Gene expression profiles and single-nucleotide polymorphism (SNP) profiles are modern data for genetic analysis. It is possible to use the two types of information to analyze the relationships among genes by some genetical genomics approaches. In this study, gene expression profiles were used as expression traits. And relationships among the genes, which were co-linked to a common SNP(s), were identified by integrating the two types of information. Further research on the co-expressions among the co-linked genes was carried out after the gene-SNP relationships were established using the Haseman-Elston sib-pair regression. The results showed that the co-expressions among the co-linked genes were significantly higher if the number of connections between the genes and a SNP(s) was more than six. Then, the genes were interconnected via one or more SNP co-linkers to construct a gene-SNP intermixed network. The genes sharing more SNPs tended to have a stronger correlation. Finally, a gene-gene network was constructed with their intensities of relationships (the number of SNP co-linkers shared) as the weights for the edges. Today, both genome-wide gene expression and SNPs can be measured at the same time, which allows identification of such cis- and trans-acting loci, often called (pleiotropic) expression quantitative trait loci (eQTLs) at the "omics" scale. By treating gene expressions as quantitative traits and SNPs as genomic landmarks, the analysis can proceed in the same (or extended) manner as mapping genetic loci for physiologic or clinical traits [It is increasingly recognized through genomic studies that genes regulated via the same mechanisms are likely to have similar mRNA expression profiles, for example, by sharing the same transcriptional factors, or pathways, or any unknown but important factor. Several investigators have provided indirect evidence for this hypothesis by clustering genes according to their mRNA expression profiles . Thus, il traits .In this study, following the conventional linkage analysis for identification of the "susceptibility" SNP/loci for each gene, we further identified these SNP co-linkers by measuring the strength of the relationship between the linked genes and the co-linker. After finding SNP co-linkers, the SNP-gene intermixed network could be further expanded by linking two genes if they shared a common SNP co-linker. We used Haseman-Elston sib-pair linkage analysis to establish gene-SNP linkages. Then, hub genes and SNPs were identified by their high degree of connectivity. Finally, a SNP-gene intermixed network was constructed.In this study, we used data for Problem 1 from Genetic Analysis Workshop 15 (GAW15), which provided expression levels of 3554 genes in lymphoblastoid cells from fourteen three-generation Centre d'Etude du Polymorphisme Humain (CEPH) Utah families. Genotypes of 2882 autosomal and X-linked SNPs were also included [jth sib-pair with the subscript ii', and define the mean transcriptional expression for a gene as:We used the SIBPAL program in S.A.G.E. for sib-pair linkage analysis . This isN sib pairs. Then the dependent variable for the jth pair waswhere the summands were the gene expression values measured on The basic regression model we fitted was of the form:α was the intercept, and βh and h were the total genetic variance due to the hth SNP marker and the estimated IBD at the marker respectively, and ε was the residual error. This regression model was used to establish the gene-SNP linkages.where A gene-SNP network was constructed using the identified relationships between genes and SNPs, where genes and SNPs were two types of nodes. Two nodes were connected using an edge if a relationship between them was presented Fig. . Some noGi be a group of n genes that were linked to a common SNP . The hypothesis tested (Ht) was whether the genes in Gi were significantly co-expressed by comparing it with the null model (H0) that depicts the random expression patterns among groups of genes of the same size as Gi. The averaged Pearson's correlation coefficient (The genes that were linked to a common SNP(s) might have correlated mRNA expression profiles because they share a genetic factor. Let rij was the Pearson's correlation coefficient between ith and jth genes. A gene could be clustered into different functional groups if it was linked to multiple SNP co-linkers. A permutation approach was used to determine the consensus threshold for Gi. We randomly sampled n genes from the original whole gene pool and calculated the averaged correlation coefficient between the n genes. The same process was repeated 100,000 times and the 95% quantile was then defined as the empirical threshold that corresponds to the type I error of 0.05 [where p < 0.05)). As shown in Figure Gene expressions are often influenced by multiple factors . The more factors two genes share, the closer the relationship they tend to have. However, the strong linkage disequilibrium (LD) among the SNP co-linkers might influence the result. To investigate the issue, we assessed the LD for all SNP pairs by implementing a likelihood ratio test using the software Arlequin , whose e-7 after multiple test correction using Bonferroni's method. There were 60 pairs defined as cis-acting where the SNPs localized within the extended 10-Mb region of the paired genes, and all the remaining were trans-acting.We found a total of 4727 gene-SNP linkage pairs at the significance level of 10A gene-SNP network was constructed from the above gene-SNP linkages. Genes and SNPs had 2.4 connections on average. Some genes and SNPs had a significantly larger number of relationships than the average. These genes and SNPs were defined as hub nodes (either hub genes or hub SNPs) as illustrated in Figure p-values correspond to the empirical values derived from the null distribution generated by 100,000 permutations. In this study, we found that the genes among a group having number of connections >18 were significantly co-expressed. If the number of connections dropped down between 18 and 7, co-expressions of most gene clusters were less significant. But, if the number dropped down below 7, co-expression might be occurring by chance . Alternatively, one may consider using purely multivariate modelling to include all the genes, but this is not practical yet due to the prohibitive computing demand. One may also consider several data reduction techniques such as principal-component analysis as seen in several applications in this workshop. From both theoretical and applied views, all the methods have their own merits and weaknesses in analyzing modern high-dimension data. Further comparisons between different approaches are expected to provide novel methodological insights.Although we identified gene-SNP relationships using very strict criteria, it is likely that the resulting gene-SNP intermixed network (or the further derived gene-gene network) includes some noise links. Hub SNPs or hub genes, which are expected to play key roles in maintaining the underlying biological networks in a working condition, should be further studied either computationally or using molecular biology techniques prior to applying these hub SNPs or hub genes in more practical settings.The proposed bioinformatics approach, which attempts to identify co-regulated gene clusters from the correlated genes linked to a common SNP(s) as the shared factor, has been demonstrated via analysis of the GAW15 Problem 1 data, to be a promising and feasible strategy to identify transcriptional QTLs (hub SNPs) and to elucidate the underlying transcriptional genetic networks on the global scale. However, further studies, including topological and functional evaluation and validation of the resulted networks using more data sets and large-scale simulations are warranted.The author(s) declare that they have no competing interests.


Dicistroviridae  includes species that infect insects and other arthropods. These viruses have a linear positive-sense ssRNA genome of ~8-10 kb, which contains two long ORFs. The 5' ORF encodes the nonstructural polyprotein while the 3' ORF encodes the structural polyprotein. The dicistroviruses are noteworthy for the intergenic Internal Ribosome Entry Site (IGR-IRES) that mediates efficient translation initation on the 3' ORF without the requirement for initiator Met-tRNA. Acute bee paralysis virus, Israel acute paralysis virus of bees and Kashmir bee virus form a distinct subgroup within the Dicistroviridae family. In this brief report, we describe the bioinformatic discovery of a new, apparently coding, ORF in these viruses. The ORF overlaps the 5' end of the structural polyprotein coding sequence in the +1 reading frame. We also identify a potential 14-18 bp RNA stem-loop structure 5'-adjacent to the IGR-IRES. We discuss potential translation initiation mechanisms for the novel ORF in the context of the IGR-IRES and 5'-adjacent stem-loop.The family  Dicistroviridae includes a number of insect- and arthropod-infecting species such as Cricket paralysis virus, Black queen cell virus, Plautia stali intestine virus and Taura syndrome virus. The species Acute bee paralysis virus (ABPV), Israel acute paralysis virus of bees (IAPV) and Kashmir bee virus (KBV) - which have been associated with Colony Collapse Disorder of honeybees - form a tight subclade within the family  or any of the usual initiation factors  was apparent at the 5' end of CDS2  a portion of ribosomes, or rather 40S ribosome subunits, binding to the IGR-IRES somehow start scanning, and normal AUG-initiation takes place at a conserved tandem pair of +1 frame AUG codons ~35 codons downstream  a portion of ribosomes initiate at more-or-less the normal IGR-IRES mediated non-Met-tRNAm Figure  or, in sThe synonymous site conservation plot peaks around the tandem +1 frame AUG codons Figure , fallingIf ORFX initiation occurs at the normal IGR-IRES initiation site but in the +1 frame then translation of ORFX would result in an 11.2 kDa, 93 amino acid product in KBV, and 92 and 94 amino acid products in ABPV and IAPV respectively. If, however, initiation takes place at the downstream tandem AUG codons, then translation of ORFX would result in a 7.1 kDa, 60 amino acid product in all three species. Within the longer (i.e. 92-94 amino acid) potential ORFX product, there are 61 residues that are completely conserved between the KBV, ABPV and IAPV GenBank RefSeqs. In the region of the structural polyprotein that is encoded by the portion of the CDS2 sequence that ORFX overlaps, there are 66 completely conserved residues. Thus the putative ORFX product is apparently subject to slightly weaker functional constraints than the 'corresponding' portion of the structural polyprotein.NC_006559]; [NC_003005]; ; ).FJ229495] - with partial coverage of the ORFX region contained an ORFX-frame premature termination codon [PTC] that truncates ORFX by 33 codons. However, apart from the potential for sequencing errors, PTCs in a small number of isolates are not unusual for short overlapping genes, which tend to have non-essential 'secondary' functions, and we do not believe that this ORFX-defective partial sequence necessarily precludes the presence of a functional ORFX in SINV-1.)SINV-1 clusters with the bee paralysis viruses in the phylogenetic tree Figure .  potential RNA hairpin structure immediately 5'-adjacent to, but not overlapping, the IGR-IRES in the bee paralysis viruses Figure . In the i [Recent results suggest that under certain circumstances (namely the presence of an initiator tRNA species that recognizes the P-site codon) the IGR-IRES can, at some level, mediate initiation at the P-site (presumably in competition with A-site initiation) . The codi .Other dicistroviruses lack a long overlapping ORF at this genomic location and lack the corresponding extended region of synonymous site conservation (data not shown). At least some other dicistroviruses do exhibit some degree of heightened synonymous site conservation at the very 5' end of CDS2, but the 3' extent of these regions appears to be much more limited than in the bee paralysis viruses . In facOverlapping genes are difficult to identify and are often overlooked. However, it is important to be aware of such genes as early as possible in order to avoid confusion (otherwise functions of the overlapping gene may be wrongly ascribed to the gene they overlap), and also so that the functions of the overlapping gene may be investigated in their own right. Although overlapping the structural polyprotein, there is no reason to suspect that ORFX encodes a structural protein - indeed the limited phylogenetic distribution of ORFX suggests that it does not. We are currently investigating the translation mechanism for the putative ORFX and how it relates to the IGR-IRES and the potential upstream hairpin structure.Note: during the preparation of this manuscript, the positive coding potential of ORFX was also predicted by Ref.  (who namThe authors declare that they have no competing interests.AEF carried out the bioinformatic analysis and wrote the manuscript. All authors edited and approved the final manuscript.


