The AXL receptor tyrosine kinase and its major ligand, GAS6 have been demonstrated to be overexpressed and activated in many human cancers  and have been correlated with poor prognosis, promotion of increased invasiveness/metastasis, the EMT phenotype and drug resistance. Targeting AXL in different model systems with specific small molecule kinase inhibitors or antibodies alone or in combination with other drugs can lead to inactivation of AXL-mediated signaling pathways and can lead to regained drug sensitivity and improved therapeutic efficacy, defining AXL as a promising novel target for cancer therapeutics. This review highlights the data supporting AXL as a novel treatment candidate in a variety of cancers as well as the current status of drug development targeting the AXL/GAS6 axis and future perspectives in this emerging field. The tyrosine kinase family of proteins is composed of two major groups, receptor tyrosine kinases (RTKs) and non-receptor tyrosine kinases (NRTKs). RTKs are well known to be involved in tumorigenesis and many of these serve as actionable targets for cancer therapy. The TAM group of RTKs is a recently identified class of the RTK subfamily that transduces crucial extracellular signals to the inside of the cell . The smaThe TAM family kinases were initially considered to be orphan receptors , 7 but nAXL can be activated through a number of different mechanisms: ligand-dependent dimerization , ligand-independent dimerization, interaction between two monomers on neighboring cells and heteromeric dimerization with a non-TAM receptor Figure  3, 12, , 20. GasThe TAM family of RTKs regulates an intriguing mix of physiological processes, including cell proliferation, survival, cell adhesion and migration, blood clot stabilization, and regulation of inflammatory cytokine release. Although expression of TAM receptor mRNAs is observed in embryonic tissues –28, singAXL has been reported to be overexpressed or ectopically expressed in a multitude of cancers Table . While oOverexpression of AXL has been observed in approximately 60% of NSCLC cell lines, and AXL is also highly expressed in a significant fraction of primary lung cancers , 74. It AXL is overexpressed in highly invasive breast cancer cell lines ; in contrast, weakly invasive breast cancer cell lines do not or only weakly express AXL. It has also been demonstrated that AXL expression correlates with motility and invasiveness in breast cancer cells . The miRAXL was found to be an independent prognostic marker and therapeutic target in acute myeloid leukemia (AML). It appears that AML cells can induce expression and secretion of Gas6 from bone marrow derived stromal cells and Gas6 in turn mediates proliferation, survival and chemoresistance of AXL expressing AML cells. This paracrine axis creates a chemoprotective tumor cell niche. AXL inhibition with the small molecule inhibitor, BGB324 is able to overcome this mechanism and can synergize with chemotherapy. In this study, 57% of AML patient samples showed AXL expression and overall outcome in this subset was worse. 90% of samples showed Gas6 expression, however further analysis showed that this expression was predominantly related to stromal expression .AXL in prostate and pancreatic cancerIncreased AXL expression was demonstrated to promote migration and invasion of prostate cancer cells in vitro , 57, 84,The epithelial–mesenchymal transition (EMT) describes a reversible switch from an epithelial-like to a mesenchymal-like phenotype and it is a global program that endows epithelial cells with the ability to migrate and invade surrounding tissue. It is essential for the development of normal epithelium, and also contributes to the invasive and metastatic properties of carcinomas , 87. In In order to reveal the actual mechanisms underlying the association of AXL and EMT, many factors related to EMT have been explored. For example, vimentin expression was shown to be required for the induction of AXL expression and such regulation functionally contributed to the EMT phenotype in breast cancer cells and accordingly silencing of vimentin decreased AXL levels significantly . MZF1 waSeveral studies suggest that overexpression of AXL may result in resistance to both targeted therapies and conventional chemotherapy in different models, such as lung cancer , breast Recently, expression of AXL has been identified as a predictor for lack of response to EGFR–targeted inhibitors in triple-negative breast cancer cells. In thisOverexpression of AXL in esophageal carcinoma has been shown to promote cisplatin resistance through regulation of c-ABL/p73 signaling . In AML,In addition to AXL overexpression, MET overexpression and the expression of its ligand, HGF have both been described as in vitro and in vivo mechanisms of resistance to EGFR TKI therapy in EGFR-mutated lung cancers. The AXLDeficiencies in TAM signaling have been shown to play key roles in sustained immune activation and chronic inflammation raising some concerns about the use of AXL inhibitors in cancer therapy. For example, in many cells, some cytokine receptor signaling systems, such as signaling via the type 1 interferon receptor, are co-dependent on TAM family receptors . AXL andOn the other hand, another recent study suggests a reverse role for TAM receptors in the regulation of cancer metastases by the modulation of NK cell activity. This study found that mice with targeted inactivation of the E3 ubiquitin ligase, Cbl-B demonstrate enhanced NK cell activity against metastatic tumor models and this unique activity was found to be related to the regulation of TAM family receptors that were found to be ubiquitylation substrates for Cbl-b. Indeed, further studies showed that a small molecule TAM kinase inhibitor, LDC1267 confers treatment potential through enhancing in vivo NK cell activity and very interestingly, this activity is mimicked by the anticoagulant warfarin which through its gamma-carboxylase inhibitor activity leads to the generation of deficient Gas6 unable to activate TAM receptors. These key observations suggest that inhibition of TAM/AXL activity could in fact have additional anti-cancer activity through NK cell potentiation against metastatic disease .As highlighted before, an overexpressed/overactivated Gas6-AXL axis in a wide variety of cancers can contribute to their progression, including invasion, metastasis, and resistance both to chemo as well as targeted anti-cancer therapies, indicating that the Gas6/AXL pathway is a very promising target for cancer therapy. Inhibition of this pathway can practically be achieved through multiple means e.g. by using AXL TKIs, drugs targeting the AXL/MET/EGFR interface, and their downstream signaling effectors or by using blocking antibodies against Gas6 and AXL. As shown in Table Many of the ongoing clinical trials of such multikinase drugs have been initiated without a current focus on AXL as a main target. As early phase studies of such compounds are completed and AXL continues to emerge as a promising target, studies are starting to emerge with a specific focus on AXL. Some more relevant studies are listed below. For example, LY2801653 is a type-II ATP competitive multi kinase inhibitor of MET and AXL and MST1R that has been shown to inhibit cellular functions of MET, including cell migration and proliferation and anti-tumor activities in multiple mouse xenograft models  121]. P. P121]. Other novel methods of inhibiting AXL receptor specifically include an anti AXL monoclonal antibody, YW327.6S2 which has shown highly specific activity in preclinical models. AnotherAnother somewhat different route of targeting AXL overexpression/activity might be through the inhibition of key proteins involved in the regulation of protein trafficking called chaperones, such as heat shock proteins (HSP’s) involved in protein processing. Recently AXL in fact was shown to be a client protein of the hsp90 chaperone. In an AXL-dependent thyroid cancer model system, treatment with the hsp90 inhibitor, 17-AAG led to a substantial reduction in AXL expression accompanied by downregulation of AXL activation and downstream signaling activity. Elegant studies demonstrated that this activity is dependent on modulation of the trafficking of the fully glycosylated, mature 140 kDA form of AXL and this phenomenon appears independent of AXL phosphorylation. Downregulation in the presence of hsp90 inhibition is mediated by proteasomal degradation as a result of polyubiquitination through binding of the hsp70/CHIP E3 ligase. These data strongly suggest that AXL overexpression and activity could be successfully targeted in AXL-addicted tumors or in AXL-mediated drug –resistant cancers via hsp90 inhibition .125 via SPECT/CT imaging in mice xenografted with AXL-high and AXL-low pancreatic and prostate cancer cell lines and uptake appeared to correlate closely with IHC findings. As AXL expression can be variable within tumors and as acquired drug resistance studies suggest that it can change temporally, a biomarker that can image AXL expression spatially as well as over time would be highly desirable and with positron-emitting isotopes, such as 89ZR might be amenable to immuno-PET imaging which could be readily incorporated into AXL-targeting clinical studies [One key issue for the development of AXL-targeted therapies for human use is the selection of appropriate biomarkers for patient enrichment. As no genetic changes have been reported so far correlating with AXL overexpression, IHC appears to be the method of choice and has been utilized in a number of in vitro and animal studies successfully. Another potentially appealing biomarker for clinical studies might be imaging AXL expression in vivo using labeled probes. One study showed successful labeling with the use of an anti-human monoclonal AXL antibody radiolabelled with I studies .What is the mechanism of AXL overexpression/activation in human cancers? Is AXL overexpression mediated through genetic, epigenetic or other mechanisms in different cancer subsets and could better understanding of AXL regulation yield clinically useful biomarkers?What is the correlation between AXL expression and the elusive EMT phenomenon? Is AXL a driver or an effector of EMT or is it just an epiphenomenon of the EMT process?How do the AXL/MET cell surface complexes form in drug resistant tumors and could better understanding of this key bypass pathway yield novel therapeutics to affect drug resistance?How does AXL inhibition impact cancer immunity outside of its utility to block tumor metastasis, invasion and reverse drug resistance? Can immune deficiency be a major roadblock in the development of AXL inhibitors or can it be bypassed through some means? Alternatively, could inhibitors of the AXL/GAS6 axis have beneficial anti-cancer effects through NK cell activation?Clinical studies of AXL inhibitors will need to incorporate multiple potentially relevant biomarkers of AXL activity/dependency as well as biomarkers of anti-tumor immunity to ensure that key signals from ongoing studies are not missed in this area which currently lacks a validated biomarker for appropriate patient selection. In addition, given the very different contextual aspects of AXLs role in carcinogenesis, invasion/metastasis/EMT and drug resistance, clinical studies will need to assess these carefully in each particular scenario.The last few years have seen tremendous advances in our understanding of the wide relevance of AXL activation in multiple aspects of oncogenesis, invasion, metastasis and drug resistance. The field appears poised to take on the next and most important task and define the true translational potential of AXL inhibition in the clinic. Key issues to address in the coming years include the following relevant questions:


Neuronal rhythms of different frequencies are ubiquitous in the brain activity. These rhythms are thought to be not just a mere epiphenomenon of neural dynamics, but to play an important role in information processing performed by the brain networks. However, the character of their functional involvement remains still largely elusive.Fast brain rhythms in the gamma frequency range of 40-100 Hz, known to modulate both neuronal activity and synaptic plasticity, were often proposed to provide a reference frame for operations performed by cortical microcircuits . More prWe use here a hierarchical recurrent network that employs gamma cycle as an atomic fragment for unsupervised learning of object identity from natural image input . UnsuperThus, the presented network model provides interpretation of the gamma cycle as an elementary fragment of ongoing processing and learning, where each cycle embeds a winner-take-all-like computation that supports memory trace formation and memory trace maintenance in hierarchical recurrent network pathways of the cortex.


