Major depressive disorder (MDD) has become a leading contributor to the global burden of disease; however, there are currently no reliable biological markers or physiological measurements for efficiently and effectively dissecting the heterogeneity of MDD. Here we propose a novel method based on scalp electroencephalography (EEG) signals and a robust spectral-spatial EEG feature extractor called kernel eigen-filter-bank common spatial pattern (KEFB-CSP). The KEFB-CSP first filters the multi-channel raw EEG signals into a set of frequency sub-bands covering the range from theta to gamma bands, then spatially transforms the EEG signals of each sub-band from the original sensor space to a new space where the new signals  are optimal for the classification between MDD and healthy controls, and finally applies the kernel principal component analysis (kernel PCA) to transform the vector containing the CSPs from all frequency sub-bands to a lower-dimensional feature vector called KEFB-CSP. Twelve patients with MDD and twelve healthy controls participated in this study, and from each participant we collected 54 resting-state EEGs of 6 s length . Our results show that the proposed KEFB-CSP outperforms other EEG features including the powers of EEG frequency bands, and fractal dimension, which had been widely applied in previous EEG-based depression detection studies. The results also reveal that the 8 electrodes from the temporal areas gave higher accuracies than other scalp areas. The KEFB-CSP was able to achieve an average EEG classification accuracy of 81.23% in single-trial analysis when only the 8-electrode EEGs of the temporal area and a support vector machine (SVM) classifier were used. We also designed a voting-based leave-one-participant-out procedure to test the participant-independent individual classification accuracy. The voting-based results show that the mean classification accuracy of about 80% can be achieved by the KEFP-CSP feature and the SVM classifier with only several trials, and this level of accuracy seems to become stable as more trials  are used. These findings therefore suggest that the proposed method has a great potential for developing an efficient  and effective (~80% classification accuracy) EEG-based brain-computer interface (BCI) system which may, in the future, help psychiatrists provide individualized and effective treatments for MDD patients. Major depressive disorder (MDD) is a prevalent mood disorder with the presentation of persistent sadness, feeling of worthlessness, restlessness, and loss of interest in daily activities , and patAmong the candidate endophenotypic markers, neuroimaging evidence has suggested that there is a close association between MDD and abnormal structural changes of brains . Abnk-nearest neighbor (k-NN) classifier-based classification accuracy of 99.1% was achieved with nine depressive and nine non-depressive participants  . KPCA isk-NN, linear discriminant analysis (LDA), and support vector machine (SVM) [In this study, we compare the proposed KEFB-CSP with other features, including EEG band powers (BP), band-specific CSP , and the GPFD which had been shown to be better than other features in . Three kne (SVM)  classifiThe whole experiment and EEG data acquisition were conducted in the National Taiwan University Hospital (NTUH), Taipei, Taiwan. Twenty-four subjects  participated in this study and they all provided signed informed consent approved by the Institution Review Board at NTUH (201203036RIB). The patient participants  were aged from 43 to 70 years, with an average of 57 (w (MINI) .All emotional stimuli and experimental cues were presented on a 17-inch CRT screen. Participants were seated in a fixed and comfortable chair. The distance between the eyes of each participant and the CRT display were controlled to be about 60 cm. EEG signals were recorded by 33 Ag/AgCl electrodes mounted on an electro-cap  where the locations of the electrodes follow the international 10–20 system. Among the 33 channels, two were references positioned at A1 (left mastoid) and A2 (right mastoid), and one is a Ground channel at forehead, leaving a total of 30 EEG channels used in this study. Impedances of the electrodes were kept below 5 kΩ by applying Quick-Gel . Ocular artifacts were monitored by horizontal  and vertical  bipolar EOG electrodes. We used artifact removal software of NeuroScan to remove eye blinks and eye-movements related artifacts embedded in the recorded EEG. The artifact removal is based on an EEG-VEOG covariance analysis, a linear regression procedure, and the creation and use of an LDR file to perform a point-by-point proportional subtraction of the eye blinks . ParticiIn the current study, we collected EEGs from a resting state as the feature basis for classification. Each participant underwent two sessions of EEG acquisition with each session contained three trials of the resting state. Prior to each trial of resting state, there was a 5-s ready-to-start period during which the participants could make very slightly body/eye movements. For each trial (lasted for 54 s) in the resting state, participants were asked to relax and loosely look at the central fixation cross shown in the monitor screen while not to think anything purposefully. They were also asked to maintain a minimum arousal level without falling into sleep. The EEG recorded in each trial of resting state was further partitioned into nine resting EEG epochs of 6-s length. There was a break between two sessions. The length of the break period was 5–10 min, depending on the participants. As a result, for each participant, there were 54 EEG signals of 6 s from the two EEG acquisition sessions.In this subsection, we first introduce the features to be compared, including BP and GPFD, and then derive the proposed KEFB-CSP method in detail. Major depressive disorder group and the healthy control group are defined as positive class (class 1) and negative class (class 2), respectively. Vectors and matrices are marked as boldface.N-dimensional vector in which the elements are the theta BPs computed from the EEGs of N different channels.The spectrum of a 6-s EEG signal from one channel were calculated by discrete Fourier transform and powers of theta (4–8 Hz), alpha (8–13 Hz), beta (13–30 Hz), and gamma (30–44 Hz) bands were extracted. In the experimental results, for example, the theta band power (theta BP) feature is an T, where m-dimensional vectors as:Fractal dimension of a time series can be measured by GP algorithm. Let In numerical computation, the value of ested in . FurtherThe KEFB-CSP method is composed of three stages, including band-pass filtering, filter-bank CSP extraction, and KPCA-based transformation, as illustrated in Stage 1: Band-pass FilteringThe frequency band ranging from theta to gamma bands (4–44 Hz) is partitioned into Stage 2: Filter-bank CSP Feature ExtractionStep 1.t denotes the transpose of a matrix, tr(.) denotes the trace of (.), ith training EEG data of class 1, ith training EEG of class 2, and Calculate the averaged spatial covariance matrices of the two classes Step 2.Diagonalize the composite covariance Step 3.I = 1,2, where Whiten the averaged spatial covariance metrics of the two classes by Step 4.Perform the simultaneous diagonalization of the whitened spatial covariance matrices:Step 5.N-channel signals Projecting the whitened EEG of a trial onto the eigenvectors in Given a filtered Thus, the CSP transformation matrix is given by p and the last p rows of p new signals The first p CSP features are extracted from a filtered multi-channel EEG as a result. The CSP features extracted from the p needs to be determined experimentally, and the optimum value of p should be searched within the range from 1 to For each frequency sub-band, 2Stage 3: KPCA-based TransformationF using a nonlinear mapping F:F, i.e., d leading eigenvectors of the covariance Let d eigenvectors of the covariance are computed by:For a test data d-dimensional feature vector The projections In order to obtain the participant-independent classification accuracy, the leave-one-participant-out cross validation (LOPO-CV) procedure described in k-NN classifier was employed to compute the classification rate, where the number of nearest neighbors k was set as 3. The parameters of the feature extractions methods are summarized in d represents the minimum number KEFB-CSP features. The accuracies reported in the following results were the best CV accuracies.In step 3, a N is listed in N-channel EEG configuration, a total of k-NN classifier. Please note that the feature dimensions of the six areas are different. Taking the theta BP as an example, the feature dimension is 30 if the area of interest is the “entire”  but only 7 if the region is the “frontal” .We selected six electrode montages covering different scalp regions in order to compare the differences between patients with MDD and controls see . The monAccording to Next, we compare the accuracy among FBCSP, FBCSP+PCA, and KEFB-CSP. Here, the PCA is implemented by replacing the kernel PCA’s Gaussian kernel with the polynomial kernel k-NN classification results with the results by LDA and SVM classifiers. LDA involves no free parameters [C) was found in the set In this subsection, we further compare the rameters . SVM hasrameters ,38. In tk-NN, depending on the use of feature. Compared with k-NN, LDA achieved better accuracy (72.07%) for beta CSP feature; however, LDA gave a worse accuracy (53.16%) for the alpha BP feature. One possible reason is that the distributions of the two groups are nonlinearly distributed in the space of alpha BP patterns, making the LDA unable to effectively classify the two groups because LDA is essentially a linear classifier. And therefore, we did not consider the LDA classifier in the subsequent experiments. By contrast, the nonlinear classifier SVM achieved better results for all features. Also, KEFB-CSP outperforms the other three  for all classifiers. According to the results in Question 1:How many participants can be correctly classified based on the use of KEFB-CSP feature?Question 2:Can the individual classification accuracy be improved by using multiple single-trial EEG signals?The results reported in firstTo answer these two questions, we designed a voting-based LOPO-CV procedure which can estimate the participant-independent individual classification accuracy. The steps of this procedure are summarized in The LOPO-CV  estimateAs nt=15 , 10 part as nt=1 , the sen1 , and compared the KEFB-CSP with other features that have been applied in previous MDD studies, including the BPs and the fractal dimension features. Moreover, previous studies about the discrimination