Rather than being slowly eroded and destroyed, countless numbers of varied forms of life adapt to the diverse aspects of an ever changing environment. However, the amount of variation is maintained at a practical optimum, as too much variation would make the population ill-adapted in a stable environment, while too little variation would render it unable to adapt to environmental stresses. This principle is perhaps well exemplified by a phenomenon described for microbial cells termed “persistence” where in the face of antibiotics bacterial populations avoid extinction by harboring a subpopulation of drug-insensitive dormant cells. Although this phenomenon poses a major obstacle for the treatment of infectious diseases, persistence has been underappreciated for some time as a mechanism for bacteria to evade antibiotics. But the mechanisms of bacterial persistence are becoming clearer and so are ways to combat them. This article highlights the phenomenon of survival and persistence in cells as diverse as microbial and human and summarizes the recent advances that have taken us one step closer to understanding what persistence is all about.Candida albicansIn the early 1940s, it was only appropriate for Joseph Bigger to refer to a small subpopulation of bacterial cells that survived killing by penicillin, as “persisters” Persisters have been described to arise spontaneously on the basis of random stochastic events Recent findings from studies examining the rate of bacterial persister-cell formation over time showed that the highest frequency (∼1%) occurs in the nongrowing stationary phase hipA, which encodes a toxin (HipA) that inhibits translation in Escherichia coli. This toxin was identified to be implicated in forming persisters because its overexpression increased the frequency of persistence by 10,000-fold and resulted in drug tolerance hipBA has been categorized as a toxin/antitoxin (TA) module The simplest strategy to trigger entry into dormancy would be to overproduce proteins or toxins that inhibit cellular processes and growth E. coli, exposure to a DNA-damaging antibiotic triggered the gene encoding a small membrane-acting peptide TisB, which decreases proton motive force and ATP levels suggesting that TisB protein may induce dormancy by shutting down cell metabolism tisB gene resulted in decreased frequency of persisters tolerant to DNA-damaging antibiotic tisB resulted in cell death, minor overproduction of the peptide induced persister formation suggesting that induction of TisB is involved in the production of multidrug tolerant cells, in turn identifying tisB as a persister gene Perhaps, the best defined mechanism by which persister bacterial cells arise comes from the fact that DNA damage induces one or more components of the protective SOS stress response, a signaling pathway that upregulates DNA repair functions Persister cells are highly enriched in biofilms, which are complex and highly organized surface-attached communities of microbes embedded in a polymeric matrix Pseudomonas aeruginosa, E. coli, and Staphylococcus aureusC. albicansC. albicans isolates recovered from nonresolving infections appeared to be high-persister variants. Similar to bacteria, C. albicans forms adherent biofilms, which are essentially recalcitrant to antifungals C. albicans biofilm antifungal resistance remains largely unknown; however, biofilms have been described to exhibit a biphasic killing pattern in response to antimicrobial agents, indicating that a subpopulation of highly tolerant cells existed C. albicans persisters, analogous to their bacterial counterparts, are not mutants but phenotypic variants and that attachment to a surface is what initiates dormancy that leads to the formation of persisters Persisters are formed by all bacterial species studied and are present at 0.1%–1% in the biofilms of Similar to the obstacle in treatment of patients that develop resistance to antimicrobials, acquisition of resistance to anticancer drugs is a major problem in cancer therapy. Most treatments, even ones that work, fail over time because tumor cells become resistant. Different mechanisms of resistance have been described for cancer cells such as modification of drug target and active extrusion of drugs by efflux pumps and, therefore, it was largely assumed that random gene changes confer resistance to drugs 50 values. Following three rounds of 72-h treatments, the authors consistently detected a small subpopulation of reversibly “drug-tolerant” cells demonstrating >100-fold reduced drug sensitivity. Further analyses demonstrated that these cells maintained viability via engagement of insulin-like growth factor 1 (IGF1) receptor signaling and an altered chromatin state and treatment with IGF1 receptor inhibitors or chromatin-modifying agents selectively ablated the drug-tolerant subpopulationIn a recent study by Sharma et al. Cancer-initiating cells are proposed as a potential resistant subpopulation because of their ability to escape the effect of drug treatment by becoming quiescent Whether microbial or human in nature, it appears that cells have evolved analogous redundant strategies where the function of survival is assigned to a small dormant subpopulation of cells within a more rapidly proliferating population. With most of the currently available chemotherapeutic agents targeting exponentially growing cells, our therapeutic arsenal is ineffective in eradicating these dormant persister cells. Coupled with the increasing emergence of drug resistance and failure of therapies despite our medical advances, it has become critical to develop novel classes of drugs. The prospect that persisters are responsible for the persistence of chronic infections and, more gravely, recalcitrance of disseminating cancers have identified these culprit cells as viable targets for new therapies. However, such discoveries rely heavily on the depth of our understanding the nature of these intriguing cells, which would provide us with fundamental insights into the mechanisms involved in the development of drug tolerance. Inopportunely, their transient nature and low abundance, has impeded experimental advancements to elucidate the dynamics of the formation of these specialized cells that neither die nor grow. Nevertheless, the recent unearthing of an inherent tactical approach shared by diverse cellular insurgents will undoubtedly herald a new era of research into the new field of “persisters.”


Staphylococcus aureus occurs rapidly, and in response to all known antimicrobial treatments. Numerous studies of model species describe compensatory roles of mutations in mediating competitive fitness, and there is growing evidence that these mutation types also drive adaptation of S. aureus strains. However, few studies have tracked amino acid changes during the complete evolutionary trajectory of antibiotic adaptation or been able to predict their functional relevance. Here, we have assessed the efficacy of computational methods to predict biological resistance of a collection of clinically known Resistance Associated Mutations (RAMs). We have found that >90% of known RAMs are incorrectly predicted to be functionally neutral by at least one of the prediction methods used. By tracing the evolutionary histories of all of the false negative RAMs, we have discovered that a significant number are reversion mutations to ancestral alleles also carried in the MSSA476 methicillin-sensitive isolate. These genetic reversions are most prevalent in strains following daptomycin treatment and show a tendency to accumulate in biological pathway reactions that are distinct from those accumulating non-reversion mutations. Our studies therefore show that in addition to non-reversion mutations, reversion mutations arise in isolates exposed to new antibiotic treatments. It is possible that acquisition of reversion mutations in the genome may prevent substantial fitness costs during the progression of resistance. Our findings pose an interesting question to be addressed by further clinical studies regarding whether or not these reversion mutations lead to a renewed vulnerability of a vancomycin or daptomycin resistant strain to antibiotics administered at an earlier stage of infection.The evolution of resistance in  S. aureus isolates produced a ß-lactamase enzyme mediating resistance to the antibiotic S. aureus (MRSA) S. aureusS. aureus isolates evolving following exposure to vancomycin treatment are increasing in prevalence and are of great concern since these drugs are “last-line of defense” antibiotics against infection Within a decade following the accidental discovery of penicillin G, the majority of known S. aureus that are associated with adaptation to vancomycin or daptomycin exposure have recently been reported, and these studies have also established that the progression of resistance in these isolates is accompanied by phenotypic alterations in virulence S. aureus strains has been reported to be the consequence of specific mutations in the mprF gene encoding a membrane protein, the ) gene encoding a sensor histidine kinase, and the rpoB gene encoding a RNA polymerase subunit vraG, agrA, dltA, rpoB, yvqF, and stp1) acting in multiple genetic pathways have been previously shown to reduce the susceptibility of S. aureus isolates to vancomycin treatment Recent studies of several infectious pathogens have revealed how processes of horizontal gene transfer, recombination, and parallel evolution can lead to sequence variations that give rise to the progression of antibiotic resistance S. aureus mutations associated with increased resistance have not been evaluated in the context of evolution. In general, neutral evolutionary trends over time help to establish a priori expectations of functional effect because each position in each protein has undergone functional evaluation across evolution in silico prediction methods that have been developed and commonly applied to studies of human genomes in order to provide a diagnosis of a given variation as functionally benign or damaging Previously identified We have discovered that these prediction methods are significantly inaccurate when applied to diagnosing known RAMs. Furthermore, by tracing the evolutionary history of the false negative