Understanding community transmission of SARS-CoV-2 variants of concern (VOCs) is critical for disease control in the post pandemic era. The Delta variant (B.1.617.2) emerged in late 2020 and became the dominant VOC globally in the summer of 2021. While the epidemiological features of the Delta variant have been extensively studied, how those characteristics shaped community transmission in urban settings remains poorly understood.Using high-resolution contact tracing data and testing records, we analyze the transmission of SARS-CoV-2 during the Delta wave within New York City (NYC) from May 2021 to October 2021. We reconstruct transmission networks at the individual level and across 177 ZIP code areas, examine network structure and spatial spread patterns, and use statistical analysis to estimate the effects of factors associated with COVID-19 spread.We find considerable individual variations in reported contacts and secondary infections, consistent with the pre-Delta period. Compared with earlier waves, Delta-period has more frequent long-range transmission events across ZIP codes. Using socioeconomic, mobility and COVID-19 surveillance data at the ZIP code level, we find that a larger number of cumulative cases in a ZIP code area is associated with reduced within- and cross-ZIP code transmission and the number of visitors to each ZIP code is positively associated with the number of non-household infections identified through contact tracing and testing.The Delta variant produced greater long-range spatial transmission across NYC ZIP code areas, likely caused by its increased transmissibility and elevated human mobility during the study period. Our findings highlight the potential role of population immunity in reducing transmission of VOCs. Quantifying variability of immunity is critical for identifying subpopulations susceptible to future VOCs. In addition, non-pharmaceutical interventions limiting human mobility likely reduced SARS-CoV-2 spread over successive pandemic waves and should be encouraged for reducing transmission of future VOCs.The online version contains supplementary material available at 10.1186/s12879-023-08735-6. Since September 2020, the global circulation of SARS-CoV-2 has been characterized by the continual evolution of the novel coronavirus and the emergence of multiple new variants , 2. The Epidemiological studies have highlighted that the Delta variant was more transmissible than previous VOCs –7. StudiDespite an improved understanding of the epidemiological features of the Delta variant, much remains unknown regarding how these characteristics manifest in population-level community transmission in urban settings. Addressing this knowledge gap is particularly challenging due to heterogeneous immunity during the Delta wave, caused by individual differences in natural infection and vaccination, as well as non-pharmaceutical interventions implemented to limit viral transmission. Data collected through contact tracing can provide valuable insights into the community transmission of infectious diseases . In thisWe analyzed the contact tracing data in NYC collected by the contact tracing team from May 11, 2021 to October 14, 2021. The contact tracing data contain information gathered from contact tracing phone calls, such as the age and home locations of index cases, their close contacts, and contact type. Contacts identified via facility investigations were excluded from the analysis. Index cases and their contacts were identified in the dataset using a matching algorithm based on personal identifying information (see details in Demographic and socioeconomic data for NYC ZIP code tabulation areas (ZCTA) were compiled from the 5-year American Community Survey (ACS) . COVID-1Persons infected with SARS-CoV-2 can be contagious before symptom onset or even without symptoms –27. TherTo uncover potentially stable structural features of the transmission networks, we focused on a larger spatial scale than ZIP codes and identified communities, clusters of ZIP codes that were tightly connected by transmission. This approach acknowledges that the transmission of COVID-19 is not confined to neighboring ZIP codes and the patterns of connectivity between geographically distant communities may be persistent. We detected communities using a greedy search algorithm, which was chosen to optimize the modularity score , 31. ModWe used conditional autoregressive (CAR) models –35 to asHere mentclass2pt{minimmentclass2pt{minimDuring the study period, the Delta variant displaced other VOCs and became dominant in the city Fig. A 22]. W. W22]. WWe reconstructed the exposure networks between index cases (both persons tested positive and symptomatic contacts who completed case investigation) and contacts. The number of contacts reported by cases was highly skewed Fig. A, with mWe compared cumulative reported cases at the ZIP code level in the pre-Delta and Delta periods Fig. A-B. Statp < 0.001). Given the higher transmissibility of the Delta variant and increased mobility during the summer of 2021, both local and long-range transmission occurred more frequently. The increase in long-range transmission, in particular, may have created non-local transmission clusters. We examined distributions of index cases who initiated transmission and their infected contacts across ZIP codes and found that certain ZIP codes were more involved in the spatial spread of COVID-19  and increased transmissibility of the Delta variant. Heterogeneity in the numbers of close contacts and secondary infections persisted during the Delta wave, but the maximum number for self-reported contacts was lower.We observed a less clustered community transmission of SARS-CoV-2 among ZCTAs during the Delta wave, with more frequent long-range transmission events occurring in Queens, Brooklyn, and Manhattan. This is likely the result of the increased transmissibility of the Delta variant and increased human contact following the gradual relaxation of control measures. Coupled with the increase in local transmission, the increase in long-range transmission of SARS-CoV-2 across NYC communities made containment of the virus in the metropolitan area challenging.Many of the findings are at odds with the results from the same analysis for the pre-Delta period . For insA few limitations exist in this study. Firstly, self-reported contact tracing data are subject to observational biases. These biases include differential reporting rates by contact type (overwhelmingly biased to household contacts) and age group, and the tendency of contacts to get tested. Due to the incomplete records of contacts as well as strong under-reporting of infections , 40, ideAdditional file 1.


The access to reproductive planning and contraception services during the COVID-19 pandemic is fundamental.Contraceptive methods should be initiated or maintained for couples who do not wish to get pregnant during the COVID-19 pandemic.There is no known relationship between contraceptive methods and potential treatments against COVID-19.There are no specific restrictions for any contraceptive methods in women with COVID-19. Eligibility criteria must be respected for choosing the most appropriate contraceptive modality.Conditions must be ensured so that the consultation environment does not become a place of risk of contamination of patients and health professionals.Continued access to sexual and reproductive health services, especially reproductive planning and contraception is essential, even during the COVID-19 pandemic.Patients already using a contraceptive method and well adapted, can have their prescriptions renewed without face-to-face evaluation for another 6-12 months during the COVID-19 pandemic, respecting the eligibility criteria.Women using long-acting reversible contraception (LARC) may have its use extended for 1-2 years beyond the recommended in the package leaflet after counseling on risks and benefits with a health professional.Patients not using contraceptive who wish to prevent pregnancy during the COVID-19 pandemic should receive reproductive counseling via telemedicine and/or in person.Women who wish to start using LARC must have face-to-face consultation, respecting the sanitary etiquette to protect themselves and others.Efforts to restructure health services are essential, aiming at the tracking of asymptomatic individuals, correct diagnosis of symptomatic individuals for greater safety, and the appropriate use of personal protective equipment (PPE) by health professionals.There is no contraindication to the use of any contraceptive method in conjunction with COVID-19 treatments under study.It is acceptable, although not mandatory, to change the contraceptive method for fear of deep vein thrombosis (DVT) or pulmonary thromboembolism (PTE).First described in China in December 2019 as an outbreak of pneumonia, COVID-19 (coronavirus disease 2019) has changed the dynamics of society and health care. Caused by SARS-CoV-2 (Severe Acute Respiratory Syndrome Coronavirus 2),The impact of the COVID-19 pandemic on reproductive and sexual health services is clear,Brazil is already largely affected by unintended pregnancies: among 23,894 puerperal women interviewed from February 2011 to October 2012 for the “Birth in Brazil“ survey, 25.5% wanted to have waited longer and 29.9% did not want to get pregnant; only 44.6% actually wanted to become pregnant.The question “Can I get pregnant in a pandemic?