Epidermal stem cells are a population                        of somatic stem cells responsible for maintaining and repairing the                        epidermis of the skin. A malfunctioning epidermal stem cell compartment                        results in loss of the epidermis and death of the whole organism. Since the                        epidermis continually renews itself by sloughing a layer of cells every                        day, it is in a constant state of cellular turnover and requires continual                        cell replacement for life. Thus, maintaining a pristine epidermal stem cell                        population is of prime importance, even during aging. Unlike stem cells                        from internal tissues, epidermal stem cells show little response to aging.                        They do not appear to decrease in number or functionality with age, and do                        not show changes in gene expression, developmental responsiveness, or                        age-associated increases of reactive oxygen species. Thus, epidermal stem                        cells may be a unique somatic stem cell.                 How an organism and its cells                            age is an ongoing debate. One view is that organisms age because their cells                            accumulate a series of accidental, but detrimental events throughout life. Another                            view espouses that cells follow an established program of genetic and                            epigenetic changes which slowly, but deliberately result in loss of cellular                            repair mechanisms and ultimately in organismal death (for review see ). A    Perhaps epidermal stem cells are unique                            among somatic stem cells because no matter how old the skin is, the epidermis                            must continually replace itself with correctly functioning cells in order to                            protect the organism from the outside world . MammaliWe have known for nearly thirty years that                            stratified squamous epithelia contain slowly or intermittently cycling                            keratinocytes. These cells are identified as label-retaining cells (LRCs) by                            the long term retention of a tritiated thymidine or bromodeoxyuridine (BrdU)                            label -15. MorpOur method preferentially                            selects for the LRC population, and thus highly enriches for the epidermal stem                            cells . It combWe have shown that epidermal stem cells                            isolated from newborn or aging mouse skin have a similar plasticity response                            when injected in a developing blastocyst environment  ,7. The lIt was not determined in these experiments                            whether it is contact with the cells in the blastocyst or a response to something                            secreted by the cells that reprogram the epidermal cells. In vitro, exposure to                            cell-free extracts or conditioned media from pluripotent cells results in                            reprogramming of differentiated cells ,25. The How epidermal stem cells maintain the                            ability to be developmentally responsive into old age is not understood. One                            potential mechanism might be to control the levels of reactive oxygen species                            within the cellular borders. We have three reasons for posing this possible                            scenario. First, oxidative stress has been associated with increased aging at                            the molecular level as shown by the deletion of the superoxide dismutase 1                            (Sod1) gene producing a decrease in the lifespan of mice . SuperoxThe redox state of the epidermal stem                            cells, as indicated by changes in ROS such as superoxide, could affect the developmental                            responsiveness Figure . These aEpidermal stem cells subjected to analysis                            of superoxide levels by dihydroethidium (DHE) show so little superoxide that it                            is difficult to measure Figure . This isIn conclusion, epidermal stem                            cells have several characteristics that make them unique in the somatic stem                            cell world: They appear to resist aging. They show no age-related changes in                            gene expression. They maintain a developmental responsiveness to changes in                            their environment. They show no effects associated with increasing levels of                            reactive oxygen species found in aging cells by keeping levels of ROS low,                            perhaps by maintaining high levels of superoxide dismutase (SOD1). Exactly how                            these epidermal stem cells remain "young" requires further research.