Self-administration of recombinant human follicle-stimulating hormone (r-hFSH) can be performed using injection pen devices by women undergoing assisted reproductive technology procedures. The objective of this study was to explore the use of the prefilled follitropin alfa pen in routine assisted reproductive technology procedures in Germany.This prospective, observational study was conducted across 43 German IVF centres over a period of 1.75 years. Patients who had used the prefilled follitropin alfa pen in the current or a previous cycle of controlled ovarian stimulation completed a questionnaire to assess their opinions of the device.A total of 5328 patients were included in the study. Of these, 2888 reported that they had previous experience of daily FSH injections. Significantly more patients reported that less training was required to use the prefilled follitropin alfa pen than a syringe and lyophilized powder . Significantly more patients rated the prefilled follitropin alfa pen as easier in terms of use  and daily injection  than existing injection methods. Approximately one third of respondents rated the prefilled follitropin alfa pen as easier to use than the follitropin beta pen with reloadable cartridges. The majority  of patients had a general preference for the prefilled follitropin alfa pen over other injection methods.In this questionnaire-based survey, routine use of the prefilled follitropin alfa pen was well accepted and associated with favourable patient perceptions. Users of the pen found it easier to initially learn how to use, and subsequently use, than other injection methods. In general, the prefilled follitropin alfa pen was the preferred method for self-administration of gonadotrophins. Together with previous findings, the results here indicate a high level of patient satisfaction among users of the prefilled follitropin alfa pen for daily self-administration of r-hFSH. Exogenous follicle-stimulating hormone (FSH) is used for ovulation induction and controlled ovarian stimulation (COS) during fertility treatment. Recombinant human FSH (r-hFSH) was first introduced into the market in 1995 and, unlike previously used sources of gonadotrophins, provides an unlimited, consistent, pure supply of FSH [® filled-by-mass [FbM]) offers the most consistent and precise dosing of all FSH products [Recent developments in recombinant technology have led to improvements in the quality and consistency of gonadotrophins ,2. Folliproducts -6.® (FbM) Prefilled Pen  is prefilled with premixed follitropin alfa, is ready-to-use and disposable, whereas the Puregon Pen®  is a reusable device, designed for use with premixed, prefilled loadable cartridges of follitropin beta.As r-hFSH can be administered subcutaneously, it is suitable for self-injection by patients. r-hFSH was originally supplied in single or multidose vials or ampoules for reconstitution and injection using a syringe, but is now available in premixed solutions for use with injection-pen devices. Two injection-pen devices for the self-administration of r-hFSH are currently available. The GONAL-fAn observational study was conducted in Germany over almost 2 years to explore patient perceptions of the prefilled follitropin alfa pen for the administration of r-hFSH in routine assisted reproductive technology (ART). Here, we present the results of a questionnaire-based survey to assess patients' evaluation of the pen, its perceived ease of use, and acceptability versus previously used injection methods.This was a prospective, observational study conducted across 43 German IVF centres, from April 2004 until December 2005. Routine clinical data for patients undergoing cycles of COS for conventional IVF or intracytoplasmic sperm injection were entered prospectively into an electronic database (RecDate). Only one cycle per patient was included in this study.When patients returned for oocyte retrieval, those who had used the prefilled follitropin alfa pen were asked to complete a multiple-choice questionnaire comparing their experience with that of other injection methods . If the patient had used the follitropin alfa pen in a previous stimulation cycle (rather than the current cycle), she was asked to complete the questionnaire with reference to the particular cycle in which she had used the follitropin alfa pen. The questionnaire . No statistical hypotheses were specified in advance and, due to the nature of the study, the sample size was not pre-specified. In retrospective analyses, exact binomial tests were used to assess differences in the proportions of patients who gave particular responses.2 (n = 5279). The mean (SD) number of days of COS per patient was 10.9 (2.7) days, with a mean (SD) cumulative dose of 2148 (993) international units of follitropin alfa per patient.A total of 5328 patients attending the participating centres during the study period had used the prefilled follitropin alfa pen in the current or a previous cycle of COS, and were, therefore, eligible for inclusion in this study. The mean (SD) age was 33.8 (4.3) years (n = 5326); the mean (SD) body mass index was 23.4 (4.2) kg/mWhen questioned about previous experience with daily injections of FSH, 2888 respondents reported that they did have experience. The most common preparation of FSH previously used (by 52.9% of those with prior injection experience) was that of ampoules containing lyophilized powder. In total, 24.9% of patients with prior experience of daily injections with FSH had previously used the reusable follitropin beta pen.The majority  of respondents reported that they were trained to use the prefilled follitropin alfa pen by a nurse. The majority (52.4%) of respondents required between 5 and 9 min to be trained to use the pen Table ; the meaPatients who had used the prefilled follitropin alfa pen (1040 respondents) and follitropin beta pen (50 respondents) reported that they changed the pen/cartridge a mean value of 2.3 and 2.4 times per treatment cycle, respectively.Significantly more respondents rated the overall ease of use of the prefilled follitropin alfa pen as easier than existing injection methods   of respondents stated that they generally preferred the prefilled follitropin alfa pen when questioned about their favoured method for injection of r-hFSH  number of oocytes retrieved per cycle was 9.75 (5.83). Over 90% of cycles resulted in embryo transfer; the clinical pregnancy rate per transfer was 32.21%. Other clinical outcomes are presented in Table Out of a total of 1549 pregnancies, there were 363 (23.43%) spontaneous miscarriages and 1076 (69.46%) live births (data were missing for 110 pregnancies). Of the 1076 births, there were 841 singleton births, 228 twin births, 6 triplet births and 1 quadruplet birth. There were 94 cases (1.95% of cycles which resulted in embryo transfer) of grade II ovarian hyperstimulation syndrome (OHSS), 22 cases (0.46%) of grade III OHSS; 28 cases of OHSS (0.58%) required hospitalization.In this questionnaire-based survey, the routine use of the prefilled follitropin alfa FbM, ready-to-use injection pen was well accepted, and associated with favourable patient perceptions in 5328 ART cycles. Patients reported that use of the follitropin alfa pen required less training compared with a syringe and vials/ampoules of follitropin alfa. The prefilled pen was perceived as being easier to use than existing injection procedures/devices, including the reusable follitropin beta pen, and there was a general preference for the follitropin alfa pen.Injection-pen devices are used to self-administer medications that require daily injection on a long-term basis. Most experience of injection-pen devices to date has been obtained in diabetic patients who self-inject insulin. Pen devices are the preferred mode of administration for insulin, as they have made the injection process easier, less painful and more convenient. This has resulted in increased patient acceptance of therapy, and has improved patient compliance with therapy and treatment outcomes, as demonstrated by improvements in glycaemic control -10.Previous studies have highlighted a number of benefits for the use of pen devices for the administration of r-hFSH. Compared with the use of syringes and vials/ampoules, women undergoing fertility therapy find the use of pen devices to be less painful, less stressful, easier and more convenient, and their use is associated with greater patient satisfaction -14.Results from comparative studies of the two available pen devices for injection of r-hFSH indicate a preference for the prefilled follitropin alfa pen among both patients and nurses ,16. In aA study of patients undergoing ART at an Australian centre compared the prefilled follitropin alfa pen with previous experience of the reusable follitropin beta pen ,16. PatiA survey conducted at a centre in the USA provided questions for patients about their preferred administration device following nurse-led training in different injection-administration methods . Of 94 pThe current study is a much larger evaluation of the use of the prefilled follitropin alfa pen in routine clinical practice than those previously conducted. During the 1.75-year study period, approximately 35,000 prospective ART cycles were performed per year in Germany . These dIt has been suggested that pen devices may also improve the efficacy of ovarian stimulation regimens, with better clinical outcomes associated with use of a pen device to administer r-hFSH compared with a conventional syringe ,20,21. HIn summary, this study represents almost 9% of ART cycles conducted in Germany over a 1.75-year period. The results confirm previous findings on the acceptance, ease of use and preference for the prefilled follitropin alfa pen among women who self-administer r-hFSH for ART. The findings from this and previous user surveys are reflected in an audited report of pharmacy data obtained (post-study) for the 2004-2009 period which show that the majority of patients who have utilized follitropin alfa in Germany in the last 6 years have done so in the form of a prefilled pen.JT Welcker and F Nawroth declare that they have no competing interests. W Bilger is an employee of Merck Serono GmbH, Darmstadt, Germany, an affiliate of Merck KGaA, Darmstadt, Germany.All authors contributed equally to the design of the study, the collection and analysis of the data and the writing and reviewing of the manuscript. All authors have read and approved the final version of the manuscript.Questionnaire: comparing injection methods. QuestionnaireClick here for file