between MDD patients and normal subjects did not conduct experiments to analyze the performance difference between electrodes of different scalp areas in the two-class classification  based on machine learning methods. In our study, we conducted such experiment and found that the temporal area is able to achieve higher accuracy than other areas. The advantage of this analysis is two-fold. First, the fact that only eight channels provides the highest classification accuracy suggest a BCI system with low numbers of electrodes is feasible for classification of MDD vs. healthy controls. Second, this finding  also points to potential directions for neuroscientists to further investigate the difference in brain activities between MDD patients and normal individuals.The proposed KEFB-CSP method has several advantages. First, it is able to achieve higher classification accuracies than the existing feature extraction methods for classification between MDD patients and normal subjects. Second, it requires only eight channels over the temporal area to achieve the highest accuracy (81.23%). Compared with BP which requires 30 channels covering the entire brain area to achieve its optimum performance (69.91%), the proposed KEFB-CSP requires a much smaller number of EEG channels. However, the proposed KEFB-CSP has a much higher computational complexity. In FB-CSP, the eigenvalue problem formulated in Equation (5) has the time complexity of In Taiwan, the sensitivity and specificity of PHQ-9 for identifying MDD has been reported to be 86.0% and 91.1%, respectively . The KEFIn the current study, we presented a novel EEG feature extraction method called kernel eigen-filter-bank common spatial pattern (KEFB-CSP) for the classification between patients with MDD and heathy controls. Based on the experimental results, several conclusions can be drawn. First, the spectral-spatial feature extraction method KEFB-CSP outperforms the conventional CSP, and other EEG features that had been used in related works, including the powers of different EEG frequency bands and the fractal dimension extracted from EEG time series. Second, KEFB-CSP feature is able to achieve a participant-independent individual classification accuracy of 91.67% when a nonlinear support vector machine (SVM) serves as the classifier, meaning that the probability that one person is correctly classified into the depression or control groups is higher than 90%. Lastly, the accuracy of 91.67% was achieved with only the first single-trial resting-state EEG signal of 6 s from 8 EEG electrodes located at the temporal area.The successful implementation of the proposed method has several implications for future development of an EEG-based BCI system for major depression detection. First, the proposed method only requires eight electrodes to record EEG. According to our experience, the preparation time for an 8-electrode setting  can be shorter than 10 min. Users will not feel uncomfortable due to the short duration of electro-cap wearing. Second, the method only requires a few 6-s single-trial resting-state EEG signals for testing. Users do not need to experience a long and exhausted EEG data collection procedure. The two technical strengths increase the feasibility of its clinical application.Moreover, the search for a suitable biomarker that can help elucidate the endophenotypic signs for refining the spectrum of MDD is therefore important for optimizing treatment plans. As a simple and efficient method to measure the brain electrophysiological activity, the proposed KEFB-CSP based EEG feature seems to have a potential to provide psychiatrists with a valid and reliable candidate biomarker that can assist psychiatrists to dissect heterogeneous etiology of MDD and to selectively adjust effective treatment plans optimized for different subgroups of MDD patients.Nevertheless, several follow-up studies will be needed. First, only 24 subjects participated in the current study. To further validate the validity of the proposed method, more participants are needed in the future. Second, although the current results suggest that the temporal area is better than other scalp areas in the classification between MDD patients and healthy controls, a combination of EEG electrodes from multiple scalp areas might achieve even higher classification accuracy. For example, the combination of some electrodes over the temporal area and some electrodes over the parietal area may lead to a better classification performance. Future developments of an electrode selection algorithm based on machine learning technologies  could provide an effective approach to find the optimum electrode combination across scalp areas. Finally, the mental state in which EEGs are recorded could be optimized. In the current study, the EEGs were recorded in the resting state. However, EEGs recorded in a different state may result in better performance for classifying between MDD patients and healthy controls. For example, it is evidenced that the emotion regulation ability for MDD patients seems to decline. Accordingly, the EEG signals recorded in the emotion-induction state may lead to better classification accuracy than the resting-state EEGs.


IgG4-related hypophysitis is a rare, inflammatory process of the pituitary that mimics more commonly seen pituitary tumors. We report a case of IgG4-related hypophysitis in a 16-year-old female with diabetes insipidus who was found to have IgG4-related hypophysitis based on tissue diagnosis. This entity has not been previously described in a pediatric patient. Recognition of certain inflammatory processes of the pituitary may lead to alternative means of diagnosis and medical management without a biopsy. IgG4-related disease (IgG4-RD) is a rare, newly recognized, multi-organ disease characterized by a tendency to form tumefactive lesions in multiple sites throughout the body. Pituitary involvement, IgG4 hypophysitis, is less commonly reported and, when described, is usually associated with IgG4-RD elsewhere in the body. In this case report, we present a pediatric patient who presented with diabetes insipidus and an isolated suprasellar mass which was subsequently resected revealing a pathologic diagnosis of IgG4 hypophysitis. This is the first report of IgG4 hypophysitis in a pediatric patient. Given that the treatment of IgG4 hypophysitis is drastically different than treatment for other more common pituitary tumors within this population, it is important to consider this entity in the differential in order to prevent unnecessary invasive procedures and subsequent morbidity.A 16-year-old female presented to our endocrinology, otolaryngology, and neurosurgery clinics for an evaluation of a suprasellar lesion. She had presented three months previous to an outside endocrinologist for excessive polyuria and polydipsia. She was found to have a serum osmolality of 292 mOsm/kg and a urine osmolality of 50 mOsm/kg, and was given a diagnosis of diabetes insipidus. During the workup, magnetic resonance imaging revealed a 2 cm peripherally enhancing, partially cystic sellar/suprasellar mass causing compression of the optic chiasm  (Wegener's) were not present. Because of the possibility of mass effect on the optic chiasm and radiologic findings consistent with craniopharyngioma, namely the solid/cystic appearance and the peripheral enhancement of the lesion, an endoscopic transsphenoidal resection of the pituitary was performed. The lesion was found to be encapsulated and consisted of a white-tan diffluent material. The lesion was completely resected from the sella and sent, in aggregate, for pathologic evaluation.Sections of the lesion showed extensive infiltration of mature plasma cells intermixed with lymphocytes Figure . SectionPostoperatively, the patient experienced a small CSF fluid leak which was repaired surgically without issue. She was discharged from the hospital on steroid replacement and DDAVP. Given the diagnosis, the patient was referred to Rheumatology for follow-up. She was found to have no obvious sign or symptoms of systemic involvement of IgG4-RD. An IgG4 level was performed and was normal; however, the patient was receiving chronic steroid replacement therapy at that time. Unfortunately, there have been no follow-up visits at our institution since that time.e.g.Churg-Strauss syndrome, multicentric Castleman’s disease, sarcoidosis, Sjogren’s syndrome) by additional histopathological examination. Granulomatosis with polyangiitis (GPA) (Wegener's) may mimic IgG4-related disease and is an important consideration in the differential diagnosis [IgG4-related disease (IgG4-RD) is a newly recognized, fibroinflammatory disease that has been shown to affect almost every organ of the body, with preference for the pancreas, salivary gland, orbital tissue, lymph node, lung, and kidney. It is characterized by tumorous swelling of affected organs, prominent lymphoplasmacytic infiltrate rich in IgG4-positive plasma cells, and high serum IgG4 concentrations. IgG4-RD can also cause diffuse infiltrative lesions presenting without constitutional symptoms, which usually makes the diagnosis incidental and based upon radiographic findings or examination of pathological specimens. Spontaneous improvement is very rare, and the majority of cases show slow and indolent progression. IgG4-RD affects mostly middle-aged and elderly men, but the male-female ratio is balanced in patients with predominantly head and neck involvement. It is important to differentiate IgG4-RD from malignancies with mass-forming lesions and some immune-mediated diseases  and several more rare forms . Interestingly, while lymphocytic hypophysitis is also pathologically characterized by a lymphoplasmacytic infiltrate, there is a predominance of lymphocytes (B and T cells) rather than plasma cells . AdditioA review of the 18 reported case reports of IgG4-related hypophysitis -24 showsDemographic details of the 18 reported cases demonstrated a mean age of 62.5 years (range 27-77) and a male predominance 13/18 (72%). The majority of the cases have been described in patients of Asian descent; however, this may be reflective of the increased awareness of IgG4-RD within the community. Each of these cases had other organ manifestations either synchronously or metachronously except two cases having hypophysitis as the sole manifestation in a 74-year-old female  and 55-yDiagnosis of IgG4-related hypophysitis can be made a variety of ways. Pituitary biopsy is the most definitive; however, a biopsy can be invasive and unnecessary in certain cases. Diagnosis of IgG4-related hypophysitis can also be suggested based on biopsy-proven IgG4-related disease in other organs when