalities of the cell nucleus and/or cytoplasm to be taken into account are listed in Hypo-agranularity of neutrophils is considered a highly specific dysplastic feature; usually, it is more evident in peripheral blood smears and better assessable with Sudan black or peroxidase reaction.31Micromegakaryocytes are highly specific for dysmegakaryopoiesis, but there is still no consensus on their definition. It is recommended to consider as micromegakaryocyte a megakaryocyte of about the size of the surrounding myeloid cells, with scanty granular cytoplasm. Other categories of dysplastic megakaryocytes are illustrated in As already mentioned, morphological abnormalities of erythroid cells, as megaloblastic features and non-round nuclei, are commonly observed in many hematological as well as non-hematological disorders, and have a low diagnostic power. Only ring sideroblasts are considered highly specific dysplastic changes. Recommendations for the definition of ring sideroblasts have been provided by the IWGM-MDS.Recently, the term of MDS-E or MDS Ery has been proposed to indicate forms of MDS with marked erythroid hyperplasia. Marked erythroid hyperplasia (50% or greater) with or without left-shifted erythroid maturation can be seen in approximately 15% of patients with MDS and is often associated with the presence of ring sideroblasts.The problems in the morphological diagnosis of MDS are mainly due to the non-specificity of dysplastic changes. Morphological alterations may be observed even in healthy bone marrow and in patients with non-clonal disorders; moreover, poor quality of marrow specimens and various artifacts may cause misinterpretation. On the other hand, recent studies have demonstrated discrepancy in morphological diagnosis in rather high proportions of cases as well as low reproducibility of the WHO 2008 criteria. Unfortunately, unanimous agreement on the type of morphological alterations that characterize MDS and on the threshold to be considered is still missing.36Several studies have addressed the impact of the single morphological abnormalities and the degree of dysplasia on prognosis, and grading systems have been proposed to increase the diagnostic accuracy of MDS.39A Japanese- German study concerning patients with MDS without excess blasts, 5q-syndrome excluded, showed the adverse prognostic significance of three parameters: the presence of at least 10% of micromegakaryocytes, dysmegakaryocytopoiesis > 40% and dysgranulopoiesis >10%. The authors suggested using these threshold values for the identification of multilineage dysplasia40On the other hand, dysplastic features may also be observed in the normal bone marrow, as reported by some authors in the late ‘90s.45It should be emphasized the possible role of the barriers that can hinder a correct diagnostic definition: poor quality of marrow specimen, lack of clinical information, lack of available cytogenetic results, inter-observer variability in the assessment of dysplasia.SF3B1 mutations and between severe granulocytic dysplasia and mutations of ASXL1, RUNX1, TP53 and SRSF2 genes.In a retrospective study of 318 patients with MDS, a group of patients with other types of non-clonal cytopenias used as pathological controls, and a group of normal subjects, bone marrow hematopoietic cells were carefully examined and classified according to their nuclear and cytoplasmic morphological alterations to identify minimal reproducible morphological criteria to define marrow dysplasia and to evaluate the prognostic relevance of the degree of dysplasia.In conclusion, this morphological score improving the objectivity and reproducibility of microscopic analysis might be very useful in the work-up of patients with suspected MDS. On the other hand, prognostic systems including the evaluation of the degree of bone marrow dysplasia should be adopted for clinical decision-making.A bone marrow trephine biopsy may increase the diagnostic accuracy and help in refining the prognostic scoring system for MDS. It provides information on cellularity and stroma and is essential for the identification of MDS with fibrosis and hypoplastic MDS.47Bone marrow biopsy also allows a better evaluation of megakaryocytes and may show the presence of aggregates or clusters of blasts, a typical finding in aggressive subtypes.The combination of manifest bone marrow dysplasia and clonal cytogenetic abnormality allows a conclusive diagnosis, but this is possible for only a part of patients. Diagnosis may be particularly difficult in patients with <5% bone marrow blasts and only one cytopenia. If a patient with a clinical and laboratory suspect of MDS has inconclusive morphological features, a presumptive diagnosis of MDS can be made in the presence of a specific chromosomal abnormality demonstrating clonality. If there is only unilineage dysplasia, in the absence of recurrent cytogenetic abnormalities, without increase of peripheral or bone marrow blasts, with less than 15% ring sideroblasts, an observation period of 6 months and repeating bone marrow examination is recommended