The aim of this study was to evaluate whether community-based nurse-led continence care interventions are effective in improving outcomes for adult Chinese primary care patients with lower urinary tract symptoms (LUTS).A case-controlled intervention study was conducted. An intervention group of 360 primary care patients enrolled into a nurse-led continence care programme were recruited by consecutive sampling. A control group of 360 primary care patients with LUTS identified by screening were recruited from the waiting rooms of primary care clinics by consecutive sampling. Both groups were monitored at baseline and at 12 months.Outcome measures included symptom severity, health-related quality of life (HRQOL), self-efficacy, global health and self-reported health service utilization at 12-months. The effect of the continence care programme on symptom severity and HRQOL was assessed by the difference-in-difference estimation, using independent t-test and multiple liner regression. Chi-square test was used to compare the self-efficacy, global health and self-reported health service utilization between the two groups at 12-months.After adjusting for baseline severity and socio-demographics, the intervention group had significant improvements in LUTS severity (P<0.05) and HRQOL (P<0.05). Improvements in the amount of urine leakage were not significantly different between the two groups. A higher proportion of subjects in the intervention group reported increased self-efficacy (43.48% vs. 66.83%), improved global health condition (17.74% vs. 41.5%), having doctor consultation (18.5% vs. 8.06), having medication due to LUTS (26.50% vs.11.29%) and having non-drug therapy due to LUTS (59.5% vs.9.68%).Community-based nurse-led continence care can effectively alleviate symptoms, improve health-related quality of life, and enhance self-efficacy and the global health condition of Chinese male and female primary care patients with LUTS. As a result of population ageing and shifts in patient needs, there has been an increased demand for chronic disease management delivered in the community. Whilst the number of primary care doctors is limited, one solution has been to introduce allied health and nurse–led services to assist in health care delivery. A number of countries, namely the United Kingdom, Australia, Canada and the United States, have introduced multidisciplinary allied-health clinics, nurse practitioner, and nurse-led clinics into routine practice in primary care. Under certain circumstances, available evidence shows that this model for care delivery has the potential to reduce health costs without compromising quality of care ,2. Such Lower urinary tract symptoms (LUTS) are a highly prevalent that impacts quality of life. It is estimated that the worldwide prevalence of LUTS will rise from 45.2% in 2008 to 45.8% by 2018. LUTS affects both men and women. In order of frequency, the most common type of LUTS are storage symptoms, followed by voiding symptoms and post-micturition symptoms . UrinaryA recent systematic review of community-based nurse-led continence services found that such care is effective , howeverTo help build the evidence base on nurse-led continence care, the aim of this study was to evaluate the effectiveness over 12 months of community-based nurse-led continence care services for male and female Chinese primary care patients with LUTS.This was a prospective, observational, case-control intervention study. Two cohorts of primary care patients with LUTS were recruited and monitored over 12 months . One groIntervention group: All new patients referred to the NAHC-CC programme at one of four General Out-Patient Clinic (GOPC) locations distributed across Hong Kong during the study period were identified from the appointment list and screened for LUTS prior to their initial assessment by the nurse. All eligible subjects were invited to participate in the study.Control group: Waiting room patients waiting to consult a doctor at one of four GOPC locations where NAHC-CC services were not available, were consecutively screened for LUTS prior to their medical consultation. All eligible subjects were invited to participate in the study.For both groups, a modified International Consultation on Incontinence Questionnaire-Urinary Incontinence-Short Form (ICIQ-UI SF) questionnaire was used to screen for patient eligibility. Patients with scores ≥ 3 were considered to have LUTS . PatientEligible patients were identified by trained field workers who approached the subjects in person to invite them to take part in a telephone survey. The aims, procedures and nature of the study were explained before consent was obtained. Subjects who consented were asked to provide their contact details and were subsequently contacted by trained interviewers who were blinded to the recruitment setting to administer the study instruments by telephone within two weeks of recruitment (baseline) and at 12-month after their baseline interview (follow-up). The questionnaires were read verbatim in a standardized way. Subjects were contacted using a computer-aided telephone interviewing system by the interviewers between 10:00 am and 10:30 pm on weekdays. A maximum of five attempts were made for unanswered lines.NAHC-CC services are delivered by nurses with specialty related training related to urology or continence care, certified by the Hospital Authority. The nurses conduct the consultations, assessment and provide treatments in specially equipped consultation rooms located in the primary care Government-Outpatient clinics of the Hospital Authority, as part of a multi-disciplinary clinic with primary care doctors and nurse assistants. The main source of referrals is through the primary care physicians, clinic patients can also self-refer.Patients enrolled in the NAHC-CC programme receive an initial assessment conducted by continence care nurses who conduct the history, physical examination and baseline investigations . Subsequent interventions are protocol-based and include conservative measures tailored to each patient according to the type of LUTS being experienced. Interventions include pelvic floor muscle exercise, diet modification, bladder training and urethral massage for male patients:Pelvic floor muscle exercise involves repeatedly contracting and relaxing the pelvic floor muscles to improve the stiffness, the strength, the endurance, the coordination and the function of the muscles .Diet modification included evening fluid restriction and reduction in the consumption of fluids containing alcohol or caffeine .Bladder training is used to re-establish bladder control and restore a normal bladder patter by setting a schedule in which the patient may not use the toilet for voiding within a set period of time and to gradually increase the inter-voiding times. As the interval between visits to the toilet increases, the amount of urine that the bladder holds also increases .Urethral massage is used to eliminate post micturition dribble in male patients. The patient is instructed to place his fingers behind his scrotum after urination and to massages his bulbar urethra in a forwards and upwards direction so that the urine retained in the bulbar urethra can be released .Patients subsequently receive one to two follow-up sessions provided at approximately 3–4 monthly intervals to monitor progress. If required, the continence care nurse may arrange referral to a specialist for patients who require advanced urological care or more specialized investigations such as urodynamic testing.The IPSS comprises seven symptom questions and one health-related quality of life question. It asks about the severity of LUTS including incomplete bladder emptying, frequency of urination, intermittency, urgency, weak urine stream, straining and nocturia with higher scores indicating greater symptom severity. The psychometric performance of the Chinese IPSS has been evaluated in male and female patients with LUTS in Hong Kong primary care ,17. The The original ICIQ-UI SF consists of four questions to assess the frequency (question 1) and amount of urinary leakage (question 2), the impact of urinary leakage on quality of life (question 3) and the perceived causes of urinary leakage (question 4), with higher scores indicating greater symptom severity and poorer health-related quality of life (HRQOL) . For thiThe modified IIQ-7, which consists of 7 questions, was used to evaluate the impact of LUTS on HRQOL, with higher scores indicating poorer HRQOL. The psychometric performance of the modified Chinese IIQ-7 has been evaluated in male and female patients with LUTS in Hong Kong primary care ,19.The PEI consists of six questions: able to cope with life, able to understand your illness, able to cope with your illness, able to keep yourself healthy, confident about your health and able to help yourself . SubjectThe single item asks subjects to rate the change in their global health condition since the baseline interview . The GRSEach subject was asked (i) whether he/she had consulted a doctor for urinary problems in the past 12 months, (ii) whether they had received medications for urinary problems in the past 12 months, (iii) whether he/she had surgery for urinary problems in the past 12 months, (iv) whether he/she had received non-drug therapy  for urinary problems in the past 12 months, (v) whether he/she had attended the emergency department for their urinary problems in the past six months and (vi) whether he/she had been admitted to hospital admission for urinary problems in the past 12 months.The modified ICIQ-UI SF, IPSS and modified IIQ-7 were administered at baseline and 12-months. The PEI, GRS and self-reported health service utilization were only administered at 12-months. The Chinese versions of the instruments were used.The sample size for the evaluation of the difference in the mean change of the IPSS total symptom score after 12- month between groups with moderate effect size 0.3 was estimated. A sample size of 176 subjects in each group was needed in order to have 80% power and 5% level of significance by independent t-test. With 30% attrition rate at each time point, the minimum number of subjects in each group at baseline is 360.Descriptive statistics were used to calculate the baseline characteristics of socio-demographics and clinical outcomes at baseline and 12-month. For calculation of the mean change in outcomes , within-subject changes 12-months after baseline were analyzed by paired t-test. Unadjusted difference-in-difference estimation in outcomes between groups were reported and analyzed by independent t-test. The amount of urine leakage (the ICIQ-UI SF question 2) was further analyzed in patients with urinary incontinence by gender groups. Adjusted difference-in-difference was used to further analyze the outcomes including ICIQ-UI SF, the IPSS and the IIQ-7. Adjusted difference-in-difference estimation between groups was assessed by multiple liner regressions by the adjustment of confounding factors . Chi-square test was used to assess the difference in PEI, GRS and self-reported health service utilization at 12-months between intervention and control groups.All statistical analyses were performed using STATA Version 13.0 . All significance tests were two-tailed and findings with a p-value less than 0.05 were considered statistically significant.The study protocol of the present study was approved by the institutional review boards: the University of Hong Kong/Hospital Authority Hong