RAMs, we have found that these mutations are genetic reversions to conserved ancestral alleles that are carried in a phenotypically methicillin-sensitive isolate (MSSA476). Reversion RAMs are more prevalent in strains exposed to daptomycin treatment and show a tendency to accumulate in enzymes mediating certain reactions of complex biosynthetic pathways. Our findings should therefore be of interest to clinical researchers who have the means to evaluate the relevance of genetic reversions as potential drug targets during the course of treatment.S. aureus sequences includes efforts to identify non-neutral sequence changes that are adaptive in the presence of an antibiotic. We therefore adapted popular tools  Performance statistics for accurately predicting known Given the low accuracy of prediction tools in identifying known RAMs, we traced the evolutionary history of the false negative cases and discovered that a significant number are reversion mutations to ancestral alleles, also carried in the genome of the MSSA476 methicillin-sensitive isolate .S. aureus strains, including the MSSA476 isolate (agrC and SA0248 reversion RAMs that were accurately predicted by PolyPhen (agrC) or CAROL (SA0248)  and amino acid metabolism (putative 8-amino-7-oxononanoate synthase) also carry reversion RAMs . UDP-N-aagrC, tcaR and walk genes walk homologous protein sequences yielded different predictions regarding their functional relevance  elevance . In a lancomycin . Point magrC, it is possible that other reversion RAMs identified in our studies are also compensatory in function, or general suppressors that may reduce fitness costs, even though their role has mainly been previously described relative to the progression of resistance S. aureus that exhibit reduced gentamicin susceptibility, identified several sequence variations in the menB gene S. aureus adaptation.Similar to A total of 47 amino acid variations previously identified as conferring lowered susceptibility or resistance of MRSA isolates following exposure to either vancomycin or daptomycin were used as positive controls for testing computational prediction algorithms Staphylococcus, Listeria, Macrococcus, and Bacillus (filtered). Custom python scripts were used to run a prediction pipeline including PolyPhen, SIFT, and CAROL and predictions were calculated as described in Amino acid variations identified in resistant clinical and laboratory isolates and the susceptible strain pair allele (reference sequence) were used to assay for damaging predictions . AdditioG, parameter = 0.1000). The rate variation model allowed for some sites to be evolutionarily invariable . The tree is drawn to scale, with branch lengths measured in the number of substitutions per site. The analysis involved 18 nucleotide sequences. All positions containing gaps and missing data were eliminated. There were a total of 50440 positions in the final dataset. Evolutionary analyses were conducted in MEGA5 Sequence alignments were used to assess overlap of homologous RAM positions and codons with 2- or 4-fold degenerate sites in MEGA5


Several new approaches for treatment of Central Nervous System (CNS) disorders are currently under investigation, including the use of rehabilitation training strategies, which are often combined with electrical and/or pharmacological modulation of spinal locomotor circuitries. While these approaches show great promise in the laboratory setting, there still exists a large gap in knowledge on how to transfer these treatments to daily clinical use. This thematic series presents a cross section of cutting edge approaches with the goal of transferring basic neuroscience principles from the laboratory to the proverbial "bedside". Central nervous system (CNS) disorders such as stroke, spinal cord injury (SCI), traumatic brain injury, multiple sclerosis or Parkinson’s cause a variety of functional impairments ranging from impaired control of gait or reach through to deficits in cognition and autonomic dysfunction . DevelopBased on simultaneous exploration of animal models and clinical trials on humans, the last decades brought significant improvements in our knowledge of pathophysiology of numerous neurological disorders. From improved understanding of the basic neuroscience and biochemistry associated with CNS damage and recovery from it, many new experimental therapeutic approaches have emerged, including: neural regeneration , modulatFocusing on the CNS integrated control of movement, there are several approaches that have been successful in the laboratory setting, including the use of rehabilitation training strategies, which are often combined with electrical and/or pharmacological modulation of spinal locomotor circuitries to improve functional outcomes in people living with CNS impairment. To this end, this thematic series presents some of the current work that bridges the gap from basic science to clinical application. The articles represent a cross section of cutting edge approaches with the goal of transferring basic neuroscience principles from the laboratory to the proverbial “bedside”. The contributions explore the feasibility and efficacy of novel activity-dependent training strategies for both upper and lower extremities and the development of new technologies for spinal stimulation.Hubli and Dietz set the stage by reviewing the physiological basis and state of the art of rehabilitation after spinal cord injury. The authors emphasize the importance of task specific sensory clues, which were shown to be highly relevant for neural plasticity and consecutive optimization of functional recovery. As already shown in animal experiments , they coStarting with healthy subjects, Zimmermann et al. present a new brain-computer-interface approach for rehabilitation paradigms involving the upper extremities. The authors take a first step towards real-time control of rehabilitation robots or prosthetics based online decoding of movement intention during a finger-pinching task. Using functional Near-InfraRed-Spectroscopy (fNIRS) recordings from motor-cortex M1 of healthy subjects, in combination with physiological signals (including heart rate and skin conductance), they detect movement onset in real time. By decoding the motor intention in real-time and relaying it to a robotic device that generates the desired movement, the resulting sensory signals better match the initial motor intention and command. In current rehabilitation paradigms, particularly in severely affected patients, the physical therapist generates functionally relevant sensory signals to the CNS by moving the patient’s limbs; these sensory signals are not necessarily temporally congruent with the movement intention generated by the patient. The faster setup time of fNIRS compared to other brain computer interfaces, such as EEG, promises easier clinical use. While it remains to be confirmed that patients with motor cortex lesions would be able to activate the respective adjacent preserved or undamaged motor cortex regions to be able to use this brain computer interface, this work opens a whole line of research on novel treatment paradigms.Koopmann et al. take on the problem of designing subject-specific lower extremity robotic rehabilitation interventions after stroke. While rehabilitation robots in the past followed a “one fits all” approach, the authors propose to divide the gait cycle into sub-tasks such as weight support, forward propulsion or control of the swing phase. Focusing on swing phase in this paper, the authors developed an assist-as-needed controller for the LOPES rehabilitation robot  that canAlso on the topic of individualized therapy interventions, Gad et al. present their work on designing and evaluating a new high-density array for spinal stimulation in rats with traumatic spinal cord injury. While most current implantable stimulators rely on broad tonic stimulation of spinal segments, the authors hypothesize that high density arrays allowing high spatial resolution stimulation of select motor circuitry will allow training of specific gait related functions such as ankle or knee flexion during swing or the amount of weight bearing during stance. In addition, such arrays will allow addressing the problem of potential spontaneous movement (drift) of the stimulating electrodes within the spinal tissue. Showcased in a single case study on one rat, the authors provide evidence that the stimulation site is of crucial importance to elicit stepping in the rat. In addition, the same device can be used to assess functional conductivity between specific motor pools via motor-evoked potentials, and could thereby be used as a diagnostic and rehabilitation training tool. As the optimal location for stimulation can vary from animal to animal, from patient to patient and even from day-to-day, the improved spatial resolution of such arrays could in the future be expected to allow tuning the stimulator to a pattern optimally adjusted to each patient’s individual motor deficit.Finally, Patten et al. investigate the efficacy of a novel training paradigm, namely high intensity, dynamic resistance power training, on clinical outcome scores in 19 stroke survivors. In a cross-over design, the authors show that a dose equivalent combination of functional training and strength training yields larger functional improvements that are better retained at six months post-intervention. This supports the hypothesis that intensity of movement therapy is crucial for maximal recovery after neurological injury.Taken together, these articles highlight the importance of patient-centered approaches towards improving functional outcomes and quality of life. All these approaches look at specific aspects of the rehabilitation continuum. As these techniques mature into clinical reality, they provide a path forward for individualized rehabilitation programs, consisting of modules specifically customized to address a patient’s underlying functional deficits. Given the heterogeneity of deficits observed clinically, an adaptable combination of interventions will likely be required to address each individual’ impairments and needs. Determining the appropriate "dose response" and the best combination of approaches remains to be scientifically and clinically validated.