prior to making the diagnosis of MDS. For patients with persistent cytopenia(s) (at least 6 months), in the absence of morphological or cytogenetic evidence sufficient for a definitive diagnosis of MDS, the term “idiopathic cytopenia of undetermined significance” (ICUS) should be used .The term ICUS was first proposed by the IWGM-MDS at a meeting in Lisbon in 2005, and subsequently used in the 2008 WHO classification and by others. ICUS and idiopathic dysplasia of undetermined significance (IDUS) are conditions in which the criteria for the diagnosis of MDS are not satisfied, even if cytopenia or dysplasia is present.Despite the WHO diagnostic and classification criteria, the morphological diagnosis of MDS is still often critical and requires considerable expertise.


The purpose of this review is to report how administrative data have been used to study AKI, identify current limitations, and suggest how these data sources might be enhanced to address knowledge gaps in the field.“communication” and “translation” within and across administrative jurisdictions, and 4) To suggest how administrative databases might be configured to inform ‘registry-based’ pragmatic studies.1) To review the existing evidence-base on how AKI is coded across administrative datasets, 2) To identify limitations, gaps in knowledge, and major barriers to scientific progress in AKI related to coding in administrative data, 3) To discuss how administrative data for AKI might be enhanced to enable Literature review of English language articles through PubMed search for relevant AKI literature focusing on the validation of AKI in administrative data or used administrative data to describe the epidemiology of AKI.th, 2015, Banff, CanadaAcute Dialysis Quality Initiative (ADQI) Consensus Conference September 6-7Hospitalized patients with AKIThe coding structure for AKI in many administrative datasets limits understanding of true disease burden , its temporal trends, and clinical phenotyping. Important opportunities exist to improve the quality and coding of AKI data to better address critical knowledge gaps in AKI and improve care.A modified Delphi consensus building process consisting of review of the literature and summary statements were developed through a series of alternating breakout and plenary sessions.Administrative codes for AKI are limited by poor sensitivity, lack of standardization to classify severity, and poor contextual phenotyping. These limitations are further hampered by reduced awareness of AKI among providers and the subjective nature of reporting. While an idealized definition of AKI may be difficult to implement, improving standardization of reporting by using laboratory-based definitions and providing complementary information on the context in which AKI occurs are possible. Administrative databases may also help enhance the conduct of and inform clinical or registry-based pragmatic studies.Data sources largely restricted to North American and EuropeAdministrative data are rapidly growing and evolving, and represent an unprecedented opportunity to address knowledge gaps in AKI. Progress will require continued efforts to improve awareness of the impact of AKI on public health, engage key stakeholders, and develop tangible strategies to reconfigure infrastructure to improve the reporting and phenotyping of AKI.Rapid growth in the size and availability of administrative data has enhanced the clinical study of acute kidney injury (AKI). However, significant limitations exist in coding that hinder our ability to better understand its epidemiology and address knowledge gaps. The following consensus-based review discusses how administrative data have been used to study AKI, identify current limitations, and suggest how these data sources might be enhanced to improve the future study of this disease.The current coding structure of administrative data is hindered by a lack of sensitivity, standardization to properly classify severity, and limited clinical phenotyping. These limitations combined with reduced awareness of AKI and the subjective nature of reporting limit understanding of disease burden across settings and time periods. As administrative data become more sophisticated and complex, important opportunities to employ more objective criteria to diagnose and stage AKI as well as improve contextual phenotyping exist that can help address knowledge gaps and improve care. The clinical study of acute kidney injury (AKI) has been facilitated in recent years by the increasing availability of administrative data. The housing of vast amounts of information in accessible data warehouses and the relatively low cost of procurement suggest potential usefulness. However, as usually not collected for conducting clinical research, concerns over the quality of the data and its ability to fill knowledge gaps and evaluate quality of care have been raised , 2. On SThe ADQI methodology has been previously detailed . In brieWe conducted a 2-day conference in September 2015 in Banff, Canada, where summary statements were developed through a