Kong West Cluster (UW12-558), Hong Kong East Cluster (HKEC-2010-095), Kowloon West Cluster (KW/EX/10-149(34–16)) and Kowloon East Cluster (KC/KE-10-0209/ER-3). Participants provided their written informed consent to participate in this study. The ethics committees approved this consent procedure and this study before enrollment of participants started.A flowchart outlining subject recruitment, follow-up and analysis is shown in The results of unadjusted difference-in-difference estimation of the IPSS total symptom, IPSS HRQOL, ICIQ-UI SF and IIQ-7 scores between groups were shown in Results of the adjusted difference-in-difference estimation of scores between groups are shown in The result of the patient enablement index (PEI) and global rating of change scale (GRS) at 12-months is shown in This study examined the impact of community-based nurse-led continence care interventions on Chinese primary care patients with LUTS. This is one of the first studies to evaluate whether the model of community-based nurse-led continence care is effective in an Asian public sector healthcare setting. The 12-month cohort design allowed evaluation of effectiveness as well as sustainability of interventions in improving clinical outcomes.Our key finding was that whilst both groups experienced statistically significant improvements in the amount of urine leakage, IPSS total symptom scores and IPSS HRQOL scores between baseline and 12 months, improvements observed in the intervention group were significantly greater than those in the control group. Improvements observed between baseline and 12 months indicates that even without specific LUTS interventions, many patients can naturalistically improve. This may be a result of treatments provided during usual medical care , or patiThe magnitude of the IPSS total symptom score reduction in the intervention group (2.89 out of 35 points) in this study setting appears to be smaller than score reductions reported in a previous study males with LUTS (8.55 out of 35points) , howeverAnother important finding in this study was that the intervention group, but not the control group reported significant improvements in HRQOL as measured by the IIQ-7 over 12 months. This may be an outcome of treatment interventions which included intensive lifestyle modification with the aim of enhancing patient self-empowerment, which in turn helped to substantially alleviate the negative impacts of LUTS on their daily lives.A subgroup analysis of the effect of the programme on urine leakage as measured by the ICIQ- UI SF found that in both intervention and control groups, female subjects reported significant improvements in the amount of urine leakage. We hypothesized that female subjects might be more willing to report the presence of urinary symptoms to their healthcare provider or social circle, and as a result may have received advice or treatments for incontinence during usual care or in the course of their usual social activities. Further study is needed to explore the coping mechanism of female patients with urinary incontinence problems. On the contrary, lower urinary tract problems are often linked to masculinity and reduced sexual competency in males . As a coAt the 12-month follow up, the NAHC-CC programme, intervention subjects reported increased self-efficacy and improved general health condition. Similar to studies in other chronic disease conditions, we found that self-management strategies provided by continence care nurses can increase self-efficacy in illness management for patients with LUTS . The immThis study had a number of notable limitations. First, a randomized control trial was not conducted and unknown confounders may have biased the results. However, this was a naturalistic study which is more easily translatable to real clinical care . Second,This longitudinal observation study found that a structured nurse-led continence care programme is effective in alleviating symptoms and improving HRQOL at 12-months in Chinese patients with LUTS, but is less effective in improving urinary incontinence. Different from other studies on self-management programmes for LUTS, this evaluation study investigated the effect of nurse-led interventions for LUTS patients in a pragmatic primary care setting, which provides better translational evidence. A further study focusing on the long term effects of the programme is currently being conducted.S1 FigOverall, 720 subjects (360 subjects in each group) with LUTS were recruited. Of these, 406 subjects (200 intervention subjects and 206 controls) completed the 12-month telephone interview. Twenty subjects in the control group were excluded from analysis as they had joined the NAHC-CC programme for their LUTS subsequent to the baseline interview(PDF)Click here for additional data file.S1 File(PDF)Click here for additional data file.


How nice, I thought as a child, would it be to not feel physical pain. Later I realized that sense of pain may exist for a reason; it was suggested that physical pain has evolved as an alarm system to protect the body from serious damage. Much later I read about human disorders involving severe insensitivity to physical pain. Still, the idea of not feeling pain remains appealing .SCN9A leads to the inability to experience pain [et al.[SCN11A, which, when harboring a particular missense mutation, causes loss of pain perception. SCN11A encodes the voltage-gated sodium ion channel NAv1.9, which is highly expressed in nociceptors . The authors started out with whole-exome sequencing of healthy German parents and their child diagnosed with the congenital inability to experience pain. A heterozygote non-synonymous mutation in SCN11A was identified as the only de novo event detected in this affected child. Aiming to confirm this finding in independent samples, the authors performed Sanger sequencing of SCN11A exons in 58 additional individuals diagnosed with early-onset severe sensory loss, most of them representing sporadic cases. One Swedish individual showed the very same heterozygous SCN11A mutation, and the clinical history of both individuals was also similar. From these findings, the authors hypothesized that the identified mutation that leads to a replacement of leucine with proline (p.Leu811Pro) at the distal end of one of the transmembrane segments in domain II of NAv1.9 is disease causing and leads to loss of pain perception.Previously, it was demonstrated that a loss-of-function mutation in the sodium ion channel gene nce pain . In a mon [et al. identifiScn11a gene, but found no obvious morphological changes in sensory axons or in nerve fibers in the skin of the viable heterozygote knock-in mice. However, 11% of the knock-in mice had severe lesions that were not observed in the wild-type mice. Since the lesions also appeared in knock-in mice housed solitarily, it was assumed that they were self-inflicted. Also other experimental evidence pointed towards reduced pain sensitivity in these knock-in mice.Seeking molecular proof, the authors introduced the orthologous alteration (Leu799Pro) into the mouse v1.9 had been suggested to influence the excitability of dorsal root ganglia (DRG) neurons , the authors then investigated the electrical potential of DRG neurons isolated from wild-type and mutant mice. They found that a significant fraction of the mutant channels were active under resting conditions, and that the duration of action potentials was significantly reduced in the mutant neurons compared with wild-type neurons. In knock-out mice, however, only a minor effect on action potentials was observed. Additional experiments showed that the excessive activity at resting conditions caused sustained depolarization of nociceptors, impaired generation of action potentials and aberrant synaptic transmission.Because NAv1.9 and NAv1.9 Leu811Pro mutant channels in ND7/23 cells . They found that the phenotype of human NAv1.9 Leu811Pro mutant channels resembled that of mouse NAv1.9 Leu799Pro mutant channels, except in terms of steady-state inactivation. From the weak influence of the mutation on inactivation in the human channel, they concluded a stronger gain-of-function effect in humans than in knock-in mice.To study the effect of the mutation further, the authors heterologously expressed human NAv1.7 channel encoded by SCN9A[Besides impressively demonstrating the power of whole-exome sequencing to find rare candidate disease causing mutations, this study provides a new gain-of-function view on the molecular basis of pain loss, which was previously linked to loss-of-function mutations such as in the NA by SCN9A.The author declares that they have no competing interests.


Drosophila Swiss cheese (SWS) or its vertebrate orthologue neuropathy target esterase (NTE), respectively, cause progressive neuronal degeneration in Drosophila and mice and a complex syndrome in humans that includes mental retardation, spastic paraplegia and blindness. SWS and NTE are widely expressed in neurons but can also be found in glia; however, their function in glia has, until now, remained unknown. We have used a knockdown approach to specifically address SWS function in glia and to probe for resulting neuronal dysfunctions. This revealed that loss of SWS in pseudocartridge glia causes the formation of multi-layered glial whorls in the lamina cortex, the first optic neuropil. This phenotype was rescued by the expression of SWS or NTE, suggesting that the glial function is conserved in the vertebrate protein. SWS was also found to be required for the glial wrapping of neurons by ensheathing glia, and its loss in glia caused axonal damage. We also detected severe locomotion deficits in glial sws-knockdown flies, which occurred as early as 2 days after eclosion and increased further with age. Utilizing the giant fibre system to test for underlying functional neuronal defects showed that the response latency to a stimulus was unchanged in knockdown flies compared to controls, but the reliability with which the neurons responded to increasing frequencies was reduced. This shows that the loss of SWS in glia impairs neuronal function, strongly suggesting that the loss of glial SWS plays an important role in the phenotypes observed in the sws mutant. It is therefore likely that changes in glia also contribute to the pathology observed in humans that carry mutations in NTE.Mutations in  Drosophila Collection: Loss of sws in glia results in locomotion deficits, suggesting that glial changes contribute to the paralysis and spastic paraplegia in humans carrying mutations in its orthologue, NTE. Intriguingly, however, other neurons revealed an incomplete glial wrapping . To address whether these phenotypes are caused by the loss of SWS in glia, we used a knockdown approach. To achieve a knockdown of SWS in all glia, we induced the GD3277sws RNAi line with the pan-glial loco-GAL4 or repo-GAL4 driver lines . Owing to SWS still being expressed in neurons in these flies, the observed reduction in the overall levels of SWS suggests a substantial knockdown of SWS in glia.Our previous characterization of the ll death . Like ther lines . Both drloco-GD3277GAL4;sws flies (lacZ (as a control UAS construct) with this driver (not shown). However, at 14 days old, vacuoles had formed in the lamina cortex ], we used another RNAi line (JF03428sws) which again showed the formation of lesions in the lamina cortex when induced with loco-GAL4 , whereas we did not detect them in age-matched controls . However, already in 2-day-old