Though synesthesia research has seen a huge growth in recent decades, and tremendous progress has been made in terms of understanding the mechanism and cause of synesthesia, we are still left mostly in the dark when it comes to the mechanistic commonalities (if any) among developmental, acquired and drug-induced synesthesia. We know that many forms of synesthesia involve aberrant structural or functional brain connectivity. Proposed mechanisms include direct projection and disinhibited feedback mechanisms, in which information from two otherwise structurally or functionally separate brain regions mix. We also know that synesthesia sometimes runs in families. However, it is unclear what causes its onset. Studies of psychedelic drugs, such as psilocybin, LSD and mescaline, reveal that exposure to these drugs can induce synesthesia. One neurotransmitter suspected to be central to the perceptual changes is serotonin. Excessive serotonin in the brain may cause many of the characteristics of psychedelic intoxication. Excessive serotonin levels may also play a role in synesthesia acquired after brain injury. In brain injury sudden cell death floods local brain regions with serotonin and glutamate. This neurotransmitter flooding could perhaps result in unusual feature binding. Finally, developmental synesthesia that occurs in individuals with autism may be a result of alterations in the serotonergic system, leading to a blockage of regular gating mechanisms. I conclude on these grounds that one commonality among at least some cases of acquired, developmental and drug-induced synesthesia may be the presence of excessive levels of serotonin, which increases the excitability and connectedness of sensory brain regions. Synesthesia is an extraordinary way of perceiving the world, involving experiences of connections between seemingly unrelated sensations, images or thoughts . For exaThe two key characteristics of synesthesia regardless of whether it is of the projector or associator type is that it involves an aberrant binding of features from different sensory or cognitive streams that are associated with atypical conscious experiences or thoughts and that these experiences or thoughts are automatic, that is, synesthetes cannot suppress the association between an inducer and its concurrent. Other characteristics of the condition are specific to the different forms. According to (1)Developmental, or genuine, synesthesia(1)Acquired synesthesia(1)Drug-induced synesthesiaDevelopmental synesthesia, the most common type, is a form of the condition that has persisted since birth or early childhood and that remains relatively stable and systematic over time: each inducer has a highly specific concurrent. . It alsoAcquired synesthesia is a form of the condition that emerges after brain injury or disease or artificial technologies like sensory substitution . It has Drug-induced synesthesia is a blending of sensory or cognitive streams that is experienced during exposure to a hallucinogen  among developmental, acquired and drug-induced synesthesia. It is widely believed that most forms of the condition involve functional or structural aberrant brain connectivity. The proposed mechanisms include direct or indirect projection through increased structural connectivity , functioOne proposal by Thus, excitatory mechanisms. Though serotonin traditionally has been considered an inhibitory neurotransmitter, more recent evidence suggests a more complex picture according to which serotonin can function both as an inhibitory and an excitatory neurotransmitter. For example, serotonin helps reduce fear processing in the amygdala via GABA modulation but it exerts an excitatory effect on cortical brain activity when it binds to 5-HT2A serotonin receptors on layer V pyramidal neurons  can be a trigger of persistent or transient synesthesia in all the groups through  neurons .As indicated by Excessive serotonin levels may also play a role in synesthesia acquired after brain injury. Research has shown that necrosis following tissue damage leads to local neurotransmitter flooding caused by an excessive release of serotonin and glutamate , a phenoDevelopmental synesthesia has been reported as a condition in autism-spectrum disorders , and is In what follows I will provide detailed evidence for the hypothesis that one commonality among at least some cases of acquired, developmental and drug-induced synesthesia is the presence of excessive levels of serotonin or serotonin-agonists, which increase the excitability and connectedness of sensory brain regions through 5-HT2A receptors in cortical neurons.The acquired form of synesthesia usually emerges subsequent to traumatic brain injury or neuropathologic insult to the brain . SeveralIt remains largely unknown how a brain lesion may give rise to the plastic changes that lead to the increased connectivity. One possibility is that it is caused by increased neurotransmitter activity in cortical regions adjacent to the affected site. This increase is believed to contribute to the pathophysiology and neurological dysfunction after traumatic brain injury . In trauThe increased levels of serotonin and glutamate immediately following brain injury do not normally stay elevated for very long . Eysel eOne hypothesis for how brain injury or disease may cause synesthesia, then, is that the initially elevated neurotransmitter levels down-regulate serotonin receptors in neural regions in the ipsilateral hemisphere, leading to decreased serotonin levels. Individuals who acquire synesthesia also sometimes develop autistic traits and savant-like abilities of the sort seen in 10 percent of autistic individuals . EmerginThe second hypothesis is more plausible than the first when synesthesia is acquired after brain injury. It would explain the increased ipsilateral connectivity found in at least one case of acquired synesthesia . It gainThe above considerations raise the question of why only a small fraction of brain injury patients acquire synesthesia-like experiences. One possible answer is that individual differences originate in variance in the degree of plasticity of the subject’s brain prior to the incident. Research on brain injury in children has shown that alterations in neurotransmission during the critical period when a brain region is most plastic can promote outgrowth of abnormal neural connections . Since iBorn on a Blue Day that he acquired synesthesia after childhood seizures. Though his grapheme-color synesthesia appears unusually rich, it may have neurological underpinnings akin to more typical developmental forms. Other forms of acquired synesthesia appear to be transient and may well be a more direct product of excitatory neural activity, similar in many respects to synesthetic experience occurring under the influence of hallucinogens (see below). An example would be synesthesia experienced during occipital and temporal lobe seizures, which can lead to brief experiences quite similar to psychedelic experiences  and the phenethylamines , are potent partial agonists at serotonin 5-HT1A/2A/2C receptors, with 5-HT2A receptor activation directly correlated with hallucinogenic activity . HoweverA promising suggestion for how the hallucinatory effects occur is that hallucinogens activate layer V pyramidal neurons in the cortex, which engage in gating functions in communication between the cortex and subcortical brain regions . When a Figure 1).The view that the hallucinatory effects of hallucinogens are primarily a result of enhanced neural activity may appear inconsistent with a recent fMRI study showing that psilocybin causes decreased activity in the ACC/medial prefrontal cortex and a significant decrease in the positive coupling between the medial prefrontal cortex and the posterior cingulate cortex, and that these findings were correlated with subjective effects . As Lee To my knowledge, no model of how hallucinogens trigger synesthesia has yet been proposed. One natural proposal would be that the mechanisms in developmental and drug-induced synesthesia are similar. There is, however, some reason to doubt this suggestion. The phenomenological differences between developmental and drug-induced synesthesia are quite striking . As a result of this aberrant binding, the two inputs may be experienced as an inducer-concurrent pair, for example colored, geometrical music.One tentative suggestion is that drug-induced synesthesia, like hallucinations, originates in the hyperactivity of layer V pyramidal cells resulting from the binding of hallucinogens to 5-HT2A receptors in the cells’ dendrites, which then increases local glutamate levels. Layer V pyramidal cells bind multisensory information through feedback loops that synchronize oscillatory neural responses . In the usic see . One posThe proposed mechanism leads to the testable prediction that drug-induced synesthesia will not usually be systematic. In developmental cases sound-color synesthesia is systematic in the sense that very specific sounds normally trigger very specific colors. Given the aberrant binding proposed, however, it appears that drug-induced sound-color synesthesia will not tend to be systematic because random activity will be paired with available auditory information. So, we should expect that the same sound may have many different colors and shapes.There are only few reports of drug-induced synesthesia that endures post-exposure, though there is evidence that other practices that can induce altered states of consciousness, such as meditation and posthypnotic suggestion, frequently cause enduring synesthesia . The sugThe proposed mechanism of hyperexcitability followed by disruption may appear to be inconsistent with a related finding for developmental synesthesia. It is believed that enhanced cortical excitability at an early developmental stage might contribute to atypical grapheme-color binding, even though it does not appear to be a direct cause of synesthesia at later stages . A recenA version of the proposed model also appears consistent with the findings of A further interesting question is whether the above model could be adapted to explain acquired synesthesia in which necrosis leads to neurotransmitter flooding and elevated local serotonin levels. Though we do not have enough data on acquired synesthesia to make any firm conclusions at this point, it remains a possibility that some forms of developmental synesthesia are acquired in childhood in the same way as the persistent cases of acquired synesthesia, whereas temporarily acquired synesthesia is mechanistically akin to drug-induced synesthesia. If this is correct, then we should expect drug-induced synesthesia and temporarily acquired synesthesia to both lack systematicity, as they would result from pairing features with random information. We should furthermore expect persisting forms of acquired synesthesia to have the same patterns of permanence and systematicity as at least some forms of developmental synesthesia.Though it is difficult to say whether alterations in the serotonergic system play a role in the development of the most common forms developmental synesthesia, such as week-color and grapheme-color, developmental synesthesia seen in autism spectrum disorder is plausibly triggered by unilateral changes in the serotonergic system . CytowicThe evidence that serotonin plays a crucial role in autism is overwhelming. About 30 percent of autistic individuals have a 25 to 70 percent increase in blood levels of serotonin, also known as hyperserotonemia . HyperseSeveral PET imaging studies have suggested that autism may be a lateralized syndrome, with decreased serotonin release from raphe terminals in one hemisphere  and elevated serotonin release in the contralateral hemisphere . SignifiOne possible explanation of the asymmetry is that the early serotonin depletion in the dominant left hemisphere leads to overcompensation in the right hemisphere. It has been reported that a decrease in extracellular serotonin over time may lead to an excessive spread of thalamocortical axon branches, resulting in lower information-transmission and structural changes in affected cortical regions as well as underdeveloped long-range connections between different brain areas . When thA hemispheric effect does not provide clear evidence for a role of serotonin in synesthesia, as not all individuals with autism have synesthesia. But the expected high frequency of synesthesia in autistic individuals together with the lateralization hypothesis point to the possibility that increased extracellular levels of serotonin in the autistic brain may be a causal influence on the genesis of synesthesia in individuals with this disorder. There appears to be two ways in which serotonin could be implicated in synesthesia in autistic individuals. One possibility is that the high serotonin levels in very young children with autism sometimes trigger altered multisensory processing. Another possibility is that compensatory high serotonin levels in the contralesional hemisphere sometimes cause unusual feature binding. If the former hypothesis is correct, then we should expect to find evidence of synesthesia in autistic individuals at a very young age.There are multiple ways that elevated serotonin levels may lead to synesthesia in autistic individuals. If the onset of synesthesia in autism occurs at an early age, it could be the result of serotonin-triggered hyperactivity in glutamatergic neurons in layer V and resulting destabilization of thalamic connections. If this hypothesis is correct for synesthesia in autistic individuals, then we should expect that the synesthetic connections can persist only in the form of tight memory connections after the subsequent loss of serotonin-terminals in large areas of the brain. Accordingly, on the assumption that projector synesthesia is not normally mnemonic, we should not expect to find a significant number of projector synesthetes among autistic individuals. Another way synesthetic connections could form would be through the early excessive formation of neural pathways. Persisting synesthesia in this case would require that the early formed structural connections could survive the extensive pruning that appears to take place when serotonin-terminals are lost. If the onset of the synesthesia does not occur at an early age, structural or functional synesthetic connections could still form in the spared right-hemisphere regions that are also believed to be responsible for the savant skills founds in 10 percent of autistic individuals. Structural connectivity mechanisms have been proposed for standard cases of grapheme-color synesthesia, suggesting unusual connectivity between the color area and the fusiform gyrus . EnhanceWhether a hyperactive serotonergic system can contribute to developmental synesthesia in non-autistic individuals is unknown. As autism is partly defined by sensory processing deficits, the emergence of synesthesia in autism could be a consequence of other sensory alterations and originate from a unique set of mechanisms distinct from those present in other cases of developmental synesthesia. But some data points indicate that serotonin may be mechanistically involved in producing synesthetic experience through altered functional connectivity. As Drawing on evidence that the 5-HT2A receptor may be involved in generating synesthetic experience, Other evidence gives some credit to the hypothesis that synesthesia in non-autistic individuals could be related in terms of brain structure to autism and savant syndrome and hence that a particular brain structure may underlie all of these conditions. Population studies suggest that there may be a higher incidence of synesthesia among people with creative talent . ConversHowever, we do not yet have enough data to draw any firm conclusions about the role of serotonin in developmental synesthesia in non-autistic individuals or the connection between developmental synesthesia and autism. More systematic population studies as well as whole-genome linkage scans and family linkage analyses may be able to shed more light on this connection. The extent to which serotonin is mechanistically involved in developmental synesthesia could be tested more systematically in pharmacological studies using drugs known to inhibit 5-HT2A receptors, such as SSRIs , and serThe primary aim here has been to defend the hypothesis that synesthesia is at least sometimes a hyperserotonergic condition that triggers synesthesia through excitatory neurotransmitter action. The main evidence in favor of this hypothesis can be summarized as follows:First of all, brain injury that gives rise to acquired synesthesia leads to necrosis and excessive release of serotonin and glutamate. Though this increase in excitatory neurotransmitter activity leads to lower excitability in local areas through negative feedback within weeks, decreased activity in affected neural regions could lead to a disinhibitory enhancement of neural activity and connectivity in unaffected cortical regions. Alternatively, the early increase in serotonin levels could lead to the formation of unusual feature binding.Secondly, administration of certain hallucinogenic serotonin agonists  induces synesthesia. The mechanism underlying drug-induced synesthesia plausibly involves serotonergic excitatory activity in layer V pyramidal neurons implicated in multisensory binding.Thirdly, serotonin synthesis is typically increased unilaterally in individuals with autism, about 15 percent of which are believed to experience synesthesia compared to about 4 percent population-wide. In terms of a potential mechanism, one possibility is that serotonin causes aberrant structural binding in the spared neural regions that are also responsible for the savant skills found in 10 percent of autistic individuals.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.