Considering the existence of clinical trials currently evaluating the efficacy of autologous PRP, the present review analyses fundamental questions regarding the putative role of platelet derived fractions as regulators of angiogenesis and evaluates the possible clinical implications of these formulations.Platelet degranulation allows the release of a large amount of soluble mediators, is an essential step for wound healing initiation, and stimulates clotting, and angiogenesis. The latter process is one of the most critical biological events observed during tissue repair, increasing the growth of blood vessels in the maturing wound. Angiogenesis requires the action of a variety of growth factors that act in an appropriate physiological ratio to assure functional blood vessel restoration. Platelets release main regulators of angiogenesis: Vascular Endothelial Growth Factors (VEGFs), basic fibroblast growth factor (FGF-2), and Platelet derived growth factors (PDGFs), among others. In order to stimulate tissue repair, platelet derived fractions have been used as an autologous source of growth factors and biomolecules, namely Platelet Rich Plasma (PRP), Platelet Poor Plasma (PPP), and Platelet Rich Fibrin (PRF). The continuous release of these growth factors has been proposed to promote angiogenesis both  Wound healing, a natural restorative response to tissue injury, is governed by an elaborate response driven by resident and circulating cells, homing to the injury site, that release soluble mediators or signals generated from the extracellular matrix  the importance of growth factors and biomolecules related to angiogenesis present in plasmatic fractions with different concentrations of platelets and (2) the clinical rationale for their use in cell therapies involved in the treatment of traumatic injuries as well as degenerative diseases.After the inflammatory phase has been initiated, the wound healing response requires angiogenesis as a process that modulates the activation, proliferation, and migration of endothelial cells to establish new blood vessels from pre-existing vasculature  in craniofacial bone grafts in the late nineties   low or without Leukocytes: Plasmatic preparations from anticoagulated venous blood “without leukocytes and with a low- density fibrin network.” The white blood cell count of these samples is less than the whole blood percentage  with Leukocytes: Plasmatic fractions from anticoagulated venous blood “with leukocytes and with a low-density fibrin network.” The leukocytes content in these preparations is at least five times compared with the base line of whole blood counting  low or without Leukocytes: These correspond to “preparations without leukocytes and with a high-density fibrin network.” Fibrin, in combination with growth factors, has been shown to effectively support cell adhesion and proliferation. P-PRF only exists in a solid activated gel form. To date, only one product of this family is commercially available, known as Fibrinet PRFM  with Leukocytes: Also named Choukroun's PRF. In this preparation venous blood is obtained without any anticoagulant and directly centrifuged. A cascade of calcium chloride or thrombin is used, which results in the isolation of this plasmatic fraction without any biochemical modifications. These preparations, existing only in gel form, have leukocytes and a high-density fibrin network  used in traditional cell culture protocols  11121294 (CM), (FONDECYT) 1130618 (PS), (FONDECYT) 1140697 (VP), and Fondo de Fomento al Desarrollo Científico y Tecnológico (FONDEF) D09E1047 (VP).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.


B receptors also regulate glutamate receptors. There is increasing evidence that metabotropic GABAB receptors are now known to play an important role in modulating the excitability of circuits throughout the brain by directly influencing different types of postsynaptic glutamate receptors. Specifically, GABAB receptors affect the expression, activity and signaling of glutamate receptors under physiological and pathological conditions. Conversely, NMDA receptor activity differentially regulates GABAB receptor subunit expression, signaling and function. In this review I will describe how GABAB receptor activity influence glutamate receptor function and vice versa. Such a modulation has widespread implications for the control of neurotransmission, calcium-dependent neuronal function, pain pathways and in various psychiatric and neurodegenerative diseases.Brain function depends on co-ordinated transmission of signals from both excitatory and inhibitory neurotransmitters acting upon target neurons. NMDA, AMPA and mGluR receptors are the major subclasses of glutamate receptors that are involved in excitatory transmission at synapses, mechanisms of activity dependent synaptic plasticity, brain development and many neurological diseases. In addition to canonical role of regulating presynaptic release and activating postsynaptic potassium channels, GABA B receptors cross-talk and discuss the roles of specific proteins that might control these processes.Most excitatory signals that a neuron receives are mediated via glutamate receptors whereas most inhibitory signals are mediated via γ-aminobutyric acid (GABA) receptors  are GPCRs that can mediate slow inhibitory neurotransmission in the CNS. GABABRs are located at both presynaptic and postsynaptic compartments and changes in their number, localization and activity affect the level of synaptic inhibition. Presynaptic GABABRs inhibit release of neurotransmitter by inhibiting Ca2+ channels  to generate slow inhibitory postsynaptic potentials  was characterized to mimic schizophrenic-like behavior , which in-turn enhances receptor coupling to GIRKs . GABABRs stability at cell surface is due to high constitutive phosphorylation of GABAB2R and dephosphorylation of this subunit selectively targets the receptors for lysosomal degradation  at cerebellar parallel fiber Purkinje cell synapses is a form of synaptic plasticity critical for cerebellar motor learning and requires the activation of the metabotropic glutamate receptor mGluR1   was used to specifically activate synaptic NMDARs, leading to significant increase in surface expression of AMPARs  protocol (chem-LTP) leads to an increase in surface GABABR subunits are differentially regulated under oxygen/glucose deprivation (OGD) conditions, which stimulates release of excess glutamate resulting in excitotoxic activation of NMDARs  and plays a major role in regulating NMDARs. Yotiao was first identified as a binding partner of the GluN1 subunit and later found to be an AKAP via its ability to bind PKA-RII subunits B1Rs were previously shown to interact with a scaffold protein, GISP that enhances cell surface expression of heteromeric complex GABAB1/GABAB2 (Kantamneni et al., BRs as well as regulatory protein kinases and phosphatases. Thus, while speculative, it is tempting to suggest that AKAP9 functions to assemble the signaling complex responsible for mediating the observed cross-talk between the NMDARs and GABABRs. From expression studies it is known that AKAP9 is expressed in the brain and localized to synapses (Collado-Hilly and Coquil, BRs and NMDARs. At least in yeast-two hybrid assay it has been confirmed that GISP does not interact with NMDAR sub-type 1 (Kantamneni et al., BRs has not been tested, and that this warrants further work. Another protein that may potentially mediate direct crosstalk between GABABR signaling and glutamate receptor signaling is CaMKII. CaMKII is a Ca2+ calmodulin dependent protein kinase, previously been shown to interact with both GABAB and NMDA receptors and regulate NMDAR mediated plasticity (Bayer et al., B receptors. If further characterized these complexes may eventually serve as potential drug targets.GABAB receptors. Regulation of NMDAR-mediated synaptic signals by GABABRs comprises a powerful mechanism for controlling the major excitatory systems in brain. Conversely, NMDAR-mediated control of GABABRs is clearly an important emerging concept in dictating the balance of excitability in the brain. Studying the trafficking and signaling pathways utilized by these excitatory and inhibitory receptors in an integrated manner will undoubtedly provide more understanding of these critical regulatory mechanisms and will ultimately shed light on how the balance between excitatory and inhibitory neurotransmission is dictated in the brain. While many examples of interactions between glutamate and GABAB receptors have been discovered, importantly, the molecular players involved in mediating this cross-talk are only just beginning to be discovered. With this in mind, investigation of the potential players in these processes, such as the AKAPs, is an exciting future avenue of study. Ultimately, targeting these specific regulatory pathways may form the basis of new therapies to treat a number of neurological disorders that are characterized by aberrant balance between excitatory and inhibitory neurotransmitter systems in the brain.Taken together we can conclude that there is very tight regulation between glutamate and GABAThe author declares that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Although the etiology of dizziness in older patients differs significantly from that of younger patients, most guidelines on dizziness advocate the same diagnosis-oriented approach for all patients regardless of their age. However, this diagnosis-oriented approach may be insufficient for older patients presenting with dizziness in general practice, because (1) general practitioners are often not able to identify an underlying cause of dizziness, (2) general practitioners regularly identify causes of dizziness that cannot be treated, and (3) general practitioners may identify causes of dizziness for which treatment is available but not desirable. In this article, the authors present a simultaneous diagnosis- and prognosis-oriented approach for older dizzy patients. This approach may enable general practitioners to improve their care for a voluminous group of impaired older patients, even if a diagnosis is not available (yet). Dizziness – like falling and incontinence – is one of the geriatric giants. Thirty percent of people above 65 years of age experience some form of dizziness, increasing to 50% in persons above 85 years . Nine peAlthough the etiology of dizziness in older patients differs significantly from that of younger patients, most guidelines on dizziness advocate the same diagnosis-oriented approach for all patients regardless of their age. However, this diagnosis-oriented approach may be insufficient for older patients presenting with dizziness. Firstly, GPs are often not able to identify an underlying cause of dizziness . Secchronic dizziness  andFinally, we do not want to advocate diagnostic nihilism. The suggested approach should not be at the expense of a thorough diagnostic evaluation. Benign paroxysmal positional vertigo, for example, is a cause of dizziness in older patients that can be easily diagnosed  and effThe current diagnosis-oriented approach does not suit older patients presenting with dizziness. A simultaneous diagnosis- and prognosis-oriented approach for older dizzy patients may enable GPs to improve their care for a voluminous group of impaired older patients, even if a diagnosis is not available (yet). Hopefully, such an approach will not only improve the patient’s quality of life, but also reduce inappropriate drug prescribing and unnecessary referral.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.