P = 0.919) was observed in serum tamoxifen concentrations between the anastrozole and placebo groups during the trial. The serum concentration of oestradiol was significantly suppressed (P < 0.0001) in patients co-administered anastrozole compared with placebo in the presence of tamoxifen, confirming that anastrozole remained an effective suppressant of oestradiol in the presence of tamoxifen. The combination of tamoxifen and anastrozole was well tolerated, with very little difference in side-effects reported between anastrozole and placebo. In conclusion, the results of this study confirm that anastrozole does not affect the pharmacokinetics of tamoxifen when the two drugs are given in combination to post-menopausal women with early breast cancer. In addition, the oestradiol suppressant effects of anastrozole appear unaffected by tamoxifen. © 1999 Cancer Research CampaignThirty-four post-menopausal women with early breast cancer who had received 20 mg tamoxifen once daily as adjuvant therapy for at least 10 weeks participated in a randomized, double-blind, parallel-group, multicentre trial. The primary aim of the trial was to determine the effect of anastrozole upon tamoxifen pharmacokinetics, with secondary aims of assessing the tolerability of the two drugs in combination and whether or not tamoxifen had any effect upon the oestradiol suppression seen with anastrozole. Patients were randomized to receive either 1 mg anastrozole (16 patients) or matching placebo (18 patients) once daily on a double-blind basis for 28 days. No significant difference (


Lipopolysaccharide (LPS) contained in tobacco smoke and a variety of environmental and occupational dusts is a toxic agent causing lung inflammation characterized by migration of neutrophils and monocytes into alveoli. Although migration of inflammatory cells into alveoli of LPS-treated rats is well characterized, the dynamics of their accumulation in the perivascular space (PVS) leading to a perivascular inflammation (PVI) of pulmonary arteries is not well described.E. coli LPS and euthanized after 1, 6, 12, 24 and 36 hours. Control rats were treated with endotoxin-free saline. H&E stained slides were made and immunohistochemistry was performed using a monocyte marker and the chemokine Monocyte-Chemoattractant-Protein-1 (MCP-1). Computer-assisted microscopy was performed to count infiltrating cells.Therefore, we investigated migration of neutrophils and monocytes into PVS in lungs of male Sprague-Dawley rats treated intratracheally with Surprisingly, the periarterial infiltration was not a constant finding in each animal although LPS-induced alveolitis was present. A clear tendency was observed that neutrophils were appearing in the PVS first within 6 hours after LPS application and were decreasing at later time points. In contrast, mononuclear cell infiltration was observed after 24 hours. In addition, MCP-1 expression was present in perivascular capillaries, arteries and the epithelium.PVI might be a certain lung reaction pattern in the defense to infectious attacks. Lipopolysaccharide (LPS) is a glycolipid of gram-negative bacterial cell walls and is present in many different airborne particles, such as tobacco smoke and a variety of environmental and occupational dusts ,2. InhalRecently, we identified the perivascular space (PVS) around pulmonary arteries as a unique morphological compartment with possible impact on inflammatory responses in the lung ,10. The Currently, there are no data on the temporary migration of inflammatory cells into the PVS in LPS-induced lung inflammation. Therefore, we conducted this study to define the kinetics of neutrophils and monocytes/macrophages into PVS in lungs of LPS-treated rats. In addition, we examined the immune-histological expression of monocyte chemoattractant protein-1 (MCP-1) in PVS of normal and LPS-treated rats.The experimental protocols were approved by the University of Saskatchewan Committee on Animal Care Assurance and experiments were conducted according to the Canadian Council on Animal Care Guidelines. Specific pathogen-free, ten-week-old, male Sprague-Dawley rats were procured from Charles River laboratories, Canada. Rats were maintained in the animal care unit and were acclimatized for a period of one week and randomly divided into six groups of five each Table .E. coli LPS diluted in 80 μl of saline  was injected in the trachea. Animals were euthanized at 1, 6, 12, 24 and 36 hours (n = 5 per group) post-treatment and were observed during the post-LPS treatment period hourly during the day after application. Although LPS-treated rats appeared to be sluggish, none of them died prior to euthanasia. Control animals (n = 5) were euthanized at 6 hours post saline treatment  around pulmonary arteries (PA). We have not evaluated PVS areas around pulmonary veins because the changes there are weaker as compared to pulmonary arteries. Only those PA were included in the analyses, which were fully captured in a cross section and had inner diameter of more than 100 μ. The PVS area was digitally displayed and determined in square microns by the delineation with the cursor. In most of the cases the PVS was clearly separated from the adjacent alveolar tissue as well as the adventitia of the adjacent bronchi and other vessels Figure . The totE. coli LPS. To minimize changes to morphology and introduction of artifacts, the lungs were neither lavaged nor perfused. The histological signs of lung inflammation observed were similar to those reported in various other studies using intratracheal instillation of LPS [Lungs from saline-treated rats showed normal histology and no accumulation of inflammatory cells in alveoli or the PVS. In contrast, lungs from LPS-treated rats displayed a typical accumulation of cells Fig. . Single n of LPS ,5,14.Our study showed distinct patterns of recruitment of leukocytes into the PVS. The total leukocyte numbers increased slightly 6 hours post-LPS treatment. Significance was calculated only after 36 hours which was due to the moderate increase with high variations and to a small number of animals used in this study. The neutrophils were primarily absent and were increased rapidly after 1 and 6 hours and disappeared again after 24 hours. Compared to the alveolar recruitment leukocytes came slow but neutrophil migration into the PVS was as quick as into the alveoli ,14,15. TThe mechanisms and route of recruitment of inflammatory cells into PVS remain largely unknown. Recently, we reported that there are strain-dependent differences in inflammatory cell recruitment into PVS in acute and chronic airway inflammation . AlthougWe conclude that PVS may be a unique anatomical and functional site for the migration of inflammatory cells in acute lung inflammation. Therefore, PVS may contribute to immune responses in lung inflammation provoked through various stimuli. We still need to answer intriguing questions such as the route and mechanisms of migration of inflammatory cells into PVS.The authors declare that they have no competing interests.KSJ performed the animal experiments and was involved in the morphological evaluation and helped to draft the manuscript. TT performed the analysis of the lung sections and drafted the manuscript. RP was involved in coordination of the study and helped to draft the manuscript. BS conceived of the study, participated in its design and helped to draft the manuscript. All authors read and approved the final manuscript.


The growth of a CBA mammary adenocarcinoma has been studied following transplantation to syngeneic and allogeneic recipients, with particular reference to the susceptibilities of the primary and secondary responses elicited by the tumour allografts, to impairment by whole-body X-irradiation and by treatment with rabbit-anti-mouse lymphocyte serum. In syngeneic recipients, the diameter of tumour implants increases linearly with time and there is no difference in the growth curves in females and in males. Later tumour generations grow faster than earlier generations. In allogeneic recipients, there is a relationship between the tumour diameter on day 21 (T) and the dose of X-irradiation (D) administered before implantation:T = 0.028 D - 9.17for early tumour generations (SMT4) but this is obscured for later generations (SMT21). The primary response to tumour allografts was radiosensitive whereas the secondary response was radioresistant. This radioresistance of the secondary response persisted for at least 5 months after primary sensitization. Unlike whole-body X-irradiation, treatment with rabbit-anti-mouse lymphocyte serum suppresses both the primary and secondary responses to tumour allografts. The possibility is considered that after exposure to antigenic stimulation, an immunologically reactive cell population is formed which is radioresistant but sensitive to ALS, unlike the precursor cells from which this population is derived, which are radiosensitive and sensitive to ALS.


Desmoid tumors are soft-tissue neoplasms arising from fascial or musculo-aponeurotic structures. Most reported thoracic desmoid tumors originate from the chest wall. However, intrathoracic desmoid tumors are rare. We present a case of a 35-year-old male patient complaining of mild shortness of breath. The patient was diagnosed to have a huge intrathoracic desmoid tumor, which was successfully resected. Desmoid tumors are soft-tissue neoplasms arising from fascial or musculo-aponeurotic structures.2 Most reA 35-year-old male patient was admitted to the emergency room complaining of mild shortness of breath of 12 weeks’ duration. He had history of road traffic accident about 1 year back, with unilateral lower limb fracture. Otherwise, the history was unremarkable.Clinical examination of the patient showed stable vital signs, one small left supraclavicular lymph node, trachea shifted to the right and decreased air entry on the left side with dull percussion note; otherwise, no abnormality was detected. Blood work-up did not show significant changes. Chest x-ray was done, and it showed homogenous opacity on left hemi-thorax and shifting of the mediastinum to the right. So, CT scan of the chest was done, and it revealed huge left-side intrathoracic mass pushing the mediastinum to the right side, with complete collapse of the left lung . Fine-neThe patient was prepared for surgery, posterolateral thoracotomy was done and about 20 × 15 × 20 cm lobulated intrathoracic tumor was found. The tumor was attached to the apicolateral portion of the chest wall near the brachial plexus; so we excised the tumor completely except a very small part which was adherent to the area of brachial plexus, and decortication of the left lung was done . The hisJohn Macfarlane first described desmoid tumors in 1832. The over6They most often arise from the musculo-aponeurosis of the abdominal wall. Common s1014Several pathophysiological hypotheses are suggested. Abnormal62216Complete resection of the tumor with a clear surgical margin is currently the mainstay of curative treatment for desmoid tumors. The recurrence rate is high and varies from 29% to 54% in some reported series.