repo-GD3277GAL4;sws knockdown flies, their number was reduced  and this was even more prominent in 14-day-old knockdown flies . To quantify the loss of glial cells, we counted the immune-positive cells surrounding the optic lobes  or the epithelial glia cells in the lamina neuropil . Comparing 2-day- and 14-day-old control flies revealed no difference, showing that, within this time frame, aging was not affecting glial cell number . However, 2-day-old repo-GD3277GAL4;sws knockdown flies showed a clear reduction in glial cell numbers, with a reduction to 58% of the number of glial cells surrounding the optic lobes as compared with controls, and 75% of epithelial glial cells present when compared to controls . In 14-day-old knockdown flies, the number of the optic-lobe glia was further decreased to only 33%, which is not only significantly different from the age-matched control but also from 2-day-old knockdown flies (P<0.001). Counting the epithelial cells in 14-day-old knockdown flies still revealed a significant difference to age-matched controls but there was no difference between 2-day- and 14-day-old knockdown flies . To determine whether the glial death is due to apoptosis, we used an antibody against the apoptotic marker activated Caspase 3 in combination with anti-REPO. As shown in Fig. S3F (arrow), we could occasionally detect glial nuclei, in this case a giant glia cell of the outer chiasm  and 14-day-old control flies carrying only the r chiasm , that weGAL4 lines to identify glial subpopulations that are affected by the loss of SWS. The main types of glia in Drosophila are surface glia , which provide the blood-brain barrier, cortex glia, which are mostly associated with neuronal cell bodies, and two types of neuropil glia: astrocyte-like glial cells and ensheathing glia , this phenotype seems to be due to a loss of SWS in pseudocartridge glial cells.The results above suggested that different glial subpopulations react somewhat differently to the loss of SWS, and our previous immunohistochemistry experiments suggested that some glial cells might not express SWS . We thering glia . To induver line  but coulver line A. Similaial glia , resulteial glia B that wel nerves . Again, l nerves C, and th arrows, D. Althou arrows, E, they w arrows, E. The la arrows, F, which  arrows, . Becausemz0709-GAL4 is not only expressed in subperineurial glia but also in the ensheathing neuropil glia throughout the brain, so we therefore investigated whether we can detect phenotypes of the glial knockdown in other brain areas. Because the lamina contains both glial types, we focused on the medulla and lobula for these experiments. In wild type, glial cells (which are more electron-dense) extend fine processes that form thin glial sheaths between cell bodies . As expected from results using the electron microscopic images, these GFP-positive processes were almost completely absent in 14-day-old GD3277mz0709-GAL4;sws flies and only in the first optic chiasm was some staining still detectable , an age at which we already found these structures in 1sws mutants .Analyzing the  mutants , or evenS985D carries a mutation in the active site serine in the phospholipase domain and is catalytically inactive . This suggests that the PKA function plays a minor role in glia, whereas they do depend on the phospholipase function. To address whether the degeneration in the SWSS985D rescue experiment might be due to a dominant-negative function of SWSS985D, we expressed wild-type SWS and SWSS985D in glia using loco-GAL4 in the wild-type background. Whereas overexpression of wild-type SWS resulted in the formation of vacuoles at the position of the outer chiasma glia in 14-day-old flies -long transmembrane protein with a highly conserved C-terminal domain that mediates its phospholipase function, and a N-terminal region that shows homology to the regulatory subunit of PKA . To addrinactive , whereast PKA-C3 . We also77 flies A, SWSR13s arrow, B, overexo effect C. To anao effect D,E. In ct . Knocking down SWS via the JF03428sws construct caused an even more severe reduction in performance, with 34% (loco-GAL4) and 12% (repo-GAL4) transitions towards light; the latter is not significantly different from 1sws mutants . Using alrm-GAL for the knockdown, which did not result in a histological phenotype (see P<0.05) phototaxis phenotype at 14 days of age, with 57% transitions (which is a 23% reduction compared to wild type), suggesting that SWS might play a minor role in astrocyte-like glia. mutants A. Testinme point B. We alsdays old C. Correltype see A, induceR133A (the mutation in the PKA-binding domain) in 14-day-old loco-GD3277GAL4;sws rescued the behaviour, it was not in fact significantly different from wild-type SWS . That all SWS constructs have this effect strongly suggests that, also in this case, the remaining behavioural deficits in the rescue with SWSS985D are due to this construct not being functional rather than inducing a dominant-negative effect of SWSS985D.To confirm that this effect on behaviour is due to the loss of glial SWS and whether the phospholipase function is required, we again performed rescue experiments. As expected, expression of wild-type SWS significantly improved the performance, although it did not restore it to the levels of controls D. Similatype SWS D. In conrepo-JF03428GAL4;sws knockdown flies did not reveal a difference in 3-day-old flies compared to controls but, at 7 days and 14 days of age, the activity of these flies was significantly reduced  on 1- to 3-day-old and 14-day-old na cells . Measurina cells D were si28 flies E. In addrepo-JF03428GAL4;sws flies with control flies (only carrying the driver or only carrying the RNAi construct) did not reveal significant differences and also aging the mutants for 14 days did not change their response time compared to age-matched controls  escape response pathway. The GFs are an identifiable pair of interneurons that relay input from the visual system to the thoracic ganglia to trigger a jump response or initiate flight. Whereas the jump response is achieved by a mixed chemical-electrical synapse between the GFs and the tergotrochanteral motor neurons (TTMns), the initiation of flight requires activation of an additional interneuron [the peripherally synapsing interneuron (PSI)] that transmits signals to the dorsal longitudinal muscle (DLM) motor neurons via a cholinergic synapse A Allen . First, controls C. Howevecontrols D. This il groups G. TogethFig. S7), the reduced following frequency through this circuit was not caused by impairments of motor neurons or neuromuscular functions. Direct electrical stimulation of the DLM motor neurons showed shorter latencies of DLM responses than following GF stimulation , and these increased with age but were not affected by the glial sws knockdown . Furthermore, DLM following frequencies upon direct motor neuron stimulation were larger than 150 Hz in controls and sws-knockdown flies at 3 and 14 days post-eclosion. First DLM failures occurred at 200 Hz of direct motor neuron stimulation in both wild type and the sws knockdown . No statistically significant differences existed between controls and glial sws knockdowns or between young and old flies with regard to the reliability of DLM firing upon motor neuron stimulation . By contrast, in 14-day-old glial sws knockdown flies, median maximum DLM following frequencies for GF stimulation were about 60 Hz  in the fast phototaxis assays at 14 days, suggesting that the loss of SWS in neurons does contribute to the locomotion deficits. The intact visual orientation and ERGs suggest that the locomotion defects are not caused by a disrupted visual input, and we did not detect changes in motor neuron function. This suggests that the movement deficits are due to changes in CNS neurons that integrate information to orchestrate behavioural output rather than changes in motor neuron output or visual input. Surprisingly, however, defects in neuronal transmission in the GF system could only be detected in 14-day-old knockdown flies and affected the frequency with which the information was reliably processed and not the response time. However, it should be noted that the response time significantly increased with aging in knockdown flies, indicating that age-related changes do occur in the knockdown flies. As mentioned above, our experiments suggest that the behavioural deficits are due to changes in CNS neurons that integrate information. Therefore, the locomotion phenotypes in the fast phototaxis assays observed already at 2 days could be attributed to decreased coding fidelity in the brain of young flies, which is not detected in physiological testing of the GF system. The behavioural defects might also be more dramatic because they rely on the combined effects of several central neuronal circuits, whereas the GF electrophysiology focuses on a small set of neurons. Alternatively, it is possible that the behavioural deficits are caused by an uncoordinated response of neurons, possibly due to the missing modulating or insulating effect of glia on neuronal networks, whereas the transmission within a single neuron is not dramatically affected. Such an uncoordinated activity is supported by the seizure-like behaviour of the glial knockdown flies when startled . Finally, we investigated whether the reduced reliability in neuronal transmission could be due to deficits in the release of synaptic vesicles or to a reduction in active sites owing to initiation of neuronal degeneration. However, the levels of CSP, which is involved in vesicle release -deficient mutant mice reveal axonal damage and Wallarian degeneration, although fully myelinated , Gli-GAL4 by Vanessa Auld , Appl-GAL4 by Laura Torroja , and mz0709-GAL4, TIFR-GAL4, NP2222-GAL4, alrm-GAL4 and mCD4-GFP by Mary Logan [Oregon Health & Sciences University (OHSU)]. The GD3277sws RNAi line was obtained from the VDRC Stock Center.The 2 microscope.Paraffin sections for light microscopy were prepared as described in To quantify vacuoles, we photographed the paraffin section that showed the most severe phenotype, without knowing the genotype. Degeneration in the lamina was determined using the threshold discrimination function of ImageJ. For each measurement the total area of the lamina (neuropil and cortex) was selected and the area within that region that fell below a predetermined fluorescent threshold (corresponding to vacuoles) was determined as a percentage of the total area of the lamina. Statistics were performed using GraphPad Prism and one-way ANOVA with a Dunnett's post-test comparing experimental groups to the control.Vibratome sections were prepared as described in Vibratome sections at the level of the first optic chiasm that showed all optic neuropils were photographed without knowing the genotype. For the optic lobe measurements, we counted all REPO-positive cells surrounding the medulla, lobula and lobula plate neuropils, and, for the epithelial glia, the REPO-positive nuclei within the lamina neuropil were counted before revealing the genotype. Owing to the glial whorl phenotype, the retina was often separated from the lamina in the glial knockdown and we did therefore not count glial cells in the lamina cortex, although this area shows a severe phenotype.Fig. S2) was created in our laboratory and is described in Western blots were performed as described in Fast phototaxis assays were conducted in the dark using the countercurrent apparatus described by t-test for significance.Flies with their wings cut (1 day before testing) were analyzed in an LED arena as described in We used thin-walled microelectrodes (borosilicate) as extracellular electrodes to record compound field potentials from photoreceptors and downstream first order visual interneurons in response to transient light pulses.sws knockdown are caused by defects of central synapses (GF to PSI and PSI to DLMns) or by defects of the neuromuscular synapse (DLMn to DLM fibre), we also conducted experiments with direct stimulation of the DLMn by inserting the fine tungsten stimulation electrodes directly into the mesothoracic neuromere . Direct electrical stimulation of the DLMns and recording from the muscle monitors the combined result of action potential conduction along the DLMns and glutamatergic transmission at the NMJ, which is always <1 ms (The giant fibre (GF) interneuron can be stimulated in two ways see : first, ys <1 ms . For bot2 and glued by their neck to a thin metal wire (20 μm diameter) with UV-light curing adhesive  by applying a 10 s UV pulse with a Dental UV curing lamp . Flies were allowed to recover for 30 min and then fixed to a micromanipulator by clamping them into a holder, so that the legs and wings were free to move. For GF or DLMn stimulation, a pair of electrolytically sharpened tungsten wires was inserted either into the eyes or the mesothoracic. A third tungsten wire was inserted into the DLM fibre 6, and a fourth wire was placed into the thorax just beneath the scutellum as the reference electrode (Flies were anaesthetized with COlectrode . Stimuli