Sir,We read with interest the recent article indicating that a preoperative systemic inflammatory response is an underlying host characteristic that predisposes to postoperative infection in patients undergoing potentially curative resection for colorectal cancer. In this article, the Glasgow group found that elevated C-reactive protein together with low albumin levels  were the only host-associated factors that had a high predictive value, which included 40% of patients affected by postoperative infectious complications  and remote infections. An SSI as represented by wound infection and anastomotic leak is an infection that occurs after surgery in the part of the body where the surgery occurred, and is further classified into incisional and organ/space SSIs. In contrast, a remote infection as represented by respiratory organ infection, infection via catheters, urinary tract infection, and antibiotic enterocolitis, is an exogenous and/or cross infection that occurs at sites not directly subjected to operations. With regard to aetiological bacteria of these infections, the onset of an SSI is usually caused by contaminants that exist in the operative fields. The onset of a remote infection is often caused by antibiotic-resistant bacteria that cause nosocomial infections, such as  factors . It is in=455) and the patients with postoperative complications could be nearly equally divided into an SSI group (n=31) and a remote infection group (n=39) If the odds of developing rates of SSI and remote infection are identified for each risk factor, then the GPS can be used by the surgeon to determine whether he/she should correct host-associated pathological states before surgery for preventing remote infection, or select less invasive surgery for minimising adverse effects of surgery-associated factors for preventing SSI. Although prospective randomised studies are required to clarify whether these suspected advantages can be realised in clinical practice, colorectal surgeons need to select from the strategies mentioned above for their cancer patients, if the GPS can differentiate the SSIs from remote infections.In our previous study, we determined site-specific patterns of risk factors for incisional and organ/space SSIs in 285 colorectal cancer patients to develop predictive models using inflammatory mediators (


A core assumption of current toxicologic procedures used to establish health standards for chemical exposures is that testing the safety of chemicals at high doses can be used to predict the effects of low-dose exposures, such as those common in the general population. This assumption is based on the precept that “the dose makes the poison”: higher doses will cause greater effects.We challenge the validity of assuming that high-dose testing can be used to predict low-dose effects for contaminants that behave like hormones. We review data from endocrinology and toxicology that falsify this assumption and summarize current mechanistic understanding of how low doses can lead to effects unpredictable from high-dose experiments.Falsification of this assumption raises profound issues for regulatory toxicology. Many exposure standards are based on this assumption. Rejecting the assumption will require that these standards be reevaluated and that procedures employed to set health standards be changed. The consequences of these changes may be significant for public health because of the range of health conditions now plausibly linked to exposure to endocrine-disrupting contaminants.We recommend that procedures to establish acceptable exposure levels for endocrine-disrupting compounds incorporate the inability for high-dose tests to predict low-dose results. Setting acceptable levels of exposure must include testing for health consequences at prevalent levels of human exposure, not extrapolations from the effects observed in high-dose experiments. Scientists trained in endocrinology must be engaged systematically in standard setting for endocrine-disrupting compounds. The very public debate about potential harmful consequences of exposure to the plastic monomer bisphenol A (BPA) is a leading high-profile battleground in a scientific revolution currently under way in toxicology . But mucThe core assumption of regulatory toxicology is that experiments using high doses will reveal potential effects of low doses. This is derived from 16th-century dogma but is still typically applied today by federal regulators , althougThe approach of using very high-dose testing to predict consequences of much lower doses that are typically within the range of widespread human exposure emerges from a 16th-century observation by Paracelsus that toxicologists paraphrase as “the dose makes the poison” . ParacelIndeed, Paracelsus’ assumption is directly contradicted by decades of research in endocrinology and clinical medicine showing that hormonally active compounds have dose–response curves in which low doses can cause effects opposite to those at high doses. This issue is so central to hormone action that it is a critical component of determining the dose required for hormonally active drugs. Two well-known examples are Lupron [used to treat reproductive disorders in women and men ] and tamNonmonotonic dose–response curves result from multiple mechanisms. Hormones and hormone-mimicking chemicals act through receptors in target cells. Very low doses can stimulate the production of more receptors (receptor up-regulation), resulting in an increase in responses, whereas higher doses  can inhibit receptors (receptor down-regulation), resulting in a decrease in responses . The conIf only one response is being measured, a nonmonotonic dose–response curve is a common finding for EDCs. An additional complication, however, is that when multiple outcomes are examined, qualitatively different