Control of walking has been described by a tripartite model consisting of stepping, equilibrium, and adaptability. This review focuses on walking adaptability, which is defined as the ability to modify walking to meet task goals and environmental demands. Walking adaptability is crucial to safe ambulation in the home and community environments and is often severely compromised after a stroke. Yet quantification of walking adaptability after stroke has received relatively little attention in the clinical setting. The objectives of this review were to examine the conceptual challenges for clinical measurement of walking adaptability and summarize the current state of clinical assessment for walking adaptability. We created nine domains of walking adaptability from dimensions of community mobility to address the conceptual challenges in measurement and reviewed performance-based clinical assessments of walking to determine if the assessments measure walking adaptability in these domains. Our literature review suggests the lack of a comprehensive well-tested clinical assessment tool for measuring walking adaptability. Accordingly, recommendations for the development of a comprehensive clinical assessment of walking adaptability after stroke have been presented. Such a clinical assessment will be essential for gauging recovery of walking adaptability with rehabilitation and for motivating novel strategies to enhance recovery of walking adaptability after stroke. Approximately, 600.000 individuals incur a stroke each year and stroke is the leading cause of long term disability in the United States , 2. WalkWalking in everyday life necessitates walking adaptability, which is the ability to modify walking to meet behavioral task goals and demands of the environment –13. The Despite the relevance of walking adaptability to everyday mobility and the reduced ability of individuals with stroke to adjust walking to task and environmental demands, assessment of walking adaptability has received relatively little attention. Frequently used assessments of walking recovery after stroke involve walking short distances  and examination of isolated limb movements  to predict walking recovery –29. AlthA major rationale for the need to measure walking adaptability separately from steady-state walking is that adaptability has some distinct neural control requirements. Among the earliest works identifying adaptability as an independent neural control construct is the framework proposed by Forssberg  and GrilAccumulating evidence further supports a model of walking that distinguishes some of the neural control requirements of walking adaptability from stepping and balance. The basic reciprocal pattern of stepping is primarily controlled by pattern generating circuits in the spinal cord , 34. ForMeasurement of walking adaptability has received relatively little attention in clinical settings, as indicated in part by the absence of a comprehensive, well-accepted assessment of walking adaptability. A number of factors may account for the lack of progress in this area. First, there is no uniform terminology to define the construct of walking adaptability. Second, the construct of walking adaptability covers a broad spectrum of situations because adaptations of walking may be required under varied task and environmental demands. Clinical assessments of walking adaptability must therefore reflect this multi-faceted and complex nature of adaptability.While walking adaptability has been the subject of interest in several studies, there is a lack of uniform terminology used to describe the construct. The most common task paradigms that refer to similar constructs as walking adaptability are “gait adaptability,” “obstacle crossing/clearance/negotiation,” and “locomotor adaptation.” Houdijk and colleagues define “gait adaptability” as “the ability to adjust gait to environmental circumstances, such as obstacles and targets” . They haOur conceptualization of walking adaptability is founded on the previously mentioned tripartite locomotor control model of stepping, equilibrium, and adaptability. Terminology based on this fundamental neural control model provides a strong foundation and a broader context for the use of the term, “walking adaptability.” Furthermore, since emerging rehabilitation paradigms have utilized and focused on this tripartite model , 13, 68,Walking adaptability is necessitated when the complexity of the task situation exceeds what can be accomplished with basic stepping. For example, walking adaptability is crucial when walking on uneven or cluttered terrains (unpredictable environment), to ensure safe and appropriate foot placement , 69. SimWhile we primarily conceptualized the domains of adaptability based on Patla and Shumway-Cook's proposed dimensions of community mobility, there are some differences in our approach. First, we conceptualize the “domains” of walking adaptability as the “capacity/ability” of an individual  as opposed to Patla and Shumway-Cook's emphasis of the environmental context . Second, we incorporated seven of the eight dimensions of community mobility proposed by Patla and Shumway-Cook, excluded one dimension, and modified two dimensions to create overall nine domains of walking adaptability. Particularly, we modified the “traffic density” dimension of Patla and Shumway-Cook's framework  and subcEach of these domains represents a demand  that may necessitate walking adaptability. The domains of walking adaptability most notably investigated and reported in the stroke literature include “obstacle negotiation,” “temporal demands,” and “cognitive dual-task demands.” There is also emerging evidence pertaining to “terrain demands” and “ambient demands.” Other domains have received some attention as components of clinical assessments, but specific performance results for persons after stroke are not readily available in the literature. These include the domains of “postural transitions,” “motor dual-task demands,” “physical load,” and “maneuvering in traffic.” Here, we review some of the most pertinent evidence highlighting the impairments in walking adaptability after stroke.The capability to negotiate obstacles in the environment is crucial for safety during walking. Obstacle negotiation involves modifying the typical gait pattern to prevent a collision between the lower limb and the obstacle. This often requires a well-timed coordination between the visual and motor systems in order to produce an appropriate limb trajectory while maintaining dynamic balance. Limitations in walking adaptability using obstacle clearance paradigms have been well studied in the stroke population. Individuals with a stroke have greater failures rates when avoiding obstacles despite using a more cautious strategy of stepping over with a higher toe clearance with the lead limb . AdditioThe deficits in adjusting foot placement when clearing obstacles are shown to be even more prominent when executed under time pressure as when individuals had to avoid obstacles that suddenly appeared before them , 101. FuWalking tasks often require time constraints, such as needing to walk faster when crossing a busy intersection or when walking to answer a ringing phone. In some cases, temporal demands might also require slower walking such as when walking with a slow moving crowd. A number of studies demonstrate the compromised ability of individuals after stroke to increase walking speed over and above their self-selected speed –104, whiSecondary task demands involve combining walking with other attention-demanding tasks such as engaging in conversation, reading a map, and so forth. This is commonly referred to as “dual-tasking,” and is known to degrade walking performance even in healthy adults . After aTerrain refers to walking on surfaces that are not flat and firm. This includes stairs, escalators, ramps, curbs, side slopes, grass, sand, trails with tree roots, and so forth. Relatively little work has been conducted to assess the capability of individuals after stroke to adapt walking to challenging terrain conditions. Phan and colleagues  showed tAmbient conditions refer to factors such as lighting, temperature, weather conditions, noise levels, familiarity with surroundings, and other such factors that may interact with walking. Although most of these factors have not been specifically examined, there is emerging evidence that the ambient environment, in general, can influence walking function. One recent study found that faster walking speeds were obtained when stroke participants walked outdoors relative to walking indoors . Other sThere is a need for research to examine poststroke deficits in the domains of “postural transitions,” “motor dual-tasking,” “physical load,” and “maneuvering in traffic.” Postural transitioning refers to the capability of an individual to alter body orientation or head position in order to perform a task, such as turning a corner, observing the surrounding environment , reaching during walking, bending during walking, or walking through a narrow space. Motor dual-task includes such tasks as carrying a tray of food and dialing a phone while walking. Like cognitive dual-task, this involves a competition for attentional resources. However, manual dual-tasking may also involve a competition for resources (such as motor programs) that are detrimental to safe control of walking. Physical load demands while walking include tasks such as opening a heavy door, walking while wearing a heavy backpack, or carrying a weighted package. Interaction with a physical load during walking necessitates successfully adapting to any changes to the walking pattern  created by the additional physical load. Maneuvering in traffic can include factors such as other people , large environmental objects , or pets in the home. In some cases, maneuvering may require some online processing of information about speed and direction of movement, in order to predict where the object is likely to move relative to oneself. Since maneuvering in traffic may require discrete set of abilities (like processing the speed and direction of movement), we propose its assessment as a separate domain of walking adaptability.It is important to consider that walking adaptability tasks in each of the proposed domains require the integration of all three neural control requirements of walking: stepping, equilibrium, and adaptability. While the limitations in steady-state