“ has been frequent in gynecological and obstetric consultations. Data available in the current medical literature are not yet categorical in relation to greater risks in the pregnancy-puerperal cycle or for the newbornIf a couple does not wish to become pregnant, the choice of any modern contraceptive method, respecting the eligibility criteria,The supply of contraceptives and menstrual and hygiene items  is important for women's health, women's empowerment and the full exercise of sexual and reproductive health rights, in particular for vulnerable populations.For women already adapted to a contraceptive method, it is plausible to perform an additional remote prescription for the next six months for users of combined hormonal contraception (CHC) and up to 12 months for progestogen-only pills (POP). In relation to medroxyprogesterone acetate (MPA), subcutaneous formulations are interesting for self-administration. For LARC methods, including copper and levonorgestrel (LNG) intrauterine devices and subdermal etonogestrel (ENG) implants, it is appropriate to advise the patient on the possibility of prolonged use. Restrict face-to-face consultations for removal of the method if the woman wants to get pregnant or has important side effects. As long as social distancing remains, it is recommended to offer much of the contraceptive consultation process remotely. The benefits of using LARCs outweigh the risk of COVID-19 transmission.In April 2020, the Specialized Contraception Commission of Febrasgothand 12thyear) of 0.00 pregnancies per 100 person-years.There is a great deal of scientific evidence suggesting that the risk of pregnancy while using a LARC method for more than 1-2 years beyond the usual duration remains extremely low. We can advise LARC users on the effectiveness of extended use beyond the stated durationthyear) and 0.43 (7thyear) per 100 woman-years.thyear) and 0.03 (7thyear) per 100 woman-years.There are also data suggesting a possible use of the LNG IUD  beyond five years. In a medical record review of 766 Brazilian women who maintained the same LNG IUD for more than 60 months, pregnancies were not observed during prolonged use .Finally, for subdermal implants, a prospective cohort study of 291 ENG implant users (mean age 29.9 years) and follow-up of 444.0 woman-years, no pregnancy was documented during the two years of use beyond the three-year approved duration. Neither there was any difference in mean serum ENG levels between groups with different body mass index (BMI): ENG levels were above the contraceptive limit of 90 pg/mL in all BMI classes at the end of three, four and five years.To date, there is no specific pharmacological therapy for COVID-19. The available evidence does not raise concerns about potential pharmacological interactions between contraceptive methods and possible new therapies against COVID-19.Despite being a frequent concern of many women and some professionals, venous thromboembolism (VTE) - whether DVT or PTE - is a rare event in women of reproductive age. The safety of combined methods is well documented, and the occurrence of contraceptive-related VTE is quite rare, especially in the young population.We stress that women should not be encouraged to discontinue contraceptive methods unless they want to become pregnant. Given the slight increase in the risk of VTE with CHC,Given the significant risk of an increase in unintended pregnancies during the COVID-19 pandemic, we encourage women, health professionals, legislators and the whole of society to discuss sexual and reproductive health services as priority services, emphasizing contraception and the protection of women against violence. All women must have proper access to effective contraceptive methods, as well as consistent information on the topic, including LARC and emergency contraception. Women who are well adapted to their current contraceptive methods can maintain them, respecting medical eligibility criteria. Those who are not using contraceptives or need to change the current method should seek reproductive counseling. Digital technologies are useful to advise new users and answer questions. If a face-to-face consultation  is necessary, sanitary protocols must be respected, including the use of masks, temperature measurement, search for symptoms and minimization of physical contact. Current users of LARC (IUDs and implants) should be advised about the possibility of extended use, reserving face-to-face appointments for removal due to the desire to become pregnant or serious side effects. So far, limiting interactions between available contraceptive methods and medications against COVID-19 being studied are not known. Although acceptable, it is not mandatory to advise CHC users to migrate to progestogen-only methods, implants, copper or LNG IUD; considering the time until coagulation returns to baseline, adding heparin is more reasonable. Ensuring proper use of contraceptives is of utmost importance.National Specialty Commission for Contraception of the Brazilian Federation of Gynecology and Obstetrics Associations (FEBRASGO)President:Rogério Bonassi MachadoVice-President:Ilza Maria Urbano MonteiroSecretary:Jaqueline Neves LubiancaMembers:Carlos Alberto PolitanoCristina Aparecida Falbo GuazzelliEdson Santos Ferreira FilhoJarbas MagalhãesLuis Carlos SakamotoMaria Auxiliadora BudibMariane Nunes de NadaiMilena Bastos BritoSheldon Rodrigo BotogoskiTereza Maria Pereira FontesValeria Barbosa PontesZsuzsanna Ilona Katalin de Jarmy Di Bella


This study evaluates the safety of early oral ambulatory treatment of adult patients diagnosed with bacteremia after their discharge from the emergency department. A cohort of 206 febrile ambulatory patients was assessed. Bacteremic low-risk patients were recommended an oral treatment and were compared with matched febrile non-bacteremic outpatients. Rates of 14-day mortality and unplanned re-consultations were similar and below 5% in both cohorts, highlighting the safety of oral therapy of low-risk bacteremia, even from its onset. Randomized trials have unanimously shown the benefits of oral antibiotic treatments for stable patients with bacteremia . However), in order to prompt parenteral treatment.Occult bloodstream infections (oBSIs) are defined as those bacteremias diagnosed after the patient is discharged from the emergency department (ED) . DespiteThis study aims to evaluate the safety of the oral ambulatory treatment of patients with oBSI, proposing this syndrome as a proof-of-concept for the feasibility of oral treatment of bacteremic infections even from its early onset.Retrospective observational matched-cohort study.The study was performed at University Hospital Virgen del Rocío (Spain). In our center, the microbiology department reports to the infectious diseases (ID) department all patients with positive blood cultures on a 24/7 basis. Patients with low-risk oBSI are routinely managed as outpatients, according to the criteria in The objective of this study was to evaluate the safety of early oral ambulatory treatment of patients with oBSI.Adult patients with blood cultures drawn at the ED between March 2020 and November 2021 were consecutively assessed. Two cohorts were followed up: (i) bacteremic febrile patients (BFPs), defined as those discharged from the ED with a febrile syndrome, in whom an oBSI was demonstrated and for whom the ID team recommended an outpatient management; and (ii) non-BFPs, defined as those discharged from the ED with a febrile syndrome, with negative blood cultures. Each BFP was matched with a non-BFP, according to these criteria: (i) first negative blood culture received in chronological order immediately after the BFP blood sample and (ii) the patient should have the same age as the BFP (±10 years). Patients in palliative care and contaminated cultures  were excluded.The primary endpoint was unplanned consultation in the emergency department (UCED) 30 days after the first ED visit. Secondary endpoints were all-cause 14- and 90-day mortality.Differences between BFP and non-BFP were assessed through univariate analyses. As a sensitivity analysis, multivariate logistic regression was developed pooling both cohorts to determine factors associated with primary and secondary outcomes. Data were obtained through regional healthcare system database consultation.). No studies were identified assessing outpatients. Using these data and assuming an alpha error of 0.05 and a power of 80%, we calculated a sample size of 206 patients (103 per group).UCED rates of 17% have been reported for febrile patients discharged from EDs . No stuDuring the study period, 193,400 patients were attended at the ED, with a global rate of UCED at 72 hours of 6.4%. Blood cultures were performed in 5,205 patients, and 777 were positive (14.9%).Overall, 123 patients were diagnosed with oBSI. Outpatient management was recommended to 103 of these patients (83.7%). Ninety-nine of them (96.1%) finished their follow-up without hospitalization. No deaths were reported on day 14 after diagnosis, and the 90-day mortality rate was 1.9%. Clinical features of the 20 patients requiring hospital admission on oBSI diagnosis are detailed in Table S1.P < 0.001), while non-focal fever was more frequent among non-BFP , and empirical antibiotic treatment was started at ED discharge less frequently among the latter . BFP and non-BFP presented low and similar rates of 30-day UCED  and 14-day (0 cases) and 90-day  mortality.Baseline characteristics and outcomes of BFP and non-BFP are shown in Multivariate analyses were performed for detecting factors independently related to unfavorable outcomes (Table S2). No variables were associated with increased UCED or 14-day mortality, including belonging to the cohort of bacteremic patients treated orally, the selection of any specific antibiotic class as definite therapy, or the use of an initial intravenous dose of antibiotics during the initial ED attendance. Malignancies  and Pitt score at first ED visit  were associated with 90-day mortality.Our study supports the safety of the oral, ambulatory treatment of patients with low-risk oBSI, whose outcomes were similar to other febrile patients without bacteremia routinely attended as outpatients. To our knowledge, this is the first comparative study assessing the safety of this approach for bacteremic infections.Randomized trials have unanimously shown the benefits of switching to oral treatments in stable patients with bacteremia , but the), but this may be due to insufficient dosing of oral betalactams, as suggested by later works . In our center, high-dose oral betalactams are recommended as first-line empirical treatment due to quinolone resistance . Our results suggest that high-dose oral betalactams may be a good alternative for low-risk bacteremic patients, but our sample was not powered to assess differences between agents.Another remarkable aspect of our results is that most BFPs were managed with oral betalactams with good outcomes. Most studies performed to date advocate for quinolones as the preferential treatment for intravenous-to-oral switch due to their high bioavailability . Increaser works , 13. Insistance  14). O. O), buOur study has some limitations. First, despite performing sample size calculations, the cohort may be underpowered to detect small differences. However, the low incidence of complications in absolute terms supports our hypothesis. Second, there were imbalances between groups regarding a higher rate of non-focal fever and lower rates of empirical treatments among non-BFP. These differences probably respond to the requirement of negative blood cultures for non-BFP, which may have favored the inclusion of non-bacterial fever in this group. Clinicians may have been reluctant to initiate empirical treatment for these cases. In our opinion, these differences define a profile of less-severe patients in the non-BFP cohort, which would reinforce our hypothesis.In conclusion, the early oral, ambulatory treatment of low-risk bacteremic infections seems feasible and safe. These results provide a proof of concept for the efficacy of oral antibiotic therapy for bacteremia even from its onset and may enable outpatient care programs for these infections.