series of alternating breakout and plenary sessions. Panelists were assigned to 3–5 person workgroups. In each breakout session, the workgroups refined the key questions, identified the supporting evidence, and generated consensus statements. Workgroup members presented their findings during the plenary sessions and then revised their drafts as needed until a final version was agreed upon. A writing committee assembled the individual reports from the workgroups and each report was edited to conform to a uniform style and for length. The final reports were provided to each participant for comment.Question #1: What is the existing evidence-base for how AKI is coded across various administrative datasets?Consensus Statement #1A: Administrative data are defined as information collected and stored for patient or disease registration, to inform transactions, or to promote other record keeping. The coding of AKI using these data sources has utilized billing/claims, limited laboratory-based definitions in disease-specific registries, and population-based health registries.Consensus Statement #1B: Commonly used administrative codes for AKI generally demonstrate poor sensitivity and high specificity.http://www.adls.ac.uk/adls-resources/guidance/introduction/).For this manuscript, we will define health care-related administrative data as information collected and stored for patient disease registration, to inform transactions, or perform other record keeping  and procedure codes and the American Medical Association’s Current Procedural Terminology (CPT) codes to capture the diagnosis of AKI and renal replacement therapy (RRT) [http://www.sts.org/sites/default/files/documents/Training%20Manual%20for%20website_2.pdf).Major producers of administrative data include, but are not limited to, governmental agencies , insurers, and healthcare systems. Most literature using administrative data to study AKI have applied the 9py (RRT) , 4. Withpy (RRT) –7. This Coding performance has been examined in several studies by comparing them to a reference standard of creatinine change or manual chart review –11. VlasQuestion #2: What are the limitations, gaps in knowledge, and major barriers to scientific progress in AKI related to how AKI is coded?Consensus Statement 2a: Major limitations of current administrative data include poor awareness of AKI and the subjective nature of its assessment, lack of information on severity, and the use of non-consensus criteria for defining and staging AKI.Consensus Statement 2b: Major knowledge gaps in AKI using current administrative data sources include, but are not limited to, lack of contextual phenotyping, information on complications including dialysis-dependence or other indicators of recovery, and coding structure and performance in non-North American registries.The collective performance of administrative codes for detecting AKI, particularly when not directly linked to serum creatinine, has important implications. For example, poor or changing sensitivities limit value in understanding true disease burden; provide overly conservative estimates of disease prevalence, skew temporal trends due to changes in the sensitivity of diagnostic codes, and contain uncertainty in distinguishing acute from chronic disease. The relative high specificities may make current administrative data more amenable to examining outcomes of patients identified with AKI. However, positive predictive value may vary depending on the underlying risk of the population studied and the severity detected may also vary across regions or time.Figure One major limitation likely contributing to the low sensitivities observed is poor provider awareness. Accurate and sensitive reporting of AKI depends on recognition that 1) AKI has occurred and 2) it was clinically relevant. As most AKI does not require dialysis and not linked to a procedure code, coding becomes wholly dependent on provider recognition. AKI is generally well-recognized by nephrologists or other experts, however, primary diagnosis codes for patients requiring acute care are most often entered by providers or coding personnel with less expertise or interest in the area. While consensus criteria have likely improved awareness, overall sensitivity remains modest.  The resuSubjective coding may also be influenced by external forces, including patient related factors (i.e. patient complexity), variations in practice and coding patterns across medical disciplines, geography, and practice settings. For example, capturing AKI in a critically ill patient with prolonged hospitalization, multi-system organ failure, and contributing comorbidities requires overcoming substantial coding ‘inertia’. In addition, while sensitivity has improved, the resulting changes make interpreting temporal trends challenging. For example, uncertainty exists as to whether increases in disease incidence and improvement in survival observed are attributable to better reporting of less severe AKI, changes in case-mix (e.g. more acute on chronic disease), or true improvements in care , 15. SimIt