Rehabilitation plays an important role to improve the outcomes of total knee arthroplasty (TKA). Evidence about the appropriate dose of exercise to recover gait dysfunction after TKA is limited. We posed the research question: In patients during the post-acute stage after TKA, is increased dose of exercise associated with larger improvements in gait parameters such as step length and single support time?This was a secondary analysis from two randomized studies on exercise after TKA to investigate dose-dependence of gait parameters in response to exercise. Participants were 50 years or older who underwent unilateral TKA at least two months prior. They participated in 2 months of supervised exercises followed by 4 months of a home exercise program. The primary outcome was change in gait parameters from baseline to 6 months. Participants were divided in three groups according to the dose of exercise: group 1 (light-to-moderate intensity exercise), group 2 , and group 3 . Jonckheere-Terpstra test was used to test if the magnitude of changes in gait parameters increased from group 1 to group 3 in an ordered fashion.Increased dose of exercise was associated with progressive increases in step length in the operated-limb (p=0.008) and decreases in step length in the non-operated limb (p=0.011). Increased dose of exercise was associated with ordinal decreases in loading response time (p=0.049) and increases in single-leg support time (p=0.021) on the operated- limb, but not on the non-operated-limb. Increased dose of exercise was associated with decreases in unloading time on the non-operated-limb (p=0.011) but not on the operated-limb (p=0.400).Significant dose-response of exercise on gait parameters support the promotion of more intensive exercise programs that combine functional and balance training programs after TKA. Knee osteoarthritis (OA) is among the most disabling medical conditions in the world’s ageing population -4. HowevWhile TKA has shown to be a cost-effective treatment for alleviating pain and restoring physical function , some gaRehabilitation plays an important role in functional recovery after TKA. However, effective rehabilitation approaches to improve gait alterations after TKA remain elusive. It has been suggested that high-intensity resistance training along with functional and balance exercises are effective to improve functioning after TKA -26. EmpiA complete description of the studies included in this analysis is detailed in the primary publications ,27. OnlySubjects from both studies were recruited through letters sent to patients who had undergone a tri-compartmental cemented TKA performed by the same surgeon. After surgery, all participants received the same rehabilitation while in the hospital and outpatient physical therapy as needed prior to study participation. Participants who were interested in the study called the study coordinator who fully explained the study, obtained consent, and examined subjects for eligibility.Inclusion criteria were age above 50 years and a unilateral TKA done 2 to 6 months prior to starting the study. Subjects were excluded if they reported 2 or more falls within the previous year, were unable to ambulate a distance of 30 meters without an assistive device, had an acute illness, and had a history of cardiovascular disease, uncontrolled hypertension, severe visual impairment, lower-extremity amputation, or progressive neurological disorder. For this study, subjects were also required to have participated in the assessment of gait parameters.Subjects were tested at baseline and 6 months after randomization by testers who were masked to study assignment. During baseline the subjects completed demographics, pain, and physical function questionnaires, which were used to describe the sample. Pain intensity in the surgical knee was assessed using an 11-point numeric pain scale anchored on the left with the phrase “No pain” and on the right with the phrase “Worst imaginable pain” ,29. Phys® v 3.8, CIR Systems Inc., New Jersey, USA) connected to a portable computer [Gait parameters were the main outcome of this study and were tested at baseline and 6 months. Gait parameters were measured using a reliable and valid electronic walkway  Light-to-moderate Intensity Exercise or b) High-Intensity + Functional + Balance Exercise. In study two, the groups were c) High-Intensity + Functional Exercise or d) High-Intensity + Functional + Balance Exercise. To test our hypothesis, groups ‘b’ and ‘d’ were combined as one group since the exercise programs were then defined in an orderly fashion according to increased dose of exercise. Group ‘a’ (light-to- moderate intensity exercise) was defined as Group 1, group ‘c’  was defined as Group 2, and groups ‘b’ and ‘d’ were combined and defined as Group 3 . All parThis exercise program included warm-up, light-to-moderate intensity aerobic exercise, and resistance exercise. Warm-up consisted of 15 minutes of lower extremity stretching, range of motion, and stationary bike without resistance . AerobicSubjects performed the same warm-up as described for Group 1, followed by high-intensity aerobic and resistance exercise, and functional task-oriented training. Aerobic training consisted of 20 minutes of treadmill walking between 50-75% of the age estimated maximal heart rate. The resistance exercise program was the same as in Group 1 but at a higher intensity. For weight machines, all exercises were performed at high intensity; between 60 - 80% of 1 RM. The level of effort using elastic bands and ankle weights as resistance was appraised by a perceived exertion scale with rates from moderate to vigorous. Subjects performed 2 sets of 8 repetitions of each exercise reaching fatigue ,38. ResiSubjects received the same program as described in Group 2, plus balance exercises that consisted of side stepping, tandem walking, cross-over steps during forward and backward walking, forward and backward walking to designated markers, multiple changes in direction, and standing over unstable surfaces  . These eDifferences in baseline characteristics across the groups were determined by Analysis of Variance (ANOVA) or Kruskal-Wallis, for continuous variables with normal or non-normal distribution respectively. Data normality was assessed by Shapiro-Wilk test. Chi square test was used for nominal variables. We also visually inspected these data for differences that could be clinically important but did not reach significance.To test the hypothesis of significant dose-associated changes for spatial and temporal gait parameters, we first calculated the mean change for each gait parameter and then utilized the non-parametric test for ordered alternatives (Jonckheere-Terpstra for k samples). Johckheere-Terpstra test assesses the alternative that the magnitude of change in gait parameters increases from group 1 to group 3 in an ordered fashion. Jonckheere-Terpstra is the most appropriate and powerful test to use when samples are expected to have a natural ordering .Details of recruitment and retention are available in Both visual inspection and ANOVA results revealed no differences between the groups for demographic and biomedical characteristics . SubjectTo the best of our knowledge, this is the first study to investigate the dose-response of exercise programs on improvements in gait parameters in individuals after TKA. Our hypotheses of significant dose-associated changes for spatial and temporal gait parameters were affirmed. More specifically, ordinal increases in dose of exercise was associated with progressive increases in step length in the operated limb, and decreases in the non-operated limb; decreases in loading response time and increases in single-leg support time in the operated limb; and decreases in unloading time in the non-operated limb. Since gait alterations after TKA have been characterized by decreased support time and shorter step length in the operated limb, the findings of increased step length and single support time in the operated limb are positive ones and indicate beneficial effects of high exercise dose ,14. ThusThe longitudinal studies of pre and post TKA indicate that pre-surgery gait abnormalities are usually retained up to 18 months after surgery despite improvements in pain and range of motion . As suchDespite the widespread use of TKA, there is a notable lack of consensus regarding which rehabilitative post-operative practices should be employed in this patient population ,24. GiveThis study has limitations. Although this study supports a dose-response of exercise programs on improvements in gait parameters, the impact of these changes on knee joint kinematics or kinetics were not evaluated. Future work should consider evaluating the dose-response effects of exercise on the changes in the overall biomechanical characteristics of both operated and non-operated limbs. Moreover, the changes in spatiotemporal gait parameters from pre to post intervention, although significantly dependent on the dose of exercise, seemed rather small. The changes in gait parameters reported in the current study could not be directly compared to those of previous investigations as the raw values were either not reported or normalized differently ,14. FurtThe results of this study indicate that in patients in the post-acute stage after TKA, increased dose of exercise associate with larger improvements in gait parameters such as step length, loading response time, single-leg support time, and unloading time. The findings of significant dose-response of exercise combined with previous reports of better clinical outcomes after intense and comprehensive exercise programs justify promotion of more intensive exercise programs that combine functional training and balance programs after TKA. Further efforts are required to determine whether gait changes have an impact on the rate of further disease progression in the non-operated lower limb.