COVID-19 is an important public health concern due to its high morbidity, mortality and socioeconomic impact. Its burden varies by geographic location affecting some communities more than others. Identifying these disparities is important for guiding health planning and service provision. Therefore, this study investigated geographical disparities and temporal changes of the percentage of positive COVID-19 tests and COVID-19 incidence risk in North Dakota.COVID-19 retrospective data on total number of tests and confirmed cases reported in North Dakota from March 2020 to September 2021 were obtained from the North Dakota COVID-19 Dashboard and Department of Health, respectively. Monthly incidence risks of the disease were calculated and reported as number of cases per 100,000 persons. To adjust for geographic autocorrelation and the small number problem, Spatial Empirical Bayesian (SEB) smoothing was performed using queen spatial weights. Identification of high-risk geographic clusters of percentages of positive tests and COVID-19 incidence risks were accomplished using Tango’s flexible spatial scan statistic. ArcGIS was used to display and visiualize the geographic distribution of percentages of positive tests, COVID-19 incidence risks, and high-risk clusters.County-level percentages of positive tests and SEB incidence risks varied by geographic location ranging from 0.11% to 13.67% and 122 to 16,443 cases per 100,000 persons, respectively. Clusters of high percentages of positive tests were consistently detected in the western part of the state. High incidence risks were identified in the central and south-western parts of the state, where significant high-risk spatial clusters were reported. Additionally, two peaks (August 2020-December 2020 and August 2021-September 2021) and two non-peak periods of COVID-19 incidence risk (March 2020-July 2020 and January 2021-July 2021) were observed.Geographic disparities in COVID incidence risks exist in North Dakota with high-risk clusters being identified in the rural central and southwest parts of the state. These findings are useful for guiding intervention strategies by identifying high risk communities so that resources for disease control can be better allocated to communities in need based on empirical evidence. Future studies will investigate predictors of the identified disparities so as to guide planning, disease control and health policy.The online version contains supplementary material available at 10.1186/s12889-023-15571-5. Coronavirus disease 2019 (COVID-19) was declared a pandemic on 11 March 2020 by World Health Organization . TherefoThere is evidence that the incidence and severity of COVID-19 vary by geographical region due, at least in part, to differences in population characteristics such as socio-economic, demographic, and chronic health conditions –8. For ePopulation differences in levels of mobility is another factor that might contribute to geographic differences in COVID-19 risks. Previous studies found high correlations between mobility and the COVID-19 burden in counties of China and the US , 17. ChaIdentifying geographical disparities of COVID-19 risk is important for guiding health planning and policies for disease control and prevention. Unfortunately, very little is known about geographic disparities of COVID-19 risk in ND. Therefore, the objective of this study was to identify geographic disparities and temporal changes of percentage of positive COVID-19 tests and COVID-19 incidence risk in ND to guide control efforts.This study was approved by the University of Tennessee Institutional Review Board (IRB number: UTK IRB-22–07032-XM) and all study methods were carried out in accordance with relevant guidelines and regulations. The investigators did not contact the subjects.o55’-49o N and ranks 19th by area in the United States. As of 2020, the most populated county was Cass county with 179,937 people, while Slope County was the least populated  performed in North Dakota during the study period were downloaded from the North Dakota COVID-19 Dashboard . County-Descriptive statistics of percentages of positive tests and COVID-19 incidence risks were calculated using SAS 9.4 . To asseCounty-level Spatial Empirical Bayesian (SEB) smoothed incidence risks were computed in GeoDa –29 to adTango’s flexible spatial scan statistic (FSSS) was computed in FleXScan  to identAll cartographic displays were performed in ArcGIS version 10.8.1 . ChoroplPercentages of positive tests varied across the state ranging from 0.11% to 13.67%. Higher percentages of positive tests were observed in August-December 2020 and August–September 2021 (0.72%-13.67%) compared to March-July 2020 and January-July 2021 (0.11%-5.83%) Fig. . The couSimilar to the geographic distribution of percentages of positive COVID-19 tests, significant clusters of high percentages of positives tests were consistently identified in the western part of the state Figs.  and 5. HSignificant high-risk spatial clusters of COVID-19 incidence were identified in the middle and southern-west parts of the state Fig. , which wThe overall number of COVID-19 cases increased from 2020 to 2021. Two peaks of incidence risk were observed: (i) August-December 2020 and (ii) August–September 2021 Fig. . The higThis study investigated geographic disparities and temporal patterns of county-level COVID-19 incidence risks in North Dakota. The findings of this study are useful for identifying communities with high COVID-19 incidence risks so as to guide planning and intervention efforts.th 2020, and mass vaccination throughout the US was started a few days later [The observed high risks in August to December 2020 followed by a decline in the Summer, and then a steady increase in August to September 2021 are comparable to findings reported by the Centers for Disease Control and Prevention (CDC) and other previous studies in the US –35. Thisys later .There was evidence of geographical disparities in COVID-19 incidence risks with most of the high risks being observed in rural communities. This is probably due to high rates of poverty, smoking, respiratory diseases, high blood pressure, and obesity in the rural areas compared to urban areas . Some prThe high incidence risks and high-risk clusters observed in the central and south-western parts of the state may be due to low levels of education attainment in these areas. Statistics show that the percentage of post-secondary degree attainment is substantially higher in the eastern regions compared to the west and central parts of North Dakota . A recenRacial differences in population distribution may also account for the observed disparities. A previous study reported that minority populations tend to work in high-contact occupations , which increases the probability of SARS-CoV-2 infection . Similaret. al. in Utah reported that the percentage of test positivity increased with the level of deprivation [The high percentage of COVID-19 positive tests, as well as high risk clusters of the positive tests, also showed a similar distribution. The western parts of the state tended to have high percentages of positive tests compared to the other parts of North Dakota. This might be due to the high proportions of Hispanic population in these areas . Hispanirivation .This is the first study in North Dakota that has investigated geographical disparities of COVID-19 incidence risks using a rigorous spatial statistics approach. The strengh of Tango’s FSSS used in this study is that it does not involve multiple comparisons and can identify both circular and irregularly-shaped clusters. The findings of this study are helpful for guiding resource allocation for control efforts. The current study revealed geographic disparities across North Dakota from March 2020 to September 2021. Performing such investigations on a regular basis will be beneficial in identifying if the geographic distribution of high risk clusters are consistent or if they change over time. Therefore, such investigations should be part of regular health surveillance programs to guide resource allocation geared at reducing disparities. However, this study is not without limitations. It used administrative/surveillance data which may inherently have geographic differences in case attainment and reporting. Although the SEB smoothed rates improved visualization of spatial patterns, they can only be used for visualization and should not be used for statistical analyses and inference. Additionally, although Tango’s FSSS can identify non-circular clusters more accurately, it has low power for detecting circular clusters. Furthermore, the study only investigated disparities at the county level which may not reveal lower level geographic disparities.There is evidence of geographic disparities of COVID-19 incidence risks in North Dakota with high risk clusters being observed in the rural central and southwest parts of the state. The findings of this study will be useful in guiding health equity programs aimed at reducing disparities in the burden of COVID-19 in North Dakota. These investigations should be part of regular health surveillance programs to provide the most current information to guide health planning and service provision. Future studies will investigate predictors of the identified disparities to guide planning, disease control and health policy.Additional file 1. The data used in this study have been provided as supporting information files together with the submission.


Computational simulation using numerical analysis methods can help to assess the complex biomechanical and functional characteristics of the mitral valve (MV) apparatus. It is important to correctly determine physical contact interaction between the MV apparatus components during computational MV evaluation. We hypothesize that leaflet-to-chordae contact interaction plays an important role in computational MV evaluation, specifically in quantitating the degree of leaflet coaptation directly related to the severity of mitral regurgitation (MR). In this study, we have performed dynamic finite element simulations of MV function with and without leaflet-to-chordae contact interaction, and determined the effect of leaflet-to-chordae contact interaction on the computational MV evaluation.Computational virtual MV models were created using the MV geometric data in a patient with normal MV without MR and another with pathologic MV with MR obtained from 3D echocardiography. Computational MV simulation with full contact interaction was specified to incorporate entire physically available contact interactions between the leaflets and chordae tendineae. Computational MV simulation without leaflet-to-chordae contact interaction was specified by defining the anterior and posterior leaflets as the only contact inclusion.Without leaflet-to-chordae contact interaction, the computational MV simulations demonstrated physically unrealistic contact interactions between the leaflets and chordae. With leaflet-to-chordae contact interaction, the anterior marginal chordae retained the proper contact with the posterior leaflet during the entire systole. The size of the non-contact region in the simulation with leaflet-to-chordae contact interaction was much larger than for the simulation with only leaflet-to-leaflet contact.We have successfully demonstrated the effect of leaflet-to-chordae contact interaction on determining leaflet coaptation in computational dynamic MV evaluation. We found that physically realistic contact interactions between the leaflets and chordae should be considered to accurately quantitate leaflet coaptation for MV simulation. Computational evaluation of MV function that allows precise quantitation of leaflet coaptation has great potential to better quantitate the severity of MR. The mitral valve (MV) has the most complex structural characteristics of the four human heart valves-3. All cAdvances in ultrasound imaging techniques have allowed clinicians to accurately assess MV physiology, and have aided in determining the degree of valvular abnormalities and the necessity for appropriate surgical intervention. Conventional two-dimensional (2D) echocardiography provides excellent insight into the complex cardiac anatomy in real time. Three-dUsing FE analysis and computational simulation, it is important to correctly model the contact interaction between the MV apparatus components. We have recently demonstrated that failure of proper leaflet coaptation leads to reversal of blood flow from the left ventricle into the left atrium, i.e., mitral regurgitation (MR),18. ContWe hypothesize that leaflet-to-chordae contact interaction plays an important role in computational MV evaluation, specifically in quantitating the degree of leaflet coaptation directly related to the severity of MR.In this study, we have acquired two different MV types from patients using 3D echocardiographic data, modeled virtual MVs, performed dynamic FE simulations of MV function with and without incorporation of leaflet-to-chordae contact