The health risks of crack cocaine smoking in public settings have not been well described. We sought to identify factors associated with public crack smoking, and assess the potential for a supervised inhalation facility to reduce engagement in this behavior, in a setting planning to evaluate a medically supervised crack cocaine smoking facility.Data for this study were derived from a Canadian prospective cohort of injection drug users. Using multivariate logistic regression we identified factors associated with smoking crack cocaine in public areas. Among public crack smokers we then identified factors associated with willingness to use a supervised inhalation facility.Among our sample of 623 people who reported crack smoking, 61% reported recently using in public locations. In multivariate analysis, factors independently associated with public crack smoking included: daily crack cocaine smoking; daily heroin injection; having encounters with police; and engaging in drug dealing. In sub analysis, 71% of public crack smokers reported willingness to use a supervised inhalation facility. Factors independently associated with willingness include: female gender, engaging in risky pipe sharing; and having encounters with police.We found a high prevalence of public crack smoking locally, and this behavior was independently associated with encounters with police. However, a majority of public crack smokers reported being willing to use a supervised inhalation facility, and individuals who had recent encounters with police were more likely to report willingness. These findings suggest that supervised inhalation facilities offer potential to reduce street-disorder and reduce encounters with police. The use of illicit drugs in public settings, including street, alleys and parks is both a public health and public order concern in many urban areas -3. To daIn Vancouver, Canada the popularity of crack cocaine and ease of administration through smoking has made public crack cocaine use a common feature of the streets in the city's drug use epicentre, known as the Downtown Eastside . Public Given the dramatic rise in crack cocaine smoking and the public order and public health concerns associated with it, the need for targeted interventions for people who smoke crack cocaine is unambiguous. One potential intervention that is receiving increasing attention from public health officials, health researchers and local community groups is supervised drug consumption facilities analogous to supervised injection sites but that accommodate crack smoking and distribute drug consumption materials specific to safer inhalation  ,29-33. TPrevious studies have assessed general willingness among local drug users to use a supervised inhalation facility ,36; howeData for this study was obtained from the Vancouver Injection Drug Users Study, which is an open prospective cohort that began enrolling people who inject drugs (IDU) through street outreach as self-referral in May 1996. This study has been described in detail previously ,38. In ba priori selected a range of socio-demographic and behavioural variables we hypothesized might be relevant to smoking crack cocaine in public areas. This selection was informed by the 'risk environment framework' and previous analyses among street-involved drug users highlighting connections between social, structural and environmental level factors and risky drug consumption practices [In our first analysis among crack cocaine smokers, the outcome of interest was using drugs (non-injection) in public areas in the last six months. As in previous analyses, public areas included city streets, parks, public washrooms, parking lots, clubs or bars and abandoned buildings. To characterize our outcome of interest we ractices ,31,39-41In a second analysis, we sought to assess and identify predictors of willingness to use a supervised inhalation room. Because we were particularly concerned with public drug use we restricted our sample to crack cocaine smokers that reported recently using non-injection drugs in public areas. To measure willingness we asked participants "If there was a safe place to smoke your drugs , close to where you buy or use, would you use it?"a priori based on factors we hypothesized might be associated with willingness to use an inhalation room. These included age (per year older); gender ; Aboriginal Ancestry (yes vs. no); limited access to private space, as defined above (yes vs. no); drug scene exposure, defined as spending an average of seven or more hours on the street each day in Vancouver's drug use epicentre in the previous six months (yes vs. no); most drug use in public areas, defined based on reports that public locations were where they most frequently used drugs (yes vs. no); daily crack cocaine smoking (yes vs. no); risky pipe sharing, defined as reporting sharing a crack pipe or mouthpiece in the same six month period as having burns or sores on their mouth (yes vs. no); encounters with police in the last month (yes vs. no); and being a victim of violence (yes vs. no). As above, unless otherwise stated, all drug use and behavioural variables refer to the previous six month period.Variables of interest for our second analysis were also selected p < 0.05 in univariate analyses were entered into the respective multivariate regression models. All statistical analyses were performed using SAS software version 9.1 . All p-values are two sided.For both of our first and second analyses, we used univariate and multivariate statistics to determine factors associated with our outcomes of interest. In univariate analysis categorical explanatory variables were analyzed using Pearson's chi-square test and continuous variables were analyzed using the Wilcoxon rank sum test. Fisher's exact test was used when one or more of the cell counts was less than or equal to five. To evaluate factors independently associated with our outcomes of interest, all variables that were During the study period 623 participants were seen for study follow-up visits and reported smoking crack cocaine in the last six months. These included 249 (40%) women and 231 (37%) persons who identified as Aboriginal. The median number of times that participants reported smoking crack cocaine in an average day was 4 (interquartile range = 2-10). Among our sample of 623 crack smokers, a total of 382 (61%) reported using in public areas in the last six months. The characteristics of the study sample stratified by public drug use are presented in Table For our second analysis, the demographic and behavioural characteristics of public crack cocaine smokers stratified by willingness to use a supervised inhalation room are presented in Table We found that the majority of crack cocaine smokers in our study reported having used drugs in public areas at some point in the last six months. This group was more likely to be higher-intensity drug users with respect to heroin injection and crack cocaine smoking, have encounters with the police and be involved in drug dealing. Of these public crack cocaine smokers, 71% reported being willing to use a supervised inhalation room if one was available. Individuals who reported being willing were more likely to be female, engage in risky pipe sharing and have encounters with the police.The profile of public crack cocaine smokers as higher-intensity drug users who have interactions with the criminal justice system is reflective of previous findings describing public injection drug user populations ,5. The aOur finding that 71% of public crack cocaine smokers are willing to use an inhalation facility also supports previous willingness estimates conducted among the general population of Vancouver-based illicit drug users and suggests that an intervention of this nature will likely reach the target population . The higThe increased likelihood of being willing to use an inhalation facility among female participants may reflect heightened vulnerability of women involved in street drug use and it is noteworthy that Vancouver's supervised injection facility has had success in attracting vulnerable female drug users and providing them with safer alternatives to street-based drug using venues. In previous research female IDU have described the unique role that Vancouver's supervised injection facility has played in promoting their physical security and health safety .Interestingly, one of the common features among both public crack cocaine smokers and those who are willing to use a supervised inhalation facility is their elevated likelihood of recently having encounters with law enforcement. This suggests that public crack cocaine smokers who are the subject of law enforcement attention are very willing to relocate to alternative off-street and health-focussed environments if they were made available. Indeed, our data indicate that 81% of public crack cocaine smokers who have had a recent encounter with police are willing to use a supervised inhalation facility.A key implication of these findings is that there is a large demand for supervised inhalation rooms among individuals that are potentially key contributors to drug-related street disorder. The association between public crack smoking and encounters with police suggests that interventions of this nature are likely to target a critical sub-population of drug users and could be a valuable tool for police in the management of street disorder. Previous studies have found that Vancouver police regularly refer public injection drug users to the local supervised injection facility . Since oIt is critical to note that although this study suggests that supervised inhalation facilities could aid in the reduction of public disorder, drug consumption facilities do not address the route causes of street disorder and are not appropriate substitutes for other essential health and social interventions such as supportive housing and addiction treatment. To be effective supervised inhalation facilities should be integrated into broader comprehensive approaches to addressing the problems associated with illicit drug addiction.This study has a number of limitations. Firstly, VIDUS is a community recruited non-randomized sample and therefore our findings may not be generalizable to other settings. If supervised inhalation facilities are being considered in other settings, willingness studies should be conducted among the local target population and should not rely on the findings emerging from our setting. The generalizability of our findings is also limited by our study sample which was restricted to individuals with a history of injection drug use. Crack cocaine smokers who did not have a history of injection drug use were not eligible for our study. Given the harms associated with injection drug use we anticipate that if a selection effect were present it would likely bias our sample towards high risk drug users, suggesting that this group would be an appropriate target population for public health intervention. We should also note that among our study sample daily crack cocaine smoking was significantly more common than daily injecting, suggesting that despite the requirement of a history of injecting, our sample represents a primarily crack cocaine smoking population. Secondly, some of our measures relied on self-report and could be vulnerable to socially desirable reporting. This would have likely been of most relevant to our measure of willingness, since respondents might perceive a pressure to report being willing to engage with low-threshold services of this nature given the widespread activism among local drug users in our study setting to implement supervised drug consumption facilities . While iIn summary, our study found that locally public crack smoking is a common practice that is also associated with recent encounters with police. We found that the majority of public crack smokers were willing to use an inhalation facility if one were available. Furthermore, public crack smokers who had recent encounters with police were even more likely to be willing to use an inhalation room, suggesting that supervised inhalation facilities may offer unique opportunities to decrease one component of drug-related street disorder and reduce the burden on local law enforcement agencies.JM has received grants from, served as an ad hoc advisor to, or spoke at various events sponsored by; Abbott, Argos Therapeutics, Bioject Inc, Boehringer Ingelheim, BMS, Gilead Sciences, GlaxoSmithKline, Hoffmann-La Roche, Janssen-Ortho, Merck Frosst, Pfizer, Schering, Serono Inc, TheraTechnologies, Tibotec, Trimeris.Authors declare no other competing interests.The specific contributions of each author are as follows: KD, TK, and EW were responsible for study design; JQ conducted the statistical analyses; KD prepared the first draft of the analysis; TK, JB, JM and EW contributed to the main content and provided critical comments on the final draft. All authors approved the final manuscript.The study was supported by the US National Institutes of Health (R01DA011591) and (R01DA021525) and the Canadian Institutes of Health Research . Thomas Kerr is supported by the Michael Smith Foundation for Health Research and the Canadian Institutes of Health Research. Kora DeBeck is supported by a Michael Smith Foundation for Health Research Senior Graduate Trainee Award and a Canadian Institutes of Health Research Doctoral Research Award. Julio Montaner has received an Avant-Garde award (DP1DA026182) from the National Institute of Drug Abuse, US National Institutes of Health.