The growing worldwide obesity epidemic and obesity-related disorders present a huge unmet medical need for safe and effective anti-obesity medications. The discovery of leptin in 1994 was rapidly succeeded by a wave of related discoveries leading to the elaboration of a hypothalamic melanocortinergic neuronal circuit regulated by leptin and other central and peripheral signaling molecules to control energy homeostasis. The identification of specific neuronal subtypes along with their unique connections and expression products generated a rich target menu for anti-obesity drug discovery programs. Over the course of the last decade, several new chemical entities aimed at these targets have reached various stages or successfully completed the drug discovery/regulatory process only to be dropped or taken off the market. There are now in fact fewer options for anti-obesity drug therapies in late 2010 than were available in 2000. The challenge to discover safe and effective anti-obesity drugs is alive and well. Developing in an environment of nutritional scarcity, humans evolved to ingest available nutrients and to store and process them efficiently. Consequently, in modern societies marked by nutrient excess with ubiquitous food of high palatability and caloric density and life styles requiring low energy output, obesity has become a growing affliction such that there are now more than 10Excess fat storage is typically accompanied by a low-grade inflammation which, in conjunction with lipotoxicity, leads to insulin resistance of insulin-sensitive tissues such as muscle and liver ,3,4. ObeEffective anti-obesity drug therapies would either restrict energy intake or increase energy expenditure by acting either centrally or peripherally. The US Food and Drug Administration (FDA) and the European Medicines Agency (EMA) have set guidelines for what constitutes a minimally effective anti-obesity therapy. In brief the FDA requires a drug to produce a ≥5% placebo-subtracted reduction from baseline body weight due to loss of body fat after one year of treatment and the EMA requires a ≥10% body weight reduction that also must be ≥5% greater than obtained in the placebo group ,8. AdditDuring the 1990s some of the more promising areas for the pharmacotherapy of obesity included central and/or peripheral neurochemical mechanisms involving serotonin , catecholamines and certain neuropeptides. Serotonergic and catecholaminergic mechanisms were targeted by the effective combination therapy, Fen-Phen, composed of the 5-HT releasers fenfluramine or dexfenfluramine combined with phentermine, a noradrenergic releaser . The comAnother target of promise was the peripheral β-3 adrenergic receptor. This receptor was targeted using selective agonists to increase energy expenditure through the activation of brown fat but these compounds lacked efficacy and the less selective compounds produced adverse side effects in humans ,15,16.At the preclinical level, a variety of neuropeptides were studied for effects on feeding with the most encouraging of these being neuropeptide-Y (NPY) which was shown to be expressed in the hypothalamus, a brain region known to control appetite. In addition, hypothalamic NPY stimulated feeding and its expression was shown to be responsive to hormonal and metabolic state indicated by induction with fasting and streptozotocin diabetes and suppression by insulin . Drug diThis scarcity of potential pharmacotherapies to treat obesity was suddenly reversed with the discovery of leptin and leptin-regulated networks within the CNS. These discoveries produced a rich menu of potential anti-obesity targets  and wereob/ob and db/db mouse mutants, respectively. The cellular and molecular components of the melanocortinergic pathways were discovered through studies aimed at understanding the coat color and obese, hyperphagic phenotype of the mouse yA mutant. The basic circuit, composed of three distinct neuronal subtypes, elevated analysis of energy homeostasic control by the hypothalamus from the gross anatomical level of hypothalamic areas  to defined, interacting cell phenotypes responding to defined molecular inputs with defined molecular outputs.The discovery of leptin and its receptor in the brain ,19 in coIn both mouse and man, monogenic models of obesity, in which a spontaneous mutation in a single gene results in obesity, have been described ,24. All yA) mutation was due to ectopic expression of Agouti protein. Normally confined to the skin as a paracrine competitive antagonist at the melanocyte melanocortin-1 receptor (MC1R), Agouti protein is ubiquitously expressed in yA mice [Appreciation for the melanocortinergic regulation of body weight began with the discovery that the yellow, hyperphagic and obese mouse phenotype carrying the agouti lethal yellow  uniquely expressed in the brain, which, like Agouti protein, was shown to be a highly potent MC4R antagonist [yA obesity profile [The role of MC4R in the central regulation of body weight in mice was demonstrated by the MC4R-knockout mice, which displayed an obesity phenotype identical to that of Ay mice . ImportaAy mice . Overexptagonist ,32. Also profile . In addi profile  although profile .Identification of the neurons, which synthesized MC4R and its agonist and antagonist peptide ligands resulted in the mapping of a hypothalamic neural circuit composed of three distinct neuronal subtypes. Transcripts for AgRP were found to be co-localized with the orexigenic neuropeptide-Y (NPY) in neurons of the arcuate nucleus of the hypothalamus . POMC-exob/ob) or without a functioning leptin receptor (db/db) exhibit increased expression of AgRP and NPY and decreased expression of POMC. Under these conditions, the consequent reduction in MC4R activity likely promotes the hyperphagia and massive obesity of these mice although leptin also acts at other sites in the brain to suppress feeding [The role of the melanocortinergic hypothalamic circuit in body weight regulation is further supported by the strong control over neuropeptide expression and neuronal activity of the arcuate neurons by metabolic hormones ,21. Both feeding . In addi feeding   and reduced molecular effects in the hypothalamus  in response to leptin administration [The absence of the fat cell-derived hormone leptin, in both mice and humans with loss-of-function leptin mutations, signals to the brain that energy stores of fat are depleted and the organism should decrease metabolism, activity and reproductive behavior and increase energy (food) intake . As a restration . In thisOne view of leptin resistance states that the excess nutrients of a HFD can generate an inflammatory response in hypothalamic neurons which renders them resistance to leptin ,57. A reCentral administration of NPY and AgRP induce vigorous feeding responses in rodents and the modulation of their actions by drugs might be expected to affect appetite. Although the deletion of NPY and AgRP genes did not result in robust metabolic phenotypes, subtle effects were noted in obese and ageing mice ,64,65 EaNPY is widely expressed in the brain and is therefore involved in diverse brain systems subserving a variety of functions . NPY effin vivo [AgRP presents a different challenge since it operates as an endogenous antagonist, competitively blocking the binding of the anorexigenic neuropeptide, α-MSH, to the MC4R. An effective anti-obesity AgRP antagonist would have to prevent AgRP binding without blocking the binding of α-MSH. This is conceivable given the apparent accessory binding to a syndecan co-receptor required by AgRP for binding to MC4R  althoughin vivo  Selectivin vivo .Deletion or haploinsufficiency of MC4R results in obesity in mouse and man ,76,77,78Up to 6% of patients with early onset obesity have been reported to carry loss-of-function mutations of MC4R ,77,84,85There are at least three important challenges that arise in the search for effective MC4R anti-obesity drugs. First, the search is for agonists, which must bind and then activate the receptor unlike antagonists, where only receptor binding is required. Also, given the obesity phenotype associated with loss-of-function of a single MC4R allele, it would appear that full agonists might be required and that partial agonists with low enough intrinsic activity could actually oppose the desired effects. Second, as the name implies, MC4R is a member of the melanocortinergic subgroup of GPCRs which consists of five family members with diverse physiological functions and therefore raising the requirement for subtype selectivity . Third, Recently, the overall drug discovery approach for anti-obesity MC4R agonists has been complicated by studies linking MC4R activation with therapeutic effects for erectile dysfunction, sexual libido and inflammation on the one hand and adverse elevations in blood pressure ,92,93,94Although Fen-Phen was removed from the market in light of its adverse side effects, the combined action of fenfluramine and phentermine, to release serotonin and catecholamines, respectively, proved to be an effective weight loss treatment. It is not surprising, therefore, that sibutramine, a non-selective 5-HT and noradrenergic re-uptake inhibitor proved to have some weight-reducing efficacy . HoweverData from a variety of transgenic mouse experiments show that the 5-HT receptor subtypes, 5-HT1b and 5-HT2c, control the activity of key neurons within the energy homeostasis circuit of the hypothalamus. Activation of these receptors, like activation of the leptin receptor on these cells, either stimulate the release of the anorectic neuropeptide, α-MSH or inhibit activity in orexigenic AgRP/NPYneurons ,107. TheNeurons expressing either MCH or orexins are abundant in several hypothalamic sites including the lateral hypothalamus and exhibit reciprocal connectivity with POMC and AgRP/NPY neurons in the arcuate nucleus  althoughAMRI  has recently begun a Phase I clinical trial for ALB-127158(a), an MCH-1 receptor antagonist, for anti-obesity therapy . ActelioThe orexigenic AgRP/NPY neurons are directly activated by ghrelin, a hormone synthesized and released from the stomach in response to fasting . GhrelinO-acyltransferase (GOAT), responsible for the post-translational activation of ghrelin. Biological activity of ghrelin is entirely dependent upon its acylation with an eight-carbon fatty acid and this reaction is uniquely catalyzed by GOAT [Although ghrelin interacts with other physiological systems in addition to energy homeostasis , it is p by GOAT . An enzyThe incretin hormones, glucagon-like peptide-1 (GLP-1) and glucose dependent insulinotropic polypeptide (GIP), are posttranslational proteolytic products of the proglucagon gene and are released from the intestinal mucosa in response to nutrient intake . GLP-1 aGLP-1 is rapidly inactivated in the blood by dipeptidyl peptidase IV (DPP-4) and this challenge has been addressed by the development of GLP-1 analogues that are DPP-4 resistant, such as exenatide  and liraglutide  and by the development of DPP-4 inhibitors such as sitagliptin  and saxagliptin  to elevate endogenous level incretin levels. Only the GLP-1 analogues have been shown to reduce weight while DPP-4 inhibitors are weight neutral and GIP is either weight neutral or promotes adiposity through lipogenic action on adipocytes ,141,142.Both GLP-1 analogues are approved as anti-Type2 diabetes mellitus (T2DM) drugs and are typically prescribed in conjunction with other anti-T2DM medications. They are not used as weight reduction medications per se although the weight-reducing effects of these agents likely play an important role in their overall anti-diabetic profile ,140. A p9-tetrahydrocannbinoid (Δ9-THC) resulted in the elaboration of the endocannabinoid (EC) system composed of EC ligands, synthetic and catabolic enzymes and EC ligand receptors [9-THC is to stimulate feeding and the EC system has been shown to interact with the hypothalamic circuit for