At the start of the last decade, we provided evidence that levels of the peptide neurokinin B were highly elevated in pre-eclampsia. We hypothesized that elevated levels of neurokinin B may be an indicator of pre-eclampsia and that treatment with certain neurokinin receptor antagonists may be useful in alleviating the symptoms. At the time of the original hypothesis many questions remained outstanding. These included - Does neurokinin B have any diagnostic value in the detection and diagnosis of pre-eclampsia? - What is the cause of the elevated levels of neurokinin B during pre-eclampsia? - What is the physiological significance of neurokinin B in the placenta? This review discusses the answers to these questions taking into account the subsequent developments of the past ten years and analyzing the plethora of discoveries that have arisen from those initial observations. The precise origin of pre-eclampsia remains elusive, but it is believed to be multifactorial and to include a scenario of required steps . One cruTAC3 that encodes NKB [From all the candidates NKB, which is a member of the tachykinin family , appeareodes NKB , a gene odes NKB . This exodes NKB . In tranodes NKB ,13. Usinodes NKB . NKB wasodes NKB . In termodes NKB . In addiodes NKB ,11. Hereodes NKB . We, theodes NKB , generalodes NKB , oedema odes NKB  and eclaodes NKB . Nonethe2) only trace amounts of NKB in the plasma from pre-eclamptic women and only minute amounts of NKB in placental extracts could be detected when compared to the results of the commercial RIA [® Peptide HR 10/30 column [In the case for a diagnostic marker the measurement of elevated levels of NKB in pregnancies complicated by pre-eclampsia has been subsequently confirmed in several studies ,18-24. Ncial RIA . This brcial RIA . Howevercial RIA  indicati0 column . This inIn general, the differential diagnostic value of NKB has been determined predominantly around term, but does it have any predictive value early in pregnancy? We originally found low or undetectable levels of NKB throughout normotensive pregnancies though a proportion did exhibit higher levels during the first trimester comparable to levels found at term . A few sIt would seem apparent that NKB could have a diagnostic role to play at term and could also serve a role in determining differences between those with differing severities of the disorder. This may serve to allow some degree of sorting of pregnant women into different categories that can then be used to improve their clinical management. Its role as a predictor in earlier pregnancy before the onset of clinical symptoms is less clear. Although Li et al.  have conTAC3 are found to be significantly higher in pre-eclamptic placenta at term when compared to controls [TAC3 expression could be up-regulated in response to poor placental perfusion. However, it is still not known at what stage in pregnancy these differences first occur. In spite of this, term placental cytotrophoblasts grown in hypoxic conditions were found to be associated with decreases in TAC3 expression, whilst cytotrophoblasts exposed to conditions of oxidative stress demonstrated no significant changes in TAC3 expression from controls [Defective trophoblast invasion has been described as a consistent feature of pre-eclampsia that can lead to placental ischaemia and the potential release of NKB as a signal to the mother to maximize blood flow to the feto-placental unit. Proposed physiological triggers include hypoxia  and oxidcontrols ,34; a recontrols . In anotcontrols  showed tcontrols . This lecontrols  to hypotTAC3 (which has 80% sequence identity with human TAC3) expression could be undertaken during late pregnancy there was found to be a significant three fold decrease in TAC3 expression from day 16 to 21 [TAC3 expression or whether this represents a species-specific difference. Moreover, by day 19, the expression of the placental rat NK3 receptor (TACR3) appeared to be virtually non-existent indicating the gene was switched off [TAC3 gene promoter has revealed the presence of estrogen response elements and many potential half sites [In the rat, where a longitudinal study of 16 to 21 . It is nched off . In esseched off ; a similched off ,39. A prched off ; where iched off . Furtherlf sites . Cintadolf sites  tentativlf sites . Therefolf sites .TAC3 and TACR3 genes [2-terminal dibasic cleavage site of NKB [Genomic analysis has also been performed to determine whether the altered circulating NKB levels are due to sequence variants in the encoding R3 genes . MutatioR3 genes . On the R3 genes . Indeed,R3 genes . TherefoR3 genes ,27. InstR3 genes  who obseR3 genes . In contR3 genes ,27. Thise of NKB ,27. Thise of NKB ,45. Thise of NKB .TAC3 in the placenta are considerably higher than in any other organ or tissue in the human body so far analysed [TAC3 mRNA levels are higher than those found in the brain typically NKB peptide levels found in pre-eclamptic placenta are three times lower than those detected in rat brain [The physiological roles of NKB in the placenta are only just starting to unravel themselves, but one thing is clear the expression levels of analysed ,34. Tradanalysed  and sincanalysed ,22,23,31analysed ,20,25. Fat brain . In addiat brain . This caat brain ,27,43. Iat brain ,27 and tat brain ,22,29.in vivo and in vitro. By contrast, high dose NKB increased resting blood pressure, increased the pressor response to angiotensin II in vivo and increased maximum phenylephrine induced vasoconstriction in vitro. The effects of low dose NKB were shown to be through the direct modulation of vascular tone, while chronic high dose NKB induced increases in blood pressure through both central and peripheral pathways [in vitro.The biological effect of NKB, for example, constriction or dilation of blood vessels depends on the relative tissue distribution of, and binding to, the three tachykinin receptor subtypes given here in order of affinity for NKB, NK3>NK2>NK1 . More repathways . This wopathways  concludepathways  stress tin vitro under arterial flow conditions, increased bleeding times in mice, and a decrease in experimentally induced thromboembolism [Beyond the hypertension, the discovery of secreted NKB during pre-eclampsia has led other researchers to investigate some of the other associated symptoms of pre-eclampsia. In severe cases of pre-eclampsia, we predicted that concentrations of NKB may be high enough to stimulate peripheral NK1 receptors on platelets. Since, a major complication of pre-eclampsia is platelet pathology; Graham et al.  examinedembolism . This haembolism . Substanembolism . Data noembolism . Unexpecembolism  concludeembolism  has hypoembolism  concludeembolism .There is also evidence to support an autocrine/paracrine role for NKB in the placenta. Female rats treated with the NK3 receptor antagonist SR142801 before mating exhibited a tendency towards decreased fertility with a significant reduction in their litter sizes . In addiTAC3 indicate not only to take into account the possibility of up-regulation, but the potential failure/disruption to down-regulate. The role of hormones such as estrogen in these responses will be interesting to investigate for their effect on gene expression. However, the main mechanism of control appears at the level of post-translational modification and may indicate that a general increased activity of certain processing enzymes occurs during pre-eclampsia. This could go some way to explaining the increased plethora of vasoactive peptides that are secreted during pre-eclampsia and is certainly worthy of further research to determine whether there are common processing pathways involved in the elevation of these vasoactive peptides. NKB in the placenta is found to have both paracrine and endocrine roles. In a paracrine role it may modulate implantation, suppress several proteins involved in the cellular response to hypoxia and oxidative stress and act as an anti-angiogenic factor. Locally, it maintains low placental resistance, while its dose dependent and bimodal effects support a mechanism whereby in normal pregnancy it contributes to the modest fall in blood pressure and reduced vascular tone, whilst at high doses it contributes to raising blood pressure and increasing pressor sensitivity as seen in pre-eclampsia. Animal models also show that in the periphery NKB can have significant effects on platelet clotting and lung oedema. The repetition of animal studies with potent and selective combinations of NK receptor antagonists is needed to show their potential effectiveness in the treatment of pre-eclampsia. NK3 antagonists might alleviate the effects of high NKB in the plasma of mothers suffering from pre-eclampsia, whilst NK1 antagonists could control the effects of thrombocytopenia and generalized inflammation. Moreover, recent research has shown a diversity of mechanisms such as mRNA splicing, precursor processing and post-translation modification that can lead to a complex and continually expanding repertoire of tachykinin peptides. The proteomic analysis of the tachykinins has been hindered by the lack of specific methodologies to capture, purify and characterize them and it will be important in the future to develop these methodologies [The precise etiopathogenesis of pre-eclampsia remains the subject of much debate and intensive research. The last ten years has heralded many advances and revealed potential new markers, yet no defining predictive test is yet available to identify women who will subsequently develop pre-eclampsia. This is likely to reflect the fact that pre-eclampsia is multifactorial with an onset, severity and progression that can be significantly distinct in different women. This raises questions to the presence of factors such as NKB to whether they are causative or merely associated with pre-eclampsia. Yet, there is evidence to support a role for NKB right from the time of implantation to the high levels found circulating in the blood of pre-eclamptic women at term. It is apparent the high levels of circulating NKB are a diagnostic feature of pre-eclampsia at term, but its role as an indicator before the onset of symptoms is less clear. Longitudinal studies are still required along with the development of a user friendly and robust test that can be performed directly using plasma. In terms of understanding the regulation of genes involved in pre-eclampsia, the results with dologies . We lookNKB: neurokinin B; TAC3: tachykinin 3 gene; RIA: radioimmunoassay; ELISA: enzyme-linked immunosorbant assay; NK1: tachykinin 1 receptor; NK2: tachykinin 2 receptor; NK3: tachykinin 3 receptor; IUGR: intrauterine growth restriction; TACR3: tachykinin 3 receptor gene; NO: nitric oxide; SFTL-1: soluble FLT-1; VEGF: vascular endothelial growth factor; PIGF: placental growth factor; VEGFR-1: VEGF receptor-1; VEGFR-2: VEGF receptor-2.The author is listed as an inventor on patent WO0136979 .NP drafted and wrote the manuscript. The author read and approved the final manuscript.