walking ability after a stroke due to compromised stepping and equilibrium are well characterized , quantifSince there is no gold-standard clinical assessment of walking adaptability, performance-based clinical assessments of walking function were reviewed to determine the extent to which they measure the construct of walking adaptability. Assessments included in this review contained at least a subset of walking activities requiring adaptability, had at least one peer-reviewed study with detailed information about the content of the assessment, were developed for any adult population (not limited to stroke), and were clinically feasible. While some of the clinical assessments included in our review may lack recommendation for clinical use based on earlier published criteria , our purThe dynamic gait index (DGI) was developed to assess an individual's ability to modify gait in response to changes in task demands . The DGIThe functional gait assessment (FGA) is based on the DGI and was developed for persons with vestibular disorders to reduce the ceiling effect of the DGI for this population . The FGAThe modified Emory functional ambulation profile (mEFAP) is a modification of the functional ambulation profile, is a timed measure of walking under five environmental challenges, and was developed for individuals with stroke . The mEFThe spinal-cord injury functional ambulation profile (SCI-FAP) is modified from the mEFAP and is a timed measure of functional walking developed for individuals with an incomplete spinal cord injury . The SCIThe high-level mobility assessment test (Hi-MAT) was developed for persons with traumatic brain injury (TBI) to assess high-level mobility skills , 91. TheSimilar to the Hi-MAT, the community balance and mobility (CB&M) scale is a relatively challenging assessment and is reported to evaluate high-level deficits in gait, balance, and mobility . The CB&The sensory-oriented mobility assessment instrument (SOMAI) was designed to understand how sensory inputs are utilized in mobility performance and included modifications of assessments to create the tasks for this test . The SOMThe walking InCHIANTI toolkit (WIT) is a battery of 14 standardized walking tests developed to capture the typical conditions encountered in daily life. The battery was developed in association with the InCHIANTI study, an epidemiologic study of risk factors for mobility disability in old age . The walTwo obstacle course-based assessments have been developed and validated in elderly, community-dwelling, and primarily male study populations (mean age = 75 years) , 32. RubThe obstacle course developed and validated by Means and colleagues consists of a series of 12 stations where functional tasks commonly encountered in the home environment are presented . The staThe multiple tasks test (MTT) is a test that simultaneously assesses the multiple components of postural control and was developed for individuals with Parkinson's disease . The MTTFirst, the review of performance-based clinical assessments indicates that there are several existing performance-based clinical assessments that capture aspects of walking adaptability and a pool of assessment items  may be available for the measurement of walking adaptability. However, there is lack of a comprehensive assessment of walking adaptability, with most assessments capturing only 4-5 domains of walking adaptability. The WIT and MTT measured the most number of domains of walking adaptability (7 out of 9 domains) compared to other assessments but there is very limited testing of these assessments and it is unknown if these tests are appropriate for clinical populations with diverse mobility limitations, including stroke , Table 2The lack of a comprehensive, rigorous, and well-accepted clinical assessment for measuring adaptability after stroke implies the fact that it is difficult to assess the extent to which different rehabilitation approaches are effective for inducing recovery of adaptability. A rigorous and comprehensive clinical assessment of walking adaptability will also provide clinicians with an objective measure to accurately assess adaptability performance and recovery, thereby motivating the design of novel interventions to enhance recovery of adaptability. Therefore, there is an urgent need for the development and validation of a comprehensive multidomain and rigorous clinical assessment of walking adaptability after stroke. Development of such a clinical assessment may not necessarily require designing entirely new assessment items since our review shows that currently a pool of assessment items are available in existing clinical walking assessments. However, it may be essential to develop a comprehensive and rigorous tool by validating relevant items for adaptability measurement after stroke and developing hierarchically ordered assessment items. A comprehensive assessment consisting of different domains of task and environmental demands necessitating adaptability can prompt the clinician to administer the most relevant domains and assess patient strategies and performance. Choice for the administration of specific domains could be based on factors like (a) the individual's unique task and environmental constraints and (b) patient's self-report of limitations in specific domains. For example, for an 85-year-old woman after stroke, living independently at home with hard wood flooring, selecting assessment items from the terrain domain may be most relevant. Combining items on this domain with another relevant domain for this case  will provide greater demands for walking adaptability. Furthermore, patients' self-report of limitations when walking under varying task and environmental constraints may assist the clinical administration of selected and most relevant domains, as recently suggested by a study that preliminarily validated a self-report measure of environmental challenges to correlate with direct observations of mobility disability in individuals with stroke . UltimatDevelopment of a comprehensive and rigorous clinical assessment for walking adaptability can be facilitated by utilization of a recently proposed integrated approach to assessment scale development , 132. TrWhile a comprehensive and rigorous assessment tool of walking adaptability may be critical for targeted assessment, the familiar dilemma in outcome measurement development is the need to balance feasibility with comprehensiveness and precision. For instance, a comprehensive and rigorous assessment of walking adaptability may require several hierarchically developed items in each domain that can simulate the testing of real-life complexities of walking adaptability. However, a clinically feasible tool would necessitate efficient clinical administration of only relevant domains and those domain-specific items that match and further challenge the patient level. Contemporary methods of test administration such as IRT-based computer adaptive testing or IRT-based static short forms may offer a solution for developing a rigorous assessment of walking adaptability. For instance, an IRT-based computer adaptive test can provide efficient testing of only the most relevant items by providing item parameters to computer algorithms .  Figure how the task was accomplished. For instance, an individual after stroke may successfully clear an obstacle in a timely manner and yet do so, primarily utilizing compensatory approaches like heavily relying on an assistive device or using inefficient movement strategies such as excessive hip hiking and circumduction of the affected leg. Current walking assessments would fail to capture these compensatory movement strategies and in turn primarily grade the individual for simply the success in negotiating the obstacle. Assessment of how an individual performs a task provides insight into the extent to which a behavior is recovered and can directly guide effective recovery-based intervention strategies. Without this focus on the quality of task performance, clinical assessments are unable to distinguish between compensation and recovery and the extent to which rehabilitation approaches are impacting the reacquisition of normal motor behaviors [We also recommend that a comprehensive multi-domain assessment of walking adaptability should include the assessment of movement strategies utilized to perform the adaptability tasks. The majority of the clinical assessments for walking function quantify the success of task performance, the amount of assistance required, and the time it takes to perform these tasks using ordinal rating scales . While these are useful and validated approaches to quantify functional impairments, these methods provide limited information regardingehaviors . Recentlehaviors . ImportaThis review article examines the conceptual challenges for the measurement of walking adaptability and summarizes the current state of its clinical assessment. First, we have clarified the use of the terminology of walking adaptability based on the neural control model of walking to synchronize with the current recovery-based paradigms of walking rehabilitation. Second, we incorporated seven dimensions of community mobility proposed by Patla and Shumway-Cook and modified two dimensions to create overall nine unique domains of walking adaptability that can be applied to any ambulatory environment. Third, we have presented a thorough description of the existing clinical assessments of walking function that include items assessing walking adaptability and identify domains of adaptability captured by these assessments. Cumulatively, the evidence points to an urgent need for a comprehensive and rigorous approach for the clinical assessment of walking adaptability after stroke. We recommend that development of a comprehensive and rigorous clinical assessment may require (a) validation of hierarchically developed assessment items in each of the nine domains of walking adaptability, (b) utilization of contemporary measurement methods (such as IRT-based computer adaptive testing) for test administration and (c) assessment of “movement strategy” when performing adaptability tasks. Since accurate assessment is essential for the application and development of targeted interventions, future work in this area has great potential to contribute to breakthroughs in the rehabilitation of walking adaptability recovery after stroke and improved quality of life for individuals after stroke.