energy homeostasis with a profile suggesting a direct relationship between energy intake and EC system activation [Efforts to understand the mechanisms of action of the exogenous cannabinoid, Δeceptors ,149. Onetivation ,153,154.tivation  leading tivation ,157.Thus, selective CB1 antagonists were highly promising anti-obesity therapies. Such expectations were validated as rimonabant was shown to reduce body weight and improve metabolic parameters in a number of clinical trials leading to the successful marketing of the drug in Europe as an anti-obesity therapy in 2006 . HoweverThe involvement of central CB1 receptors in the functioning of central motivational pathways most likely underlies the adverse psychiatric effects seen with rimonabant ,163,164.In light of the above considerations, Qnexa, the combination anti-obesity therapy consisting of phentermine and the anti-convulsant topiramate, put forth by Vivus, Inc.  was recently rejected for marketing by an FDA advisory panel . It remaCNS anti-obesity drug targets present major hurdles to drug development programs. To gain access to central neurons, a compound must navigate the blood brain barrier and then act selectively amidst a complex and interconnected target-rich tissue to produce its effect without adverse side effects ,176. PerPancreatic lipase is an enzyme made in the exocrine pancreas that is secreted into the intestinal lumen to breakdown ingested triaglycerides to fatty acids and 2-monoglycerides for absorption by the gut. To date, only one peripherally-targeted drug, Orlistat, has been developed as an anti-obesity therapy although other compounds, such as the incretins and endocannabinoid antagonists, could produce at least part of their anti-obesity effects at peripheral sites. Orlistat  is a lipase inhibitor which prevents the breakdown of triglycerides in the intestine and therefore decreases fat absorption. Orlistat is the ultimate peripherally-acting compound in that the drug, itself, is minimally absorbed, having its action in the lumen of the gut. However, the drug is, at best, only modestly effective and its use is accompanied by unpleasant gastrointestinal side effects which limit its long-term use  and reduDespite strong evidence from rodent models for the permissive role of glucocorticoids in a variety of obesity models, there is little evidence for elevated plasma glucocorticoid levels in common forms of human obesity . These oAnti-obesity therapies are typically aimed at reducing energy intake although some might also have the additional effect of increasing expenditure. The targeting of BAT represents an effort to uniquely target energy expenditure by driving the metabolic activity of this tissue; an approach that has been shown to have powerful anti-obesity effects in rodents . Drug diper se, and, in some cases such as peroxisome-profilerator-activated receptors γ (PPARγ) agonists, could even increase adiposity [Even if efficacious anti-obesity drug therapies are developed there will likely be many obese patients that will require treatment for their existing obesity. Therefore natural or synthetic products will be necessary to combat the consequences of obesity, such as inflammation and insulin resistance to limit obesity-induced pathologies such as Type 2 diabetes and dyslipidemias. Among these targets are adiponectin and its receptors ,193, thediposity ,201, thediposity ,202. To diposity ,204.per se. At least 10 years is typically required to go from target discovery/validation to regulatory agency approval of a new drug therapy. From this perspective, it is not surprising that many new drug discovery programs for anti-obesity targets discovered since the discovery of leptin have not led to new drug therapies. Far more troubling is the fact that several new chemical entities have successfully navigated through to various stages of the process, with some actually being approved, only to be dropped or restricted in light of new evidence regarding safety or lack of efficacy. Among these are sibutramine, MC4R agonists, lorcaserin, rimonabant and Qnexa. Moreover, several of the new compounds nearing evaluation by regulatory agencies are similar to those already rejected. The GLP-1 agonists, which appear to have both central and peripheral appetite reducing effects, are primarily Type 2 diabetes drugs given their powerful promotion of glucose-stimulated insulin release and may not be prescribed as anti-obesity drugs Thus, at 2000, the choice of approved long-term anti-obesity drug therapies was between Orlistat and sibutramine . Now, a


We compared the cost-utility analysis for edoxaban at both doses with that of dabigatran at both doses, rivaroxaban, and apixaban  in a German population. Data of clinical outcome events were taken from edoxaban's ENGAGE-AF, dabigatran's RE-LY, rivaroxaban's ROCKET, and apixaban's ARISTOTLE trials. The base-case analyses of a 65-year-old person with a CHADS2 score >1 gained 0.17 and 0.21 quality-adjusted life years over warfarin for 30 mg od and 60 mg od edoxaban, respectively. The incremental cost-effectiveness ratio was 50.000 and 68.000 euro per quality-adjusted life years for the higher and lower dose of edoxaban (Monte Carlo simulation). These findings were also similar to those for apixaban and more cost-effective than the other NOAC regimens. The current market costs for direct oral anticoagulants are high in relation to the quality of life gained from a German public health care insurance perspective. The willingness-to-pay threshold was lowest for 60 mg edoxaban compared to all direct oral anticoagulants and for 30 mg edoxaban compared to dabigatran and rivaroxaban. In a large prospective randomized double blind and double dummy study (ENGAGE-AF), once-daily dosing of the oral direct factor Xa inhibitor edoxaban 60 mg (dose adjusted to 30 mg) was noninferior warfarin for the prevention of the primary endpoint of stroke and systemic embolic events in patients with nonvalvular atrial fibrillation (NVAF), when compared to warfarin with INR  adjusted to 2 to 3; edoxaban 60 mg was also associated with a significantly lower rate of major bleeding and cardiovascular mortality . Other nOne of the main limitations for prescribing NOAC in real life is their higher daily price compared to warfarin. The pharmacoeconomic aspects of dabigatran, rivaroxaban, and apixaban were analysed for many countries. All have been demonstrated to be cost-effective in many countries for the health care system mainly based on the reduced incidence of major bleeding complications but also for some of the NOAC, due to a lower incidence of ischemic stroke and systemic embolism . RelatedWe used the Markov decision model to analyse the QALYs, total costs , and ICER based on the data of the ENGAGE-AF  study. TFor the base-case analysis we used a hypothetical population cohort of patients with the starting age of 65 years with NVAF who were at increased risk for stroke (CHADS2-score >1) with no contraindications to anticoagulation as reported in the ENGAGE study , 10. A hThe adverse outcome events and endpoints with the 95% confidence intervals (CIs) were taken from the ENGAGE-AF study  and wereIschemic stroke was classified into fatal, moderate to severe, mild, and no neurologic deficit (4 categories) as reported . A seconHaemorrhage was categorized into fatal, ICH with moderate to severe neurologic sequelae, ICH with no neurological deficit, major extracerebral haemorrhage, and minor extracerebral haemorrhage , 13. A mThe mortality rates (death from vascular cause and death from any other cause) were taken from the ENGAGE-AF study . The annThe quality-adjusted life years   were cal InEK) which included German-diagnosis related groups (G-DRGs) [One-time costs for most events were taken from the institute for payment regulations in German hospitals   and were(G-DRGs) . Of note(G-DRGs)  with a d(G-DRGs) , 24, 25. InEK. These entries were used to examine the cost-effectiveness based on the event probabilities  for event probabilities . Medicat InEK and a gamma- and log normal distribution.The Monte Carlo simulations (MCS) were made using random sampling and random distribution of variables for 10 000. Beta-distribution of the event probabilities was assumed for the calculation except for subcategories of stroke using Dirichlet distribution . The DirThe models and analyses were created with TreeAge Pro 2013 and Microsoft Excel 2003.The calculated QALY, the total costs, and the ICER with edoxaban and warfarin are shown in Tables The results of the one-way sensitivity analysis showed that the costs for edoxaban (both doses), the quality of life utilities, the treatment of ischemic stroke, and the treatment of major and intracerebral bleeding complications were important values in our model. Edoxaban and apixaban thus were most cost-effective compared to the other NOAC .The two-way sensitivity analyses of key variables for varying risk rates for ischemic stroke and intracerebral haemorrhage showed that both doses of edoxaban were preferable as a therapy for combinations of moderate to high risks for ischemic stroke and high risk of intracerebral haemorrhage at a set willingness to pay of 50.000€ per QALY against INR-dose-adjusted warfarin. These findings were also similar to those for apixaban and more cost-effective than the other NOAC regimens [The various willingness-to-pay thresholds were analysed by using the probabilistic sensitivity analysis (PSA) in the Monte Carlo simulation (MCS) and varying all variables simultaneously. As a result edoxaban 60 mg od and edoxaban 30 mg od were cost-effective at willingness-to-pay threshold of 52.000€ per QALY and 67.000€ per QALY higher . The resTotal costs increased and the ICER decreased in a base-case analysis for a 65- to 85-year-old cohort from the German public health care insurance perspective excluding a discount for costs and utility values.The absolute numbers of QALY and total costs decreased when costs and utility values were discounted by 10%. In the same time the ICER increased in a base-case data for a 65- to 85-year-old cohort from the German public health care insurance perspective.The present study shows that the two dosage regimens of edoxaban 60 mg od and edoxaban 30 mg od are nearly cost-effective bid for prevention of ischemic stroke and systemic embolic events in patients with NVAF based on the data of the ENGAGE-AF study based on a societal willingness to pay comparable to data from other countries. Comparing these data obtained with the other four treatment regimens with dabigatran 110 mg bid, dabigatran 150 mg bid (RE-LY study ), rivaroSimilar analyses were reported for the two doses of dabigatran based on the health care costs and willingness to pay in USA , 13, CanDespite differences in model designs and structures of the cost-effectiveness analyses, it was mostly possible to replicate the results published by different authors in different countries like USA, UK, and Canada and identify variables responsible for differences between ICERs using a reference model approach . All anaLimitations of pharmacoeconomic analyses include that they are not prespecified. Therefore the trials did not include patient-level documentation of medical resource use for estimates of total medical costs and administration of the EQ-5D for evaluation of health preferences . The economic evaluation is more dependent on assumptions to calculate costs and the use of literature-based estimates of quality of life to generate QALYs . Other lIn conclusion, edoxaban in addition to apixaban may be regarded as the most cost-effective NOAC from a German public health care insurance perspective. The larger reduction in medical cost was mainly driven by reductions in the risks major bleeding events. Additional real life use of NOAC has to substantiate the present results for specific countries, which should be collected with a support of scientific and other independent organizations.