A number of noninvasive alternatives to hysterectomy have become available as treatments for uterine fibroids. These alternative therapies, however, may not relieve all symptoms. Consequently, the need for patient-reported outcomes to assess symptom reduction of uterine fibroids has become increasingly important to evaluate the clinical success of patients who choose these alternative therapies. The purpose of the study was to examine the responsiveness of the Uterine Fibroid Symptom and Health-Related Quality of Life Questionnaire (UFS-QOL) with treatment of uterine fibroids.The responsiveness of the UFS-QOL was assessed as a post-hoc analysis of patients treated with MRI-guided focused ultrasound thermal ablation (MRgFUS) for uterine fibroids. The UFS-QOL and SF-36 were completed at baseline and months 1, 3, and 6. Patient perceived overall treatment effect (OTE) was assessed at month 3, while satisfaction with treatment was collected at month 6. The responsiveness of the UFS-QOL was examined using effect sizes and change scores by patient-reported overall treatment effect and satisfaction.A total of 102 women with complete UFS-QOL data were included in the analysis; the mean age was 45 years and 79% were Caucasian. From baseline to 6 months, significant improvements were observed in UFS-QOL Symptom Severity and all Health-Related Quality of Life (HRQL) subscale scores (p < 0.0001). When examining change in general health status over the 6-month follow-up period, significant improvements were noted in all 8 SF-36 subscales. The UFS-QOL was highly responsive with subscale effect sizes ranging from 0.74 for Sexual Function to -1.9 for Symptom Severity. Improvements in UFS-QOL subscales were associated with patient perceptions of perceived benefit and treatment satisfaction.The UFS-QOL is responsive to treatment for uterine fibroids and is a useful outcome measure for uterine-sparing uterine fibroid treatments. Uterine leiomyoma, or uterine fibroids (UF), are the most common neoplasms of the female pelvis, occurring in 20–25% of women of reproductive age . AlthougA variety of minimally and noninvasive alternatives to hysterectomy that leave the uterus otherwise intact have been introduced as treatments for uterine fibroids -9. TheseThe Uterine Fibroid Symptom and Health Related Quality of Life Questionnaire (UFS-QOL) is a uterine fibroid-specific questionnaire developed to evaluate the symptoms of uterine fibroids and their impact on HRQL. The UFS-QOL has been used in a number of studies of uterine fibroid treatment, including studies of uterine artery embolization -15, radiA post-hoc analysis of data from a prospective, nonrandomized, multi-center study to evaluate the safety and efficacy of MRI-guided focused ultrasound (MRgFUS) thermal ablation to treat uterine fibroids was performed to examine the responsiveness of the UFS-QOL. Inclusion criteria included women who: 1) were pre- or perimenopausal; 2) 18 years of age and older; 3) had completed their family; and 4) presented with symptomatic uterine fibroids, with a score of 41 or greater on the UFS-QOL Symptom Severity screener . Women wThe UFS-QOL is a disease-specific questionnaire that assesses symptom severity and HRQL in patients with uterine fibroids . It consThe SF-36 is a generic measure of HRQL and is comprised of 8 subscales: Physical Functioning, Role-Physical, Bodily Pain, General Health, Vitality, Social Functioning, Role-Emotional, and Mental Health . Scores Patient-rated change was assessed using the OTE Scale . PatientPatients were asked three questions regarding their satisfaction with treatment at month 6. The first item asked patients how satisfied they were with their treatment, with responses based on a 6-point Likert scale, ranging from "very satisfied" to "very dissatisfied." A second item asked patients whether they would recommend their UF treatment to a friend with the same health problems. A four-point response scale was used: "definitely yes," "probably yes," "probably not," and "definitely not." The third item asked patients how effective their treatment was in eliminating their symptoms, with response options based on a 6-point Likert scale, ranging from "very effective, relieved all of my symptoms" to "very ineffective, did not relieve or lessen my symptoms."This post-hoc analysis is based on data from patients who were included in the intent-to-treat (ITT) cohort, defined as patients who completed the UFS-QOL at baseline and at least one follow-up assessment. For this responsiveness analysis, missing data was not imputed. Change scores for the UFS-QOL were calculated from baseline to month 3 and baseline to month 6, with the primary analysis based on the change from baseline to month 6. All statistical tests were two-tailed and were conducted with Type I error probability of 0.05. Categorical variables are presented in terms of frequencies and percents; means and standard deviations were calculated for continuous variables.The responsiveness of the UFS-QOL was examined using patient-reported overall treatment effect at the 3-month assessment. For this analysis, patient responses were examined two different ways. Patients were first grouped based on their rating of overall treatment effect using categorical data responses . Patient responses were also examined with continuous data responses, whereby improvement is represented by a patient rating greater than or equal to 2; unchanged is represented by a patient rating of -1, 0, and 1; and deterioration is based on a rating of less than or equal to -2. Due to sample size issues, UFS-QOL change scores were compared among the "worse" or "same" versus "improved" patient groups using general linear models (PROC GLM) controlling for age and baseline UFS-QOL scores.UFS-QOL change scores by patient-reported satisfaction were also examined. Due to sample size issues, the satisfaction items were dichotomized according to whether the patients were satisfied with treatment (satisfied/not satisfied), whether they would recommend the treatment to a friend (yes/no), and whether the treatment was effective in eliminating symptoms (effective/not effective). UFS-QOL change scores were compared among the above-noted patient groups using PROC GLM controlling for age and baseline UFS-QOL scores.® Version 9.1.3.Effect sizes, a quantitative measure of change that standardizes the comparison between groups, were calculated for each UFS-QOL and SF-36 subscale by using the difference in mean scores from baseline to month 6 and dividing by the standard deviation of baseline scores of all participants. Effect size was interpreted as small (0.20), moderate (0.50), or large (0.80) according to the guidelines proposed by Cohen . All anaOf the 108 patients who received UF treatment and completed a baseline UFS-QOL, 5 patients did not complete a 6-month follow-up assessment and 1 did not provide a baseline UFS-QOL assessment, thus resulting in a sample of 102 patients. Among the study participants, the mean age was 45 years, 79% (n = 81) were Caucasian, with a mean body mass index (BMI) of 26.0  Table . Mean chSimilar patterns of patient perceived improvement were found with the SF-36, although the magnitude of change was less than that observed with the UFS-QOL  at 3 months compared to those who reported that their symptoms were the "same" or "worse" 38.4%). The Symptom Severity subscale and all of the HRQL subscales demonstrated significantly greater change for those who reported improvement (OTE score > 2) compared to those who did not (OTE score ≤ 1). Change scores for "improved" patients ranged from 24.8 to 31.5 while change scores for patients who were the "same" or "worse" ranged from 10.1 to 17.5. The mean difference in change scores between the "improved" and "same/worse" groups ranging from 9.0 for Activities to 15.2 for Self-consciousness  and between patients who reported that their treatment was effective (compared to those who did not) in all subscales of HRQL. The UFS-QOL was not able to discriminate between patients who indicated that they would recommend the treatment to a friend compared to patients who would not, but this may be an indication that this particular item is not a good measure of patient satisfaction.In prior research, the SF-36 subscales Social Function, Bodily Pain, and Vitality have been shown to be responsive to hysterectomy ,29. In tThe approach we used to assess the responsiveness of the UFS-QOL is consistent with that outlined by Juniper et al.  by addre1. In patients who truly change their health status, can we measure this change by comparing baseline and follow-up scores?2. Is the instrument able to distinguish between patients whose health status changes and those who remain stable?3. What is the magnitude of the instrument's responsiveness?A major strength of this study is the demonstrated responsiveness of the UFS-QOL in several different analyses. Greater confidence can be placed in the interpretation of clinically significant effects with consistent evidence from multiple sources. In the current study, the UFS-QOL Symptom Severity and HRQL subscale scores between consecutive assessments demonstrated improved symptoms and HRQL for within-patient comparisons. Discriminant ability with patient perceptions was also observed in addition to the large effect sizes. The consistency of our findings strongly suggests that the observed score changes are valid and clinically meaningful.Due to ethical considerations, a placebo group (or sham treatment) could not be included in this study. As such, a limitation of this study is that change in the UFS-QOL due to placebo effect cannot entirely be ruled out, although follow-up of this patient cohort shows that the reductions in symptom severity appear to be maintained over time. Future research examining the responsiveness of the UFS-QOL with placebo-controlled alternative therapies for which the uterus remains in tact is needed to address this limitation.Patient-reported outcomes of symptom severity and HRQL are becoming increasingly important for evaluating treatment of uterine fibroids within the clinical setting. With the increasing availability of noninvasive therapies to hysterectomy, it will be especially important to assess symptom reduction of uterine fibroids and evaluate the clinical success of patients who choose these treatment options. Psychometrically sound patient-reported outcome measures, with demonstrated reliability, validity, and responsiveness, are needed to evaluate interventions among this patient population. The current study indicates that the UFS-QOL is responsive to change in patient health status and able to discriminate between those who improve with treatment for uterine fibroids and those who do not. Consequently, the UFS-QOL appears to be a useful evaluative tool for assessing symptoms and HRQL in studies among patients with uterine fibroids.The UFS-QOL is responsive to treatment for uterine fibroids and is a useful outcome measure for uterine-sparing uterine fibroid treatments.FIBROID: Fibroid Registry Outcomes for Outcomes Data; HRQL: Health-Related Quality of Life; ITT: Intent-to-Treat; MRgFUS: MRI-guided Focused Ultrasound thermal ablation; OTE: Overall Treatment Effect; PROC GLM:General Linear Models comparison; SF-36: Short-Form 36; UF: Uterine Fibroids, also known as uterine leiomyoma; UFS-QOL: Uterine Fibroid Symptom and Health-Related Quality of Life Questionnaire.Funding for this research was provided by InSightec-TxSonics, Inc.All coauthors contributed equally to this manuscript. All authors read and approved the final manuscript.