classic imaging findings of hypophysitis are present, including homogeneously enhancing sellar mass/thickened pituitary stalk. A guideline for a histologic diagnosis of IgG4-related disease has been previously described in a consensus statement on the entity and includes a dense lymphoplasmacytic infiltrate, storiform fibrosis, obliterative phlebitis, and an increased number of plasma cells Table .For some organs, obliterative phlebitis and storiform fibrosis are uncommon, and consensus histologic criteria for these features with pituitary involvement have not been described . The numWhile there is no standardized regimen for steroid therapy for this disease, a dose of 0.6 mg/kg/day of prednisolone is most often used. This should be continued for 1-2 months, with a taper of 5 mg per week. If relapse should occur, the physician may consider a maintenance dose for an extended period of time, up to three years, or a combination of immunosuppressants -27.The present case differs from the reported cases of IgG4-related hypophysitis in several important aspects. The first aspect which makes this case interesting is the lack of convincing systemic features. Most patients with this disease have concurrent or previous involvement of other organs. Her lack of systemic involvement made it difficult to diagnose hypophysitis without tissue examination. Imaging studies were also misleading in this patient, with features suggestive of a neoplastic process, particularly solid and cystic components that would be most commonly seen in craniopharyngioma.Another unusual aspect is the age of the patient. There have been no reported cases of IgG4-related hypophysitis in a patient less than 27 years old. While rare, IgG4-RD has been described in the pediatric population, usually within the context of autoimmune pancreatitis. Often these patients have additional systemic manifestations including retroperitoneal fibrosis, sialadenitis, and mediastinal adenopathy . It is lIgG4-related hypophysitis is a rare condition not previously reported in a pediatric age group. The clinical presentation is similar to that for other inflammatory conditions of the pituitary. The decision to biopsy a pituitary mass in the teenage population is often straight forward for cases of a tumor; however, inflammatory processes which create a mass effect can sometimes be treated without a biopsy. This relies on the physician’s ability to recognize the possibility of rare, inflammatory processes such as IgG4 hypophysitis and having a knowledge of alternative ways to confirm the diagnosis. Avoiding a biopsy can decrease morbidities associated with the procedure and may avoid the need for long-term hormone replacement. Because this disease process has not yet been described in the pediatric population, and due to lack of systemic organ involvement or serum IgG4 levels to indicate a possible IgG4-related disease process, a biopsy was necessary to rule out a more common pituitary tumor and to achieve the diagnosis of IgG4-related hypophysitis. Recent literature has suggested that not infrequently there are cases of hypophysitis with IgG4 plasma cells that are not part of the systemic syndrome. Although it appears likely that this patient is not at risk for further involvement of multiple sites, a definitive biopsy has allowed the patient to seek close clinical follow-up by a rheumatologist.


A sentinel lymph node (SLN) tracer can gain multi-functionality by combining it with additional components. We developed a SLN tracer consisting of iodine and docetaxel and applied it as a theragnostic nanoparticle to simultaneously perform SLN computed tomography (CT) lymphography and locoregional chemotherapy of the draining lymphatic system.®. The particle size and drug concentration were stable during storage for up to 3 months in optimized nanoemulsions. Popliteal LN enhancement on CT was observed in all healthy rabbits (n=3) and VX2 tumor-implanted rabbits (n=6) 12 hours after injection. The rate of SLN metastasis was significantly lower in the treatment group  than in the non-treatment group  (P=0.038).Docetaxel could be loaded in iodine emulsions at a drug-to-surfactant weight ratio as high as that in the drug formulation TaxotereWe prepared a nanoemulsion carrying both iodine and docetaxel in a single structure by optimizing the composition of surfactants surrounding the inner iodized oil core. CT was performed 12 hours after subcutaneous injection of the emulsion in healthy rabbits (n=3) and VX2 tumor-implanted rabbits (n=6) for SLN imaging. Next, we tested the effect of treatment by histopathologically assessing the popliteal LN metastasis rate in VX2 tumor-implanted rabbits 7 days after subcutaneous injection of the emulsion  and comparing it with that of non-treatment group rabbits (n=17).We developed an iodine-docetaxel emulsion and demonstrated that it can be applied to simultaneously achieve CT SLN imaging and local chemotherapy against nodal metastasis. Regional lymph nodes (LNs) are one of the most frequent sites of early carcinoma metastasis. The presence of regional LN metastasis not only reflects a more malignant nature of the tumor, but also is a potential source of subsequent distant metastasis . It has The sentinel lymph node (SLN) is defined as the first LN that directly receives lymph flow from the primary tumor, and is the most likely site of early nodal metastasis. If the SLN is free from metastasis, the risk of metastasis to other LNs is considered low . TherefoIn practice, the basic strategy to identify the SLN is to perform peri-tumoral injection of lymphatic tracers and subsequently detect the LNs that uptake the tracers. Traditionally, radioactive colloids and vital dyes have been the most popular lymphatic tracers used. However, in spite of their usefulness, these tracers also have technical limitations, such as rapid wash away of vital dyes and poor resolution for radioactive colloids . To enhaIn our previous work, we synthesized an emulsion consisting of iodine and indocyanine green that served as a SLN tracer that enabled hybrid imaging by CT and optical imaging . Such exThe purpose of this study was to synthesize a theragnostic emulsion containing both iodine and docetaxel and apply it to a rabbit tumor model, to achieve simultaneous SLN detection by CT lymphography and locoregional chemotherapy against microscopic metastasis within the draining lymphatic system.®, a commercially available docetaxel product.The optimal combination of surfactants with a high and low hydrophilic-lipophilic balance value is critical for achieving a stable and fine emulsion . To prodWe first prepared nanoemulsions of different surfactant compositions with a fixed total amount of surfactant (240 μmole) to investigate the optimal hydrophilic/hydrophobic surfactant ratio in terms of the loaded docetaxel concentration and particle size of the resultant emulsions. When nanoemulsions were prepared with increasing Tween 80 content (25 to 87 mol%), the loaded docetaxel content increased, but the mean particle size of the emulsions decreased in a Tween 80 content-dependent manner . The polReducing the total surfactant amount may be beneficial for reducing surfactant-related side effects, such as hypersensitivity reactions after administration in cancer patients. We therefore investigated the effect of the total amount of surfactant mixture on the loaded docetaxel concentration, mean droplet size, and PI of the nanoemulsions. As shown in Because the use of nanoparticles as a carrier for taxane drugs, including docetaxel, is often hampered by the time-dependent release/precipitation of the drug , the staThe diameter and morphology of the emulsion obtained with the 87:13 mixture of Tween 80:Span 85 were also determined by TEM. As demonstrated by the representative TEM image shown in Figure In our previous study, we demonstrated that water-soluble emulsions containing iodine can serve as an effective CT lymphography tracer . Our newThe LN metastasis model was generated by passage of tumors from the popliteal LN of VX2 tumor-implanted rabbits to additional heathy rabbits. Initially, the passage of VX2 tumors harvested from the popliteal LN was successful in no more than 50% of the rabbits, but the success rate gradually increased as we repeated passaging the tumors (data not shown). We believe that a tumor subpopulation with an enhanced tendency for nodal metastasis was selected for during passaging, causing the rate of popliteal LN metastasis to gradually increase. After several cycles of tumor passaging, we were able to establish a VX2 tumor line that showed enhanced nodal metastasis potential and usually achieved a popliteal LN metastasis rate of approximately 90% (data not shown) when incubated for 4 weeks after implantation. All subsequent experiments were performed using this VX2 tumor line.We performed CT lymphography in tumor-free healthy rabbits (n=3). CT images obtained 12 hours after subcutaneous injection of the iodine-docetaxel emulsion demonstrated focal contrast enhancement within the popliteal lymph node ipsilateral to the tumor Figure .Next, we conducted SLN imaging in the rabbit microscopic LN metastasis model (n=6). Similar to the tumor-free healthy rabbits, CT lymphography was performed 12 hours after subcutaneous injection of the iodine-docetaxel emulsion, which also revealed focal intra-nodal enhancement by the uptake of emulsion Figure . A secon3 vs. non-treatment group, 0.447 ± 0.137 cm3; P=0.612). The size of the contralateral side popliteal LNs were also the same between the two groups upon allocation   or non-treatment (control) group (n=17) according to the size of the popliteal LN ipsilateral to the implanted tumor so that the two groups had matched LN size . Meanwhile, the sizes of the ipsilateral popliteal LNs significantly increased in both the treatment and non-treatment groups when the size measured on the post-treatment CT was compared with that of the pre-treatment CT within each group  , a post-treatment CT was performed. Volumetry based on the post-treatment CT revealed that the sizes of the ipsilateral LNs in the treatment group compared to the non-treatment group were not significantly different .Both the non-treatment group Figure  and treaIn the current study, we developed an iodine-docetaxel emulsion and demonstrated that it can be applied as a SLN lymphography tracer and a vehicle that selectively delivers a chemotherapy agent into the tumor draining lymphatic system. We showed that peri-tumoral injection of our iodine-docetaxel emulsion can significantly reduce the rate of LN metastasis in a LN micro-metastasis model (VX2 tumor-implanted rabbits).In our previous study, we developed