outcomes are commonly observed at low and high doses of EDCs. One basis for this is that the suite of genes whose expression is regulated by low doses of endogenous hormones and chemicals that mimic these hormones can be completely different from the genes affected by high doses . As the Another consideration is that the effects of EDCs classified as “xenoestrogens” are not identical. As research has progressed into identifying the molecular mechanisms mediating responses, a consensus has emerged that this class of EDCs should be categorized as selective estrogen receptor modulators, to highlight the fact that each can result in a unique array of responses. However, conducting studies that involve comparing activities of different xenoestrogens  requires understanding the importance of the doses being used .EDCs may also act by mechanisms that do not require direct mediation by classical hormone receptors. Nonspecific (non–receptor-mediated) toxicity can occur at high but not low doses. EDCs also exert actions upon synthesis or function of enzymes that may be responsible for the synthesis or degradation of hormones and on coregulatory proteins that interact with receptors and, in the case of neurologic actions, affect neuro-transmitters and their receptors . For exaOf great importance, above the dose at which a hormonally active chemical saturates  receptors, any change in response that occurs cannot be caused by a receptor-mediated mechanism, which requires a change in receptor occupancy. Receptors for steroid hormones are ligand-activated transcription factors that require a change in ligand binding to affect the rate of gene transcription. Thus, high-dose experiments cannot be used to predict low-dose results mediated by EDCs binding to hormone receptors and altering receptor-mediated responses at low doses. The current paradigm in regulatory toxicology of only testing a few very high doses of chemicals within a relatively narrow dose range (with the highest dose being the maximum tolerated dose) thus does not serve to predict the hazards posed by low-level exposure to numerous EDCs found in most people in biomonitoring studies conducted in the United States and elsewhere .Nonmonotonic dose–response curves have been reported for adverse effects with a number of EDCs , includiIn an experiment explicitly designed to test the adequacy of high-dose testing of DEHP in rats, Other experiments have documented nonmonotonicity in rat pituitary and cerebellar cortex cells exposed to picomolar through micromolar levels of BPA . Acting Research over the past 20 years has identified multiple EDCs that mimic or disrupt hormone function at low doses in ways that are not predicted by high-dose studies. Biomonitoring studies have established that many of these contaminants are widespread in people. Yet classical regulatory toxicology ignores nonmonotonicity despite the fact that, similar to hormones, EDCs would be expected to display nonmonotonic dose–response patterns for many responses. This disconnect with current science pervades virtually all regulatory agencies responsible for chemical safety around the world, and it means that many regulatory decisions are highly likely to have underestimated risks.If the health implications of these decisions were inconsequential, the clash between regulatory toxicology and endocrinology would appropriately remain buried in academia. But the range of health conditions now plausibly linked to EDCs—including, but not limited to, prostate cancer , breast in vitro, including with human cells and tissues, are applicable to human health (These chronic diseases are major contributors to the steadily increasing human disease burden and to the escalating cost of health care throughout the world. Extensive, careful, and replicable animal research suggests that numerous common man-made chemicals to which people are exposed every day, but that have not been adequately studied for health effects in humans, may be significant contributors to these adverse health trends. Because the endocrine system is highly conserved between animals used as models in biomedical research and humans, the default assumption should be that nonmonotonic dose–responses of EDCs observed in laboratory animals and n health . ModerniWe recommend the following:Animal testing protocols used to establish regulatory safety standards must include experiments that examine effects of chemicals over a wide dose range that at their low end overlap with typical human exposures, particularly those experienced by vulnerable populations based on biomonitoring data, or modeling if actual data do not exist.Current scientific knowledge obtained through studies on the endocrine system and its disruption by exogenous chemicals should be applied systematically when regulatory standards on EDCs are to be established. For the best interest of public safety, cooperation of chemical manufacturers in reevaluating safety of their products under the new criteria is critical. Their acceptance of the endocrinology-derived concept that high-dose experiments are insufficient to establish safety standards for EDCs is essential. Continued denial of the reality that nonmonotonic dose–response curves are predicted to occur for EDCs is no longer tenable .The soaring health care crisis unfolding in countries around the world demands that the regulatory apparatus of governments move into the 21st century. Blind obedience to 16th-century dogma will not solve the problem. Unless and until regulatory agencies incorporate modern endocrinologic principles into their risk assessment paradigms, they will continue to provide false assurances of “safety” and fail to recognize the actual health risks posed by chronic low-level exposure to an increasing number of chemicals found in commonly used products.