Can we create engaging training programs that improve working memory (WM) skills? While there are numerous procedures that attempt to do so, there is a great deal of controversy regarding their efficacy. Nonetheless, recent meta-analytic evidence shows consistent improvements across studies on lab-based tasks generalizing beyond the specific training effects (Au et al.,  However, despite evidence these techniques improve memory Here we review recent WM training approaches discussing their strengths and limitations and suggest methods that are based on the principles of perceptual learning (PL) and game design to make them more effective. Off-the-shelf computer games and standard cognitive approaches each contain component properties that can benefit WM. We propose that integrating knowledge from psychology and neuroscience along with the science of video game design could critically inform the development of engaging, cognitively immersive challenges that will more optimally train WM memory processes.Span training targets WM capacity  is adaptively adjusted in response to participants’ performance. N-back training-related improvements are wide-ranging, including non-trained WM functions , were originally modeled after successful approaches in PL  have fundamental importance in guiding learning. For example, Seitz et al.  found imThe human brain has evolved to learn and operate optimally in natural environments in which behavior is guided by information integrated across multiple sensory modalities. Crossmodal interactions are ubiquitous in the nervous system and occur even at early stages of perceptual processing  modalities that are not coordinated, which research shows does not promote learning, and may in fact interfere with it  can invoke memories of their face (vision), and so on. However, existing memory tasks, such as the dual One way to overcome specificity of learning is by training with multiple stimuli, as demonstrated in PL  Studying incidental benefits of off-the-shelf video games; and (2) Transforming standard cognitive tasks into training tasks. We suggest that the most success will come from integrating knowledge of memory systems with that of brain plasticity and modern game-design principles.As a first attempt to implement this approach, we created a prototype game that incorporates mechanics of the n-back into an engaging 3D space-themed gameThe game also incorporates principles from PL, where participants are trained on multisensory  features, where sounds and visuals are designed to facilitate each other, and where attention and reinforcement are carefully sculpted to lead to the best learning. While much work is still required to maximize the game’s efficacy, e.g., by incorporating a broader stimulus set, adding other memory tasks, and creating an even more compelling game framework, we put it forward as a first example of how to build such an integrative game. Initial piloting with our prototype indicates participants are engaged in the game and improve performance (n-level) across training sessions. However, more research is needed to make firm conclusions regarding its transfer potential.In summary, we suggest that more integrative approaches will lead to better learning outcomes. We suggest that the general mechanisms that promote PL are shared across brain regions and will also promote WM. Furthermore, there is enough known about the aspects of conventional video games that lead to positive learning outcomes that these principles can be applied to achieve more effective WM training. Additionally, there are other principles, that were beyond the scope of the present review, such as deliberate practice (Ericsson et al., 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.


Fibromyalgia is a chronic pain syndrome of unknown etiology characterized by diffuse pain, sleep disorders, fatigue, cognitive dysfunction and a cohort of different symptoms implying comorbidity with diseases with common pathophysiological basis. There is a growing body of evidence that abnormal pain processing at a central level has a role in FM pathogenesis, though recent evidence supports the coexistence of a peripheral nociceptive fibers sufferance. In recent years, clear phenomena of temporal summation of pain (or windup) and central sensitization have been extensively reported. Neurophysiologic methods able to explore the nociceptive afferent system suggest that FM syndrome is heterogeneous, with pain processing dysfunction at both peripheral and central level. Reduced habituation to multimodal and especially painful stimuli characterizes FM, as well as associated conditions, one of the most common is migraine. A genetic dysfunction of ionic channels may possibly explain neuronal abnormalities at both central and peripheral level in FM, opening a new scenario also in the comprehension of pathophysiological basis of associated conditions.


Blast-related traumatic brain injury (TBI) has received much recent attention because of its frequency in the conflicts in Iraq and Afghanistan. This renewed interest has led to a rapid expansion of clinical and animal studies related to blast. In humans, high-level blast exposure is associated with a prominent hemorrhagic component. In animal models, blast exerts a variety of effects on the nervous system including vascular and inflammatory effects that can be seen with even low-level blast exposures which produce minimal or no neuronal pathology. Acutely, blast exposure in animals causes prominent vasospasm and decreased cerebral blood flow along with blood-brain barrier breakdown and increased vascular permeability. Besides direct effects on the central nervous system, evidence supports a role for a thoracically mediated effect of blast; whereby, pressure waves transmitted through the systemic circulation damage the brain. Chronically, a vascular pathology has been observed that is associated with alterations of the vascular extracellular matrix. Sustained microglial and astroglial reactions occur after blast exposure. Markers of a central and peripheral inflammatory response are found for sustained periods after blast injury and include elevation of inflammatory cytokines and other inflammatory mediators. At low levels of blast exposure, a microvascular pathology has been observed in the presence of an otherwise normal brain parenchyma, suggesting that the vasculature may be selectively vulnerable to blast injury. Chronic immune activation in brain following vascular injury may lead to neurobehavioral changes in the absence of direct neuronal pathology. Strategies aimed at preventing or reversing vascular damage or modulating the immune response may improve the chronic neuropsychiatric symptoms associated with blast-related TBI. It was first recognized during world war (WW) I that blast exposure can be associated with psychological and neurological symptoms reminiscent of both the post-concussion syndrome and what would now be called post-traumatic stress disorder (PTSD) . While aInitially most attention focused on the moderate to severe end of the TBI spectrum , the typInterest in how blast affects the nervous system has led to a rapid expansion of clinical as well as animal studies. Animal studies show that blast pressure waves are transmitted through the brain and exert a variety of biochemical, pathological, and pathophysiological effects , 13. HowVascular pathology is a well-recognized component of non-blast TBI in humans and animals . Few humThe role of vascular pathology in human cases of mTBI is less clear. Cases of mTBI rarely come to autopsy, and little is generally known about the pathology of mTBI especially in the acute phase . Only a Due to the lack of human data, most of our knowledge of how blast exposure affects the nervous system comes from animal studies. Animals have been exposed to various forms of blast ranging from direct exposure to live explosives to more commonly controlled blast waves produced by compressed-air generators with rats being most often used , 13. AppBlast-related vascular effects in animals are summarized in Tables While the hemorrhagic component is more apparent at high-level blast, pathologically hemorrhage also seems to be a feature of lower-level exposure. For example, Saljo et al.  observedHistologically, blast exposure can also induce a microvascular pathology in the absence of hemorrhage. Goldstein et al. , studyinPhysiologically acute blast exposure causes prominent vasospasm  and decrAt the functional level, acutely blast exposure has been associated with increased vascular permeability and blood-brain barrier (BBB) breakdown. Multiple studies have described at least transient increases in BBB permeability acutely as judged by IgG immunostaining , 68, 75.Morphological and functional data indicate that both large and small brain vessels are affected by blast injury. Little is known about the molecular changes associated with these abnormalities. Reductions of the BBB tight-junction proteins occludin, claudin-5, and zonula occludens 1 (ZO-1) in brain microvessels have been observed 6–24 h after exposure , althougThe long-term effects of blast on the vasculature are likewise poorly understood, although one study observed altered immunostaining of the microvasculature with collagen IV and laminin several months after blast exposure  Figures–3. This in vivo  serves as an interesting comparison. Similar to blast, FUS involves generation of a compression-rarefaction longitudinal wave. However, in contrast to blast, a FUS longitudinal wave has a higher frequency content than a blast wave, and is applied focally in a typically pulsed fashion leading to generally higher peak pressures than a blast wave , 88. Yetin vivo, blast effects on large cerebral blood vessels acutely are well established  are transmitted to brain even when the body is protected . Other sInflammatory changes in brain after blast exposure in animals are well documented Tables  and 2. BAt the cellular level, microglial activation has been reported in many studies , 74, 79.Inflammatory changes in brain have been studied mostly following acute blast exposure with some of the changes being short-lived. For example, TNF-α while increased in cortex at 3 h was not increased at 48 h . HoweverIn animal models, blast is also associated with markers of inflammation in blood and plasma Table . ElevatiOne of the striking features of the mTBI cases in veterans returning from Iraq and Afghanistan is the frequent presence of PTSD. PTSD or depression is present in over one-third of Iraq veterans who suffered mTBI , 119. ThWhether vascular and inflammatory factors play a role in neurobehavioral effects associated with blast injury is unknown. Supporting a potential role is a substantial literature suggesting that chronic low-grade inflammation is a consistent feature of many neuropsychiatric disorders including major depression and PTSD , 124. EpHow inflammation is related to the clinical features of major depression and PTSD is not clear. Some of the most compelling evidence for cytokine production playing an etiological role comes from patients treated with interferons which have documented high rates of depression with either IFN-α or IFN-γ . ProinflThe brain vasculature is a central target of blast-induced effects Tables  and 2 wiChronic vascular pathology could have another effect in that recently a brain-wide network of paravascular channels has been identified, termed the “glymphatic” pathway along which CSF moves through the brain parenchyma . ThroughThe cellular response following blast includes a microglial and astroglial reaction. Microglia play central roles in brain inflammatory responses and could therefore play critical roles in activating a brain inflammatory response following blast , 137. AsAn additional cellular element that likely plays a role in this process is the pericyte, which is damaged acutely in blast-associated vascular injury . PericytMarkers of both a central and a peripheral inflammatory response are found after blast injury . While tThus, evidence collectively points to the need to develop strategies to prevent or repair vascular damage following blast injury. It also points to targeting the immune response. Inflammation is a recognized component of non-blast TBI , 146 andThe possible effects of blast exposure on the nervous system have been discussed since WWI. Public interest in this topic as well as interest in the scientific community has expanded rapidly in recent years because of the prominence of blast-related TBI in the conflicts in Iraq and Afghanistan. In humans, high-pressure blast exposure can cause extensive CNS injury with a prominent hemorrhagic component. Less is known about the pathology of human blast-related mTBI, and animal studies are the source of most knowledge about low-level blast exposure. As in humans, acute high-level blast exposure in experimental animals is associated with a prominent hemorrhagic component. At the functional level, high-level blast exposure acutely disrupts the BBB. Low levels of blast exposure are also associated with a microvascular pathology that can be seen in the presence of an otherwise normal brain parenchyma, suggesting that the vasculature may be selectively vulnerable to blast injury. Multiple studies have shown that shielding the body can reduce or eliminate the adverse effects of blast on the brain supporting the role for thoracically mediated effects whereby pressure waves transmitted through the systemic circulation cause damage in brain.Inflammatory changes after blast exposure in animals are also well known. In brain, blast exposure induces a number of inflammatory mediators including many interleukins, interferons and cytokines. At the cellular level, microglial and astroglial reactions occur. In animal models, blast is associated with increases in inflammatory markers in blood and plasma including many of the factors elevated in brain. Evidence of oxidative stress which is commonly found in association with inflammation has also been documented in brain and blood.Thus much evidence supports a role for vascular and inflammatory factors in the pathophysiology of blast-related brain injury, although most animal studies have utilized relatively high-level blast exposures that likely more approximate human moderate to severe TBI than mTBI. Where information is limited is on the effects of lower-level exposures that more approximate mTBI by far the most common clinical exposure in the most recent conflicts. There is also little information on whether vascular and inflammatory effects persist chronically. Many of the vascular and inflammatory changes have been documented to occur only transiently. Few studies in animals have addressed changes weeks or months after blast exposure, the phase most relevant to the chronic persistent symptoms that are the most troublesome following human blast-related mTBI.Yet, despite the paucity of long-term studies, a chronic vascular pathology has been observed in animals. In addition, some blast-related inflammatory effects have been documented to be present weeks or months following exposure. Chronic low-grade inflammation is a consistent feature of many neuropsychiatric disorders including major depression and PTSD. Clearly, a need exists to better understand the nature of vascular damage following blast exposure and the relationship of vascular changes to neuroinflammatory effects. Understanding this relationship will be critical to determining whether chronic immune activation in brain following vascular injury may underlie blast-associated neurobehavioral changes.All authors participated in the collection, review, and analysis of the relevant literature as well as the drafting and revising of the manuscript.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.