There exists now a wide range of experimentally validated protein tools capable of modifying cellular function, including light-gated ion channels, recombinant light-gated G protein-coupled receptors, and even neurotransmitter receptors modified with tethered photo-switchable ligands. A large number of genetically encoded protein sensors have also been developed to optically track cellular activity in real time, including membrane-voltage-sensitive fluorophores and fluorescent calcium and pH indicators. The development of techniques for controlled expression of these proteins has also increased their utility by allowing the study of specific populations of cells. Additionally, recent advances in optics technology have enabled both activation and observation of target proteins with high spatiotemporal fidelity. In combination, these methods have great potential in the study of neural circuits and networks, behavior, animal models of disease, as well as in high-throughput ex vivo studies. This review collects some of these new tools and methods and surveys several current and future applications of the evolving field of optophysiology.The advent of optogenetics and genetically encoded photosensors has provided neuroscience researchers with a wealth of new tools and methods for examining and manipulating neuronal function  For example, detection parameters can include the concentration of a ligand of interest, the pH of the intracellular or extracellular environment, or neurotransmitter vesicle secretion  upon activation of one of the molecules by a photon of a particular wavelength (or two of double the wavelength in the case of two-photon excitation). For single fluorescent molecules, the efficiency of fluorescence provides a readout of changes in the fluorophore’s local environment. For FRET pairs, changes in the chemical environment affect the efficiency of energy transfer between the two fluorophores, which is then measured as a change in the ratio of their individual fluorescences. This ratiometric imaging is beneficial because it relies on changes in relative fluorescence and not absolute fluorescence levels. Since background noise such as non-specific autofluorescence may not affect FRET, ratiometric imaging may be less problematic and data can often be more easily compared across different experiments . In addiMany cellular properties may serve as functional indicators of activity, two of which are membrane potential and intracellular calcium concentration. In the past, the limited availability of voltage-sensitive proteins that exhibit fast, large-magnitude changes in photochemical properties  made calcium-sensitive probes a more frequent choice for monitoring cellular activity. Changes in intracellular calcium concentration have a clear relevance to synaptic function and serve as an indicator for pre- and post-synaptic neuronal activity. As a result of the functional link between changes in calcium concentration and neuronal activation, genetically encoded calcium indicators (GECIs) are a popular choice for optically monitoring neuronal activity. Such measurements can be performed at both the single cell and whole-brain levels .Researchers seeking calcium-responsive proteins for optical probe design have exploited the key role of calcium in signaling cascades. For example, the calcium-binding messenger protein, calmodulin (CaM) has been used to create a chimeric GECI called GCaMP. The GCaMP molecule comprises a circularly permuted green fluorescent protein (GFP) bound to both the calcium binding domain of calmodulin and the calmodulin-binding domain of a myosin light chain kinase M13; . The fusRatiometric indicators may be favorable when noisy data is expected, since background activity may have a similar impact on the detection of each fluorophore in the pair. For example, Cameleon is a chimeric, ratiometric calcium indicator, with the same calmodulin and M13 domains as GCaMP and a pair of fluorophores that exhibit FRET. Upon calcium binding, there is an increase in FRET efficiency, which provides a ratiometric measure of calcium changes , 2007. ASimilary, a ratiometric indicator of chloride concentration also exists , isolated from the photosynthetic algae C. reinhardtii . N. pharaonis halorhodopsin (NpHR), a chloride ion pump activated by 570 nm light, provides the crucial inhibitory counterpart to the stimulatory channelrhodopsin  vectors and lentiviral vectors for transgene delivery is quite common . ExpressStable transgenics, where the transgene is integrated into the host’s germline, offers several advantages including the ability to repeat experiments across animals or ensure comparability between experiments on different organ systems and brain regions. In addition, if non-targeted gene insertion will cause unwanted effects, researchers can target transgene insertion through techniques including homologous recombination . This maFigure 1; For optophysiology with genetically encoded proteins, specific over-expression is generally very important. This is both for ensuring adequate activation when using photoactuators, and for increasing the signal-to-noise ratio of experiments with photosensors. Several modular transgene systems have been developed to facilitate cell-type specificity and strong expression. The double-floxed inverse open reading frame (DIO) strategy devised by Karl Deisseroth’s group provides one such method for minimizing so called “transcriptional leakage” while simultaneously achieving high expression levels . These devices produce a variable spatial light pattern with a resolution limit set by the surface pixilation of a given DMD. The DMD operates by changing the angle of reflection in areas corresponding to the desired “dark” regions on a sample such that the beam path from these points will not reach the target. In this way, they are subtractive, meaning that there will necessarily be a loss of stimulation power when the DMD is in use, which may require a compensatory increase in the initial light power .Another approach for targeting excitation of a photoactuator involves the use of spatial light modulators SLMs; . SLMs arRecently, in vivo systems or for achieving greater light penetration, stimulation through fiber optic cables may be preferable , compensation for movement artifacts, defining discrete signals and assigning those signals to a source cell, and statistical analysis of signals to draw meaningful conclusions. Cutting-edge video processing techniques may facilitate data acquisition. For instance, a group at MIT’s CSAIL recently published open-source code for Eulerian Video Magnification that greatly amplifies small visual signals for easier detection .Optophysiology has been applied to a diverse range of animal models in order to elicit behavioral responses. The conclusions that have been drawn vary as much as the experimental model and question. In 2005, Lima and Miesenböck expressed ligand-gated ionotropic P2X purinoreceptor in giant fiber neurons implicated in escape reflex initiation in the fruit fly. This study showed that decapitated flies still had normal escape responses to giant fiber activation by photo-uncaging a modified version of ATP . This eaMore recently, Studies from primate model systems are also invaluable for our understanding of human neurophysiology and for looking toward future clinical applications of optophysiology. in vivo  studies have attempted to identify behaviors that are commonly associated with activity in specific frequency bands  is a genetic disease that causes sequential dysfunction of rod and cone photoreceptor cells, leaving afflicted patients with intact but inactive cone cells. ind mice .ex vitro drug-screening platform is appealing for its scalability and relative simplicity; much of the analysis can be automated by software, and the results are both reproducible and directly applicable to high-throughput drug evaluation.All-optical manipulation and measurement of cultured tissue may also hold promise as a high-throughput drug screening platform. One of the fastest growing areas of current clinical research is the creation of systems which may provide an informative model of neurodevelopmental disorders such as autism spectrum disorders (ASDs) or neurodegenerative disorders such as amyotrophic lateral sclerosis (ALS). The inaccessibility of nervous tissue from persons with neurogenetic disorders has been a long-standing obstacle for the study of these diseases. Recent advances in transcriptomic analysis suggest that expression data will be very valuable in characterizing disease states and evaluating potential therapeutics . HoweverGymnotiformes and Mormyriformes detect and encode changes in a projected electric field, including amplitude and frequency variation. These animals are sensitive to phase modulations of their own projected field as small as 100–300 ns, indicating an extremely high sensitivity in the frequency domain. If this sensitivity can be attributed to a sensory transduction protein, then there may be a possibility for coupling that protein’s voltage response to a fluorophore to produce a high frequency voltage probe  proteins has largely been unused in optophysiology. These TRP channels may have a unique and favorable set of properties as the basis for both sensors and actuators. Many subfamilies are sensitive to photons in infrared wavelengths, and function as the basis of thermoreceptive pit organs in reptiles, vision in some insects, and skin thermoreception in some mammals . Their dThe cell- and tissue-specific expression of transgenic proteins and the tremendous library of past electrophysiology research decoding cellular events and activity has set the stage to address large, integrative questions on topics such as memory, emotion, attention and consciousness. Current optophysiological research continues to advance these questions and improve the technologies necessary to support the use of genetically encoded photosensors and optogenetic photoactuators, often concurrently e.g., . InnovatThe 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.