This paper proposes a novel framework for bioinformatics assisted biosurveillance and early warning to address the inefficiencies in traditional surveillance as well as the need for more timely and comprehensive infection monitoring and control. It leverages on breakthroughs in rapid, high-throughput molecular profiling of microorganisms and text mining.Salmonella typhimurium genotype clustering and temporospatial outbreak analysis demonstrated better discrimination power than traditional phage typing. Half of the outbreaks were detected in the first half of their duration.This framework combines the genetic and geographic data of a pathogen to reconstruct its history and to identify the migration routes through which the strains spread regionally and internationally. A pilot study of The microbial profiling and biosurveillance focused text mining tools can enable integrated infectious disease outbreak detection and response environments based upon bioinformatics knowledge models and measured by outcomes including the accuracy and timeliness of outbreak detection. Current early warning systems successfully detect large outbreaks but show significant delays and low sensitivity in detecting moderate and small epidemics ,2. It isThe body of knowledge on the molecular profiles and epidemiology of pathogens accumulated in databases and biomedical literature has been also expanding. We have argued that bioinformatics pathogen profiling can help to predict patient outcomes, identify markers that can be applied for early diagnosis and enable tailored interventions, commonly referred to as "personalized medicine" . We propA pathogen profile can be considered as a single multivariate observation or a set of observations, comprised of classes of specific attributes, which are designed for a comparison with a knowledgebase. In contrast to traditional subtyping based on phenotypic characteristics, such as serotype, biotype, phage type or antibiogram , genetic profiling describes the phenotypic potential within the nucleic acid sequence. Sequence-based typing on one hand and randomly amplified polymorphic DNA, plasmid fingerprinting or pulsed-field gel electrophoresis (PFGE) on the other, can be viewed as examples of direct and indirect methods of assessing nucleic acid sequence, respectively. They provide both strain typing and key phylogenic data .Methods based on repetitive sequences present at several loci in the genome have been developed with the potential to generate consistent pathogen profiles that are amenable to standardization and database cataloging. Genotyping systems based on comparison of sizes and numbers of different DNA fragments separated by gel electrophoresis express their results in continuous values which are less reliable than direct sequence-based methods, due to the lack of precision and reproducibility. Typing systems that use markers with categorized values  are intrinsically highly reproducible and more appropriate for library typing. Typing techniques like MLST that allow classification consistent with phylogenetic relationships are useful tools for studying global epidemiology. However, techniques that provide real-time or near real-time typing capability are likely to provide the most relevant information and therefore have the most impact.Staphylococcus aureus (MRSA) as a significant cause of hospital- and community-acquired morbidity and mortality has prompted calls for better surveillance systems supported by analysis of the molecular epidemiology of MRSA [The emergence of multi-resistant  of MRSA . Differe of MRSA .spa typing has become a potential alternative to traditional approaches to hospital-acquired infection control [spa typing of hospital MRSA isolates and temporal-scan test statistics, were 100% and 95.2% sensitive and specific, respectively, in identifying outbreaks and more sensitive and timely than routine surveillance [There is an increasing benefit in using rapid molecular profiling for MRSA outbreak detection. For example, rapid outbreak detection by rapid MRSA  control ,6. In onThe conceptual framework of bioinformatics assisted infectious disease control presents a case how microbial genomics can be integrated with clinical data to cluster patients belonging to the same outbreak or to predict responses to treatment Figure . MicrobiThe searches and analyses are conducted on two levels. First, genotypes or pathogen profiles are compared with local databases to detect recent transmission or to predict therapy outcomes. Then, global search is performed to collect the information about temporal and spatial distribution of genotypes or profiles obtained, in order to discover transmission pathways and enhance clinical policies. Once a profile is constructed, it can be matched with those of others or with existing datasets using similarity measures and clustering techniques. Probabilistic or information theoretic distance functions and clustering algorithms have been applied to match microbial profiles .A pathogen profile is a synthesis of various markers and clinical end-points extractable from medical charts or knowledge sources that characterize an individual patient's clinical and public health outcomes. A significant increase in our knowledge of the molecular epidemiology of biothreats has been reflected in the explosion of NCBI submissions (genomic data with or without annotation) and PubMed publications related to new variants of virulence or antibiotic resistance genes and their spread in hospitals, communities, countries and continents over the last five years Figure .