Several inflammatory cytokines are involved in vascular inflammation resulting in endothelial dysfunction which is the earliest event in the atherosclerotic process leading to manifest cardiovascular disease. YKL-40 is an inflammatory glycoprotein involved in endothelial dysfunction by promoting chemotaxis, cell attachment and migration, reorganization and tissue remodelling as a response to endothelial damage. YKL-40 protein expression is seen in macrophages and smooth muscle cells in atherosclerotic plaques with the highest expression seen in macrophages in the early lesion of atherosclerosis. Several studies demonstrate, that elevated serum YKL-levels are independently associated with the presence and extent of coronary artery disease and even higher YKL-40 levels are documented in patients with myocardial infarction. Moreover, elevated serum YKL-40 levels have also been found to be associated with all-cause as well as cardiovascular mortality. Finally, YKL-40 levels are elevated both in patients with type 1 and type 2 diabetes, known to be at high risk for the development of cardiovascular diseases, when compared to non-diabetic persons. A positive association between elevated circulating YKL-40 levels and increasing levels of albuminuria have been described in patients with type 1 diabetes indicating a role of YKL-40 in the progressing vascular damage resulting in microvascular disease.This review describes the present knowledge about YKL-40 and discusses its relation to endothelial dysfunction, atherosclerosis, cardiovascular disease and diabetes and look ahead on future perspectives of YKL-40 research. Since the results of the Framingham Heart Study revealed C-reactive protein (CRP) as a cardiovascular marker even in ranges considered normal -3, severYKL-40 is a 40 kDa heparin- and chitin-binding glycoprotein also known as human cartilage glycoprotein 39 (HC-gp39) , 38-kDa CHI3L1 gene for human YKL-40 is localized in a highly conserved area on chromosome 1q31-q32 . Th. Th52]. CHI3L1 locus encoding the inflammatory protein YKL-40 did not show any association between certain gene polymorphisms and the risk of type 2 diabetes. It therefore seems reasonable, that it is the low grade inflammation and endothelial dysfunction progressing to later micro- and macrovascular complications that account for the elevated YKL-40 levels in diabetic patients.A study of polymorphisms of the Serum YKL-40 levels have been found to be elevated in other clinical conditions not directly related to atherosclerosis or cardiovascular disease. Several studies describe elevated YKL-40 levels in patients with different types of cancer ,11,53. Yin vitro study has shown, that ectopic expression of YKL-40 in breast and colon cancer cells respectively led to tumor formation with an extensive angiogenic phenotype and that recombinant YKL-40 protein promoted vascular endothelial cell angiogenesis whereas blockade of YKL-40 suppressed tumor angiogenesis both in vitro and in vivo [Recently, an  in vivo . Further in vivo . TherefoYKL-40 is not tumor specific and the studies of YKL-40 as a screening marker for cancer and as a marker useful for monitoring therapeutic results differ . FurtherSubstantial evidence supports a role of YKL-40 in endothelial dysfunction, atherosclerosis and manifest CVD. Clinical studies have demonstrated, that YKL-40 levels are associated with the presence and extent of CAD, are even higher in patients with MI and are associated with all-cause as well as cardiovascular mortality. YKL-40 plays a role in relation to cell migration, reorganization and tissue remodelling during atherogenesis and seems to play a pivotal role in the differentiation of monocytes to activated macrophages in tissues characterized by inflammation. However, the YKL-40 receptor(s) still remain to be isolated and described.YKL-40 has emerged as a promising marker of cardiovascular disease. It seems to be useful for screening because it is detectable in early stage subclinical disease, and it also seems to have the potential of becoming a prognosticator of cardiovascular events and mortality. Future research around YKL-40 should concentrate further on establishing whether YKL-40 could assess the value of a cardiovascular biomarker in clinical practice. Therefore, further investigations of YKL-40 in relation to CAD, MI and diabetes are needed as well as intervention studies describing possible changes in serum/plasma YKL concentrations concomitant with optimized medical treatment of conditions such as e.g. angina pectoris and diabetes. Furthermore, to assess the value as a useful marker in clinical practice, both specificity and sensitivity of YKL-40 in relation to CVD need to be clarified and optimized.Studies in obese with and without complications such as CVD and/or diabetes are few. Such studies could also contribute in establishing YKL-40 as a useful cardiovascular biomarker, since the weight loss following bariatric surgery is accompanied by a reduced risk of CVD in these patients. One study has described significantly reduced YKL-40 levels in obese having bariatric surgery indicating an association between serum YKL-40 levels and adipose tissue/weight loss/reduced cardiovascular risk that still remains to be clarified . CardiovFinally, elevated YKL-40 levels have also been observed in patients with highly differentiated and advanced cancers of various types as well as recurrent cancer states, but recent studies show that this could be explained by the role of YKL-40 in cancer angiogenesis and fibrogenesis.The authors declare that they have no competing interests.CNR drafted and finished the manuscript. HV made critical revision of the manuscript. Both authors have read and approved the final manuscript.CNR is one of the leading scientists worldwide in the field of YKL-40 in releation to diabetes, atherosclerosis and cardiovascular disease. CNR was the first to describe elevated YKL-40 levels in patients with type 2 diabetes and is the only scientist who has examined YKL-40 levels in patients with type 1 diabetes. Beside clinical studies in patients with diabetes and/or cardiovascular disease, CNR conduct cellular studies which hopefully will elucidate the mechanisms by which YKL-40 mediates its function. CNR obtain a Ph.D on this research field in january 2010.HV is chief scientist with primary focus on diabetes and micro- and macrovascular complications. HV is supervisor of CNR and has made substantial contributions to concept and design of the YKL-40 studies conducted by the research group.


Meningiomas located in the region of the base of skull are difficult to access. Complex combined surgical approaches are more likely to achieve complete tumor removal, but frequently at a cost of treatment related high morbidity. Local control following subtotal excision of benign meningiomas can be improved with conventional fractionated external beam radiation therapy with a reported 5-year progression-free survival up to 95%. New radiation techniques, including stereotactic radiosurgery (SRS), fractionated stereotactic radiotherapy (FSRT), and intensity-modulated radiotherapy (IMRT) have been developed as a more accurate technique of irradiation with more precise tumor localization, and consequently a reduction in the volume of normal brain irradiated to high radiation doses. SRS achieves a high tumour control rate in the range of 85-97% at 5 years, although it should be recommended only for tumors less than 3 cm away more than 3 mm from the optic pathway because of high risk of long-term neurological deficits. Fractionated RT delivered as FSRT, IMRT and protons is useful for larger and irregularly or complex-shaped skull base meningiomas close to critical structures not suitable for single-fraction SRS. The reported results indicate a high tumour control rate in the range of 85-100% at 5 years with a low risk of significant incidence of long-term toxicity. Because of the long natural history of benign meningiomas, larger series and longer follow-up are necessary to compare results and toxicity of different techniques. Surgical excision is the treatment of choice for accessible intracranial meningiomas. Following apparently complete removal of benign meningiomas the reported control rates are in the region of 95% at 5 years, 90% at 10 years and 70% at 15 years [Local control following incomplete excision of a benign meningioma can be improved with conventional fractionated external beam radiotherapy (RT) with a reported 10-year progression-free survival in the region of 75-90% -13.Advances in radiation oncology include intensity-modulated radiotherapy (IMRT), fractionated stereotactic radiotherapy (FSRT) and stereotactic radiosurgery (SRS) that allow for more localised and precise irradiation. Recent studies using these new techniques report apparently high local control rates and low morbidity for skull base benign tumors as pituitary adenomas, craniopharyngiomas and meningiomas -18. We pPost-operative conventional RT has been reported effective both following subtotal surgical resection of benign meningiomas and at the time of recurrence. Using a dose of 50-55 Gy in 30-33 fractions the 10-year and 20-year local control rates are 70-80% . Hamm et al [In a series of 41 patients with benign residual or recurrent meningiomas treated at the Royal Marsden Hospital with FSRT between 1994 and 1999  at a medmm et al  at a medmm et al . Eight pA clinical neurological improvement is reported in 14-44% of patients after FSRT ,39,41,43In summary, FSRT is an effective and safe treatment modality for local control of skull base meningiomas and tumor control is comparable to the reported results of other fractionated radiation techniques and SRS for benign skull base meningiomas. FSRT offers a more localized irradiation compared with conventional RT and the reported data from literature indicate that radiation induced morbidity is quite low. Although longer follow-up is necessary to clearly demonstrate the potential reduction of long term complications in comparison with conventional RT, currently FSRT should be preferred for the radiation treatment of large skull base tumors, especially those in close proximity to the optic apparatus.IMRT represents an advanced form of 3-D conformal which has been recently employed for the treatment of different brain tumors, especially large tumors with irregular shapes close to critical structures . IMRT foFew series are available on the use of IMRT in patients with meningiomas Table  16,47-4-447-49. Proton irradiation can achieve better target-dose conformality when compared to 3D-CRT and IMRT and the advantage becomes more apparent for large volumes. Distribution of low and intermediate doses to portions of irradiated brain are significant lower with protons when compared with photons and also could favor the use of protons in younger patients Moreover, proton therapy can be delivered as stereotactic radiosurgery or as fractionated stereotactic radiotherapy with the same used immobilization systems and target accuracy of photon techniques.3) treated with stereotactic proton beam therapy. Permanent neurological deficits were reported in 3 patients.Tumor control after proton beam RT is shown in Table In summary, proton irradiation alone or in combination with photons is effective in controlling meningiomas, with a tumor control and toxicity in the range of photon therapy. On the basis of the dosimetric advantages of protons, including better conformality and reduction of integral radiation dose to normal tissue, fractionated proton irradiation may be considered in patients with large and/or complex-shaped meningiomas or younger patients, possibly limiting the long-term late effects of irradiation. As more hospital-based proton treatment centers are becoming operational, prospective trials that assess the late toxicity of different radiation techniques are needed to confirm the expected reduction in long-term side effects with proton RT.Since 1990, either Gamma Knife (GK) or Linear Accelerator (LINAC) have been extensively employed in the radiosurgical treatment of skull base meningiomas. A summary of main recent published series of SRS in skull base meningiomas is shown in Table Only few studies have compared the outcome of SRS and FSRT in skull base meningiomas ,37,39. M3 treated with GK SRS using a dose of 12 Gy. At A median follow-up of 54 months the 2-year progression-free survival was 100%. Twenty-seven were smaller and 72 unchanged in volume. Three patients suffered adverse radiation effects. Overall, at median dose of 12-14 Gy the reported 5-year actuarial tumor control rate remains in the range of 90-95% as for higher doses [Radiosurgical doses between 12 and 18 Gy have been used in the control of skull base meningiomas. Over the last years, SRS doses have been decreased with the aim to minimize long-term toxicity while maintaining efficacy. Ganz et al  reporteder doses ,77,79-84The rate of tumor shrinkage measured varied in all studies, ranging from 16% to 69% in the different series, and tends to increase in patients with longer follow-up. Similarly, a variable improvement of neurological functions has been shown in 10-60% of patients, however the evaluation of neurological improvement is frequently retrospective and the criteria used to evaluate the functional improvement are subjective or not available in most series.Analysis of factors predicting local tumor control in most series shows no significant differences between patients underwent SRS as primary treatment and patients treated for incomplete resected or recurrent meningioma. Age, sex, site of meningioma, and neurological status did not affect significantly the outcome in most published series, however larger meningiomas are associated with worse long-term local control ,72. DiBiMore recently the image-guided robotic radiosurgery system (Cyberknife) has been employed for frameless SRS in patients with skull base meningiomas ,86. Patith nerve palsy, and trigeminal neuropathy. In the series of Nicolato et al [Complications of SRS are reported in 3 to 40% of cases (corrected mean 8%), being represented by either transient (3.0%) or permanent complications (5.0%). Although radionecrosis of the brain and delayed cranial nerve deficits after SRS are of concern, the rate of significant complications at doses of 12-15 Gy as currently used in most centers is less than 6%  offer a more localized irradiation compared with conventional radiotherapy and has the potential of reducing the risk of long term radiation induced morbidity. Currently SRS and FSRT represent the commonest treatment modality of irradiation for skull base meningiomas, providing a comparable high rates of long-term tumor control with low morbidity. The choice of stereotactic technique should be based on tumor characteristics. SRS is usually suitable only in selected patients, whereas there is no restriction to the size and the position meningioma suitable for standard dose fractionated radiotherapy. Current practice aims to avoid irradiating the optic apparatus beyond single doses of 8-10 Gy. This means that RS is usually offered to patients with relatively small skull base meningiomas not in close proximity of optic apparatus. Hypofractionated stereotactic RT in patients with large skull base meningiomas abutting the optic pathway is a promising treatment, however more robust data need to definitively evaluate the long-term efficacy and toxicity of hypofractionation. Proton irradiation may be considered in patients with large and complex-shaped meningiomas or younger patients, with the aim to limit the long-term late effects of irradiation. Because of slow-growing potential of meningiomas, the superiority of the individual techniques need to be confirmed in prospective and methodologically rigorous studies with appropriate 10-20 years follow-up.The authors declare that they have no competing interests.GM conceived and drafted the manuscript. MA helped the draft and participated in its design. RME critically reviewed/revised the article. All authors read and approved the final manuscript.