a water-soluble emulsion containing iodized oil and fluorescent dye and demonstrated that it can be used to perform SLN hybrid imaging with both CT and optical devices . Based oThe capability to simultaneously perform SLN imaging and locoregional chemotherapy of the draining lymphatic system has several clinical implications and advantages. Most importantly, under usual clinical settings a surgical biopsy may not be feasible even if SLN imaging is practically possible. Nowadays, minimally invasive procedures, such as endoscopic resection or trans-anal operation, are increasingly performed for the treatment of early gastric cancer or early colorectal cancer, but the prediction and treatment of potential nodal metastasis remains a challenge because LN biopsy is not possible during these procedures , 18. HowIn early gastric cancer, the risk of LN metastasis has been reported to range between 1% to 3% if the tumor is confined to the mucosa, and 11% to 20% if the tumor invades the submucosa , 19. CurOur iodine-docetaxel emulsion can also improve safety in patients who decide not to undergo curative resection based on a negative SLN biopsy. Although SLN biopsy is an established method in several kinds of malignancies, the risk of a false negative report cannot be eliminated for several reasons. Firstly, during daily practice, a whole-mount examination of the retrieved SLN cannot be performed, and thus under-sampling is inevitable. Secondly, the current SLN detection methods have a risk of technical failure. Water-soluble dyes, including vital dyes, not only rapidly wash away and therefore allow only limited time for assessment, but may become obscured when covered by dense fat tissue. Radioactive colloid tracers have poor spatial resolution and are known to exhibit poor sensitivity when the LN is near the injection site because of high background scattering (shine-through effect) –26.3) at pre-treatment CT.According to clinical reports, the majority of metastatic LNs discovered in colorectal and gastric cancer patients were not significantly enlarged –29, whic3 vs. non-treatment group 0.812 ± 0.193 cm3; P=0.296). This implies that although treatment with the iodine-docetaxel emulsion might lower the rate of nodal metastasis, the treatment response is not reflected by a decrease in size of a particular LN, which would make it difficult to predict eradication of potential metastasis based on size alone. We believe that the increased size of non-metastatic LNs is probably associated with the state of reactive hyperplasia [In the current study, the size of the ipsilateral LNs measured on post-treatment CT increased during the 7 day incubation period in both the treatment group and non-treatment group (P<0.001 in both) when compared with the pre-treatment CT. However, in spite of the difference in the nodal metastasis rate between the treatment group and non-treatment group, the size of the LNs of the two groups was not significantly different . The mean size of optimized emulsions was less than 100 nm, the upper size limit for colloidal particles to enter the lymphatic capillaries quickly and accumulate in regional LNs after subcutaneous administration [Our formulation study, which was performed to optimize the composition of surfactants in order to maximize the loaded docetaxel concentration in the emulsion tracer, demonstrated that 240 μmole/ml of an 87:13 mixture of Tween 80:Span 85 enabled docetaxel loading at a 4% drug-to-surfactant weight ratio, a ratio comparable to that in Taxoterestration . MoreoveWe acknowledge that our study had a few limitations. Firstly, our study was based on a microscopic LN metastasis animal model in which the presence or absence of LN metastasis was unknown at the time of iodine-docetaxel emulsion injection. As a result, we were not able to measure the direct treatment effect on LN metastasis. To compensate for this limitation, we established a balanced control group with matched popliteal LN sizes, which served as a non-treatment (control) group for comparison. Secondly, to ensure the clarity of this proof-of-concept study, we performed experiments while using the popliteal LN as the SLN for the VX2 tumor implanted in the lower extremity. However, the lymphatic vessels of this area are very simple, and therefore we do not believe that our iodine-docetaxel emulsion has been sufficiently validated as a SLN tracer. We intend to pursue further validation in a more clinically relevant tumor model with more complex lymphatic structures.In conclusion, we have developed an iodine-docetaxel emulsion and applied it to simultaneously accomplish SLN detection based on CT lymphography and eradication of potential LN metastasis by selectively delivering chemotherapy into the draining lymphatic system.This study was approved by the Experimental Animal Ethical Committee of Yonsei University College of Medicine .Sorbitan trioleate (Span 85) and polyoxyethylenesorbitan monooleate (Tween 80) were purchased from Sigma-Aldrich Inc. . Docetaxel was purchased from LC laboratories . Lipiodol, an FDA-approved iodized oil, was purchased from Guerbet . All other materials were of reagent grade and used without further purification.Oil-in-water emulsions were prepared using a homogenization method as previously described . BrieflyThe mean particle size and PI of the nanoemulsions were measured by dynamic light scattering using a fiber-optic particle analyzer . Prior to measurement, the emulsion dispersions were appropriately diluted with filtered saline. The PI was obtained as a measure of the uniformity of the particle size distribution in colloidal dispersions .The concentration of docetaxel loaded in the emulsions was determined by reversed-phase HPLC analysis . In brieThe diameter and morphology of nanoemulsions were also determined by transmission electron microscopy  at an accelerator voltage of 120 kV. For observation, 5 μl of emulsion were applied to carbon-coated grids that had been glow discharged for 3 min in air and immediately (within ∼5 sec) negatively stained using 1% uranyl acetate.The stability of nanoemulsions was evaluated by monitoring the changes in mean particle size and the docetaxel content remaining loaded in emulsions during storage at 4°C.Male New Zealand white rabbits weighing from 3 to 3.5 kg each were used. Anesthesia was induced by intramuscular injection of 5 mg of a 1:1 combination mixture of zolazepam  and xylazine hydrochloride  per kilogram body weight.3 pieces. This fresh tissue suspension was implanted into another rabbit within the muscles at the outer side of the distal portion of right tibia at a total volume of 0.1 ml. The rabbit was incubated for 4 to 5 weeks until tumor passage to the next rabbit was performed.VX2 tumors exhibiting enhanced tendency to metastasize to the LN were selected through multiple rounds of passaging. Rabbits implanted with a VX2 tumor in the lower extremity muscle were incubated for 4 to 5 weeks to allow popliteal LN metastasis to occur. Under anesthesia, the popliteal LN ipsilateral to the implanted tumor  was harvested and minced into approximately 1-mmFirst, we intended to test whether our iodine-docetaxel emulsion could serve as a SLN tracer. Under anesthesia, we subcutaneously injected the iodine-docetaxel emulsion at the right lower extremity in healthy control rabbits (n=3) and VX2 tumor-implanted rabbits . Each rabbit received three 0.7-ml injections for 2.1 ml in total, either within a narrow area  or at a peri-tumoral location (tumor-implanted rabbits). CT images were obtained before and 12 hours after subcutaneous injection of the iodine-docetaxel emulsion. The VX2 tumor-implanted rabbits underwent a follow-up CT scan 7 days after this procedure.CT lymphography was performed with a commercial 64-channel multidetector scanner  with the following parameters: 120 kV, 250 mA, 0.625-mm beam collimation, and 1.25-mm axial reconstruction thickness. The field of view was adjusted to include the entire abdomen and lower extremities.Thirty-six New Zealand white rabbits implanted with a VX2 tumor in the muscle of right side lower limb and incubated for 10 days served as a model of microscopic LN metastasis. A CT scan was performed twice, just before peri-tumoral injection of the iodine-docetaxel emulsion (pre-treatment CT) and 7 days after injection (post-treatment CT). Volumetry of popliteal LNs was also conducted twice in each rabbit based on the pre-treatment CT and post-treatment CT.For volume measurement of the popliteal LNs, the CT axial images were archived in Digital Imaging and Communications in Medicine (DICOM) format and stored on a General Electric Advantage v4 work station . The region of interest (ROI) was drawn along the margin of the popliteal LN on each slice, and total mass was calculated by adding ROI areas in consecutive images. The volumes of popliteal LNs were measured on both the ipsilateral and contralateral side to the implanted tumor.3 as a volume threshold and excluded rabbits (n=2) in which the volume of their ipsilateral popliteal LNs exceeded 1 cm3 on pre-treatment CT. The remaining rabbits (n=34) were alternatively allocated into the treatment group (n=17) or non-treatment (control) group (n=17) according to the volume of the ipsilateral popliteal LN measured on pre-treatment CT. Shortly after the pre-treatment CT scan was obtained and volumetry was performed, the treatment group rabbits received peri-tumoral subcutaneous injections  around the tumor nodule. Seven days later (17 days after the tumor was implanted), a post-treatment CT scan was conducted. Afterwards, all rabbits were euthanized with saturated potassium chloride and the bilateral popliteal LNs were sampled.In humans, it is known that metastatic LNs tend to increase in size , 37, andThe sampled popliteal LNs were fixed in 10% buffered formalin overnight, then embedded in paraffin and sectioned at 5-mm intervals. We performed hematoxylin and eosin staining and immunohistochemical staining using anti-cytokeratin monoclonal antibodies . The slides were reviewed by a pathologist (K.S.K.) with 5 years of experience in experimental animal histopathology to determine the presence or absence of metastatic tumor cells.Statistical analysis was performed using standard software . Student's t-test was used to compare the volume of popliteal LNs between the treatment group and non-treatment group. Paired t-test analysis was applied to compare the volumes of a popliteal LN measured on the pre-treatment and post-treatment CT scans. Fisher's exact test was performed to compare the rate of tumor LN metastasis between the treatment group and non-treatment group. Statistical significance was defined as P<0.05.