Accurate quantitative assessment of infection with soil transmitted helminths and protozoa is key to the interpretation of epidemiologic studies of these parasites, as well as for monitoring large scale treatment efficacy and effectiveness studies. As morbidity and transmission of helminth infections are directly related to both the prevalence and intensity of infection, there is particular need for improved techniques for assessment of infection intensity for both purposes. The current study aimed to evaluate two multiplex PCR assays to determine prevalence and intensity of intestinal parasite infections, and compare them to standard microscopy.Necator americanus, Ancylostoma spp., Ascaris spp., and Trichuris trichiura; and the second Entamoeba histolytica, Cryptosporidium spp., Giardia. duodenalis, and Strongyloides stercoralis. Samples were also subject to sodium nitrate flotation for identification and quantification of STH eggs, and zinc sulphate centrifugal flotation for detection of protozoan parasites. Higher parasite prevalence was detected by multiplex PCR . Although, all STH positive samples were low intensity infections by microscopy as defined by WHO guidelines the DNA-load detected by multiplex PCR suggested higher intensity infections.Faecal samples were collected from a total of 680 people, originating from rural communities in Timor-Leste (467 samples) and Cambodia (213 samples). DNA was extracted from stool samples and subject to two multiplex real-time PCR reactions the first targeting: Ascaris, hookworms and Giardia compared to microscopy, especially in samples exhibiting polyparasitism. The superior performance of multiplex PCR to detect polyparasitism and more accurately determine infection intensity suggests that it is a more appropriate technique for use in epidemiologic studies and for monitoring large-scale intervention trials.Multiplex PCR, in addition to superior sensitivity, enabled more accurate determination of infection intensity for  Gastrointestinal parasites including soil-transmitted helminths cause considerable morbidity worldwide, especially in resource-poor communities. Large-scale epidemiologic and treatment efficacy studies are regularly undertaken to determine the optimum ways to reduce or eliminate parasites from endemic communities, thereby reducing the burden of disease. Accurate and sensitive tests for detection of soil transmitted helminths and protozoa are of great importance to the success of such trials. Increasingly recognised is the importance of accurately determine the infection intensity, as morbidity and transmission pressure of helminth infections are directly related this and not just to prevalence. A vast majority of studies use standard microscopy methods which, although well accepted, may not be as accurate as more recently developed molecular techniques such as multiplex PCR. Therefore, there is need for further evaluation of multiplex PCR techniques and their ability to detect infections and provide infection intensity data. In the current study real-time PCR showed a higher sensitivity for the detection of intestinal helminths and protozoa especially in cases of mixed infections as well as more accurate determination of infection intensity compared to microscopy. Ascaris lumbricoides, hookworms (Necator americanus and Ancylostoma spp.), Trichuris trichiura and Strongyloides stercoralis  ,36 Ascarpy alone . Multiplpy alone ,Ascaris and Giardia when compared on a per sample basis. Multiplex PCR in particular detected a large number of positive samples not detected in microscopy; a possible result of the failure of microscopy to detect polyparasitism, present in nearly half (49.1%) of all positives samples by multiplex PCR. A small number of samples were also deemed positive by microscopy but negative in multiplex PCR. This may be due to variation in the dispersion of larvae, eggs and oocytes within the subsamples taken, due to the nonhomogeneous nature of the stool [Strongyloides positive samples detected only by microscopy, as larvae resemble hatched hookworm larvae. Alternatively further PCR optimization may be required as there have been previous reports of PCR sensitivity issues for detection of Strongyloides, as only low levels of larvae are present even in heavy infections [A large disparity in the prevalence rates between techniques was noted for the detection of hookworm, he stool , as wellhe stool ,54, causfections .Microscopy sensitivity issues of parasite detection, particularly in samples exhibiting polyparasitism suggest further compounding issues in accurately determining infection intensity levels. Data comparing PCR Ct-values to microscopy determined EPG values have been previously been reported, showing a broad range of Ct-values for each microscopy EPG value; especially for microscopy negative samples . This inThis focus on infection intensity is a major strength of the present study when considering disease burden, as STH infection prevalence alone does not provide a measure of potential morbidity, which is related directly to infection intensity . DespiteAscaris EPG interpolation is required and at higher infection intensities before it can be reliably used with field samples and significant further testing of hookworm samples is essential to produce accurate predictions of EPG. Determining this mathematical relationship between Ct-values, EPG, and by corollary adult worm burden, and assuring its accuracy represents a goal in future research, vital to progress PCR methodologies as the gold standard of intestinal nematode detection. The potential shown here to convert this PCR data to the more widely understood “EPG” format may allow this technique to provide more widely accepted and reportable STH surveillance. However, attempting to enumerate egg counts by PCR without a truly quantitative gold standard for comparison does however, represent a limitation of this work.In the present study, the full relationship between Ct-values and EPG was assessed using standard curves obtained from well-defined controls, with carefully prepared measurements. The feasibility of such an approach has been shown and further indicates that PCR quantification is likely to be more accurate and that additional detailed studies should be undertaken in the future. At this stage insufficient experimental data are available to be able to produce accurate predictions across the whole range of possible Ct-values as the current interpolation is limited to within the microscopy determined EPG range in which it was tested. Additional validation of the Despite proving successful in parasite diagnosis and providing valuable information on infection intensity, there are limitations of multiplex PCR as a diagnostic tool. The use of PCR preservatives such as potassium dichromate and ethanol temporarily arrests further egg development, and are thought to allow accurate quantitative data after many months of storage. However extensive testing into the effect of such preservatives on the genome copy numbers for the target nematodes has not been performed but is crucial for accurate interpolation to an egg count. Further compounding the issue is the ability to relate nematode egg counts to DNA intensity, when copies of DNA increase once eggs have embryonated. Literature does indicate that once embryonated the ITS1 gene target of the PCR assays remains at a constant level , suggestGiardia for optimal detection [Further testing on preservation methods is essential in terms of the effect on the quantitative accuracy over time, both those for microscopy and multiplex PCR techniques. The maximum storage time in potassium dichromate is currently undetermined, however reports have suggested a one month storage period in potassium dichromate for etection . Recent etection . MicroscThe main limitation of multiplex PCR in national control programmes is the capacity to implement it in parasite endemic low-resource settings, with the current need to send samples to well equipped labs for analysis. Microscopy based techniques can however, be undertaken with less resources and more affordable equipment. The material cost of processing samples and running both multiplex PCRs was estimated as AU$12.37 per sample . This also represents a limitation when compared to flotation based microscopy, costing just AU$1 per sample (labour not included). The trade off of the additional costs and the inability for onsite analysis compared to the higher sensitivity and ability to detect multiple infections as well as the more accurate intensity data is an issue for consideration in design of epidemiologic studies and for clinical trials of effectiveness of interventions.The use of multiplex real-time PCR for intestinal parasite diagnosis has proved to be more sensitive, and is more likely to detect mixed parasite infections than standard microscopy techniques. The real benefit of multiplex PCR is in its ability to more accurately determine infection intensity and the potential to report results in more understandable ‘EPG’ terms, which will prove to be inherently more useful in determining the success of de-worming and intervention trials.S1 Methods(DOCX)Click here for additional data file.S1 Figth percentile interval also considered for repeat extraction or repeat PCR. The specific source of the problem (PCR or extraction) was determined through EHV data comparison between the quantitative multiplex and semi-quantitative multiplex.Average EHV Ct-values for each of the 37 field DNA samples compared within PCR runs to EHV-only control sample. Major outlier amplification from each run indicated in red where repeat extraction is required. Minor deviations outside 10–90(TIF)Click here for additional data file.S2 FigAscaris Ct-EPG interpolation formula was used on 131 Timor-Leste Ascaris positive samples that were within the required Ct range (15.5–31.5) to allow adequate prediction of EPG from Ct value using calibration curve (EPG = 10−0.275*Ct +9.622). Multiplex real-time PCR duplicates were each individually calculated with mean and SD for each sample. (A) Calibration curve example—converting PCR Ct-values to EPG (B) The infection intensity range for these 131 samples within acceptable calibration curve range.The (TIF)Click here for additional data file.S1 Dataset(XLSX)Click here for additional data file.