Extradural spinal arachnoid cysts are rare lesions, which may become symptomatic due to mass effect. Multiple cysts are even rarer of which few are reported to date. A 17-year-old male with acute onset urinary retention and progressive paraparesis is presented. Magnetic resonance imaging of spine revealed multiple spinal extradural arachnoid cysts located dorsal to the spinal cord, causing mass effect. The patient underwent surgery for excision of the cyst and closure of dural defects. He gained urinary continence and near normal muscle strength of lower extremities over a period of two weeks following operation. Up to date, there have been only sixteen reported cases of multiple spinal extradural arachnoid cysts in the literature and the present case appears to be the second most extensive one reported so far. Appreciation of the rarity of such lesions as well as the importance of surgical planning  is highlighted. The term “spinal arachnoid cyst” is a relatively rare entity among spinal lesions. According to some authors, extra-dural cysts are less common than intra-dural ones , but thiA 17-year-old Caucasian male of Iranian nationality was visited at our institution complaining of forced urination and hesitancy since last two weeks which evolved to frank urinary retention on admission day 2. One month before presentation, he developed progressive weakness of both lower limbs. Neurological examination revealed the following: spastic paraparesis ; sensory level with hypesthesia to pinprick, light touch, and loss of vibration sense up to T2 level. A T4 to L5 laminectomy (sparing the T5 lamina) was performed disclosing multiple extra-dural cystic lesions. They were filled with CSF-like fluid. The cysts communicated with the subarachnoid spaces along the dural sleeves of the following nerve roots: (1) right T4, (2) left T6, (3) left T10, (4) left T11, (5) left L2. The cysts were excised and their ostia were closed. Closure was enforced in some points with muscle flaps.Microscopic examination of the specimens revealed fibrocollagenous tissue with an inner layer of arachnoid. The early postoperative course passed uneventfully. The patient regained urinary continence and was ambulatory with 4+/5 lower extremity forces over a period of two weeks following operation. The patient was symptom free during 12-month period of follow-up. Yet, kyphosis, a complication of the procedure, evolved and progressed during the follow up period which was controlled by brace and its progression ceased.Spinal arachnoid cysts were first described by Spiller in 1903 , althougth decade of life. This may be due to relatively smaller diameter of spinal canal in thoracic region. Lower thoracic, higher thoracic, and thoraco-lumbar regions are involved in order of reducing frequency [Regarding the reported case so far, multiple extra-dural spinal arachnoid cysts seem to occur with higher frequency in females . The pearequency ,4-8. FeaWith the advent of new diagnostic modalities and using state-of-the-art technologies, diagnosis of these complex lesions is not a dilemma at present. Formerly, plain X-ray studies and myelography led to clues for detection of the cysts. Plain radiographs have not been useful in the diagnosis of spinal cysts except for implicit signs such as enlarged spinal canal, bony erosions of the spine including eroded pedicles and posterior elements, slender pedicles, widened foramina, increased inter-peduncular space, and posterior vertebral body and laminar scalloping, and kypho-scoliosis  3-4,10--10-11.MRI is the technique of choice for both diagnosis and delineation of the cyst dimensions. Identification of a sharp interface between the cyst and subarachnoid space related to the cyst wall and the surrounding dura mater, particularly on T2-weighted MR images, allows easy diagnosis of an extra-dural arachnoid cyst . MRI canOne important aspect of preoperative evaluation is to determine the size and location of the dural defect, since it facilitates its repair via minimal laminectomy . HoweverTotal cyst excision, obliteration of the communicating pedicle, and repair of the dural flaw is the treatment of choice of the symptomatic lesions. Postoperative kyphosis may be prevented by performing laminoplasty rather than laminectomy . NeverthMultiple extra-dural arachnoid cysts are rare lesions. To the best of our knowledge, only sixteen extra-dural variants of these lesions are reported previously in the literature. The present case is the second most extensive case of multiple cysts reported to date. Reasonable addressing such pathology requires correct and comprehensive preoperative evaluation, along with a logical operative approach chosen. Since laminectomy and laminoplasty (in multiple levels) might lead to post-operative spinal deformity, it seems that the best approach would be exact determination of the communication site between the cyst and the subarachnoid space, which is currently suggested to be done through Myelography with and without CT . Althoug


Health care workers have a high prevalence of low back pain (LBP). Although physical exposures in the working environment are linked to an increased risk of LBP, it has been suggested that individual coping strategies, for example fear-avoidance beliefs, could also be important in the development and maintenance of LBP. Accordingly, the main objective of this study was to examine (1) the association between physical work load and LBP, (2) the predictive effect of fear-avoidance beliefs on the development of LBP, and (3) the moderating effect of fear-avoidance beliefs on the association between physical work load and LBP among cases with and without previous LBP.A questionnaire survey among 5696 newly qualified health care workers who completed a baseline questionnaire shortly before completing their education and a follow-up questionnaire 12 months later. Participants were selected on the following criteria: (a) being female, (b) working in the health care sector (n = 2677). Multinomial logistic regression analysis was used to evaluate the effect of physical work load and fear-avoidance beliefs on the severity of LBP.For those with previous LBP, physical work load has an importance, but not among those without previous LBP. In relation to fear-avoidance beliefs, there is a positive relation between it and LBP of than 30 days in both groups, i.e. those without and with previous LBP. No moderating effect of fear-avoidance beliefs on the association between physical work load and LBP was found among cases with and without LBP.Both physical work load and fear-avoidance beliefs matters in those with previous LBP. Only fear-avoidance beliefs matters in those without previous LBP. The study did not find a moderating effect of fear-avoidance beliefs on the association between physical work load and LBP. The prevalence of low back pain (LBP) among health care workers is high; studies have found that the 12-month prevalence is between 45% and 63% . Among 5Several well known LBP risk factors are present when working with care of the elderly: physical strain, such as heavy manual work; twisting and bending; standing in forward-bent and twisted postures; poor ergonomic/lifting conditions; and frequent positioning of bedridden patients -11. PrevResearch suggests that a person's coping style and beliefs about pain may be relevant in understanding its development . In a stNearly all research on fear-avoidance beliefs to date has been conducted on chronic LBP patients, except a few studies focusing on acute LBP and fear-avoidance belief. These last mentioned studies found that high levels of fear-avoidance beliefs were present already in the early stages of LBP ,20,29. TIn summary, LBP is highly frequent among health care helpers, and high physical work load is considered a risk factor. There seems to be moderate evidence showing that high fear-avoidance is positively associated with LBP mainly among hospitalized LBP patients. However, specific knowledge is lacking as to how fear-avoidance beliefs develop and how it is involved in the development of LBP. For this purpose it is relevant to study fear-avoidance beliefs in non-patient and non-chronic populations. As previous history of LBP is a well-known predictor of later LBP , we beliBased on a cohort of newly qualified female health care workers with and without previous LBP experience respectively, the aims of this study were to (a) examine the associations between physical work load and the development of LBP, (b) examine the predictive effect of fear-avoidance beliefs on the development of LBP, and (c) examine the moderating effect of fear-avoidance beliefs on the association between LBP and physical work load.Background: Data used in this study were from a national survey - the Danish Health Care Worker Cohort-Class of 2004 (DHCWC-2004), a prospective cohort study of all Danish health care helpers and assistants who qualified in 2004. The health care helpers undergo 14-19 months of education, depending on the length of their basic school education. The education of health care assistants  takes an additional 20 months. This study consists of data from baseline (2004) and the one-year follow-up (2005). In this article both health care helpers and health care assistants are referred to as health care workers.Baseline 2004: at baseline, 6329 health care workers were invited to participate; 5696 completed the baseline questionnaire (90%). The baseline survey took place shortly before the students qualified. The questionnaire was completed during class hours with a researcher from the research group present, ready to assist if needed.Follow-up 2005: the follow-up questionnaire was posted to the participants 12-months after the baseline study, irrespective of whether they were working in the nursing or home care sector, whether they had found other areas of work, or whether they were continuing their education. Of the 5696 who completed the baseline questionnaire, 3708 (65%) completed and returned the one-year follow-up questionnaire - see figure  for details). Questionnaire- and register-based studies do not need approval from the Danish National Committee on Biomedical Research Ethics .The study has been notified to and registered by the Danish Data Protection Agency  : "What iFear-avoidance beliefs: fear-avoidance beliefs at baseline were measured by the fear-avoidance beliefs questionnaire (FABQ) developed by Waddell et al. . The queBecause FAB-physical activity and especially FAB-work had an asymmetric distribution , z-scores were computed for both and standardized so the mean was zero. Converting scores to a z-score is a way of standardizing them. High scores indicated increased levels of fear-avoidance beliefs. A factor analysis confirmed the 2-factor structure of the fear-avoidance beliefs questions and Cronbach's alpha for FAB-work and FAB-physical activity was 0.80 and 0.73, respectively.Physical work load: physical work load at follow-up was measured as unfavourable postures of the body: bending, twisting, kneeling or squatting as well as handling heavy loads during work. Fourteen items were used to describe these postures. Three items described postures of the trunk: strongly inclined, twisted and laterally bent. Two items described positions of the arms: one arm above shoulder height, and two arms above shoulder height. Three items described the position of the legs: squatting, kneeling on one or both knees, walking or moving. Three items described lifting of weights with the trunk upright and three items described lifting with the trunk inclined 60 degrees: light (up to 10 kg.), medium (10- 20 kg.) and heavy (more than 20 kg.). The items were also presented as pictograms. The answers were given on a 5-point rating scale ranging from "never" to "very often" . All theAge: age was categorised into 10-year intervals: ≤ 19 years of age, 20-29 years of age, 30-39 years of age, 40-49 years of age and > 50 years of age.Leisure time physical activity: to measure leisure time physical activity we used a slightly modified version of the question from Saltin and Grimby : " If yoSmoking: smoking was assessed by asking "Do you smoke every day?" with three response categories: (1) yes, (2) no, but I have smoked before, (3) no, I have never smoked.Body Mass Index: weight and height were reported in order to compute a BMI index. BMI < 18.4 kg/m2 = underweight, BMI 