Mouse models of breast cancer with specific molecular subtypes  in an immunocompetent or an immunocompromised environment significantly contribute to our understanding of cancer biology, despite some limitations, and they give insight into targeted therapies. However, an ideal triple-negative breast cancer (TNBC) mouse model is lacking. What has been missing in the TNBC mouse model is a sequential progression of the disease in an essential native microenvironment. This notion inspired us to develop a TNBC-model in syngeneic mice using a mammary intraductal (MIND) method. To achieve this goal, Mvt-1and 4T1 TNBC mouse cell lines were injected into the mammary ducts via nipples of FVB/N mice and BALB/c wild-type immunocompetent mice, respectively. We established that the TNBC-MIND model in syngeneic mice could epitomize all breast cancer progression stages and metastasis into the lungs via lymphatic or hematogenous dissemination within four weeks. Collectively, the syngeneic mouse-TNBC-MIND model may serve as a unique platform for further investigation of the underlying mechanisms of TNBC growth and therapies. The slides were washed in 70% ethanol for 30 min, then in distilled water. The glands were stained with carmine stain [1 g Carmine (Sigma-Aldrich C-6125) and 2.5 g aluminum potassium sulfate  in 500 ml water] overnight in the dark. The tissues were washed in 70, 90, and 100% ethanol. Tissues were cleared in xylene, and a large cover glass was used to mount the gland with per-mount for long-term storage  were injected into the ducts of the 4th inguinal mammary glands through the nipple of female mice, as described in The goal of this study was to examine the time-dependent progression of Mvt-1-tumor growth in the mammary ducts and distant organs of female FBV/N mice; we monitored primary tumor growth and metastasis based on a gross and histopathological analysis. The histopathology of the primary tumors and metastasis was examined by the pathologists (OT and DM). After the first week of intraductal injection of Mvt-1 cells, there were no visible primary tumors in the mammary glands . Serial Palpable tumors appeared two weeks after cell injection in all mice (n = 5), and the growth of tumors was easily detected in the whole mount of the 4th inguinal mammary glands and H&E-stained tissue sections . At thisPrimary tumor growth, local invasion, and metastasis to the lungs were observed in four out of five mice after the third week of cell injection . The ducMultiple large outgrowths of metastases in the lungs were detected at four weeks after the injection of Mvt-1 cells . In thisWe, next, examined whether the contralateral glands of the mice were affected by tumor burden. We found that no primary tumors had developed in any contralateral glands where tumor cells had not been injected .th mammary glands of female mice, and tumor growth and metastasis in the lungs was monitored non-invasively using in vivo imaging system (Bruker). The studies showed that the fluorescence signal was first detected at day 7 in the 4th mammary ducts of tumor-bearing mice. Then at day 21, signals were detected both in glands and lungs in the tumor-bearing mice with higher fluorescence signal in the glands as compared to the glands of day 7   and α-SMDCIS-like structures were visible two weeks after Mvt-1 cell injection . We founBy the end of the second week or early third week, we observed that several Mvt-1 cells infiltrate the surrounding stroma of the mammary gland . These iNext, we investigated whether the infiltrated PCNA overexpressing cells formed any metastatic growths in the lungs; the lungs are the most attractive soil for the secondary growth of breast cancer cells in a xenograft model . By the Encouraged by our finding using Mvt-1 cells, we repeated the entire experimental setup using 4T1 cells in BALB/c mice. Results indicate that 4T1 cells are equally efficient in forming tumors in mouse mammary ducts within the same timeframe as observed in the Mvt-1-MIND model, starting with tumor initiation to DCIS, invasion, and finally metastasis to the lungs . InteresThe epithelial–mesenchymal transition (EMT) is a unique process that is essential for embryonic development. However, cancer epithelial cells, by sharing the EMT mechanism, acquire aggressive phenotypes including invasion and metastasis –68. GiveThe greatest number of TNBC patients die with metastatic disease  because Multiple animal models have been developed recently, but these models are not designed appropriately to study the step-by-step progression of metastasis in TNBC , 69, 71.The injection of TNBC cells into the mammary gland ducts through the nipple provides an ideal microenvironment of a mammary gland and possibly most closely resembles a spontaneous mammary gland tumor , 35. In Previously, the mouse MIND model was used to study the DCIS stage, where human MCF-DCIS.COM (MCF-DCIS) cells isolated from primary human DCIS were injected into a mammary gland through the cleaved nipple of an immunodeficient mouse model. Although this contributed greatly to the development of our study design , the metInduction of lung metastasis in a mouse model via tail vein injection of tumor cells was established decades ago –75. SincIn an era of targeted therapy, the choice of the appropriate model for TNBC research depends on the underlying hypothesis being tested. We believe that our "quick and easy" TNBC-MIND model in syngeneic mice will facilitate the development of improved breast cancer treatments.S1 Fig(PDF)Click here for additional data file.S2 Fig(PDF)Click here for additional data file.S3 Fig(PDF)Click here for additional data file.S4 Fig(PDF)Click here for additional data file.S5 Fig(PDF)Click here for additional data file.S6 Fig(PDF)Click here for additional data file.