A recent meta-analysis reported the most important and potentially modifiable risk factors for stillbirth . Approxi• sleep restriction (short sleep duration), which is often self-imposed because of busy lifestyles;• sleep-disordered breathing (SDB), a term which describes a spectrum of breathing problems during sleep from habitual snoring to obstructive sleep apnea, resulting in oxygen desaturation and sleep fragmentation; and• poor sleep quality.Emerging literature now suggests that sleep disruption during pregnancy is associated with poor pregnancy outcomes for both mother and infant . There aIn recent years, sleep duration has drastically fallen and has been paralleled by a rise in the prevalence of obesity. Chronic sleep restriction (such as self-imposed short sleep duration) plays a pivotal role in the pathophysiology of overweight and obesity via the modulation of neuroendocrine function. Sleep disruption, including short sleep duration and sleep fragmentation, has emerged as a major determinant of metabolic health, independently of weight and is implicated in poor glucose control  and possOf note, approximately half of all Western women of childbearing age are overweight or obese and obesity can lead to increased risk for sleep disorders such as SDB. Habitual snoring is the main symptom of SDB and its frequency reaches a peak in the third trimester, affecting approximately one third of pregnant women in general, and the majority of those with pre-eclampsia. Habitual snoring is independently associated with gestational hypertension and pre-eclampsia . AlthougPoor sleep quality during pregnancy is already evident in the first trimester and has been associated with increased risk for longer labors and Caesarean section delivery , as wellIn summary, maternal sleep disruption is emerging as a significant factor in adverse pregnancy outcomes. Future research should consider maternal sleep when investigating stillbirth.


There is a robust body of evidence supporting alcohol brief intervention (BI) in primary health-care settings, but fewer studies have explored delivery elsewhere. This qualitative evaluation followed up staff in one integrated health and social-care service in Scotland to find out if and how multidisciplinary training in alcohol BI impacted practice, and if and why BI had been delivered following the training. Nineteen semi-structured in-depth qualitative telephone interviews were carried out among 10 of the 89 practitioners who had attended the course as well as among managers and administrators from various teams . Interviews were recorded, transcribed, and analyzed thematically. All quotations were checked with interviewees. Participants felt that training had improved their knowledge and confidence around alcohol and were supportive of having a role in delivering BI, but very few had actually delivered any. Practitioners perceived that their clients did not need alcohol BI for a variety of reasons, including that they either drank too much or too little to merit one. Despite this, practitioners described giving advice on alcohol but failed to recognize these conversations as opportunities to deliver BIs. A range of other barriers to delivery emerged, including the view that specific screening, delivery techniques, and monitoring of BIs did not fit with their current practice and assessment procedures, which already included (sometimes unhelpful) questions or questionnaires on alcohol use. The barriers to delivery were at individual, team, and service levels and are likely to be best addressed by a strategic approach of which training is only one part. The findings also suggest the need to take a setting-specific approach to efforts to embed BI delivery into routine practice.


Lots has been written on use of SSRI during pregnancy and possible short and long term negative outcomes on neonates. the literature so far has described a various field of peripartum illness related to SSRI exposure during foetal life, such as increased incidence of low birth weight, respiratory distress, persistent pulmonary hypertension, poor feeding, and neurobehavioural disease. We know that different degrees of outcomes are possible, and not all the newborns exposed to SSRIs during pregnancy definitely will develop a negative outcome. So far, still little is known about the possible etiologic mechanism that could not only explain the adverse neonatal effects but also the degree of clinical involvement and presentation in the early period after birth. Pharmacogenetics and moreover pharmacogenomics, the study of specific genetic variations and their effect on drug response, are not widespread. This review describes possible relationship between SSRIs pharmacogenetics and different neonatal outcomes and summarizes the current pharmacogenetic inquiries in relation to maternal-foetal environment. Selective serotonin reuptake inhibitors (SSRIs) are commonly used antidepressants that act by inhibiting serotonin reuptake in the synaptic cleft. Medications in this group include fluoxetine, paroxetine, sertraline, fluvoxamine, citalopram, and escitalopram. At higher doses, paroxetine and sertraline also block dopamine reuptake, which may contribute to their antidepressant action. Venlafaxine is a combined serotonin-norepinephrine reuptake inhibitor. Recently, multiple studies have correlated SSRI use during pregnancy with adverse neonatal effects, including neonatal respiratory distress, persistent pulmonary hypertension, jaundice, feeding problems, abnormal movements and tonus abnormalities, birth weight below 10° centile, and even congenital cardiac disease (paroxetine only). We know very well from the literature that approximately 15% of all pregnant women have psychiatric problems, in particular depression and anxiety ; we alsoThis paper not only focuses on early neonatal outcome after foetal exposure to a serotonin reuptake inhibitors drug but also tries to investigate both the possible etiology of what is commonly called the poor neonatal adaptation and in particular what are the possible predictors of adverse outcome.Our aim was to evaluate the current literature on this topic, moreover investigating the possible correlation among genes polymorphisms and different outcome in newborn exposed to SSRI during foetal life. To the best of our knowledge only a few paper have focused on this topic.We searched PubMed (2003–2013) using the key words SSRI pharmacogenetics, newborn, and SSRI pharmacokinetics, neonatal withdrawal syndrome combining them in couple or triplets, producing several different search strategies. We searched also for neonatal pharmacogenomics and pregnancy. Papers related to early neonatal outcomes and pharmacogenetics of SSRI were acquired. More specifically we aimed to evaluate the state of art so far regarding genotypic correlation to adverse neonatal outcome in newborn exposed to SSRI during foetal life. Inclusion criteria were identified maternal SSRI exposure during pregnancy, presence of neonatal outcome assessment, and evaluation of molecular/genotypic influences on outcome. This search produced more than 1500 publications, subsequently included publications were limited to meta-analyses, randomized controlled trials, clinical trials, practice guidelines, reviews and case report and in total 108 publications were selected. Among these we excluded 79 publications because they did not meet our criteria or because they did not include a significative population sample. Finally we included in our review 36 publications. In our reference list we included other publications which we thought to be of interest in the setting of the topic debated.non-English literature;the publication did not address infant born of mothers who had been treated with SSRI during pregnancy;the publication did not address neonatal adverse effects and among them were excluded publication focused on malformative complications;the publication did only address SSRI effects on pregnant woman regardless of the newborn.Publications were excluded ifSymptoms of poor neonatal adaptation are clearly related to psychotropic drugs exposure during the whole trimesters of pregnancy, but still the exact etiology is not fully understood. A recent paper from Kievet et al.  stated tAn interesting paper from Oberlander et al.  sought tPrenatal serotonin reuptake inhibitor exposure is common and neonatal outcomes vary greatly, often leading to confusion about whether to use or even continue antenatal use of these antidepressants. Importantly, some but not all infants are affected, which raises questions about how maternal drug metabolism contributes to fetal drug exposure. To address this question, here we briefly review the role of maternal, fetal, and placental genetic factors that affect the extent of fetal drug exposure.An interesting study from Laine et al.  in 2004 Similarly to what happens with maternal opiate exposure, signs of intoxication can present immediately and dissipate over a matter of hours, whereas withdrawal may take days or weeks to resolve. This is indirectly supported by opposite findings describing a case of a baby born from parents categorized as extensive metabolizers according to their CYP2D6 genotype who experienced an episode of SSRI withdrawal reaction, although he was not at an increased genetic risk of drug accumulation. Taken together, these cases suggest that withdrawal may account for the abnormal clinical findings in these patients. Additionally, as underlined by Stiskal  the diffFurther evidence regarding the importance of genotypic pattern was added in 2009 with a controlled prospective study from Hilli et al.  who wereRecent studies have illustrated the importance of placental drug transport proteins, such as P-glycoprotein (Pgp) and breast cancer resistance protein (BCRP) in limiting fetal exposure to drugs and toxins. Moreover, increasing evidence supports a role for Pgp and BCRP in the normal development and physiological function of the placenta. Several single nucleotide polymorphisms (SNPs) in the genes encoding Pgp and BCRP have been described and are associated with altered protein expression, transporter activity, and clinical outcome in studies focusing on tissues other than the placenta . To dateIn more details to the best of our knowledge the first paper to describe a possible association between ABCB1 variants with SSRIs response was the interesting paper from Kato et al.,  which exOn respect of this topic, another paper from de Klerk et al.  studied The treatment of breastfeeding mothers with depression raises several dilemmas, including