For regulatory approval, generic versions of brand drugs need to demonstrate bioequivalence in young, healthy volunteers and have similar dissolution times. While the potency and amount of active drug within generic formulations must be identical to the brand, differences are permitted in the excipients. Significant differences in tablet disintegration time among different versions of generic and brand alendronate have been reported. Rapidly disintegrating alendronate pills may increase oesophageal bioadhesion and adverse event risk. Oesophageal-bound alendronate or slow disintegrating alendronate tablets may be made inert and ineffective by subsequently ingested food or drink. Investigations have reported a lower persistence to therapy with generic brands of alendronate as compared to brand bisphosphonates and patients switched from brand to generic alendronate have increased adverse event rates and losses in bone mineral density.Numerous differences exist between brand and generic alendronate including: disintegration time, bioadhesion to the oesophagus, patient persistence to therapy, adverse event incidence, and maintenance of bone mineral density. Generic forms of alendronate warrant closer clinical study before they are ascribed the clinical effectiveness and tolerability of brand alendronate.The online version of this article (doi:10.1186/2193-1801-2-550) contains supplementary material, which is available to authorized users. Osteoporosis is a systemic disease typified by decreased bone strength and a consequent increased risk of fragility fracture . FragiliIn light of the personal and societal costs of fragility fracture, their prevention is paramount. Positive lifestyle habits, such as varied physical activity and adequate vitamin D and calcium intakes, play an important role in the prevention of osteoporosis , zoledronic acid (intravenous amino-bisphosphonate), subcutaneous denosumab (RANK ligand inhibitor), raloxifene (selective estrogen receptor modulator), estrogen (hormone therapy) and teriparatide (recombinant parathyroid hormone)  and untreated (>70%) for osteoporosis  has also been made available as a generic option in a number of countries around the world. After its introduction, generic alendronate was widely adopted by public and private payees owing to its lower price as compared to brand alendronate.in vitro, in vivo, clinical outcome and database comparisons between brand and generic alendronate to establish whether the adherence, tolerance and efficacy results obtained from Phase III clinical trials with brand alendronate can be reasonably ascribed to generic forms of alendronate. Further, a review of the cost-effectiveness data is made.This review has the objective of detailing all published Medline was searched to identify potential papers for inclusion for this review, keywords "alendronate" AND "generic" with the limitations of papers published between January 1, 1995 and Aug 5, 2013 published in English (n = 51 papers). After reviewing each reference’s title and abstract, all papers that were deemed possibly relevant to the topic were retained and had the full paper acquired (n = 32). Reasons for non-inclusion (19) were: non-english language (1), review (5), commentary (3), not primary focus (6) and position statements (4).Reference lists from acquired papers were scanned for possible new citations. Numerous papers not gathered from the search were included to provide perspective to the discussion.When a patient chooses generic alendronate, or has it chosen for them through mandatory substitution  when given on an empty stomach to healthy, young volunteers under ideal circumstances  and safety (AEs).Another common approach to compare whether there are differences in persistence, safety or effectiveness between generic versions of alendronate and the brand version is to perform analyses of administrative databases.In an administrative database analysis, information regarding persistence to therapy of once-weekly bisphosphonates was obtained from a large cohort of patients by linking the administrative databases of the Régie de l’Assurance Maladie du Québec (RAMQ) , brand alendronate , or generic alendronate (875 patients) and the patients were then followed forward in time for a year from their first prescription. Patients who were initiated on weekly generic alendronate had a significantly (p < 0.0001) lower persistence to therapy as compared to those patients who began weekly brand risedronate or brand alendronate therapy. Even after adjusting for confounding covariates , patients initiated on weekly generic alendronate had a significantly higher probability of discontinuing therapy as compared to either brand risedronate or alendronate . The significant difference between persistence to the generic versus the brand bisphosphonates may be attributable to physiochemical differences between the formulations, or to differences in the populations dispensed the drugs.Another investigation using the same administrative RAMQ databases as the study above concluded that persistence to brand bisphosphonates was significantly (p < 0.001) higher than to generic alendronate for patients who either had (primary prevention) or had not (secondary prevention) previously experienced an osteoporotic fracture  or brand alendronate, it was concluded that there were significantly higher discontinuation rates with the generic versions of alendronate as compared to the brand alendronate  , Landfeldt & Strom  reportedSince generic alendronate has commanded such a large share of the osteoporosis treatment market in recent years largely owing to its low cost, numerous cost-effectiveness analyses have been conducted to compare the cost of preventing fractures with generic alendronate to other brand therapies, most often denosumab.Nayak et al.  used a MIn a comparison of the cost-effectiveness of denosumab to bisphosphonates for the prevention of hip fracture, generic alendronate was used as the low-cost comparator in postmenopausal women with varying fracture risk (Parthan et al.The cost-effectiveness studies have shown that generic alendronate, while being the least expensive alternative for the treatment of osteoporosis, can often be supplanted by other therapies as a first choice when long-term costs are considered, particularly when assessing the high rates of discontinuation assumed for generic alendronate in many of these models.Of note, in many countries the manufacturer of brand alendronate substantially lowered their pricing of brand alendronate, now combined with vitamin D, to be similar to that of generic alendronate. This relatively recent change requires for new cost-effectiveness studies to be completed with the newer formulation of alendronate and vitamin D with the new pricing.Alendronate continues to play an important role in the management of osteoporosis. The proliferation of generic versions of brand alendronate has been rapid worldwide. Brand alendronate has undergone years of carefully monitored randomized placebo-controlled clinical trials, utilizing tens of thousands of osteoporosis patients, to establish tolerability, safety and efficacy. Further, numerous Phase IV investigations have supported the findings reported in Phase III clinical trials. The generic versions of alendronate have not been tested with the same rigour for tolerance, safety and efficacy.Differences in excipients may be an important factor in the frequently reported differences in disintegration time between generic and brand alendronate. Most commonly, generic versions disintegrate far more rapidly than brand alendronate, increasing the potential for AEs. Differences in rupture characteristics of generic and brand alendronate may also increase the probability of oesophageal damage with the generic versions of alendronate.Lastly, clinical data has consistently demonstrated that tolerance and effectiveness of generic alendronate is lower than that of the brand versions.While generic substitutions may lead to equivalent outcomes to the brand formulation in other drug classes the weight of evidence would suggest this is not the case with alendronate; the efficacy, effectiveness and tolerance ascribed to brand alendronate should not be extrapolated to the relatively untested generic versions of alendronate.