The eye is an immune privileged tissue with multiple mechanisms of immunosuppression to protect the light gathering tissues from the damage of inflammation. One of theses mechanisms involves retinal pigment epithelial cell suppression of phagosome activation in macrophages. The objective of this work is to determine if the human RPE cell line ARPE-19 is capable of suppressing the activation of the phagolysosome in macrophages in a manner similar to primary RPE. The conditioned media of RPE eyecups, sub-confluent, just confluent cultures, or established confluent cultures of human ARPE-19 cells were generated. These condition media were used to treat macrophages phagocytizing pHrodo bioparticles. After 24 hours incubation the macrophages were imaged by fluorescent microscopy, and fluorescence was measured. The fluorescent intensity is proportional to the amount of bioparticles phagocytized and are in an activated phagolysosome. The conditioned media of in situ mouse RPE eyecups significantly suppressed the activation of phagolysosome. The conditioned media from cultures of human ARPE-19 cells, grown to sub-confluence (50%) or grown to confluence had no effect on phagolysosome activation. In contrast, the conditioned media from established confluent cultures significantly suppressed phagolysosome activation. The neuropeptides alpha-MSH and NPY were depleted from the conditioned media of established confluent ARPE-19 cell cultures. This depleted conditioned media had diminished suppression of phagolysosome activation while promoting macrophage cell death. In addition, the condition media from cultures of ARPE-19 monolayers wounded with a bisecting scrape was diminished in suppressing phagolysosome activation. This technical report suggests that like primary RPE monolayers, established confluent cultures of ARPE-19 cells produce soluble factors that suppress the activation of macrophages, and can be used to study the molecular mechanisms of retinal immunobiology. In addition, the results further demonstrate the importance of an intact monolayer of RPE cells to modulate immune cell activity within the eye. The ocular microenvironment is immunosuppressive. This immunosuppression is seen as the inhibition of inflammatory activity within the eye. This involves regulating the resident, and infiltrating immune cells within the ocular tissues. One of the immunosuppressive mechanisms is mediated by a specific set of soluble neuropeptides, and growth factors found in aqueous humor, and produced by retinal pigment epithelial cells (RPE) –5. MacroTwo of the soluble neuropeptides made by the RPE are alphamelanocyte stimulating hormone (α-MSH) and neuropeptide Y (NPY) . These tThe finding of RPE immunomodulation has involved isolating and culturing the primary RPE cells that proliferate into a monolayer ,7. This Eyecups with intact RPE monolayers were prepared as previously described ,3,4. In 5 ARPE-19 cells, and incubated for 48 hours to grown to a confluent monolayer. To make established confluent monolayers, the media was changed, and the cells incubated for an additional 72 hours. For subconfluent cultures the wells were seeded with 2.4 x 104 cells. In the last 24 hours of incubation the media was replaced with the serum-free media [The human retinal pigment epithelial cell line ARPE-19 (ATCC CRL-2302) was maintained in DMEM/F12 media (Lonza) plus 10% Fetal Bovine Serum (FBS) . The wells of a 24-well cell culture plate  were seed with 1 x 10ee media , and wasAntibodies to α-MSH and NPY  were added to the ARPE-19 established monolayer conditioned media. For a control ChromPure Rabbit IgG  was used. Antibody concentrations were 2 μg/ml, a level that would bind a molar equivalent of 1 mg of α-MSH and NPY. This far in excess of what has been measured in culture for RPE eyecups . The con5 cells into 35mm tissue culture dishes. The cells were incubated for 1 hour, and into the wells was added the conditioned media of incubated RPE eyecups, or ARPE-19 cultures at no more than a 1:2 dilution. After an additional 30 min of incubation, the pHrodo-Staphylococcus aureus bioparticles (0.02 mg) were added to the cultures. The cultures were incubated for 24 hours and the cells were imaged for fluorescence.The BALB/c-derived mouse macrophages, RAW 264.7 (ATCC TIB-71), were seeded at 1 x 10The cultures were digitally imaged with an Olympus FSX100 fluorescent microscope at a constant time of exposure. For each tissue culture dish, five images were captured. The relative corrected total cell fluorescence (CTCF) minus the background was calculated. The results are presented as fluorescence (mean ± SD) relative to the mean auto-fluorescence background of macrophages with no beads (resting cells).Nonparametric Mann-Whitney U test were run on the results to assay for statistical significance between the average values for each condition with the positive and negative controls. All experiments are the results of 3 to 4 cultures run at different times. Statistical difference was detected with P ≤ 0.05.Previously it was demonstrated that the RPE neuropeptides α-MSH and NPY suppress the activation of the phagolysosome . This waSince there are many reports showing almost the same activity of ARPE-19 cell monolayers to cultured primary RPE –11, the To generate conditioned media from established confluent monolayers, the ARPE-19 cells were grown to confluence and maintained at confluence for 3 days before changing the media for serum- free. The conditioned media from these cultures significantly suppressed phagolysosome activation in the phagocytizing macrophages compared to untreated macrophages, and macrophages treated with conditioned media from subconfluent ARPE-19 cell cultures . TherefoSince the neuropeptides α-MSH and NPY have an important role in RPE regulation of macrophage activity, the α-MSH and NPY were depleted in the conditioned media of established confluent ARPE-19 cell cultures by absorption with specific antibodies. The α-MSH/NPY-depleted conditioned media was significantly diminished in suppressing the activation of phagolysosomes in the treated macrophages . HoweverTo see if maintaining the ARPE-19 confluent monolayer is required for ARPE-19 suppression of phagolysosome activation, the confluent cultures were subjected to either a scrape wound that bisected the monolayer, or to round wounds similar to laser wounding of the RPE monolayer in vivo. Conditioned media from these cultures were used to treat the macrophages before given pHrodo-bioparticles. When the conditioned media was from a scrape wound that broke the confluent culture into separate parts there was a significant loss in suppressing the activation of the phagolysosome . MoreoveThe RPE monolayer is expected to perform multiple activities to maintain the health and function of the retina . It consThe neuropeptides α-MSH and NPY produced by the RPE are part of group of immunomodulating factors made by the RPE to suppress inflammatory activity by stimulated macrophages . Theses When the RPE monolayer is wounded in mouse eyes, they are no longer able to promote the expression of myeloid-suppressor cell characteristics in macrophages, and in vivo similar characteristics in retinal microglial cells . This haThe conditioned media of RPE eyecups depleted of α-MSH and NPY promote the activation of M1-like macrophages; however, the lack of α-MSH causes the macrophages to die . This haHaving demonstrated that the confluent cultures of ARPE-19 cells are acting in a similar manner as the RPE eyecups, and that it is a similar manner between human and mouse RPE (both α-MSH and NPY are evolutionarily conserved), it should be possible to use these APRE-19 cultures to further clarify the soluble factors that are immunomodulating and pro-apoptotic on macrophages. Moreover, it should be possible to use the cultures of treated ARPE-19 cells to assay the effects of oxidative damage, bacterial products and other immune cell cytokines on RPE modulation of macrophage and microglial cell functionality.The results further demonstrate that part of ocular immune privilege is RPE modulation of macrophage/microglial cell function in the retina. A healthy intact RPE monolayer is required for the maintenance of immune privilege. The combined effects of RPE soluble factors allows for macrophage phagocytosis, but prevents the conventional lysosomal degradation of the phagocytized materials, and the activation of inflammatory activity by the macrophages. This means that myeloid cells in the healthy eye are suppressed in phagocytic processing of antigens, and induction of inflammation, but not in phagocytic clearance and production of anti-inflammatory cytokines.