interaction, and determined the effect of leaflet-to-chordae contact interaction on the computational MV evaluation.The Committee for the Protection of Human Subjects at The University of Texas Health Science Center at Houston approved our translational research protocol to utilize 3D transesophageal echocardiography (TEE) for computational modeling of patient MVs. A Philips iE33 ultrasound system  with a 3D TEE transducer was utilized for imaging of the patient MV apparatus. Following our standard clinical protocols, 3D TEE was performed to acquire the MV geometric data in two patients. One patient had a normal MV without MR, and another had a pathologic MV with MR. MV modeling was conducted by our virtual MV modeling protocol,18. BrieDetailed protocols of material modeling and dynamic FE simulation of MV function are described in a previous study. The MV 2 for the posterior marginal chordae, 0.29 mm2 for the anterior marginal chordae, and 0.61 mm2 for the strut chordae[3 and 0.48, respectively[The chordae tendineae were modeled as nonlinear hyperelastic materials utilizing the first and second order Ogden models. Experimentally determined material characteristics of the posterior marginal chordae, anterior marginal chordae, and strut chordae from a previous study were inc chordae. Densityectively,21.Mitral annulus and papillary muscle configurations at end diastole (open) and peak systole (closed) were pre-determined in the 3D TEE data. Combined with time-varying nonlinear nodal displacements between end diastole and peak systole, dynamic boundary motion was defined for both the annulus and the papillary muscles. Free roThe contact interaction in computational MV simulations primarily consists of leaflet-to-leaflet and leaflet-to-chordae contacts. In ABAQUS, the general contact algorithm allows to define edge-into-edge contact penetrations. The genS) and a master line (connecting node 1 and 2) in the general contact algorithm. S0 and S refer to the slave node before and after loading, respectively[Figure ectively. The penKb is the stiffness matrix of contacting body, Kc is the stiffness matrix of contact surface, u is the displacement, and F is the applied force[where ed force. Any viokn is the penalty term along the normal direction, kt is the penalty term along the tangential direction, and gn and gt are the penetration and sliding along the normal and tangential directions, respectively[where ectively. Hence, μd: a coefficient of kinetic friction.with A schematic of the MV contact configuration under the normal physiologic conditions is displayed in Figure Computational MV simulation with full contact interaction was specified such that the contact domain of the general contact algorithm was defined to incorporate entire available contact interactions between the leaflets and chordae tendineae. Computational MV simulation without leaflet-to-chordae contact interaction was specified by defining the anterior and posterior leaflets as the only contact inclusion in the general contact domain. A frictional coefficient value of 0.05 was utilized to describe the frictional behavior between the contact tissue.Figure Alteration in leaflet deformation due to the incorporation of leaflet-to-chordae contact interaction revealed a difference in leaflet coaptation of the pathologic MV Figure . With leThe extent of leaflet coaptation, which directly correlates with the degree of MR, was determined by measuring the distribution of contact pressure between the anterior and posterior leaflets at peak systole Figure . A thres2 vs. 1.4 mm2) when leaflet-to-chordae contact interaction was implemented. With incorporation of leaflet-to-chordae contact interaction incorporated, the size of total contact region decreased by 3.8% and 4.2% in the normal and the pathologic MVs, respectively. This indicates that leaflet-to-chordae contact interaction affects both qualitative and quantitative determination of leaflet coaptation when evaluating MV function.The normal MV showed sufficient leaflet coaptation and little difference in overall leaflet contact pressure distribution between the simulations with and without incorporation of leaflet-to-chordae contact interaction. In the pathologic MV with MR, there was a large non-contact region near the anterolateral commissure, indicating a considerable occurrence of MR. The length of leaflet marginal edge with no coaptation in the anterolateral region was much larger in the simulation with leaflet-to-chordae contact interaction (6.9 mm) than for the simulation with leaflet-to-leaflet contact alone (2.6 mm). This data corresponds to the markedly enlarged size of regurgitant orifice area  at peak systole was comparable in the normal MV simulations with and without leaflet-to-chordae contact interaction. However, in the pathologic MV, the maximum stress value decreased from 0.7 MPa to 0.66 MPa when leaflet-to-chordae contact interaction was incorporated. A wider range of large stress concentration was found in the regurgitant areas beside both leaflets.Accurate determination of the extent and severity of MR is important as MR can cause serious pathophysiologic problems leading to left ventricular dysfunction and heart failure. The most popular modality for MR evaluation at present is color Doppler ultrasound imaging that provides semi-quantitative information of MR occurrence. ComputaIn the present study, we investigated the effect of leaflet-to-chordae contact interaction on patient-specific computational MV evaluation. To the best of our knowledge, the effect of leaflet-to-chordae contact interaction on computational MV evaluation has never been fully investigated.The greatest difference between the computational MV evaluations with and without leaflet-to-chordae contact interaction was found in the deformation of the leaflets and chordae as well as in the distribution of leaflet coaptation. Without incorporation of leaflet-to-chordae contact interaction , the computational MV simulations demonstrated physically unrealistic contact interactions between the leaflets and chordae Figure . The choStress distribution was evaluated for the normal and pathologic MVs to compare the effect of leaflet-to-chordae contact interaction on alteration of biomechanical characteristics of the MV apparatus structure during valve function Figure . The patAlthough the present study has demonstrated the effect of contact interactions between the MV apparatus components on computational MV evaluation, the simulation results should be carefully interpreted prior to defining MV pathophysiology. Although we demonstrated computational MV evaluation using two patient data , the physical influence of leaflet-to-chordae contact interaction should be effective in any types of MV simulation studies. We utilized previously published material characteristic data, employed geometric and physiologic parameters such as leaflet thickness and tissue density, and assumed homogeneous thickness and material behavior of the MV tissue. Although different types of tissue material behavior may affect computational MV simulation outcomes, it would not change the primary findings of this study in terms of the physical effect of leaflet-to-chordae contact interaction. Our computational simulation data was obtained purely by structural analysis, i.e. dynamic FE simulation incorporated with physiologic damping conditions. The latter implies that blood fluid effects on normal and shear pressure distribution over the MV leaflets and chordae were not fully incorporated in the computational simulations. Notwithstanding these limitations, the effect of leaflet-to-chordae contact interaction on computational MV evaluation presented in this study should be valid in any types of MV simulation studies.We have successfully demonstrated the effect of leaflet-to-chordae contact interaction on determining leaflet coaptation in computational dynamic MV evaluation. Two types of patient-specific MV geometric data were analyzed to assess the difference of this modeling effect in normal and pathologic MVs. We found that physically realistic contact interactions between the leaflets and chordae should be considered to accurately quantitate leaflet coaptation for MV simulation. Computational evaluation of MV function that allows precise quantitation of leaflet coaptation has great potential to better quantitate the severity of MR. Improved MR quantitation using this computational simulation combined with patient-specific 3D echocardiography can help us to better diagnose and treat MV pathology.2D: Two-dimensional; 3D: Three-dimensional; FE: Finite element; MR: Mitral regurgitation; MV: Mitral valve; TEE: Transesophageal echocardiography.The authors declare that they have no competing interests.YR carried out the algorithm design and implementation, and drafted the manuscript. DDM participated in the design of the study and coordination. HK conceived of the study, participated in the design of the study, and contributed to discussions and suggestions to complete the manuscript. All authors read and approved the final manuscript.


Tribolium castaneum the major TCAST satellite DNA accounts for 35% of the genome and encompasses the pericentromeric regions of all chromosomes. Because of the presence of transcriptional regulatory elements and transcriptional activity in these sequences, TCAST satellite DNAs also have been proposed to be modulators of gene expression within euchromatin. Here, we analyze the distribution of TCAST homologous repeats in T. castaneum euchromatin and study their association with genes as well as their potential gene regulatory role. We identified 68 arrays composed of TCAST-like elements distributed on all chromosomes. Based on sequence characteristics the arrays were composed of two types of TCAST-like elements. The first type consists of TCAST satellite-like elements in the form of partial monomers or tandemly arranged monomers, up to tetramers, whereas the second type consists of TCAST-like elements embedded with a complex unit that resembles a DNA transposon. TCAST-like elements were also found in the 5′ untranslated region (UTR) of the CR1-3_TCa retrotransposon, and therefore retrotransposition may have contributed to their dispersion throughout the genome. No significant difference in the homogenization of dispersed TCAST-like elements was found either at the level of local arrays or chromosomes nor among different chromosomes. Of 68 TCAST-like elements, 29 were located within introns, with the remaining elements flanked by genes within a 262 to 404,270 nt range. TCAST-like elements are statistically overrepresented near genes with immunoglobulin-like domains attesting to their nonrandom distribution and a possible gene regulatory role.In the red flour beetle  The TCAST transposon-like elements were analyzed in detail for the presence of hallmarks such as terminal inverted repeats (TIRs) and target-site duplications with the aid of the Gene Jockey sequence analysis program (for Apple Macintosh). Secondary structures were determined using the default parameters of the MFOLD program available online [http://mfold.rna.albany.edu/?q=mfold . Branch support was evaluated by bootstrap analysis (1000 replicates) in ML and by posterior probabilities in Bayesian analyses. Pairwise sequence diversity (uncorrected P) was calculated using the MEGA 5.05 software  was used. GeneCodis generates statistical rank scores for single annotations and their combinations. To find all the possible combinations of annotations, GeneCodis uses the apriori algorithm introduced by 2 test of independence was executed to calculate the statistical significance  for each individual annotation or co-annotations.T. castaneum chromosomes. In each chromosome the frequency of TCAST-like elements was compared with the frequency in the complete sample and the significance of deviations was calculated.Two-tailed hypergeometric test with Bonferroni correction  was used to analyze the distribution of TCAST-like elements among T. castaneum with the alignment program BLASTN version 2.2.22+. The program was optimized to search for highly similar sequences (megablast) and blast hits on the query sequence were analyzed individually. Alignments were mapped regarding start and end site, chromosome number, and total length. When the distance between two alignments on the same chromosome was short, the genomic sequence was further analyzed by dot plot to identify any potential continuity between the two alignments. Only genomic sequences with at least 140 nt (40% of TCAST monomer length) of continuous sequence and >80% identity to the TCAST consensus sequence were considered for further analysis. The total number of dispersed TCAST-like elements was 68, with 36 elements flanked by genes at both 5′ and 3′ ends, 3 elements flanked by a single gene either at 5′ or 3′ end , and the 29 elements positioned within introns  are provided.Sequence analysis of the 68 TCAST-like elements identified within the vicinity of genes enabled their classification