Its lethality primarily stems from a lack of detection strategies for early stages of GC and a lack of noninvasive detection strategies for advanced stages. The development of early diagnostic biomarkers largely depends on understanding the biological pathways and regulatory mechanisms associated with putative GC genes. Unfortunately, the GC-implicated genes that have been identified thus far are scattered among thousands of published studies, and no systematic summary is available, which hinders the development of a large-scale genetic screen. To provide a publically accessible resource tool to meet this need, we constructed a literature-based database GCGene (Gastric Cancer Gene database) with comprehensive annotations supported by a user-friendly website. In the current release, we have collected 1,815 unique human genes including 1,678 protein-coding and 137 non-coding genes curated from extensive examination of 3,142 PubMed abstracts. The resulting database has a convenient web-based interface to facilitate both textual and sequence-based searches. All curated genes in GCGene are downloadable for advanced bioinformatics data mining. Gene prioritization was performed to rank the relative relevance of these genes in GC development. The 100 top-ranked genes are highly mutated according to the cohort of published studies we reviewed. By conducting a network analysis of these top-ranked GC-associated genes in the human interactome, we were able to identify strong links between 8 highly connected genes with low expression and patient survival time. GCGene is freely available to academic users at  Gastric (stomach) cancer (GC) is the fifth most commonly diagnosed cancer  and the third leading cause of cancer-related deaths in both sexes worldwide . In total, we retrieved 2,904 PubMed abstracts. GeneRIF (Gene Reference Into Function) is a collection of short descriptions of gene functions in the Entrez Gene database . HoweverPtgs2 in the Entrez gene database. After careful manual cross-checking, we mapped all the curated genes to their corresponding human homologous groups using the NCBI HomoloGene database using the same method we implemented in a previous analysis [The curation of GC genes from literature in this study was conducted in three major steps: (1) grouping all 2,904 retrieved abstracts based on their semantic similarity using the “Related Articles” function in Entrez; (2) extracting contents related to GC from grouped abstracts; and (3) manually collecting gene names from the descriptions of the text and mapping the gene names to Entrez gene IDs. These curation steps allowed us to quickly and easily cross-check whether and how the curated abstract was related to GC. To provide a unified functional annotation, we used Entrez gene IDs as the key in all the tables of our GCGene database to cross-link the same genes from different public bioinformatics databases. To ensure the accuracy of our literature evidence, we collected the species information and the gene alias and manually mapped them to the official HUGO gene symbol. For example, in the sentence “Results suggest that the COX-2/microsomal prostaglandin E synthase-1 pathway contributes to the Helicobacter-associated gastric tumorigenesis,”  the geneanalysis , 32. In Information regarding comprehensive biological functional was retrieved from public resources for the annotation of the 1,815 human GC-associated genes in our database. The basic gene information and sequences were collected for each gene from the following databases: NCBI Entrez gene  , UniProtThe original published GC-associated articles in PubMed were hyperlinked to their respective genes. Using the Perl Script and Swiss knife modules, functional information was integrated from Gene annotations , Gene OnP-values < 0.01 were identified as over-representative annotations for each gene set. The resulting enriched gene ontology terms were further summarized and visualized by the REVIGO online server [The functional enrichment analysis of disease, pathways, and other functional annotations for each gene was accomplished using ToppFun . In these server .Using the ToppGene gene ranking tool , we prioNext, based on the extracted biological features from the training set, ToppGene builds a ranking model. The ranking model that contains multiple dimensional data is then used to prioritize the remaining 1,797 genes. Finally, the ToppGene ranking model combines all of the rankings into a global ranking for the 1,815 GC-associated genes using order statistics . In the To study the potential biological mechanisms related to GC-associated genes, we extracted protein-protein interactions between the 100 top-ranked GC-associated genes and other human genes. To accomplish this task, we first collected a list of non-redundant pathway-based human interactomes from the PathwayCommons database, which includes several biological pathway databases such as KEGG and Reactome. We then extracted a subnetwork containing the 100 top-ranked GC-associated genes from the human interactome using an approach similar to the one implemented in our previous study . All of If the function of genes is systematically studied from the point of view of the network, the complexity and interconnectedness of the biological network is revealed. In general, biological networks tend to follow some simple rules, and the topological properties of the networks may be closely related to their function . Therefo


The aim of this systematic review was to analyze the short and long-term spontaneous dentoalveolar changes of the mandibular dental arch after slow (SME) or rapid (RME) maxillary expansion in the mixed and early permanent dentitions. An electronic search was performed in the following databases: PubMed/Medline, Cochrane Library, Scopus, Embase and Web of Science. Eligibility criteria for article selection included randomized controlled trials and prospective studies written in English, with no restriction of year of publication, involving patients who underwent SME or RME during the mixed or early permanent dentitions. A double-blind search of articles was performed by two reviewers. Initially, the title and the abstract of the studies were read, and their references were also hand-searched for possible missing studies. A methodological quality scoring scale was used to analyze the selected articles. The search retrieved 373 articles, but only 6 were selected for review after application of the eligibility and exclusion criteria. Non-clinically significant spontaneous dentoalveolar changes of approximately 1mm were found in the mandibular dental arch in the short and long-term, after slow or rapid maxillary expansions. Furthermore, no significant differences were found between treated and control groups. There is enough evidence to conclude that negligible short and long-term spontaneous dentoalveolar changes tend to occur in the mandibular dental arch after SME or RME in the mixed and early permanent dentitions. More randomized studies with appropriate control group are required to better evaluate this issue. Therefore, randomizedThe protocol of this systematic review was prepared and registered in PROSPERO (CRD42016039760). This review was conducted based on the PRISMA Statement for Systematic ReviewThe exclusion criteria were patients with oral clefts or associated craniofacial anomalies, previous orthodontic treatment, intervention in the mandibular dental arch during the follow-up period, surgically-assisted rapid maxillary expansion and the lack of a control group.An electronic search was performed in the following databases with the assistance of a senior librarian specialized in Health Sciences databases: PubMed/Medline, Cochrane Library, Scopus, Embase and Web of Science. The search strategy used in the aforementioned databases included the MeSh terms “dental arch” and “palatal expansion technique” or “maxillary expansion” and “mixed dentition” or “permanent dentition”. A double-blind search of articles was performed by two reviewers. Initially, the title and the abstract of the studies found in each database were independently read by both examiners according to PICO. The references of the articles were also hand-searched for possible missing studies. In case of disagreement regarding which article fulfilled the inclusion criteria, consensus was reached by discussion between the two reviewers. The articles that fulfilled the inclusion criteria were included in the systematic review and were qualitatively analyzed using the Cochrane collaboration recommendationsK = 0.94).The electronic search retrieved 373 articles. After examination of the titles and abstracts of these studies, 56 articles were selected, however this number was reduced to 16 when duplicates were removed. Ten additional articles were found after hand-search on the references of the previous 16 studies found. The full-text copies of all of these articles were analyzed according to the eligibility and exclusion criteria, resulting in 6 studies qualified for the final analysis. The flow diagram shows the process of article selection . Kappa sA summary of the methodological characteristics of the final studies - such as authors, year of publication, study design, sample size, dentition stage, type of expansion procedure, type of appliance used, amount of maxillary expansion, follow-up period and the measurements performed in the mandibular dental arch - is given in -,-All the selected studies assessed the spontaneous dentoalveolar changes of the mandibular dental arch after slow or rapid maxillary expansion, performing measurements with digital sliding caliper in conventional dental models. The main variables assessed in these studies were: mandibular intercanine distance--,In general, the follow-up period of the spontaneous dentoalveolar changes of the mandibular dental arch after SME was greater than that of the RME. The short-term spontaneous dentoalveolar changes after slow maxillary expansion was evaluated in four studies,The removable expansion plate promoted greater increases of the mandibular intermolar distance , compared to the quad-helix appliance , six months after slow maxillary expansion.No significant spontaneous dentoalveolar changes were observed in the mandibular dental arch of the treated and untreated groups 4.24 monthsThe quad-helix appliance promoted a significantly greater increase of the mandibular inter-first permanent molar distance (0.46mm) compared to the removable expansion plate (-0.36mm), 16.24 to 18.12 months after slow maxillary expansion. However, no significant differences were found between the experimental groups and the control group (-0.18mm).Thirty-six months after the slow maxillary expansion procedure, the control group showed a significantly greater increase of the mandibular inter-first permanent molar (0.5mm), compared to the quad-helix (-0.6mm) and the removable expansion plate groups (-0.6mm).Seventy-six months after SME, the quad-helix group showed a significantly smaller decrease (-0.6mm) of the mandibular intercanine distance compared to the control group (-1.3mm).Finally, a significantly greater increase of the mandibular inter-first permanent molar distance was found for the control group (0.5mm) compared to the removable expansion plate group (-0.1mm), approximately eighty-two months after slow maxillary expansion.Significant increases of 0.9mm in the mandibular intercanine distance and 0.7 mm on the mandibular inter-second deciduous molar distance were found for the experimental group, 1.1 years after rapid maxillary expansion using the Haas-type expander. However, no statistically significant differences were found between the experimental and control groups in the mandibular intercanine and inter-second deciduous molar distances after the 13 months of follow-up. No intra and intergroup differences were found for the mandibular inter first-permanent molar distance.Only a significant increase of 0.9mm was found in the mandibular intercanine distance of the experimental group, 28 months after rapid maxillary expansion with the Haas-type expander.Similar results were found when spontaneous dentoalveolar changes of the mandibular dental arch were analyzed 3.2 years after rapid maxillary expansion using the acrylic splint expander.-Short and long-term dentoskeletal effects of slow and rapid maxillary expansion were already analyzed in systematic reviews and meta-analyses.A previous study--In this review, the selected randomized controlled trials,-,--,-,,--The selected prospective studies showed important methodological limitations, such as the lack of detailed description of randomization of patients,--Neither the selected RCTs,The follow-up assessment of treated and untreated patients is important for comparison purposes. However, two studies,Additionally, attention is required when interpreting the short and long-term results of Cozzani et alThe selected studies showed negligible spontaneous dentoalveolar changes of approximately 1mm in the mandibular dental arch of patients treated with slow or rapid maxillary expansion. The clinical implication of this is that clinically significant spontaneous dentoalveolar changes should not be expected in the mandibular dental arch after SME or RME in the short and long-term. If patients show constricted mandibular dental arch with or without incisor crowding, dentoalveolar expansion of the mandibular dental arch may be indicated.A limitation of the present systematic review was the difficulty in finding studies with adequate control groups. Additionally, a great number of articles analyze the long-term changes of maxillary expansion followed by fixed orthodontic appliances in the maxillary and mandibular dental arches. Future randomized controlled trials with appropriate control groups should analyze the short and long-term spontaneous dentoalveolar changes of mandibular dental arch after SME and RME to better evaluate this issue. Improvement in the methodological quality of studies and the homogeneity of RCTs might give further information for future meta-analyses, which can provide higher levels of scientific evidence to support the orthodontic clinical practice.» Based on the results from this systematic review, there is enough evidence to conclude that negligible short and long-term spontaneous dentoalveolar changes occur in the mandibular dental arch after SME or RME in the mixed and early permanent dentition.» More short and long-term randomized controlled trials with appropriate control groups are needed to better evaluate the spontaneous dentoalveolar changes of mandibular dental arch after slow and rapid maxillary expansion.