remains possible to enhance administrative data to address critical knowledge gaps in AKI. For example, an increased understanding of the changing case-mix of AKI and its relative impact in different settings is needed . While nFurther phenotyping of AKI severity and pre-/post- hospitalization kidney function may better understanding of the role of AKI on the natural history of kidney health and disease progression. However, lack of quality information on pre-morbid kidney function, inpatient trajectory, and post-AKI kidney function in current administrative datasets introduce uncertainty into analyses. Integration or linkage of data from advancing electronic health records would enable use of unified diagnostic criteria, distinguishing relative contributions from AKI and CKD, improve further critical phenotyping of AKI , and examine future outcomes.Integrating unified diagnostic criteria and providing contextual information will require some reconfiguration of existing infrastructure. Key stakeholders including payers, government, providers, and coders will need to be engaged and convinced that doing so will improve costs and quality by providing a fuller understanding of disease burden, help to identify patients at high risk for the sequelae of AKI, and opportunities to examine care.Meaningful changes in coding infrastructure in the kidney disease space are not without precedent. In 2005, the Kidney Disease Outcomes Quality Initiative (KDOQI) staging system for CKD was incorporated into the ICD-10 coding structure. The impetus for these changes in the US was provided by the National Center for Health Statistics, National Kidney Foundation, and the Renal Physicians Association whose goals were to improve understanding of disease burden, follow patients longitudinally, understand treatments provided, and assess the quality of care being delivered. More recent examples of mutual engagement include ongoing initiatives between the critical care community in Canada and the Canadian Institute for Health Information (CIHI) to develop a standardized structure for reporting critical care capacity, operations, quality, and outcomes data. This collaboration will enable a national description of critical care utilization, quality indicators and outcomes aimed at driving health systems improvements. Another current example that model such improvements include the National Health Services ‘Think Kidneys’ program in the United Kingdom . By coupA non-diagnosis related barrier is the deliberate transition of medical records to digital filing. Although the American Reinvestment and Recovery Act of 2009 mandated use of EHRs, integration across institutions in the United States has taken longer than anticipated leading to variability in the extractability of information (as some data remains in paper charting). Additionally, the coding structure and performance for capturing AKI in systems outside of the US, Canada, and UK are underreported. These inconsistencies negatively impact the reliability of administrative datasets across registries and limit the ability to do cross-institutional/-country comparisons.Questions #3: What would be the ideal minimal definition for AKI in administrative databases to enable “communication” and “translation” within and across administrative jurisdictions ?Consensus Statement #3: The ideal definition of AKI in administrative databases that would enable cross-registry communication would include descriptors of the onset, duration, severity, context, histology, progression, and recovery of AKI. Minimum essential elements include a standardized, objective description of AKI severity  accompanied by complementary information on the context in which AKI occurs.Finally, a down-stream concern related to changes in coding is the potential for negative reimbursement for ‘nosocomially-acquired AKI’. As value based purchasing and quality-based reimbursements by both insurance agencies and governmental emerge , granularity in AKI diagnosis with regards to the etiology of injury could actually dissuade clinicians from coding for AKI . Avoidance of this problem will require involvement of relevant stakeholders to ensure appropriate quality metrics that do not penalize accurate diagnostic coding.Definitions of AKI have evolved over the past 20 years as stakeholders have begun to appreciate the benefits of consensus, both for clinical management and for research. The achievement of standardized definitions  has advanced the field by providing a platform for communication and comparison –21. WhilAn ideal “administrative” definition of AKI would incorporate factors that describe the onset, duration, severity, context, histology, progression, and recovery of AKI Fig. . Limitatcurrently possible include improving coding of AKI severity and providing contextual information for the setting in which AKI occurs  as is currently the case for CKD coding algorithms . As most cases will not be seen by nephrologists, this structure may also have the added benefit of improving sensitivity as clinicians are more likely to