into two groups. The first group contains partial TCAST satellite monomers or tandemly arranged elements, either complete or partial dimers, trimers, or tetramers . The minFile S1). The average pairwise distances between Tcast1a subunits of TCAST satellite-like sequences was 5.8%. Alignment adjustment using Gblocks, which eliminates poorly aligned positions and divergent regions, resulted in few changes; therefore, the original, unadjusted alignment was used for the construction of phylogenetic trees. Because the sequences differ in lengths and comprise regions of divergent variability, methods that take into account specific models of DNA evolution were considered as the most suitable for the construction of phylogenetic trees, ML and Bayesian (Markov chain Monte Carlo). The ML tree showed weak resolution with no significant support for clustering of sequences derived from the same satellite-like array or from the same chromosome. Similarly, the Bayesian tree demonstrated no significant sequence clustering , was also not significantly affected by adjustment with Gblocks; therefore, the unadjusted alignment was used for the construction of phylogenetic trees  are provided. Sequence analysis of TCAST transposon-like elements determined that 13 of them were > 1000 bp, with a maximal size of 1181 bp  monomer, and a TCAST monomer segment of approximately 121 bp in an inverted orientation. These two TCAST segments are separated by a nonsatellite sequence of approximately 306 bp. Both TCAST segments are part of TIRs that are approximately 269 bp long . As a re lengths  and exac 1181 bp . The remmariner/Tc1, the only superfamily whose members are characterized by either 2- or 3-bp target-site duplication  and Chrysoperla plorabunda , but not to Mariner-1_ TCa transposase.Some TCAST transposon-like elements >1000 bp have a 3-bp duplication at the site of insertion in the form of ACT. One TCAST transposon-like element (sequence no. 39) is inserted into another repetitive DNA, indicated as Tcast2, which had been previously identified bioinformatically . The average pairwise divergence among TCAST transposon-like sequences was 12.7%. ML and Bayesian methods gave similar tree topologies , the alignment and phylogenetic analyses was performed on 25 elements that mutually overlap in their sequences, whereas the other nine TCAST transposon-like elements were excluded from the analysis due to the very low overlapping with other elements. Alignment was additionally adjusted using Gblocks . TCAST-like elements were dispersed on both arms of chromosomes 3, 5, 9, and 7, whereas on other chromosomes they were located on a single arm , pointing to their random distribution.TCAST-like elements found in the vicinity of genes were distributed on all 10 omosomes . Positioing data  and Tribbly data . Within bly data  based onngle arm . The numFigure S2 and Figure S3). The average AT content of the flanking regions for both TCAST satellite-like elements and TCAST transposon-like elements did not differ significantly from the average AT content of the whole T. castaneum genome or from the AT content of randomly selected intergenic regions and introns. Thus, this finding suggests that with regard to AT content, there is no target preference for the insertion of TCAST-like elements. Furthermore, alignment and comparison of all flanking sequences of TCAST-like elements did not identify any common sequence motifs.To determine whether there was a target preference for the insertion of TCAST-like elements, for example high AT content or another sequence characteristic, we analyzed the AT content within 100 bp of the flanking regions for each TCAST -like element, from both 5′ and 3′ sites . Each identified gene is assigned to a particular TCAST-like element within its vicinity, and the precise position of TCAST-like elements in genomic sequence (start and end site) is indicated (Table S1). Functional analysis revealed that 17 of 101 genes correspond to putative uncharacterized proteins, whereas the remaining genes are involved in different molecular functions and diverse biological processes. Among the proteins, a proportion is characterized by ATP binding activity (13 proteins) and involvement in protein phosphorylation and /or signal transduction .Uniprot gene numbers were used as identifiers of genes located in the vicinity of TCAST-like elements . All nine genes exhibit structural features of immunoglobulin-like, immunoglobulin subtype 1 and immunoglobulin subtype 2 proteins and are associated with the following TCAST transposon-like elements: 25 at the 3′end, 28 and 39 at the 5′ end, 32 and 40 within introns, and TCAST satellite-like elements: 8 at the 3′ end, 19 and 62 at the 5′ end, and 41 within intron (Table S1). Although all nine genes belong to immunoglobulin superfamily, they did not exhibit sequence similarity, which could suggest role of duplication in their evolution and spreading. The position of TCAST-like elements relative to the genes also was not consistent with the possibility that TCAST-like elements duplicated along with the immunoglobulin- like genes.To determine whether TCAST-like elements are distributed randomly relative to genes or whether they are overrepresented near specific groups of genes, we used GeneCodis 2.0 to provide a statistical representation of the genes associated with TCAST-like elements. Because many genes are still not annotated in n intron . A minimn intron . MoleculOverrepresentation of TCAST-like elements was also found near genes that exhibit ATP-binding activity and axon guidance properties but with a marginal significance (0.0183374 and 0.00865139). For the rest of genes, no significant overrepresentation of TCAST-like elements was detected. Thus, enrichment of TCAST-like elements in the vicinity of immunoglobulin-like genes potentially implicates a role of TCAST-like elements in the regulation of these genes.Drosophila melanogaster  revealed that 5′ UTR of nonlong terminal repeat retrotransposon CR1-3_TCa  genome was reported transposable element, and its subsequent mobilization and spreading by (retro)transposition, may explain the distribution of TCAST element in the vicinity of genes within euchromatin. Satellite DNA sequences are prone to undergo recurrent repeat copy number expansion and contraction in divergent lineages as well as among populations of the same species . The disThe distribution of TCAST-like elements relative to protein coding genes revealed no specific preference for insertions within introns or at 5′ or 3′ ends of genes. TCAST-like elements are distributed on all chromosomes with no significant deviation in the number among the chromosomes, and phylogenetic analysis did not detect any significant sequence clustering of TCAST-like elements derived from the same chromosome. Dispersed TCAST satellite-like elements produce tandem arrays up to tetramers, but repeats from the same array do not reveal any significant clustering on phylogenetic trees. This finding indicates there is no significant difference in the homogenization of TCAST satellite-like repeats at the level of local arrays or chromosome or among different chromosomes. The average pair-wise sequence divergence (6% for dispersed TCAST satellite-like repeats) is greater than the usual divergence of satellite elements located in heterochromatin of tenebrionid beetles [approximately 2% , on MHIIβ gene expression was demonstrated (epressus , 2009. Tepressus . Based o


Development of Traditional Chinese Medicine (TCM) syndrome-specific outcome measures is needed for the evaluation of TCM syndrome-specific therapies. We constructed a Kidney Deficiency Syndrome Questionnaire (KDSQ) for the evaluation of the common TCM syndromes Kidney-Yin Deficiency Syndrome (KDS-Yin) and Kidney-Yang Deficiency Syndrome (KDS-Yang) in middle-aged women with menopausal symptoms.KDS-Yin and KDS-Yang were traditionally defined by expert opinion were validated by exploratory factor analysis (EFA) and structural equation modeling (SEM). Content validity was tested by EFA on a sample of 236 women from a seminar and SEM on another sample of 321 women from a postal survey. Other psychometric properties were tested on 292 women from the seminar at baseline and two systematically selected sub-samples: 54 who reported no changes in discomforts 11–12 days after the baseline and 31 who reported changes in discomforts 67–74 days after the baseline. All participants completed the KDSQ, the Greene Climacteric Scale and the standard 12-item Short Form Health Survey.agreement: KDS-Yin, 0.94; KDS-Yang, 0.93). The KDSQ was responsive to changes over time as tested by effect size and longitudinal validity.The EFA and SEM established the measurement models of KDS-Yin and KDS-Yang supporting content validity of the KDSQ. Internal consistency was good (Cronbach’s Alpha >0.70). Construct validity was supported by theoretically-derived levels of correlation with the established external measures. Test–retest reliability was strong (ICCThe KDSQ was a valid and reliable measure for KDS-Yin and KDS-Yang in Hong Kong Chinese middle-aged women with menopausal symptoms. The theory of traditional Chinese medicine (TCM) is established on the basis of ancient Chinese philosophies. TCM considers health is the physiological functions in self-regulation, adaptation to the environment, resistance against pathogens and self-recovery from illness; whereas illness is the dysfunction of these physiological aspects . Guided The efficacy of TCM therapies has been the subject of study for the last few decades. Some authors have attempted to align research design with TCM clinical practice within the constraints of a clinical trial ,4; whereHowever, TCM syndromes are defined by expert opinion ,7,8 and Human research ethics approval was obtained from Institutional Review Board of the University of Hong Kong and Hospital Authority Hong Kong West Cluster and written informed consents were obtained from the study participants.In the validation of KDS-Yin and KDS-Yang study , we deveFor content validity, we set inclusion and exclusion criteria to select items into the KDSQ . The iteWe recruited Chinese women aged 40–60 years, whose primary residence was in Hong Kong, and who could read and write Chinese for questionnaire evaluation. Women were excluded if they had life-threatening diseases, traumatic injuries or currently taking anti-inflammatory, hormone replacement therapy or Chinese Medicines because inclusion of such women would confound the interpretation of the symptom reporting.All participants were screened for menopausal symptoms using the 21-item standard Greene Climacteric Scale (GCS) (Hong Kong Chinese)  and a 3-th to 12th days after the seminar  on the survey sample. These models would be validated if the comparative fit index (CFI) and the incremental fit index (IFI) were equal to or greater than .90, the root mean square error of approximation (RMSEA) was less than or equal to .05, and 90% confidence interval (CI) of RMSEA ranged from 0 to 0.08 .Finally, we attempted to strengthen these latent measurement models by trimming symptom-domain measurement relationships fulfilling the following criteria: those measurement relationships were justifiable by some but disagreed by other of the literature ,8,15,16;We further evaluated the KDSQ as follows. Internal consistency was tested by Cronbach α coefficient on the seminar sample . An intrData were processed by SPSS for Windows 16.0 and AMOS 16.0. Missing data were handled by AMOS. AMOS uses maximum likelihood imputation to estimate means and intercepts for missing data, which has been shown to have the least bias .Of the 311 women who attended the seminar, 294 were invited to complete the KDSQ, the GCS and the urogenital scale, and the SF-12 after excluding 17 women who were on medications (n = 16) or younger than 40 (n = 1). We excluded two more women who missed most data in the KDSQ (n = 2). The seminar sample included 292 women. From them, 54 women were identified for evaluating test-retest reliability and another 31 women were identified for testing responsiveness. Of the 31 women, 24 responded to all items including low libido and vaginal dryness of the KDSQ. Of these 24 women, 19 reported alleviation of discomforts and 5 reported worsening of discomforts. From the 292 women, 236 were included for the EFA after excluding women who did not respond to the item on libido due to absence of sex partners (n = 54) and women who missed some data in their KDSQ (n = 2). Except marital status and the small percentages of women who had hysterectomy and bilateral ovariectomy, demographic characteristics were similar between the 236 women and those excluded from the EFA (n = 54)  was shown with Kaiser-Meyer-Olkin Measure of Sampling Adequacy greater than 0.6 : KDS-Yin36 was shIn the second step, we constructed the initial measurement models of KDS-Yin and KDS-Yang with the factors yielded by the EFA. Then, we added 13 and 14 additional symptom-domain measurement relationships within these models