Structural and functional differences are known to exist within the cortical sensorimotor networks with respect to the dominant vs. non-dominant hand. Similarly, the cerebellum, a key structure in the sensorimotor network with its cerebello-cortical connections, has been reported to respond differently when using the dominant vs. non-dominant hand. Several groups have already investigated causal interactions during diverse motor paradigms using effective connectivity but few have studied the larger visuomotor network, including key structures such as the parietal cortex and the cerebellum, with both hands. Moreover, the effect of force level on such interactions is still unclear. We therefore sought to determine the hemispheric asymmetries in the cerebello-cortical sensorimotor network in right-handers at two force levels (5% and 10% maximum voluntary contraction) for both hands. Cerebello-cortical modulations were investigated in 28 healthy, right-handed volunteers by determining the effective connectivity during a visuomotor task at two force levels under fMRI. A network was built consisting of the left and right primary motor (M1), ventral premotor (PMv) and posterior parietal cortices (PPC), in addition to the supplementary motor area (SMA), and the ipsilateral cerebellum (Cer) to the hand performing the motor task. Task performance (precision of isometric grip force tracking) did not differ between hands, nor did task-related activations in the sensorimotor areas apart from the contralateral primary motor cortex. However, during visuomotor control of the non-dominant hand, connectivity analysis revealed causal modulations between (i) the ipsilateral cerebellum and SMA, and (ii) the ipsilatearl cerebellum and contralateral PPC, which was not the case when using the dominant hand. These cerebello-cortical modulations for the non-dominant hand were more present at the higher of the two force levels. We conclude that precision force generation executed with the non-dominant hand, compared to the dominant hand, may require enhanced cerebello-cortical interaction to ensure equivalent left-right task performance. Growing evidence suggests that there are hemispheric differences in the sensorimotor network in the healthy population at both the structural and functional level  to construct a sensorimotor network model. The inclusion of these particular ROIs was critical for elucidating the underlying network dynamics as they are all highly involved in visuomotor paradigms  in the cerebello-cortical modulations for (1) the dominant vs. the non-dominant hand and (2) force level. To this purpose, we will first describe the causal interactions in the sensorimotor network for the dominant and non-dominant hand during a visuomotor force-tracking paradigm and then analyze (if any) the relationship between force level and causal interactions in the sensorimotor network for each hand. We predicted that (1) the main cortical interactions would constitute an extensive, bilateral network and be nearly identical for the dominant and non-dominant hand : the average of three attempts was retained for each hand. The study was approved by the appropriate legal and ethical authority  and was carried out according to guidelines of the World Medical Association (Declaration of Helsinki). Written informed consent was obtained from all participants.Twenty-eight healthy volunteers  were recruited using the following criteria: (1) no history of neurological or psychiatric disorders determined through an interview with a trained neurologist , (2) age older than 18 years, (3) no contra-indications for MRI, (4) right-handedness and (5) normal or corrected vision. Volunteers were evaluated with the Edinburgh Handedness Inventory (EHI) . Zero force was equivalent to just holding/stabilizing the manipulandum in the hand. The task was performed twice with each hand individually. The target trajectory comprised seven blocks of three events: one ramp and two ramp-and-hold events. Two different target force levels were used: for the first run, the peak (hold) force was set at 10% MVC for four blocks and interleaved with three blocks at 5% MVC. The second run contained three blocks at 10% MVC interleaved with four blocks at 5% MVC. Subjects systematically began with the first run; however, the hand with which participants began was counter-balanced. A second manipulandum was placed in the inactive hand to control for eventual involuntary bilateral contractions. All subjects were trained until they felt comfortable with the task. For each trial, the root mean square (RMS) error between the target force trajectory and the subject's force trajectory was calculated and normalized by the target force level of the trial  in order to establish if errors were attributable to handedness or force levels.The functional paradigm was a mixed block-event related design: participants performed a visually guided, unilateral power grip ramp-and-hold force-tracking task , gradient-echo echo-planar functional images sensitive to BOLD contrast .MRI data was obtained with a 3T scanner  with a 32-channel head coil. The MRI protocol included a sagittal T1-weighted MPRAGE image  following standard procedures. The functional images were slice-time corrected and realigned to the first volume of the sequence to correct for head movements throughout the exercise. The functional images with posterior-anterior phase encoding were used to correct susceptibility distortions in the functional images using FSL's TOPUP  right, dominant hand grasping, (2) left, non-dominant hand grasping, (3) a conjunction analysis of both hand conditions, (4) 10% MVC > 5% MVC for the right (dominant) hand, (5) 5% MVC > 10% MVC for the right hand, and (6) 10% MVC > 5% MVC for the left (non-dominant) hand, and (7) 5% MVC > 10% MVC for the left hand. Group-level statistical parametric map results are presented with a voxel-wise Family Wise Error (FWE) correction at The visuomotor network consisted of 8 ROIs: left and right M1, ventral premotor cortex (PMv), posterior parietal cortex (PPC), a single left-right merged supplementary motor area (SMA), and lobule VI of the cerebellum (Cer) ipsilateral to the active hand. The inclusion of these particular ROIs was critical for elucidating the underlying network dynamics as they are all highly involved in visuomotor paradigms . Four families of models  and both B matrices to investigate consistencies in the subjects' models  on the SMA for two reasons: (i) due to the role of the SMA in motor planning, similar to other DCM studies . During the tracking task, RMS errors during the 5% and 10% MVC tasks were relatively low : 1.49, p = 0.2], but higher RMS errors were produced during 5% MVC events than 10% MVC events for both hands .The mean and standard deviation for the handedness (EHI) scores were 0.87 ± 0.20 (N = 26). In terms of MVC grip strength, there was no significant difference between the right 307 ± 88N) and left (301 ± 82N) hand , and cerebellum Figure , and forThe Bayesian model selection between the four types of families revealed that the “bilateral” model (Family 4) explained the observed data better than the other 3 models for both the dominant and non-dominant hand Figure .For trials at 10% MVC, the most striking difference between the network for the dominant and non-dominant hand was seen in the cerebello-cortical connectivity Figure . At 10% Despite this difference, there were some network similarities between the dominant and the non-dominant hand at 10% MVC: (i) a positive influence from SMA to contralateral M1 with a negative feedback modulation, (ii) a positive contralateral M1 to PPC influence with a negative feedback modulation and (iii) a positive bilateral parieto-premotor influence for both hands. A different picture emerged for the 5% MVC events: cerebellar modulation onto cortical areas was absent for either hand. Interestingly, regardless of the active hand, there was an inhibitory feedback modulation from right PMv to SMA . A further difference at the 5% MVC force level was the inhibitory modulation of M1 onto SMA for the left non-dominant hand, but absent for the right dominant hand. For the right hand, a bilateral negative influence of PPC onto PMv was present. For the left hand, however, this negative PPC-PMv modulation was present in the ipsilateral hemisphere. Finally, the more notable similarity between force modulatory connections  was a stronger positive influence from SMA to left and right PMv and to the M1 contralateral to the active hand.In the present study, we investigated the effective connectivity between eight regions of interest in the visuomotor  network for the control of grip force of the dominant vs. non-dominant hand in right-handers. As expected, the most likely model for both hands contained bilateral modulations within and across both hemispheres, with several already reported cortico-cortical effective connections, such as strongly coupled positive modulations between SMA and bilateral PMv  specifically during visuomotor force control with the non-dominant hand, but absent for the dominant hand. We interpret this finding as follows: (1) the particular cortical targets of the cerebellum being the SMA and the PPC suggest that these modulations sub-serve sensorimotor integration  necessary for task completion, and (2) there is no evidence for this asymmetry in cerebello-cortical modulations to be related to task performance since force-tracking error did not differ when subjects used the dominant or non-dominant hand.Why these cerebello-cortical modulations were, in our case, present at the higher (10% MVC) of the two tested force levels and only in the non-dominant hand may be explained by bringing up and combining two notions. First, this may be specific to the non-dominant hand, since control of the non-dominant hand (at similar performance levels compared to the dominant hand) may require more neuronal resources for sensory