the possible risk of drug exposure through breast milk for the infant against the disadvantage of not receiving mother's milk. . As for Only a few and inconclusive studies have explored the role of genetic background on exposure of infants to SSRI though milk lactation. In their study of 25 breastfeeding mothers who were treated with citalopram, sertraline, paroxetine, fluoxetine, and venlafaxine, Berle et al.  evaluateTaking all current knowledge into considerations it has been recently suggested that when antidepressant treatment is indicated in women with postpartum depression, they should generally not be advised to continue breastfeeding. If this is not pursuable, among the different SSRIs, paroxetine and sertraline are most likely suitable first-line agents due to their low excretion in milk. However, an individual risk-benefit assessment should always be performed.Ververs et al.  examinedThe state of the art so far describes a small pattern of studies that are relevant in their potential impact of predicting possible adverse outcomes depending on genetic variants, and our wish is that further studies will be developed in the maternal-neonatal field, in order to implement the knowledge and possible clinical implications regarding foetal outcome and newborn health. A better understanding of these polymorphisms will allow prediction of when normal placental physiology could be altered and lead to the development of appropriate preventive therapies, in summary a full understanding of which SNPs affect placental expression and function would be useful for predicting altered foetal exposure to drugs.Approximately 7–13% of infants born in the United States each year are exposed to maternal major depressive disorder during gestation and an estimated 7.6% of all pregnant women take an antidepressant. Because of their low side effect profiles and relatively low risk on the foetus, among antidepressants SSRIs are a current first-line choice for pharmacologic treatment during pregnancy, even due to the well-known fact that exposure to maternal depression in utero has been already linked to adverse neurobehavioural development.We know that the placenta is the key regulatory organ which maintains foetal homeostasis; therefore, we strongly think that it is the critical site to examine if we want to early detect alterations in neurotransmitter or genetic variations which could potentially be involved in dysregulation of the intrauterine environment and therefore foetal development. These studies account for a strong clinical relevance when limiting foetal exposure to potential teratogens or when drug delivery to the foetus is warranted for therapeutic effects, as in the case of maternal depression.When certain genetic variations can be linked with specific foetal/neonatal outcomes, individual gene sequencing may provide more knowledge for a safe maternal pharmacotherapies on an individualized basis and therefore contributing to better stratify the risk for possible adverse neonatal outcome. The development and application of this field could offer greater potential to better institute appropriate medical care but obviously raises some concerns about feasibility in daily clinical practice. Although research in the area of drug metabolism in pregnancy is rapidly evolving, physicians are often limited by lack of knowledge of pathophysiological mechanisms that link a specific drug and adverse outcomes, and we think that research in maternal-foetal-neonatal pharmacogenomics will undoubtedly not only improve our overall understanding but also help us to stratify patients based on individual risk.Further studies must be considered, in order to better clarify the role of haplotypes, environmental factors, and comorbidities, both to avoid and predict possible clinical adverse outcomes on newborns from depressed mothers.


During this intoxication, electrocardiographic abnormalities similar to those found in tricyclic antidepressant poisoning were observed, and they were reversed by intravenous sodium bicarbonate infusion.We report a dramatic case of a 19-year-old man with crack cocaine overdose with important clinical complications as cardiac arrest due to ventricular fibrillation and  The utilization of crack cocaine is increasing around the world because this drug is inexpensive and possible to smoke. The crack cocaine can cause serious clinical complications during intoxication. There are some descriptions of cardiac arrhythmias, myocardial ischemia and infarction, myocarditis, hypertension, sudden death, seizure, hyperthermia, psychomotor agitation, and so forth .The electrocardiogram helps identify patients at high risk of cardiac and neurologic complications in some types of intoxication as tricyclic antidepressant poisoning, in which a specific electrocardiogram pattern is recognized .epileptics status in which we observed an electrocardiographic pattern similar to that found in patients with tricyclic antidepressant poisoning and high risk of complications and these alterations were reversed after sodium bicarbonate infusion.We describe a case of crack cocaine overdose with clinical presentation of cardiac arrest due to ventricular fibrillation and A 19-year-old man ingested large amount of crack cocaine in a suicide attempt. He arrived in the emergency department unconscious and was intubated. After this, he had a cardiac arrest due to ventricular fibrillation reversed with defibrillation. Repeated seizures were observed, and benzodiazepines were administered. Electrocardiogram showed sinus tachycardia, prolonged PR and QTc interval (510 ms), widening of the QRS complex (200 ms), and increase in R wave amplitude in aVR (8.0 mV) and right ward of the terminal 40 ms (T40 ms) axis deviation in the frontal plane (210°), Gradual decreases in QRS duration (100 ms), in QTc interval (428 ms), in R wave amplitude in aVR (4.0 mV), and in the T40 ms axis deviation (150°) were observed after intravenous sodium bicarbonate infusion in a dose of 250 mL × 8.4% and improved ventilation (blood pH: 7.40), Toxicology screen was positive only for cocaine. Myocardial infarction and any structural cardiac involvement were ruled out because there was no electrocardiographic evidence of myocardial ischemic injury, the dosage of troponin I was only slightly elevated, and the echocardiography was normal. He was discharged without neurological disabilities, and the electrocardiogram was normal.We described a case of severe crack cocaine overdose with life-threatening ventricular arrhythmias and repeated seizures in which an interesting electrocardiographic pattern similar to that found in tricyclic antidepressant poisoning was observed, and these alterations were completely reversed through the acidosis correction.The classical electrocardiographic abnormalities observed in acute poisoning by tricyclic antidepressant are the widening of QRS; the increase in R wave amplitude in aVR, the QTc interval prolongation, the right-axis deviation of the terminal 40 ms vector of the QRS complex in the frontal plane, and the Brugada-like pattern. Many studies showed that these alterations can help identify patients with high risk of arrhythmia and seizure, mainly the prolongation of the QRS duration >100 ms. This last alteration predicts a higher risk of complications and is used as a formal indication for systemic sodium bicarbonate administration in many medical services . There are many descriptions of reversal of these electrocardiographic alterations through intravenous sodium bicarbonate infusion during tricyclic antidepressant intoxication, and it is recognized as a standard treatment in this condition . These eThe crack cocaine form is manufactured by processing the cocaine with ammonia or sodium bicarbonate to remove the hydrochloride, and in this way it is heat stable which allows it to be smoked . In our  Cocaine can block the fast sodium channels and theoretically trigger similar abnormalities . In thisThere are many descriptions of cocaine-related sudden death, but the majority of these patients die before arriving at the hospital, and the mechanisms responsible for these deaths are unclear . Ventric These life-threatening ventricular arrhythmias can be precipitated due to myocardial infarction or ischemia induced by the cocaine ; but in Acidosis can increase the toxic effect of the cocaine on the heart in that it increases the sodium channel blocking degree and decreases the conduction between the gap junctions, and, because of this, the acidosis correction is an important goal in the treatment of these patients . epileptics status, accelerated idioventricular rhythm associated with metabolic acidosis, and this arrhythmia was abated through the correction of the acidosis with bicarbonate infusion and ventilation [ Some reports have described the treatment of cocaine-induced arrhythmias with the administration of sodium bicarbonate . Jonssontilation . Kerns etilation . In our case, the cocaine-induced electrocardiographic alterations were reversed through the acidosis correction by sodium bicarbonate intravenous infusion and improved ventilation. Tricyclic antidepressant intoxication was actively ruled out in this case through the negative blood dosage.There are some descriptions of transient Brugada-like pattern after cocaine and tricyclic antidepressant intoxication which is defined by right bundle branch block associated with coved ST-segment elevation in leads V1 and V2. In our case, we observed important alterations in cardiac conduction but not the Brugada-like pattern . Postresuscitative effects on the heart might have been responsible for some of these alterations, although this electrocardiographic pattern is not commonly observed in other situations of cardiac arrest, and in this case the patient was promptly resuscitated because the cardiac arrest happened during the initial medical evaluation. The prevalence and prognostic of these electrocardiographic changes during cocaine overdose are unknown, but they could help identify patients at high risk of complications during this clinical setting, and the physicians need to suspect crack cocaine overdose in unconscious patients admitted to the hospital with electrocardiogram pattern compatible with sodium channel blocking. The crack cocaine can induce an electrocardiographic pattern similar to that observed in acute poisoning by tricyclic antidepressants which is reversed by sodium bicarbonate infusion. These alterations may help identify patients at high risk of ventricular arrhythmia and seizure during crack cocaine overdose.