of KDS-Yin and KDS-Yang, respectively, based on the disagreements in the literature ,8,15,16 In the final step, we found that the factor loadings of most of the added additional measurement relationships  and few measurement relationships as defined by the EFA , as indicated in the figure legends, were small (<0.2) and not significant at the 0.05 level. These measurement relationships were weak and trimmed off according to the exclusion criteria set at the Methods section. The measurement relationships retained in Figures The KDSQ items were found to have good internal consistency in measuring the important domain concepts: Kidney-Essence deficiency and deficiency heat of KDS-Yin, and Kidney-Qi deficiency and deficiency cold of KDS-Yang; and have weaker homogeneity in measuring the other less important domain concepts Table .agreement was 0.94 for KDS-Yin and was 0.89 for KDS-Yang, and the range was 0.87–0.93 for the domains of KDS-Yin and KDS-Yang.Test-retest reliability was good for the domains of KDS-Yin and KDS-Yang. ICC rs) of the GCS were 0.79 with KDS-Yin and 0.81 with KDS-Yang indicating strong correlations (p < 0.01), whereas the coefficients of KDS-Yin were -0.52 with the physical component score (PCS) and −0.43 with the mental component score (MCS) of SF-12, and KDS-Yang were -0.60 with CS and -0.51 with MCS, indicating expectedly weaker and negative correlations (p < 0.01). Responsiveness of the domains of KDS-Yin and KDS-Yang to change was supported by the effect sizes calculated on 19 of the 24 women who reported alleviation of discomforts during the period of 67–74 days  and moderately correlated with those measured by KDS-Yang , supporting the longitudinal validity of the KDSQ.Construct validity was supported by that the items of KDS-Yin and the items of KDS-Yang measured what they were supposed to measure. Spearman’s correlation coefficients (We have constructed a TCM syndrome-specific measure the KDSQ and found the KDSQ is a valid and reliable tool for the measurement of KDS-Yin and KDS-Yang in Hong Kong Chinese middle-aged women with menopausal symptoms.Scientific evidence is recognised to be a higher form of knowledge than expert opinion . We testHow to properly measure TCM clinical trial outcomes has been explored in recent years. Some authors developed an outcome measure for TCM syndromes in people with hepatitis C virus . In thisOther authors developed a generic Cold-Heat Pattern Questionnaire as an adjunct diagnostic tool for Cold and Heat TCM syndromes , and alsThere are limitations of the present study. We reviewed the classic literature that was recognized to have built the foundation of TCM theory  and the We constructed the KDSQ with a PRO design by excluding the signs on facial complexion, tongue and pulse that require TCM practitioners’ diagnosis. The exclusion was made because the signs were not described in the classic literature , the symInternal consistency of the KDSQ items was relatively weak in measuring “impaired Kidney orifices”, “restlessness at night” and “abnormal urine excretion”; which may be subject to further study. In contrast, internal consistency was good for Kidney-Essence deficiency and Kidney-Qi deficiency which are important domains of KDS-Yin and KDS-Yang, respectively ,2,16; anConsistently, our participants reported relatively mild deficiency heat symptoms or deficiency cold symptoms at baseline test and the magnitudes of change over the period of 66–74 days were relatively small. These may have contributed to the small effect sizes of the deficiency heat domain of KDS-Yin and the deficiency cold domain of KDS-Yang. On the other hand, the rest of the KDSQ domains were found to have about medium to large effect sizes Table , suggestKidney deficiency causes permanent cessation of menstrual periods in middle-aged women is documented in TCM classic and contemporary literature ,16. We hThe KDSQ is a valid and reliable measure for KDS-Yin and KDS-Yang in Hong Kong Chinese middle-aged women with menopausal symptoms. TCM syndrome-specific measurement tools may be developed for outcome measurement in TCM clinical research.The authors declare that they have no competing interests.RQC contributed to the design, implementation, and analysis of the study. THL and CMW contributed to the design and analysis of the study. RQC drafted the manuscript, THL and CMW revised the manuscript, and all approved the final version. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1472-6882/12/73/prepubThe Kidney Deficiency Syndromes Questionnaire.Click here for file


Drosophila CNS branches develop through a process of excessive growth followed by pruning. In vivo high-resolution live imaging of developing brains as well as loss and gain of function experiments show that activation of Epidermal Growth Factor Receptor (EGFR) is necessary for branch dynamics and the final branching pattern. Live imaging also reveals that intrinsic asymmetry in EGFR localization regulates the balance between dynamic and static filopodia. Elimination of signaling asymmetry by either loss or gain of EGFR function results in reduced dynamics leading to excessive branch formation. In summary, we propose that the dynamic process of axon branch development is mediated by differential local distribution of signaling receptors.Axonal branching allows a neuron to connect to several targets, increasing neuronal circuit complexity. While axonal branching is well described, the mechanisms that control it remain largely unknown. We find that in the DOI:http://dx.doi.org/10.7554/eLife.01699.001 In the human brain, 100 billion neurons form 100 trillion connections. Each neuron consists of a cell body with numerous small branch-like projections known as dendrites (from the Greek word for ‘tree’), plus a long cable-like structure called the axon. Neurons receive electrical inputs from neighboring cells via their dendrites, and then relay these signals onto other cells in their network via their axons.Drosophila.The development of the brain relies on new neurons integrating successfully into existing networks. Axon branching helps with this by enabling a single neuron to establish connections with several cells, but it is unclear how individual neurons decide when and where to form branches. Now, Zschätzsch et al. have revealed the mechanism behind this process in the fruit fly, Drosophila, an uneven distribution of EGFR between branches belonging to the same axon acts as a signal to regulate this pruning process.Mutant flies that lack a protein called EGFR produce abnormal numbers of axon branches, suggesting that this molecule regulates branch formation. Indeed in fruit flies, just as in mammals, the developing brain initially produces excessive numbers of branches, which are subsequently pruned to leave only those that have formed appropriate connections. In Drosophila pupae and kept alive in special culture chambers. Axon branching and loss could now be followed in real time, and were found to occur more slowly in brains that lacked EGFR. The receptor controlled the branching of axons by influencing the distribution of another protein called actin, which is a key component of the internal skeleton that gives cells their structure.To examine this mechanism in more detail, high-resolution four-dimensional imaging was used to study brains that had been removed from In addition to providing new insights into a fundamental aspect of brain development, the work of Zschätzsch et al. also highlights the importance of stochastic events in shaping the network of connections within the developing brain. These findings may well be relevant to ongoing efforts to map the human brain ‘connectome’.DOI:http://dx.doi.org/10.7554/eLife.01699.002 The establishment of functional neuronal networks relies on the correct incorporation of a neuron into a developing circuit. An extended neurite network enables a single neuron to process information from multiple input cells and to relay that information to a wide range of targets. Neurite formation during development is a dynamic process and therefore tight regulation seems necessary to achieve connection specificity. At earlier steps of circuit formation, axon guidance, an intensively investigated process, combines intrinsic factors and extracellular cues to form a trajectory towards the general target area . SubsequIn mammals, a common mechanism to regulate axon branch number is excessive axonal outgrowth and exuberant branch formation during development followed by a refinement process called pruning . PruningAn important question is how branch refinement is regulated. For a long time activity-dependent mechanisms were thought to be the major factor underlying regulation of pruning in the mammalian system . HoweverDrosophila deterministic genetic programs are thought to account for the stereotypic development of the vast majority of neuronal connections  in the central nervous system (CNS) of osophila . DCNs foosophila  and mushosophila , DCN axoDrosophila adult optic lobes. A small subset of neurons from this cluster extend their axons in the outer part of the optic lobe, the medulla (Me)  establish a complex neurite network in the lla (Me) , where tlla (Me) . This pal clones  reveal tl clones . False cl clones  of singll clones  reveals T1). In this genetic background DCN axons show short ectopic branches . In all three cases the DCNs show a significant increase of axon branches in the adult CNS. Compared to an average of 7 primary branches under wild type conditions, we observed a significant increase to 10.5 primary branches per axon in EGFRDN-A expressing DCNs  resulted in an increase to an average of 8.3 branches per axon  whose role in optic lobe development is well described  or GMR-Gal4 (photoreceptors) to down regulate Spi expression in the DCNs or photoreceptors, respectively. To visualize DCN branch formation while down regulating Spi specifically in the photoreceptors, we used the Gal4-independent LexA-based binary expression system  during brain development. Between 36 hr and 54 hr APF DCN axons form extensive branches at multiple positions along the growing axon . BetweenDN during pupal development. Between 36 hr and 48 hr APF axon branching at the second branch point is similar to wild type  and performed live imaging experiments. We find that the EGFR is dynamically transported into and out of axonal branches and their filopodia . In agreement with a differential local signaling model, EGFRCA induces a significant increase of DCN branches both in vitro . EGFR expression has been observed in neurites of mammalian neurons , UAS-EGFRDN-B, UAS-EGFRRNAi (VDRC107130), UAS-SpiRNAi , UAS-EGFRCA, UAS-Utrophin-GFP (gift from T Lecuit), UAS-Moesin-GFP . The GFP intensity of each filopodia was normalized to the mean of maximal intensities of all filopodia within a cell before and after treatment.To inhibit endocytosis, cells were incubated for 6 min with 0.14 mM dynamin inhibitor Dyngo-4a (Abcam), diluted in Schneider’s medium from stock solution in DMSO. For controls, equivalent concentrations of DMSO were diluted in Schneider’s medium. The effect of the dynamin inhibitor Dyngo-4a on levels of EGFRAlexa 488, 555 or 647, Molecular Probes, 1:500, in vitro: FITC- or Cy3-conjugated affinity-purified secondary antibodies ). In vitro filamentous actin was detected with TRITC-conjugated phalloidin (Sigma). After several washes in PBT the samples were mounted in vectashield.The following primary antibodies were used in the in vivo experiments: rabbit anti-GFP , mouse anti-GFP , mouse anti β-galactosidase , rabbit anti β-galactosidase , mouse MAb 24B10 anti-Chaoptin , rabbit anti-DsRed , mouse anti-NC82 , rat anti-DN cadherin . The following primary antibodies were used in the in vitro experiments: mouse anti-tubulin , goat anti-GFP . The incubation with the primary antibodies was followed by several washes in PBT (1 hr) and a final incubation with the appropriate fluorescent secondary antibodies (in vivo: http://pacific.mpi-cbg.de).Confocal stacks of fixed brains were made using Zeiss LSM 510 or Leica SP6 confocal microscopes. Neuronal cell culture imaging was conducted with an AxioCam camera mounted on an Olympus BX50WI microscope. DCN live imaging was conducted with a Leica SP6 resonance scanning confocal microsocope. In general, a confocal stack comprising the axonal projection of Dorsal Cluster Neurons (30–40 single projections) was recorded every 5 min. Resonance scanning allowed high scan speed with lower laser intensities and therefore ensures preservation of living tissue due to decreased photo-toxicity. Projection images were generated and further processed with ImageJ. For tracking of axon branches we have used the ‘simple neurite tracer’ a plugin for ImageJ from Mark Longair . Number of developmental branches is the number of end points from the skeleton.Images of medulla axons were skeletonized and subsequently automatically analyzed using the ‘Skeletonize3D’ and ‘AnalyzeSkeleton’ free plugins for ImageJ/FIJI  and transferred to the