18.5-24.9 kg/m2 = normal weight, BMI 25.0-29.9 kg/m2 = overweight and BMI > 30.0 kg/m2 = obese.Psychosocial work factors: psychosocial work factors were measured at follow-up by the Copenhagen Psychosocial Questionnaire (COPSOQ) . The folOf the 3708 respondents who returned the follow-up questionnaire, 2677 health care workers were included in present analyses - see figure SPSS 17.0 was used for statistical analysis Multinomial logistic regression analysis was conducted to estimate the association between physical work load and the number of days with LBP during the previous 12 months. Multinomial logistic regression is used when an outcome has more than two main categories. In the present study, LBP was categorized into four groups  to investigate the main and moderating effect of fear avoidance. We used four levels of the outcome because categorizing LBP-cases into only one group regardless of the acuteness or chronicity of their LBP may cover a multitude of underlying conditions. In one epidemiologic study it was found that various variables associated differently with LBP and differed depending on the subdefinitions of LBP in the previous year . By cateIn a preliminary analysis we tested for significant associations between psychosocial work-related variables and LBP. The two psychosocial variables that reached significance were emotional job demands and influence at work (p ≤ 0.05). They were included in the main analysis together with individual variables, physical work load and fear-avoidance beliefs. Non-associated psychosocial factors were social support, meaning at work, role clarity, role conflicts, demands for hiding emotions and predictability (p ≥ 0.05).The association between physical work load, fear-avoidance beliefs, and LBP and the moderating effects of fear-avoidance beliefs were estimated in the following three models: first (model A), we made two simple tests without covariates of: (1) FAB-physical activity and physical work load, and (2) FAB-work and physical work load to test for their associations with LBP. Second (model B), we tested for the same associations as in model A, but controlled for the individual factors: age, leisure time physical activity, smoking and body mass index and the psychosocial work-related factors emotional demands and influence at work. Third, (model C), we tested for a moderating effect by creating the interaction terms physical work load x FAB-work, and physical work load x FAB-physical activity. All analyses were stratified into two groups: cases without LBP and cases with previous LBP. The stratification was based on a question from the baseline questionnaire: "Have you ever had low back pain (pain or discomfort)?" There were two response categories: "Yes" (cases with previous LBP) or "No" (cases without LBP).The average age at baseline was 35.7 years (SD 10.74) ranging from 18 to 60 years of age.At the end of participants' education, the most prevalent musculoskeletal problem within the previous 12 months was neck pain (61.9%) among cases without LBP. Among cases with LBP, the most prevalent musculoskeletal problem during the previous 12 months was LBP (88.2%). During the 1-year follow-up period, 520 of the 1,111 (47%) who had never experienced LBP at baseline developed a LBP problem. The 520 new cases were categorized in 269 having LBP 1-7 days during the previous 12 months, 162 having LBP 8-30 days, and 89 having > 30 days. Characteristics of the sample are described in Table Among cases without previous LBP, the associations between physical work load and LBP were not significant, neither before nor after adjustment for individual factors and psychosocial work related factors .This study aimed to enhance understanding of the established link between physical work load and LBP among health care workers by studying the predictive effect of fear-avoidance beliefs. The findings provide new information on the role of physical work load and fear-avoidance beliefs on LBP and, to a certain extent, support previous research. Three main findings are discussed: (1) the association between physical work load and LBP among cases with previous LBP, and the lack of association among cases without LBP; (2) the predictive effect of fear-avoidance beliefs on higher number of days with LBP; and (3) the lack of moderating effects of fear-avoidance beliefs.First, the associations between physical work load and LBP were insignificant among cases without previous LBP but not among cases with previous LBP. Thus, those without LBP experiences currently seem to be less vulnerable to a high physical load. This might be because relatively healthy people can withstand higher work loads , while tSecond, fear-avoidance beliefs had a predictive effect on LBP. Our results indicate that both types of fear-avoidance belief-FAB-work and FAB-physical activity-are prospectively associated with a higher number of days with LBP (30 days or more) in cases with and without previous LBP experience. Our results support previous studies that found associations between fear-avoidance beliefs and LBP -20,29, aThird, we did not find any moderating effect of fear-avoidance beliefs on the association between physical work load and LBP. Accordingly, it is not likely that fear-avoidance beliefs will increase the negative effect of physical work load on LBP.before LBP episodes, but they are developed in an interaction process with the LBP experience. Furthermore, previous studies have found that fear-avoidance beliefs are higher among chronic LBP patients than among those with acute LBP [Overall, our results support an independent predictive effect of fear-avoidance beliefs on serious or more or less chronic levels of LBP. We did not find an effect on short-term LBP (1-7 days). This is in accordance with two longitudinal studies by Sieben et al. , who examined the role of fear-avoidance beliefs at early stages of LBP (≤ 3 weeks). Their results did not support a predictive effect of fear-avoidance on early stages of LBP, and they questioned the role of fear-avoidance on early stages of LBP. Linton et al. (2000) suggested that fear-avoidance beliefs already exist due to prior pain experiences, and that these beliefs are activated by pain and enhanced in a reciprocal process with the pain experience . Our rescute LBP , and in We did not find a moderating effect of fear-avoidance beliefs on the association between physical work load and LBP. It could be argued that a moderating effect would be easier to detect if the effect-variables were measured at the same time and not, as in this case, at baseline and follow-up, respectively, particularly if the level of fear-avoidance beliefs changes over time.The Danish version of FABQ has not been validated. The FAB-work scale in this study had a high positive skewness indicating that about half of the participant had no or very low fear-avoidance beliefs about work. The participants filled out the questionnaires just before they qualified and had not been employed in the last 14 to 34 months, but only had practical training. All though the participants were informed - verbally - to think of the practical training as their work when they filled out the questionnaire, this message may very well not have been communicated effectively to all. Therefore participants may have underestimated their fear-avoidance beliefs, and the prevalence of participants with no or low fear-avoidance beliefs about work may be overestimated. If this has been the case, the effect of fear-avoidance beliefs may accordingly have been underestimated.The role of distress and depression has been found to play a role on early stages of LBP due to social withdrawal and reduced activity . DistresThere might be a differential misclassification between participants with and without LBP symptoms. Persons with LBP may tend to assess their physical work load as more demanding than would those without . TherefoA part of the studied population consisted of participants without LBP experience but with experiences of musculoskeletal pain in the shoulders, neck or upper back. To our knowledge the prospective effect of neck, shoulder and upper back pain on LBP has not been investigated. However, a study by Juul-Kristensen et al. (2006) found that the prevalence of LBP was higher among female computer users with pain in the neck, shoulders or upper back compared with a control group without pain . AnotherWe believe that our categorization of LBP in four groups was useful in elucidating different relations with fear-avoidance beliefs. The results demonstrated that fear-avoidance was predictive for the group with > 30 days of LBP but not for the groups with only 1-7 and 8-30 days of LBP. This emphasizes the relevance of making subgroups when dealing with low back pain because future intervention programmes may be more effective if they aim to reduce fear-avoidance and LBP among those with relatively many days with LBP a year.The results from this study suggest that for those without previous LBP, physical work load is unrelated to the development of LBP, while fear-avoidance beliefs are prospectively related to episodes of LBP. For those with previous LBP, both physical work load and fear-avoidance beliefs are important for new episodes of LBP. Further, the results suggest that fear-avoidance beliefs are more strongly related to relatively many days of LBP than to few days of LBP. This supports the idea that fear-avoidance beliefs are present before the initiation of LBP and that fear-avoidance beliefs are developed in a reciprocal process with the LBP pain experience. From a treatment perspective, focusing on changing fear-avoidance beliefs among those with more or less chronic LBP may be beneficial. Health care professionals may benefit from additional education or information about how to cope with acute or chronic LBP. Particularly information about the potentially harmful effect of avoidance-behaviour could be useful.LBP: low back pain; FABQ: fear-avoidance beliefs questionnaire; FAB-work: fear-avoidance beliefs about work; FAB-physical activity: fear-avoidance beliefs about physical activity.The authors declare that they have no competing interests.JNJ participated in the formulation of the study, performed the statistical analysis, drafted the manuscript and was responsible for the design of the questionnaire survey and data collection. KAL participated in the formulation of the study and participated in the description of background knowledge. KNN participated in the formulation of the study and choice of statistical methods. VBO participated in the formulation of the study and choice of statistical methods. All authors critically read, revised and finally approved the manuscript.The pre-publication history for this paper can be accessed here:


Loss of DNA mismatch repair is a common finding in hereditary non-polyposis colon cancer as well as in many types of sporadic human tumours. We compared the effect of loss of DNA mismatch repair on drug sensitivity as measured by a clonogenic assay with its effect on the ability of the same drug to enrich for mismatch repair-deficient cells in a proliferating tumour cell population. Mixed populations containing 50% DNA mismatch repair-deficient cells constitutively expressing green fluorescent protein and 50% mismatch repair-proficient cells were exposed to different chemotherapeutic agents. 6-Thioguanine, to which DNA mismatch repair-deficient cells are known to be resistant, was included as a control. The results in the cytotoxicity assays and in the enrichment experiments were concordant. Treatment with either carboplatin, cisplatin, doxorubicin, etoposide or 6-thioguanine resulted in enrichment for mismatch repair-deficient cells, and clonogenic assays demonstrated resistance to these agents, which varied from 1.3- to 4.8-fold. Treatment with melphalan, paclitaxel, perfosfamide or tamoxifen failed to enrich for mismatch repair-deficient cells, and no change in sensitivity to these agents was detected in the clonogenic assays. These results identify the topoisomerase II inhibitors etoposide and doxorubicin as additional agents for which loss of DNA mismatch repair causes drug resistance. The concordance of the results from the two assay systems validates the enrichment assay as a rapid and reliable method for screening for the effect of loss of DNA mismatch repair on sensitivity to additional drugs.