recalibration and motor adaptation Ramnani, . We assuSecond, why these cerebello-cortical modulations were, in our case, present at the higher (10% MVC) but not at the lower of the two tested force levels may be explained by another, complementary notion. The reliability of sensory modalities  used in force control may vary as a function of force level  to our network. Many studies applying DCM to motor paradigms have chosen different C-matrices (input), with little consensus. For example, Wang et al.  and PoolFinally, we did not include left-handers in our analysis. Consequently, we cannot ascertain that the same observed hemispheric asymmetries would be seen in left-handers in the left hemisphere or if they would remain in the right-hemisphere.We provide evidence of differential effective connectivity in the visuomotor system of right-handers when using the dominant (right) vs. the non-dominant (left) hand during a visuomotor grip force task. The network model consisted of M1, SMA, PMv, PPC and the cerebellum. Compared to the dominant hand, additional effective connectivity was present during use of the non-dominant hand. This concerned modulations between the cerebellum and the SMA, as well as between the cerebellum and the right posterior parietal cortex. This reflects most likely additional neuronal resources required for monitoring motor execution during multi-sensorial force control of the non-dominant hand. Our results are largely consistent with but add more specificity to the reported network formed by these structures, all of which are involved in the execution of visuomotor tasks with the hand.EM, CG, CK, RV, MM, PL, and CR have met these 4 criteria: (1) substantial contributions to the conception or design of the work, (2) the acquisition, analysis, or interpretation of data for the work, (3) drafting the work or revising it critically for important intellectual content, (4) final approval of the version to be published. Agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


In this study, we investigated the effect of supplementing a non-dispersive dicalcium phosphate-rich calcium phosphate bone cement (DCP-rich CPC) with type I collagen on in vitro cellular activities and its performance as a bone graft material. Varying amounts of type I collagen were added during the preparation of the DCP-rich CPC. In vitro cell adhesion, morphology, viability, and alkaline phosphatase (ALP) activity were evaluated using progenitor bone cells. Bone graft performance was evaluated via a rat posterolateral lumbar fusion model and osteointegration of the implant. New bone formations in the restorative sites were assessed by micro-computed tomography (micro-CT) and histological analysis. We found that the incorporation of collagen into the DCP-rich CPC was associated with increased cell adhesion, cell viability, and ALP activity in vitro. The spinal fusion model revealed a significant increase in bone regeneration. Additionally, better osseointegration was observed between the host bone and graft with the DCP-rich CPC supplemented with collagen than with the collagen-free DCP-rich CPC control graft. Furthermore, compared to the control graft, the results of micro-CT showed that a smaller amount of residual material was observed with the collagen-containing DCP-rich CPC graft compared with the control graft, which suggests the collagen supplement enhanced new bone formation. Of the different mixtures evaluated in this study , DCP-rich CPC supplemented with 0.4 mL collagen led to the highest level of osteogenesis. Our results suggest that the DCP-rich CPC supplemented with collagen has potential to be used as an effective bone graft material in spinal surgery.  Over one million patients with skeletal issues require orthopedic surgery each year. Bone grafts are widely utilized in orthopedic surgery to augment bone union and regeneration . The useVarious strategies have been developed and evaluated for promoting the conversion of CPC to new bone, including increasing its porosity and using water-soluble polymers and platelet-rich plasma (PRP) as additives in apatite-forming CPCs ,6,7. A pThe aim of this study was to investigate the effect of supplementing DCP-rich CPC with type I collagen on cellular activities and its performance as a bone graft material. Collagen solution and the DCP-rich CPC were mixed to create a moldable bone graft, which was then evaluated for cell adhesion, morphology, viability, and ALP activity using bone cell progenitors. The use of the bone graft in posterolateral lumbar fusion surgery in a rat model was assessed with radiology using three-dimensional micro-computed tomography (micro-CT). Finally, the optimal ratio of collagen to DCP-rich CPC was determined.4(PO4)2O) powder was prepared via the sintering of dicalcium pyrophosphate  and calcium carbonate . The DCP-rich CPC was prepared by mixing TTCP and dicalcium phosphate anhydrous  powders at a DCPA-to-TTCP molar ratio of two. The detailed procedures for preparing DCP-rich CPC have been described previously  × 100%.n = 3). Four-micron sections were cut and stained with hematoxylin and eosin (H&E) for analysis of general morphology and identification of the slides. Images were acquired with a light microscope  equipped with a digital camera . Histological analysis was performed every week after surgery for both groups.Specimens were fixed for 24 h in 10% formalin for histological analysis. The tissue was dehydrated with 50, 70, and 95% ethanol for one hour each, and with 100% ethanol for two hours. After dehydration, the tissue was left overnight at room temperature in the resin mixture, consisting of a 3:1 solution of methyl methacrylate and dibutyl phthalate. The tissue was then embedded in a polyethylene molding cup. Coronal sections were obtained from both sides of each rat  in conjunction with Holm-Sidak post hoc testing was used to compare the results. In all cases, results were considered significantly different when In this study, D1 cell viability was measured after incorporating varying amounts of collagen solution into the DCP-rich CPC. The DCP-rich CPC was found to be difficult in forming bone cement when the volume of the collagen solution volume exceeded 0.4 mL. As shown in The results of the in vitro study showed that the DCP-rich CPC supplemented with 0.4 mL collagen led to the highest levels of cell viability, cell attachment, and ALP staining. Therefore, the DCP-rich CPC supplemented with 0.4 mL collagen was selected for comparison with control for testing in vivo. The two materials were used in L4–L5 posterolateral fusion in SD rats. Radiographs four weeks post-operatively revealed notable fusion mass in both groups. For the DCP-rich CPC supplemented with 0.4 mL collagen group, more fusion mass was clearly observed bilaterally in the L4–L5 interspace than in the control group . Coronal micro-CT images at every stage in both groups are presented in p < 0.01). Residual graft volume of both sides was measured through the contrast of the image in We noted that the control DCP-rich CPC grafts readily dropped off from the implantation site during specimen preparing procedures, including during the dehydration and cutting steps . SpecifiAutologous bone grafting has been the gold standard treatment in posterolateral lumbar fusion for many decades; however, issues associated with the use of autografts include limited availability and variability of graft quality, increased risk of hematoma, infection, and bleeding, increased operative time, chronic donor site pain, and high cost . SubsequPrevious studies have revealed that mouse MSCs show higher ALP activity and higher mRNA expression of type I collagen during osteogenic differentiation, and that type I collagen can induce MSC differentiation in vitro ,19,20. OOur study demonstrated that the addition of 0.4 mL of 0.1% type I collagen to 0.8 g DCP-rich CPC enhanced osteointegration in the space between host bone and graft in a posterolateral lumbar fusion model. Histologically, a larger quantity of osteoblast-deposited lamellae of new bone tissue and a greater number of osteocytes were observed in the DCP-rich CPC supplemented with the collagen group than in the DCP-rich CPC group. It has been noted that the ions released from CPCs could cause ion–dipole interaction, cell adhesion, proliferation, and differentiation . The bioThere were several limitations in this study. Firstly, the in vitro study only analyzed three concentrations of collagen-containing DCP-rich CPC. The most effective concentration of DCP-rich CPC supplemented with collagen might not be included. However, we hope this study could be an anchor for following research. Secondly, only the DCP-rich CPC supplemented with 0.4 mL collagen was tested in the in vivo study because it resulted in the highest levels of cell viability, cell attachment, and ALP staining. However, if the in vivo study also included the group of the DCP-rich CPC supplemented with 0.1 mL or 0.2 mL collagen, we might obtain a better understanding of the effect of osteogenesis of type I collagen.In this study, we systematically evaluated the effect of added collagen to the biological performance of the DCP-rich CPC and its ability to affect osteogenic differentiation in vitro and in vivo. Our results show that collagen not only promoted D1 cell attachment and proliferation, but that it also elicited the early stage of progenitor cell differentiation in terms of morphological characteristics and ALP activity. The DCP-rich CPC supplemented with collagen was also associated with a significantly increased bone turnover rate of L4–L5 transverse processes as shown via micro-CT. Overall, our results suggest that the incorporation of collagen promotes absorption of the DCP-rich CPC by osteoclasts as well as the laying down of a new osteoid matrix by osteoblasts, and that it has potential to be an effective treatment for use in bone defect restoration in spinal diseases.