culture plate inserts and cultured according to the whole brain explant system described previously . After ahttp://pacific.mpi-cbg.de). We have traced dynamic axon branches by using the tip of an axon at time point t0 as starting point and the tip of the same axon at time point t1. The length of the resulting fragment represents the length of the growing or retracting axon.For tracking of growth and retraction dyamics we have used the ‘simple neurite tracer’ a plugin for ImageJ from Mark Longair  from pStinger into pUAST-Attb vector (Genbank EF362409.1). Two Gly-Gly-Ser bridges (GGSGGS) have been introduced between the two open reading frames. Transgenic flies were created at GenetiVision Inc.  using PhiC31-mediated transgenesis in the VK37 docking site  and in the VK31 docking site .UAS-EGFRonstruct  and eGFPEGFRGFP in static vs dynamic filopodia were quantified in FIJI, by drawing a box at the distal ends of filopodia and measuring the maximal intensities within. Only neurons with both static and dynamic filopodia were used for the analysis, and the GFP intensity of each filopodia was normalized to the mean of maximal intensities of all filopodia within a cell. For dynamic filopodia, measurements were taken during the first 8 s of the retraction or extension. For static filopodia, measurements were taken during 8 s at the middle of the recording period. These measurements were used to calculate the ratio of EGFRGFP in dynamic minus static filopodia .Levels of t test was used for For non-normally distributed samples the nonparametric ANOVA Kruskal–Wallis test with Dunn’s multiple comparisons for CA, UAS-Ras1CA, UAS-Ras1RNAi, UAS-DrkRNAi, UAS-Actin-GFP, UAS-EGFR. Additional fly stocks and mutants used were: Vein-lacZ (gift from I Miguel-Aliaga), EGFR1k35, Spiscp2.The additional GAL4 driver line was: GMR-Gal4 and Dpp-Gal4. The UAS-reporter stocks were the following: UAS-nSyb-GFP, UAS-Syt-GFP, UAS-ERKyw; hsflp, UAS-CD8-GFP; FRT42D Tub-Gal80/ CyO; atoGal4-14a/TM6c were used in conjunction with yw; FRT42D EGFR1k35/ CyO. The crosses were set up at 25°C and transferred every day. 2 to 4 days after egg laying the samples were heatshocked for 3 hr at 37°C and shifted back to 25°C until eclosion.For MARCM experiments  yw; hsflThe following primary antibodies were used in this study: rat anti-DN cadherin , rat anti-EGFR , rabbit anti-dpERK , mouse anti-NC82 , Rabbit anti Rab5 , Rat anti Rab11 , 1:500.Culture medium was modified from Drosophila were cultured in a Schneider’s based medium . Similarly, the author response typically shows only responses to the major concerns raised by the reviewers.eLife posts the editorial decision letter and author response on a selection of the published articles . An edited version of the letter sent to the authors after peer review is shown, indicating the substantive concerns or comments; minor concerns are not usually shown. Reviewers have the opportunity to discuss the decision before the letter is sent . Finally, the authors explore the involvement of actin dynamics and show that EGFR signaling in axon branching involves a control of F-actin polymerization in axonal filopodia.This article is clearly providing novel insights into the cellular and molecular mechanisms underlying axon branching in vivo, which is a highly significant aspect of brain wiring. Therefore, the significance of results is high. However, one reviewer raised a number of substantial concerns regarding some aspects of the work, focusing on: First, the loss and gain of function of EGFR causes the same effect in branching. It is true that there might be a way to interpret this, but the understanding of the downstream signaling events is not sufficient to validate the model. Second, endocytosis blockade led to a decrease of the receptor level. This is not intuitive and needs to be explored further. Third, the subcellular localization of EGFR is very interesting. However, the correlation between the presence of EGFR in vivo and the fate of branches is not established.Therefore, we would like to have the authors respond to the major comments listed below. If they can provide experimental evidence for most of the major points (with a strong priority for point 4 below), we will be happy to consider a revised version.Major comments:1) 2) It is usually assumed that inhibition of endocytosis would lead to an increase in the level of receptors on the membrane. DN background, does the EGFR-GFP rescue the phenotype? This is of course trying to test if the EGFR-GFP construct is functional.3) In 4) The critical experiment is to understand the correlation of having strong EGFR-GFP puncta on a branch and whether they will be pruned in 5) In CA during the developmental course is necessary to test if the loss- and gain-of-function manipulation indeed has the same effects in growth and pruning.6) It is puzzling that the gain-of-function EGFR causes the same phenotype as the loss-of-function. Although the authors have a way of thinking about this result, detailed analyses of the EGFR7) It is unclear what is the cellular source of EGF ligand(s). The results implicate that EGF ligand(s) could act in an 'axon-autonomous' way to control branching through filopodia through contacts between filopodia of adjacent axons. However, the authors never document where EGF ligand(s) are located. Are there expressed by the axons themselves or by adjacent cells or both? In situ hybridization for the ligand(s) such as Spitz might clarify this important point. 1)seem to show very different modes of movements. In, it seems that vesicular transport can be seen.shows a much more diffused staining pattern. The intensity changes in this video seem to be fluctuations instead of discrete vesicular movements.2) It is usually assumed that inhibition of endocytosis would lead to an increase in the level of receptors on the membrane.showed the opposite. First, is it known whether the EGFR is mostly on the surface or internal? The main limitation of using a simple EGFP fusion protein is that the authors cannot distinguish between surface receptor from internal stores present in endosomes/exosomes. Second, it is entirely possible that the authors are correct and some type of transcytosis (which requires endocytosis) is sending EGFR to the filopodia. Is there any redistribution of EGFR from the cell body orprimary axon to the branches?Indeed we find EGFR is trafficked from cell bodies and main axon shafts in and out of filopodia. We now show this and in cultured neurons  and in v3) In, the authors use overexpressed EGFR-GFP to study the subcellular localization of EGFR. Does this construct cause there any effect on the branching phenotype? In the EGFRDNbackground, does the EGFR-GFP rescue the phenotype? This is of course trying to test if the EGFR-GFP construct is functional.DN and EGFRCA.Both wild type untagged EGFR and tagged EGFR-GFP cause no phenotypes when overexpressed in DCNs. This is likely because, as shown in When overexpressed in the eye EGFR-GFP shows similar eye defect phenotype to the overexpressed untagged wild type receptor, as stated in the original manuscript. In addition, we now show that it displays similar localization in the eye as the endogenous receptor .precisely the same position as the EGFR cDNA, fully rescues the EGFR null mutant from embryonic lethality to adult viability. These data strongly argue that the GFP-tagged EGFR is fully functional.Most importantly, as shown in the original manuscript  a genomiTo formally test this, we cannot ask if the UAS-EGFR-GFP rescues the dominant negative, wild type EGFR-GFP is still subject to inhibition by dominant negative EGFR. Instead, we turned to a classical assay that is used to gauge EGFR activity in vivo. Formation of the wing veins in flies requires spatially restricted EGFR activity. When wild type EGFR is expressed in the developing wing outside the normal vein domains, it causes the formation of ectopic vein tissue . We find that both a control untagged wild type EGFR and EGFR-GFP cause equivalent ectopic wing vein formation . Altoget4) The critical experiment is to understand the correlation of having strong EGFR-GFP puncta on a branch and whether they will be pruned in. We did not get a clear answer whether that has been attempted or not from the text.To address this question in vivo , continuTo address at least in part this important concern, we asked whether EGFR can be detected trafficking in and out of filopodia, as these filopodia move in vivo. To this end, we generated flies and developed a setup that allows high resolution imaging of EGFR-GFP movement while monitoring filopodial motion. These data  show cleAltogether, our data provide strong evidence to support the notion that dynamic asymmetries in EGFR distribution are essential for proper axonal branching and that wiping out those differences in both EGFR-DN and EGFR-CA backgrounds grinds filopodial dynamics to a virtual halt causing failure of axonal branch pruning.5) In, both growth and retraction of neurites are severely affected by the DN construct. The effects on the growth of the neurite are inconsistent with the lack of outgrowth phenotype in the loss-of-function analyses, which challenges the relevance of this long-term culture system.changes in growth. In other words existing filopodia show reduced net growth and retraction after they have initially formed. The graph in difference in growth and retraction rates between the genotypes and not the total length of filopodia. Thus, in EGFR-DN flies, initially formed filopodia no longer undergo dynamic changes, and therefore remain mostly static and develop into the excessive branches we observe in vivo. We have now changed the graph heading to reflect this and labeled the graphs as ΔGrowth and ΔRetraction to avoid the confusion we may have caused.The effects on filopodia in EGFR loss-of-function conditions are not on the initial growth of filopodia per se . Inhibition of EGFR stops 6) It is puzzling that the gain-of-function EGFR causes the same phenotype as the loss-of-function. Although the authors have a way of thinking about this result, detailed analyses of the EGFRCAduring the developmental course is necessary to test if the loss- and gain-of-function manipulation indeed has the same effects in growth and pruning.CA and find that gain of EGFR function inhibits axonal branch pruning during development, mimicking the effects of EGFR loss of function  It is unclear what is the cellular source of EGF ligand(s). The results implicate that EGF ligand(s) could act in an 'axon-autonomous' way to control branching through filopodia through contacts between filopodia of adjacent axons. However, the authors never document where EGF ligand(s) are located. Are there expressed by the axons themselves or by adjacent cells or both? In situ hybridization for the ligand(s) such as Spitz might clarify this important point.spitz mRNA is unlikely to reveal RNA at the axonal level. Vein is likely provided by cells adjacent to DCN axons, as shown by the Vein-LacZ reporter transgene. Furthermore, a more recent study shows that an overexpressed Spitz-GFP transgene is secreted from photoreceptor axon terminals (Our genetic (Spitz) and enhancer-reporter (Vein) data indicate that these two ligands as the likely sources of EGF activity. Spitz is likely provided by retinal axons, and not DCN axons and is thus not axon-autonomous. Therefore, in situ hybridization for the erminals , as stat


Chronic Rhinosinusitis with Nasal Polyps (CRSwNP) presents a Th2 profile predominance, with a remarkable eosinophil infiltration and IL-5 secretion. The influence of molecular markers on both histology and recurrence is still misunderstood.To evaluate the gene expression of IL-5, IL-8 and TGF-beta in patients with nasal polyps and control patients, as well as its correlation to tissue cellularity and diseases relapsing.The mRNA expression of the IL-5, IL-8 and TGF-beta protein was analyzed using qRT-PCR in 32 nasal polyps and 7 control samples comparing it with medium turbinate control samples (obtained from patients undergoing aesthetic rhinoplasty). The numbers of eosinophils and neutrophils were counted in samples obtained during surgical procedure, and stained with hematoxylin eosin in an optical microscope. The patients were followed up to three years after surgery, and considered with relapsing disease if there was polyp in the medium meatus through nasal endoscopy.IL-5 and IL-8 expressions were increased whereas TGF-beta was decreased in the nasal polyps when compared to the control mucosa from medium turbinates. There was no correlation between these molecules expression and tissue's cellularity, nor to relapsing of the disease.Brazilians' nasal polyps present an increased Th2 and a decreased Treg profile, as Europeans'. The expression of none of these molecules correlated to tissue cellularity, neither to recurrence of the disease. Future research is still needed to observe the real impact of these molecules in CRSwNP, especially when regarding its therapy.