While prophylactic human papilloma virus (HPV) vaccination is considered effective in young girls, it is unclear whether a catch-up vaccination of older girls would be beneficial. We, therefore, aimed to examine the potential health impact of a HPV catch-up vaccination of girls who were too old at the time of vaccine introduction, hence aged 16 and older.We systematically searched the literature for randomized clinical trials (RCTs) that examined the effect of HPV vaccines on overall mortality, cancer mortality and incidence, high-grade cervical intraepithelial neoplasia grade 2 and higher (CIN2+), vulvar intraepithelial neoplasia (VIN) and vaginal intraepithelial neoplasia (VaIN) grade 2 and higher lesions  genital warts (condyloma). We considered all lesions and those associated with HPV type(s) included in the vaccines. RCTs reporting on serious adverse events were also eligible. Selected publications were assessed for potential risk of bias, and we ascertained the overall quality of the evidence for each outcome using Grading of Recommendations Assessment, Development and Evaluation (GRADE). Meta-analyses were performed, assuming both random and fixed effects, to estimate risk ratios (RR) and corresponding 95% confidence intervals (CI), using intention-to-treat and per-protocol populations.We included 46 publications reporting on 13 RCTs. Most of the RCTs had a maximum follow-up period of four years. We identified no RCT reporting on the effect of HPV catch vaccination on overall and cancer related mortality, and on cervical cancer incidence. We found a borderline protective effect of a HPV catch-up vaccination on all CIN2+, with a pooled RR of 0.80 (95% CI: 0.62-1.02) for a follow-up period of 4 years. A HPV catch-up vaccination was associated with a reduction in VIN2+ and VaIN2+ lesions, and condyloma. No difference in risk of serious adverse events was seen in vaccinated participants versus unvaccinated women (pooled RR of 0.99 (0.91-1.08)).This systematic review indicates that a HPV catch-up vaccination could be beneficial, however the long-term effect of such a vaccination, and its effect on cervical cancer incidence and mortality is still unclear.The online version of this article (doi:10.1186/1471-2458-14-867) contains supplementary material, which is available to authorized users. Human papillomavirus (HPV) is considered the most common sexually transmitted agent worldwide , and mosEfficient prophylactic vaccines could have an important public health impact . Since 2To the best of our knowledge, three meta-analyses have been published to date and they reported results on the effect of HPV vaccination of older girls on persistent HPV infection , and onlIn this article, we present a systematic review of the international literature to investigate the health impact of a HPV catch-up vaccination of girls who were too old at the time of vaccine introduction. Taking into account the age range covered by HPV vaccines licensing, and the age at introduction of HPV vaccination in different countries, we have therefore examined the health impact of HPV vaccination of girls aged 16 and older.We included randomised clinical trials (RCT) that examined the efficacy of a HPV catch-up vaccination of young women aged 16 and older. Eligible RCTs examined the effect of HPV vaccines on overall mortality, cancer related mortality, cervical cancer, high-grade cervical intraepithelial neoplasia grades 2 and higher (CIN2+), vulvar intraepithelial neoplasia (VIN) and vaginal intraepithelial neoplasia (VaIN) grade 2 and higher lesions , and genital warts (condyloma). RCTs investigating HPV vaccination safety and reporting on serious adverse events were also eligible. RCTs that used the following comparison groups were included: HPV vaccine against placebo, HPV vaccine against placebo with in addition another vaccine (such as hepatitis B vaccine) used in the intervention and in the placebo groups, or RCTs comparing two different HPV vaccines. No language restriction was applied during the literature search.We systematically searched several databases from 1999 up to October 2012 (Ovid MEDLINE(R) In-Process & Other Non-Indexed Citations, Ovid MEDLINE(R), Embase, Cochrane Central Register of Controlled Trials, ISI web of Science, PubMed, and Google scholar). Details of the search strategy are provided in the Additional file To assess the potential health impact of a HPV catch-up vaccination, we have examined several outcomes. We planned to investigate the effect of a HPV catch-up vaccination on overall and cancer mortality, and on cervical cancer incidence. Furthermore, we aimed to examine several female genital HPV related diseases and investigate the association between HPV vaccination and these outcomes. These outcomes were CIN2+, VIN2+, VaIN2+ and genital warts (condyloma acuminata). We also examined the association between HPV vaccination and these lesions considering only HPV related lesions (i.e. HPV type(s) found in the lesion is/are the HPV type(s) covered by the examined vaccine).We examined also adverse events possibly linked to HPV vaccination. We considered only adverse events reported as serious adverse events in the included publications.The selection of articles was carried out by two of the review authors . All titles and abstracts from the reference lists of articles were screened, and full-text articles were retrieved for publications judged potentially relevant. Each full-length article was assessed for possible inclusion according to the predefined eligibility criteria. Potential disagreements were resolved by discussion with a review author.Selected publications were assessed for potential risk of bias according to the Cochrane risk of bias tool . All assOne review author extracted the data and another verified the information. When data were reported in several publications, we used the publication with the longest follow-up period. If a publication included several trials, preference was given to the publication that included the most trials. We extracted detailed data on characteristics of the clinical trial and participants, on administration of vaccine and control, and on relevant outcomes.Two review authors assessed the overall quality of the evidence for each selected outcome using GRADE  .When possible, we carried out meta-analyses to investigate the association between HPV vaccination and outcomes described above, comparing vaccine and control groups. Extracted data were pooled together by performing meta-analyses using the Review Manager software (RevMan). When the outcome data could not be pooled in meta-analyses, we described the results in a narrative manner.Random and fixed effect models were used to calculate pooled risk ratios (RR) and corresponding 95% confidence intervals (CI). If we identified fewer than three studies reporting data on the same clinical outcome, we report pooled estimates using fixed effect models. Otherwise, pooled estimates obtained with random effect models are presented.We performed intention-to-treat (ITT) analyses. However, none of the included studies used an intention-to-treat population including only randomized subjects. We, therefore, used the modified intention-to-treat populations as defined in the included publications. The modified ITT population was most commonly defined as participants who received at least one vaccine or control dose and had at least one follow-up visit post-dose 1. When possible, we conducted also analyses according to per-protocol-population (PPP). The PPP typically included participants who received the three vaccine or control doses. We pooled results published for the safety population, using estimates reported for the longest follow-up period in each study. In most trials, the safety population was similar to the modified ITT population.The study selection process is presented in Figure Characteristics from included studies –40 are pVaccines used in the trials were the bivalent vaccine containing HPV 16 and 18 virus-like particles (VLP) from GlaxoSmithKline, or the monovalent vaccine containing HPV 16 VLP and the quadrivalent vaccine containing HPV 6, 11, 16 and 18, both from Sanofi Pasteur MSD. All trials used placebo as comparator except for two studies: one used hepatitis B vaccine in both the intervention and the control groups , and oneSome of the included studies had unclear allocation concealment and unclear blinding. However, all studies were assessed as having low risk of bias.While, one of our aims was to investigate the effect of a HPV catch-up vaccination on overall and cancer related mortality, and on the incidence of cervical cancer, no RCT examining these outcomes were identified.Table Overall mortality was seldom reported, and primarily only in the text. Overall mortality was reported in 7 RCTs , 41, 45.The intention-to-treat (ITT) analysis based on five studies showed a borderline statistically significant reduction in CIN2+ lesions associated with HPV vaccination with a pooled RR of 0.80 (95% CI: 0.62-1.02) for a follow-up period of 4 years  showed a non statistically significant reduction for all CIN2+ lesions after a four year follow-up period   based on two RCTs reported in one publication . The results also indicate a protective effect against all CIN2 lesions (HPV associated and not). No difference in the occurrence of serious adverse events was found in vaccinated participants compared to control groups.High grade cervical lesions (CIN2+) were proposed by the WHO as an appropriate surrogate outcome for RCTs examining the effect of HPV vaccination . A reasoHPV vaccines were shown to be highly efficacious to prevent persistent infections with HPV , 49, 50.While HPV types 16 and 18 are the two most common HPV types worldwide, prevalence of HPV types differs geographically [While prophylactic HPV vaccination is considered effective and cost-effective in young girls, it is unclear whether a catch-up vaccination of older girls would have beneficial effect on health outcomes. This is primarily due to differences of HPV status between young and older girls, with younger more likely to be free of HPV infection. In the population included in this systematic review, the HPV status of participants varies, because of the age-range examined in this review, and differences in studies inclusion criteria: Some studies included only participants with no history of HPV infection and negative HPV tests at entry into the study , and othThe conducted RCTs on the efficacy of HPV vaccination have a relatively short follow-up period with most results published up to date based on follow-up periods of approximately four years. Two included trials published results after longer follow-up periods (6 and 8 years) but the results were based on few participants and are inconclusive , 36. TheIn most developed countries, national cervical cancer screening programs have been implemented, with a reported reduction in cervical cancer incidence probably partly due to these programs –56. A puThe evidence, to date, shows that a HPV catch-up vaccination can be considered safe, with no differences seen in serious complications between the vaccination and the control groups. However, the number of cases of published clinical studies may not be sufficient to determine the occurrence of rarely occurring (severe) adverse events in a reliable way. Furthermore, due to the relatively short follow-up period since HPV vaccination implementation in different countries, the long-term safety of the vaccines is unclear and needs to be further monitored in future studies. While different adverse events have been reported, as we examined only events reported as serious this ensures a better homogeneity of the ascertained outcome across studies.This systematic review indicates that HVP catch-up vaccination could be a valuable primary prevention against cervical cancer and national catch up vaccination programs have already been implemented in several countries. However, the long term effect of such a vaccination strategy and its impact on cervical cancer prevention remains to be determined.Appendix.(DOCX 14 KB)Additional file 1:


To date, hampered physiological function after exposure to microgravity has been primarily attributed to deprived peripheral neuro-sensory systems. For the first time, this study elucidates alterations in human brain function after long-duration spaceflight. More specifically, we found significant differences in resting-state functional connectivity between motor cortex and cerebellum, as well as changes within the default mode network. In addition, the cosmonaut showed changes in the supplementary motor areas during a motor imagery task. These results highlight the underlying neural basis for the observed physiological deconditioning due to spaceflight and are relevant for future interplanetary missions and vestibular patients.The online version of this article (doi:10.1007/s00429-015-1054-3) contains supplementary material, which is available to authorized users. Space-travelers face various stressors for their health. These can be physical , habitability-related , or psychological   was included in the analysis to account for data variance (see Online Methods for details).A 44-year-old male cosmonaut had his first long-duration mission (169 days) to the International Space Station (ISS) in 2014. During spaceflight, the cosmonaut strictly followed the physical and locomotor training in accordance with the Russian countermeasure system. His overall physical performance showed no abnormalities according to the Institute of Biomedical problems , monitoring the health of the space travelers in the Russian segment of the ISS. On the day of landing, the sensorimotor assessment showed vestibular ataxia, indicating a dysfunctional vestibular system and proprioception. Clinical investigations 3 days postflight revealed continued impairment of motor coordination, similar to earlier reports  and ventral posterior cingulate cortex . With regards to the network-level approach, all networks were characterized by their typical spatial pattern across the group of healthy volunteers  and the postcentral gyrus ; seed-by-seed secondary connectivity analysis identified that the connectivity changes resulted from the seed region placed on the left cerebellum  post-flight compared to pre-flight for the tennis paradigm. No difference in brain activation was identified for the spatial navigation task as expected.The resting state assessment encompassed 1) a hypothesis-free exploration of changes in the strength of global connectivity pattern as estimated by the intrinsic connectivity contrast  4], somatosensory problems , and movement-timing problems (cerebellum)  and its functions include processing of self-motion, spatial orientation, and memory Supplementary material 2 (TIFF 6980 kb)Below is the link to the electronic supplementary material.