This concept is suggestive of a new method for controlling the growth and spread of existing cancer cells in situ and indicates the possibility that extracellular proteins and/or embryonic mesenchymal fibroblasts may represent a fertile subject for study of new anti-cancer treatments.Extracellular matrix proteins from embryonic mesenchyme have a normalizing effect on cancer cells  Their results shed light on the potential mechanism by which embryonic mesenchyme can control tumorigenic expression of cancer cells, which was demonstrated by several investigators decades ago [in vitro. Isolated growth factors associated tightly with the purified ECM were ineffective in normalizing breast cancer cells. Finally, siRNA knockdown of biglycan mRNA and protein in embryonic fibroblasts abrogated their ability to normalize breast cancer cells or reduce their growth in vitro. Biglycan has been disrupted by targeting in mice, and variously leads to an osteoporosis-like phenotype and biomechanically affected specific tendons [Bischof and colleagues have made a case for breast cancer cell normalization by biglycan isolated from embryonic mesenchyme in vitro. Furtherades ago ,3. The e tendons -6. One wWhile the implication of a single ECM component, biglycan, is intriguing from a therapeutic perspective, this reductionist view of the role of ECM in controlling tumorigenesis is not in agreement with the published literature. Schedin and colleagues have very carefully studied the role of mammary ECM in breast tumorigenesis -10. Theyin utero at day 17. Thus, our observations and those of Schedin and colleagues do not agree with the conclusion of Bischof and colleagues that biglycan is sufficient for tumor cell normalization and that tumor cell normalization is unique to inductive mesenchyme.Our laboratory has also been interested in trying to understand tissue-microenvironment-induced suppression of cancer cell tumorigenesis. Our data demonstrate that pluripotent human male cancer cells, mouse embryonic stem cells and breast cancer cells from both mouse and human can be induced to differentiate and not produce tumors in the mouse mammary gland during regenerative growth -14. All The specific components involved in tumor-cell normalization are likely to be context dependent. Furthermore, changes in ECM architecture rather than ECM composition are implicated in tumor suppression by ECM isolated from mammary glands of parous rats , adding ECM: Extracellular matrix; siRNA: Small interfering RNA.The authors declare that they have no competing interests.


This study explored the relationship between symptoms of rapid eye movement sleep behaviour disorder, thermoregulation and sleep in Parkinson’s Disease.The study group comprised 12 patients with Parkinson’s Disease and 11 healthy age-matched controls. We investigated markers of thermoregulation (core-body temperature profile), circadian rhythm (locomotor actigraphy) and sleep (polysomnography).The mesor  of the core-body temperature in patients with Parkinson’s Disease was significantly lower than that of controls. In addition, the nocturnal fall in CBT (the difference between the mesor and the nadir temperature) was also significantly reduced in PD patients relative to controls. Furthermore, in patients the reduction in the amplitude of their core-body temperature profile was strongly correlated with the severity of self-reported rapid eye movement sleep behaviour disorder symptom, reduction in the percentage of REM sleep and prolonged sleep latency. By contrast, these disturbances of thermoregulation and sleep architecture were not found in controls and were not related to other markers of circadian rhythm or times of sleep onset and offset.These findings suggest that the brainstem pathology associated with disruption of thermoregulation in Parkinson’s disease may also contribute to rapid eye movement sleep behavioural disorder. It is possible that detailed analysis of the core-body temperature profile in at risk populations such as those patients with idiopathic rapid eye movement sleep behaviour disorder might help identify those who are at high risk of transitioning to Parkinson’s Disease. Traditionally Parkinson’s disease (PD) has been characterised by its constellation of motor symptoms, but non-motor symptoms such as disturbances of sleep, circadian rhythm and thermoregulation have been increasingly recognisedThe pathogenesis of RBD in PD is thought to involve pontine pathology within the sublaterodorsal nuclei as well as descending projections to the medullary magnocellular reticular formation, which are commonly regarded as REM-on nuclei of the ultradian system Currently, there is a paucity of literature examining disruptions to thermoregulation in Parkinson’s diseaseThis research was approved by the Human Research Ethics Committee of the University of Sydney . Written informed consent was obtained from all participants. All participants had no significant cognitive impairment on structured assessment and were deemed independently by an experienced neurologist (SJGL) and neuropsychologist (SLN) to have the capacity to consent.Twelve patients with PD  satisfying UK PDS Brain Bank criteriaExclusion criteria were: history of stroke; neurological disorder (other than PD); head injury with loss of consciousness ≥ 30-minutes; medical condition known to affect cognition (e.g. cancer); psychiatric illness; Mini-Mental State Examination Score (MMSE)Patients underwent neurological examination conducted in their ‘on’ state and levodopa dose equivalents were calculated for dopaminergic medicationsActiwatch Spectrum, Minimitter-Respironics, OR) in accordance with previously published protocolsParticipants’ average sleep duration for 14-nights prior to commencing the in-laboratory portion of the experimental protocol was recorded using actigraphy  and ambient temperature (24±1°C). Participants were asked to refrain from alcohol or caffeine consumption for the preceding 24-hour period.Compumedics Siesta, Australia). Night 1 was considered an adaptation night and included pressure flow monitoring to detect significant obstructive sleep apnoea. Sleep architecture variables were collected on night 2 with a standardised research PSG montage Participants were monitored on two consecutive nights . During sleep, CBT was recorded concurrently with PSG to allow for accurate comparison with key sleep parameters, such as sleep onset, offset and architecture. Analysis of the CBT profile involved least squares fitting with two spherical harmonics in order to extract the temperature mesor , in line with the cosinor methodThe CBT profile  was recoAll statistical analyses were performed using SPSS for Macintosh, Rel. 18.0.0 Chicago: SPSS Inc. Unless otherwise stated, statistical tests for significance between groups were conducted using the independent Student’s t-test. Where there was no homogeneity of variance, or when data was not normally distributed, t-test with unequal variances or Mann-Whitney U tests were used respectively. The Spearman correlation coefficient was used for all correlations. All results were reported in the format of mean ± standard deviation. All analyses were two-tailed and employed an alpha level of 0.05.As shown in As shown in Reduced nocturnal CBT amplitude was also associated with significant reduction in the percentage of REM sleep  and increase in sleep onset latency  among PD patients but not controls. The nocturnal CBT amplitude did not correlate significantly with age, disease duration, disease severity (H&Y or UPDRS-III), levodopa dose equivalents, mood (BDI-II) or any other PSG or actigraphy parameters measured.In the present study, we found significant differences between the CBT profiles of PD patients as compared to that of controls, suggesting that the neural circuitry controlling thermoregulation is disrupted in PD. Furthermore, this is the first study to our knowledge to demonstrate a relationship between the CBT profile and self-reported RBD symptoms in PDIndeed, previous neuropathological studies in humans have found Lewy body pathology affecting these key regions of overlap in the pons and medullaThe medullary autonomic region also plays a major role in thermoregulation via the modulation of peripheral vasomotor toneAlthough there was a trend towards circadian phase advancement in the PSG sleep onset, actigraphy rest onset and CBT nadir of PD patients relative to controls in the present study, these results did not reach statistical significance. This finding argues that the master pacemaker is probably devoid of significant pathology, which would be consistent with Braak’s caudorostral progression of Lewy body pathology in PDFinally, it should be noted that dopaminergic therapy may also influence the circadian CBT profile. Previous studies have found that higher doses of dopaminergic therapy may be associated with reduced circadian CBT amplitudeDespite being the largest study to date examining the relationship between CBT profile and sleep in Parkinson’s disease, the present study is still clearly limited by small group sizes. Thus, detailed interpretation of the CBT profiles and its associations with other sleep and circadian markers should be made with caution. However, given their close relationship, it is possible that a more detailed analysis of the CBT profile in future studies may help extend our understanding of these disruptions. Furthermore, an appreciation of the CBT profile may represent a critical advance in our ability to identify those patients with idiopathic REM sleep behaviour disorder who are at higher risk of transitioning to PD.The present study shows significant differences in the nocturnal CBT profile of PD patients compared to that of controls. Furthermore, this is the first study to demonstrate a relationship between the nocturnal CBT profile and RBD symptoms in PD patients. The findings of this study suggest there are overlaps between neural circuitries regulating REM atonia, thermoregulation and wakefulness. As a result of this relationship, detailed analysis of CBT profiles in future studies could potentially shed light on the pathophysiology of RBD and its transition to PD.