consider AKI if linked to the primary disease rather than overcoming the effort to code it as a separate entity.not prevent tangible improvements to the current coding of AKI. The reliance of physiologic and laboratory data for AKI diagnosis should prompt progressive consideration for automatic capture and inclusion as administrative datasets evolve.Question #4: How can administrative databases be configured to inform “registry-based” pragmatic studies?Consensus Statement #4A: Administrative databases can be used to identify and enrich target populations of interest and inform the feasibility and power of trials.Consensus Statement #4B: Patients enrolled in clinical trials can be potentially linked to administrative databases to enhance outcome ascertainment, reduce costs, and examine additional outcomes of interest if patient identifiers are available.In summary, limitations in the current clinical phenotyping of AKI should Administrative databases, particularly if enhanced by improvements in coding and accuracy, can be leveraged to inform clinical studies or facilitate registry-based pragmatic studies Fig. . First, Poor recruitment can hamper trials . Identiflinked through available identifiers to other outcome registries  can be a powerful and cost-saving tool to augment long-term follow up to determine basic outcome information such as mortality, or dialysis. Administrative data can also provide information on other important outcomes such as long-term healthcare resource use by individuals following an intervention as well as cost data. The latter may be an important tool as larger trials are proposed and follow-up of individuals becomes prohibitively expensive, particularly among studies where patients may be more difficult to track using traditional means such as telephone interviews or surveys.Another potential benefit of administrative data in clinical studies is the ability to enhance follow-up of patients already enrolled in studies . AdminisNotably, some administrative databases may be “locked” in terms of the data available in them (e.g. Medicare) that may preclude use for tracking specific outcomes. For example, some select adverse events used as surrogate or part of a composite outcome may require more detailed information for adjudication  that available. However, other administrative databases may have some flexibility in terms of adding data fields for the purposes of a clinical study. An example of this might be the addition of the type and duration of dialysis in a registry of ICU patients that normally only requires inclusion of a binary variable for dialysis.Given the current time lag of data availability in most administrative datasets, some may be less well-suited to guide real-time enrollment or randomization of individual patients during the acute phase of illness. This would be especially true where information on short-term events  or a greater degree of granularity to accurately capture process-oriented variables such as select adverse events or complications are required in a timely fashion. However, administrative or registry data may be potentially used in certain situations. For example, in a cluster-randomized study where a process of care such as quality improvement or compliance with care bundles (e.g. use of intravenous volume expansion prior to contrast exposure) is an outcome, the use of administrative data may be feasible. More recently developed disease and procedure registries, such as the APPROACH database, a Canadian registry of patients undergoing cardiac catheterization and cardiac surgery, are being used to capture the majority of process and outcome data for the trial. . Including research stakeholders within administrative or disease-registry development or oversight teams may facilitate their configuration to integrate research and quality improvement aims.In summary, administrative datasets have facilitated the study of AKI on a population-level and are being leveraged by an expanding user base. Major limitations currently include low sensitivity, the subjective nature of assessment, and limited clinical phenotyping of AKI. These limitations highlight important opportunities to improve the quality and coding of data to better address critical knowledge gaps in AKI and improve care. Refinements in coding and the potential to link to increasingly sophisticated EMR data represent key opportunities to advance current administrative data. While an idealized, comprehensive definition of AKI is not currently tenable, tangible progress can currently be made and can help refine how AKI is captured and described within administrative data. We propose the integration of standardized classification schemes and the improvement of linkage of AKI to the clinical context in which it occurs as feasible, substantial improvements on current coding. Progress will require continued efforts to improve awareness of the impact of AKI on public health, engagement of key stakeholders, and tangible strategies to reconfigure infrastructure and improve the reporting and phenotyping of AKI.