Participants were scanned in two different sessions during the application of self-initiated or directed instructions to apply semantic strategies at encoding of word lists. MCI participants showed reduced free recall scores when using self-initiated encoding strategies that were increased to baseline controls' level after directed instructions were provided. During directed strategic encoding, greater recruitment of frontoparietal regions was observed in both MCI and control groups; group differences between sessions were observed in the ventromedial prefrontal cortex and the right superior frontal gyrus. This study provides evidence suggesting that differences of activity in these regions may be related to encoding deficits in MCI, possibly mediating executive functions during task performance.In this study we examined differences in fMRI activation and deactivation patterns during episodic verbal memory encoding between individuals with MCI ( Mild cognitive impairment (MCI) is a heterogeneous syndrome that in some cases is transitional between normal age-related cognitive changes and dementia . Different levels of strategic processing were manipulated during unconstrained intentional encoding of word lists and after an explicit, direct instruction to apply a semantic encoding organizational strategy. We predicted that, relative to the unconstrained intentional encoding condition, both control and MCI groups would exhibit increases in memory and strategic performance after the explicit orientation to apply the semantic organizational strategy that would be paralleled by increased recruitment of frontoparietal network regions during episodic verbal encoding. We also investigated whether the MCI group would exhibit patterns of overactivation in frontoparietal network regions and/or impaired suppression  in DMN regions compared to controls during verbal episodic encoding after the explicit orientation to apply the semantic learning strategy.0349/09) and the patients signed a written informed consent form prior to their inclusion in the study.A total of 18 MCI patients and 17 HCs, all right handed, were included in the study . The general approach to manipulating semantic organization was modeled closely on the CVLT, which is a well-characterized clinical measure of strategic verbal memory  images for the whole brain acquired in a 3 Tesla Philips Achieva system with an eight-channel head coil. The acquisitions parameters were: TR = 3000 ms, TE = 30 ms, 40 slices, 3 mm slice thickness, 0.3 mm slice gap, FOV = 240 mm2 and matrix 64 × 64, 3 mm3 voxels, with 94 volumes per run. Functional acquisitions were preceded by four dummy scans to ensure steady-state magnetization. A T1-weighted structural image (voxel size: 1 mm3) was acquired before the functional sessions for coregistration with the fMRI data and to exclude brain pathology. In particular, white matter lesions were analyzed according to the Fazekas Score   interaction, in order to identify regions whose activation increased or decreased between sessions, more for the SR contrast than the UR contrast. There were no brain regions that showed a significant interaction or a main effect of list. The remaining analyses focused only in the contrast SR > fixation, giving the sensitivity of the SR word list in prompting measurable semantic clustering scores.Data processing and statistical analyses were conducted using FSL , the interaction group *session  was examined, using free recall score as a covariate to control for the possibility that activation differences between groups could reflect only the performance differences between groups. To further explore the relation between differences in session-related changes in activation and strategic performance behavior, the change in semantic clustering index for each participant  was regressed on the corresponding change in BOLD activation (Δ BOLD session). For this, a map was created in a second-level analysis subtracting the map associated with the encoding of the SR list at the spontaneous session from the directed session for each participant. To verify whether there was a difference in brain-behavior correlation patterns between groups, the interaction group*Δ strategy session was examined. All the statistical images were thresholded by using Gaussian random field-based cluster inference with a threshold of Z > 2.3 at the voxel level and a corrected cluster significance threshold of P < 0.05.Differences between the two encoding conditions were initially examined in each group separately. The effect of the explicit orientation to apply the semantic learning strategy in activation (directed > spontaneous) and deactivation (spontaneous > directed) between sessions were identified using a paired Table F = 20.766, p < 0.001], as both groups improved their free recall from the spontaneous to the directed session, after instructions to apply the semantic encoding strategy. There was also a significant list effect , showing better performance for the SR than the UR list. Controls recalled more words than MCI, independently of the list type and session . Post-hoc analysis indicated that MCI free recall performance after the orientation session to apply the semantic encoding strategy became similar to the controls performance at the spontaneous session .Behavioral performance in the word list learning paradigm related to the spontaneous and the directed fMRI sessions Table  was analF = 28.859, p < 0.001], indicating that both groups recalled a great number of clustered words after the explicit orientation to apply the verbal learning strategy than using self-initiated encoding strategies. The mean number of clusters generated by MCI patients was lower than the performed by controls in both sessions , as expected from their lower recall performances relative to controls. Mean recognition scores indicated above chance level of performance for both groups  × two (session) repeated measures ANOVA on the semantic clustering score revealed a significant session effect [We first assessed differences in verbal learning strategy application across sessions in fMRI activation and deactivation during episodic encoding of word lists separately for each group Table . IncreasZ = 4.13, cluster p-value corrected = 0.016), and in the right superior frontal gyrus, extending to the middle frontal gyrus . Plots showing the mean magnitude estimates of activity in the significant clusters for each session indicate the nature of the interaction effects, showing that only controls, but not MCI patients, exhibited a significant modulation  of the mMPFC function in response to the explicit orientation to apply the encoding strategy. In the right superior frontal gyrus, group level differences followed a “cross-over” pattern, such that in controls, activation decreased after the guided use of the semantic clustering, while patients showed increased activation. The interaction remained similar after controlling for behavioral differences in word recall between groups . Scatter plots of changes in BOLD signal between sessions against changes in strategy use for this region revealed a strong negative correlation in controls, such that higher performer participants exhibited the greatest decrease in activation (r = −0.734), whereas in MCIs, higher performer participants exhibited the greatest increase in activation from the spontaneous to the directed session (r = 0.339)  in these regions would be differently associated with changes in strategic performance in controls and MCIs. A significant group by strategy interaction was observed in a cluster located in the OFC, extending to the mPFC and anterior cingulate (peak voxel MNI coordinate 4 18–16 in the rectus gyrus; In the current study, we examined differences in fMRI brain activation and deactivation related to semantic strategy application during verbal memory encoding in MCI and HC subjects. As expected from prior reports on episodic memory performance in subjects at risk for dementia (Ribeiro et al., Results from the fMRI analysis revealed that after the explicit orientation to apply the verbal learning strategy, greater recruitment of frontoparietal network regions, including portions of the left DLPFC, VLPFC, were observed in both MCI and control groups in relation to the unconstrained encoding condition, as expected. The initial prediction of over-recruitment of portions of the DLPFC and within the IPS in MCI reflecting possible compensation mechanisms due to increased cognitive demand to perform the task was not confirmed. Group-differences in functional deactivations, however, were observed in the vmPFC and in the right superior frontal gyrus, related to the absence of modulation in the activity of the vmPFC, along with a lack of suppression of the right superior frontal gyrus in MCI. A different association between improvement in strategy use and session-related changes in activation of the medial OFC between groups was also confirmed. As previously stated (Savage et al., In fMRI studies, increases in activation with the development of a new strategy acquired by learning are often thought to reflect recruitment of additional cortical units, seen as strengthening of BOLD response within brain regions (Poldrack, Improvements in strategy application and memory performance were represented by different activation changes in the mPFC and in the right superior frontal gyrus responses between groups. These activations did not appear to be exclusively related to performance differences between groups, as we controlled for free recall scores in our fMRI analyses.APOE4 genotype carriers (Pihlajamäki and Sperling, While controls clearly suppressed the responses of mPFC and of the right superior frontal gyrus during encoding after the explicit orientation to apply the semantic strategy, MCI subjects exhibited a pattern of less deactivation in these regions. Similar results were reported by the memory training study above cited (Belleville et al., An alternative interpretation for the different pattern of results between our groups came from evidence suggesting that when performance of a task improves after learning or practice due to better application of strategies, task becomes less effortful and demands on executive control processes are reduced Jonides, . This reThe results of our study should be interpreted in the context of some potential limitations. The MCI diagnosis was performed based on cross-sectional neuropsychological data rather than on longitudinal subject-by-subject objective evidence of progressive memory loss, and so it is not possible to completely rule out the possibility that patients defined on the basis of their clinical profile belong to different subgroups and different points of a severity continuum. It must also be acknowledged that the ability to discriminate changes in activity that represent differences in cognitive function from those that represent physiological change due to a MCI diagnosis is a challenge for fMRI research, especially since neurovascular coupling processes may change with age or disease risk (D'Esposito et al., In sum, the results of our study extend the existing literature on differential cognitive processing and neural recruitment in MCI during performance on episodic memory encoding tasks. The novel contributions of our study involved an assessment of the neural correlates of strategic processes employed during encoding of episodic memory in this population. Examining differences in the patterns of deactivation during verbal encoding with increased strategic processing, we found that MCI patients failed to show modulation of activation in mPFC and less deactivation in the right superior frontal gyrus compared to normal controls. Such different pattern of responses may reflect changes in the set of cognitive processes, particularly executive functions, adopted during verbal memory encoding between normal aging and MCI.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.


Although it is well established that exercise training conditions the vasculature  on hemodynamic forces such as shear rate and pressure patterns, nitric oxide (NO) production and vessel structure  via lower absolute blood flow to active skeletal muscle . This is certainly favored by a region-specific arterial function, as evidenced by the observations that arterial constrictor function is enhanced in the upper limb after cycling training (Rakobowchuk et al., 2 during leg cycle ergometry is more closely associated with arterial dilator function determined in the lower vs. upper limb (Ridout et al., Therefore, the optimal arterial function, as regards exercise performance, must contribute to maximize blood flow to active skeletal muscle and minimize blood flow to other tissues, while maintaining the required perfusion to exercise-related athletic arterial phenotype is, at least in part, characterized by the enhancement of vascular smooth muscle dilator function. Yet, such enhanced dilator function seems to be region-specific and paralleled by increased vasoconstriction in order to efficiently distribute a finite cardiac output. The understanding of the interplay between arterial dilator-constrictor function and sympathetic drive at multiple hierarchical levels during exercise remains elusive and a challenge for future research in to the physiological bases of human performance.The remarkable arterial dilator capacity demonstrated by ATH is partly attributed to an enhanced response to vasodilator stimuli. This is particularly observed in peripheral resistance vessels, but also in upstream conduit arteries when adjusted for lumen dimensions, which are increased in young ATH. Notwithstanding the age status, the The author declares that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.