The post-pericardiotomy syndrome (PPS) is a common complication after cardiac surgery, occuring in 10-40% of patients. PPS may prolong hospitalization, and even serious complications like tamponade and constrictive pericarditis may occur. Early diagnosis and treatment may reduce morbidity. In 50 patients transferred to our hospital after cardiac surgery we found an increase in pro-inflammatory and a decrease in anti-inflammatory cytokines at admission in the patients later developing PPS compared to the patients who did not develop PPS. If confirmed in larger studies, these findings may prove useful in early identification of and targeted treatment in patients developing PPS. We screened 50 consecutive post-operative coronary by-pass patients with a panel of inflammatory markers  as wellPPS was diagnosed in 11 out of 50 patients (22%). The PPS patients were younger  and had higher levels of C-reactive protein (CRP) at admission  than those not developing PPS. Furthermore, at transferral to our hospital, serum levels of the pro-inflammatory cytokines interleukin (IL) -6 and IL-8 were higher and levels of the anti-inflammatory cytokines IL-10 and IL-1 receptor antagonist (IL-1ra) were lower in the PPS group, although this was statistically significant only for IL-8 (p < 0.05) (Figure Although usually benign, the occurence of PPS regularly prolongs hospitalization and in rare cases is associated with development of serious complications such as cardiac tamponade or constrictive pericarditis. Recently, colchicine was shown to be of benefit in preventing PPS , but as In the pilot study presented here we show that patients developing PPS seem to have a shift in levels of inflammatory mediators in the days preceding development of a cardiac effusion – with higher levels of pro-inflammatory and lower levels of anti-inflammatory cytokines. The trend was clear, and the lack of statistical significance for some of the mediators may be due to the low number of participants, an obvious limitation of our study. Another limitation is the fact that screening samples were collected 3–5 days post-operatively and not at fixed time points. Although the patients developing PPS also had relatively higher levels of CRP, this finding is unspecific and thus of less use in diagnosing PPS. The lower age among the PPS-patients may indicate a relative immune paralysis in the older patients, reducing the risk of developing PPS. We suggest that our findings should be confirmed in a larger trial as they may serve as a tool for early detection and treatment of PPS.PPS, Post-pericardiotomy syndrome; CRP, C-reactive protein; IL, Interleukin; Ra, Receptor antagonist.The authors report no competing interests.NS and KTL designed the study, KTL drafted the manuscript and both authors read and approved the final manuscript.


IP based Wireless Sensor Networks (IP-WSNs) are being used in healthcare, home automation, industrial control and agricultural monitoring. In most of these applications global addressing of individual IP-WSN nodes and layer-three routing for mobility enabled IP-WSN with special attention to reliability, energy efficiency and end to end delay minimization are a few of the major issues to be addressed. Most of the routing protocols in WSN are based on layer-two approaches. For reliability and end to end communication enhancement the necessity of layer-three routing for IP-WSNs is generating significant attention among the research community, but due to the hurdle of maintaining routing state and other communication overhead, it was not possible to introduce a layer-three routing protocol for IP-WSNs. To address this issue we propose in this paper a global addressing scheme and layer-three based hierarchical routing protocol. The proposed addressing and routing approach focuses on all the above mentioned issues. Simulation results show that the proposed addressing and routing approach significantly enhances the reliability, energy efficiency and end to end delay minimization. We also present architecture, message formats and different routing scenarios in this paper. The huge number of IPv6 addresses, the necessity for end to end communication and the advances in micro-electronics have changed the concepts of the research community , the mean number of times the process is in state jS starting from state iS is given by:Let k steps, starting from state iS, can be computed from the total number of times that the process is in the boundary states starting from state jS, the initial state. The average number of location updates (buU) in the analytical model, is given by:The total number of boundary updates in Generalizing:We can use the above equation to determine the number of binding update messages. Because we need to send a binding update message whenever the sensor node moves between IP-WSNs, each time a node enters a boundary state, a binding update message is generated. Therefore, we need to determine the expected number of times that the process enters into a boundary state within k steps.buU binding update messages, given that the sensor node experiences a total of k transitions between SMAGs. Therefore, the ratio of intra-IP-WSN mobility is denoted as Mra_IP−WSNint and is expressed by:Thus, sensor nodes need to send Mer_IP−WSNint and is expressed by:The ratio of inter-IP-WSN mobility is denoted as 4.3.We have evaluated our proposed model based on signaling cost, mobility cost and energy consumption. In the subsequent section we discuss the signaling cost and energy consumption analysis. Mobility cost is evaluated based on signaling cost. To evaluate total signaling costs, we compare the results of the analytical model of IP-WSN with those of MIPv6 and PMIPv6. We already mentioned that the proposed global IP-WSN architecture is based on SPMIPv6 which is a sensor network-based PMIPv6 protocol.sn-smag and the distance between SMAG and border router is denoted by Dsmag-BR. The corresponding node (CN) considered as the specialist doctor is communicating with the visiting doctor. There are some visiting doctors who see the patient on a continuous basis. In this analytical model, different distances are used for calculating signaling cost.Signaling cost is defined as the total cost of signaling traffic overhead which in turn, is the total number of control messages exchanged between different nodes, so the unit of signaling cost is the number of control message exchanged among different nodes. There may be five types of mobility scenarios which has already been discussed in an earlier section. If patients move to a remote site then the signal will be transmitted through the Internet domain, otherwise signal transmission will be restricted within the IP-WSN domain.mipv6) of the proposed IP-WSN scheme based on MIPv6 is calculated by summing up the individual cost of intra-IP-WSN mobility (Mintra-ip-wsn. Csd) and inter-IP-WSN mobility (Minter-ip-wsn.(Csd + Cbu)). Where, Csd and Cbu are the sensor mobility cost and binding update cost respectively. sd and Cbu are calculated in term of MIPv6 as follows:From pmipv6) of the proposed IP-WSN scheme based on PMIPv6 is calculated by summing up the individual cost of intra-IP-WSN mobility (Mintra-ip-wsn. Csd) and inter-IP-WSN mobility (Minter-ip-wsn.(Csd + Cbu)). Where, Csd and Cbu are the sensor mobility cost and binding update cost respectively:From spmipv6) of the proposed IP-WSN scheme based on SPMIPv6 is calculated by summing up the individual cost of intra-IP-WSN mobility (Mintra-ip-wsn. Csd) and inter-IP-WSN mobility (Minter-ip-wsn.(Csd + Cbu)). Where, Csd and Cbu are the sensor mobility cost and binding update cost respectively:sd and Cbu are calculated in term of SPMIPv6 as follows:From 4.4.txE and rxE is the distance-independent amount of energy consumed by the transmitter and receiver electronics and the digital processing of each:For energy consumption analysis, we consider an IP-WSN with densely deployed IP sensing devices. The network consists of two types of IP sensing device: fully functional IP sensing devices (IP-FFDs) and reduced functional IP sensing devices (IP-RFDs). IP-FFDs hold the complete 6LoWPAN protocol stack and perform the routing functions. IP-RFDs perform the sensing functions and forward the data to the IP-FFDs. We have followed the energy consumption model used in ,19–23. TSince same type of transmitting and receiving device is concerned in IP-WSN:i, control packet transmission cost can be calculated as follows:For a particular fully functional device or a SMAG node α is path loss exponent (2 < α < 5) and β is a constant [J/bit m2], r is a transmission range. inrfd(r) is the average number of reduced functional device nodes in the neighborhood of the fully functional node i within the range ctrlr. L is the length of control packets in bits, EL is the energy consumed by the transmitter device to transmit or receive a packet, and T is the time period between two consecutive topological changes of the IP-WSN.Here p, cost for information transmission from a source to the fully functional SMAG node i is calculated as follows:Now for a particular path pnffd(id) indicates the number of fully functional node for a path p and within the range pd. nrfd(id) indicates the number of reduced functional device for path p and range d.Here i can be calculated from Total communication cost for transmitting data packet from a source to SMAG node Now let us calculate the energy consumption in terms of MIPv6, PMIPv6 and the proposed global IP-WSN scheme based on SPMIPv6 with the help of Energy consumed by PMIPv6 scheme can be calculated by the following mathematical derivation. Here Finally energy consumed by the proposed IP-WSN based on SPMIPv6 scheme can be calculated in the same way. Here 5.In this section, we present the result of experiments evaluating the performance of our proposed global IP-WSN scheme, and compare the performance of our proposed scheme to MIPv6 and PMIPv6. In the figures our proposed global IP-WSN scheme is represented as SPMIPv6. First, we evaluate the performance of our proposed approach by mathematical analysis. Then, we set signaling cost and mobility related cost for the number of IP based sensor nodes and number of hops traverse during the mobility phase in order to evaluate the consequences of our proposed scheme with PMIPv6 and MIPv6. Finally, we summarize the key characteristics of our proposed approach as compared to PMIPv6 & MIPv6 approach.We have implemented the model and evaluate the parameter such as the signaling cost and mobility related cost as presented in this paper. The experiments were conducted on a computer equipped with an AMD Athlon™ 2.5 GHz CPU and 2 GB primary memory. We use the network simulator tool NS2  on VMwarThe 6.In this paper we present a global IP-WSN architecture with special attention to addressing and routing. These are the most challenging issues that must be addressed with reference to energy efficiency. Since the proposed global IP-WSN architecture is based on a localized mobility management protocol, it meets the demand for energy efficiency in terms of reducing signaling costs, mobility costs, end to end delay and increasing packet delivery ratio. Here we also present the detailed software architecture, mobility scenarios, messages formats, addressing issues and evaluate its performance by analyzing signaling costs and mobility costs, packet delivery ratio and end to end delay. Our experiments show that with respect to the number of IP-WSN nodes, the proposed global IP-WSN scheme reduces the signaling cost by 60% and 56%, as well as the mobility cost by 62% and 57%, compared to MIPv6 and PMIPv6, respectively. The simulation results also show that in terms of the number of hops, proposed IP-WSN scheme based on SPMIPv6 decreases the signaling cost by 56% and 53% as well as mobility cost by 60% and 67% as compared to MIPv6 and PMIPv6 respectively. It also indicates that proposed scheme reduces the level of energy consumption. Moreover the proposed scheme also enhances the packet delivery ratio and end to end delay significantly. In this paper, we focus on 6LoWPAN based IP-WSN of the same vendor and protocol stack. In future we will focus on the federated IP based sensor networks consisting of multi-vendor and heterogeneous protocol stacks.