®) have emerged as tools for knowledge management [Salmonella typhimurium MLVA 2-7-11-7-3 profile").Pathogen profiles can benefit from integration with knowledge representations that express the relationships and entities from the biological hierarchy. Ontologies and controlled vocabularies  fingerprinting. Specifically, clonally related strains were identified by multi-locus variable number tandem repeat analysis (MLVA) which was shown to be superior to gel-based typing for both surveillance and outbreak investigations of STM [pSLT. MLVA has high discriminatory power within clonal species and appears to be more rapid and more amenable to standardization than pulse-field gel electrophoresis for both surveillance and outbreak investigations of STM [Near real time s of STM . MLVA iss of STM .Prospective evaluation of rapid, molecular typing-based clustering of 816 STM isolates recovered from patients in New South Wales and Queensland in November 2006 – March 2007 identified 44 clusters involving 69% of all isolates tested. The average number of isolates per cluster was 12 (range 4–67). Three distinct temporal and spatial patterns were identified: (1) new point-source clusters localized in space and time,  the endemic activity of STM. An MLVA-based system demonstrated better discrimination power than traditional phage typing, identifying 9 and 11 independent clusters within each of two endemic phage types PT170 and PT135a, respectively. The performance of the detection system was significantly affected by the cluster definition employed. Around 50% of STM outbreaks are detected in the first half of their duration  [Octal code profiles were assigned to each isolate for comparison and spatio-temporal clustering. A address) . This deThe system was implemented as both a stand-alone and as a web application with Map Objects (ESRI) GIS for map visualisation. MLVA patterns were matched using hierarchical cluster analysis. Minimum spanning trees analysis was also used to overcome the potential loss of information introduced by the latter.The authors declare that they have no competing interests.All authors contributed equally to this effort through discussion, writing, and revision of the manuscript.


Mounting evidence suggests that there is frequently considerable variation in the risk of the outcome of interest in clinical trial populations. These differences in risk will often cause clinically important heterogeneity in treatment effects (HTE) across the trial population, such that the balance between treatment risks and benefits may differ substantially between large identifiable patient subgroups; the "average" benefit observed in the summary result may even be non-representative of the treatment effect for a typical patient in the trial. Conventional subgroup analyses, which examine whether specific patient characteristics modify the effects of treatment, are usually unable to detect even large variations in treatment benefit (and harm) across risk groups because they do not account for the fact that patients have multiple characteristics simultaneously that affect the likelihood of treatment benefit. Based upon recent evidence on optimal statistical approaches to assessing HTE, we propose a framework that prioritizes the analysis and reporting of multivariate risk-based HTE and suggests that other subgroup analyses should be explicitly labeled either as primary subgroup analyses  or secondary (exploratory) subgroup analyses (performed to inform future research). A standardized and transparent approach to HTE assessment and reporting could substantially improve clinical trial utility and interpretability. When the Scottish epidemiologist Archie Cochrane suggested that clinical practice should principally be guided by rigorously designed evaluations, in particular randomized clinical trials (RCTs), the reaction of the medical profession was largely negative. Critics suggested that relying on impersonal statistically-derived "evidence" based on averages to determine clinical decision-making was antithetical to the practice of medicine, which should rather be based on a physician's expertise, acumen and clinical experience, and on knowing the individual patient and considering what is best for each person given their individual circumstances and needs -3.not to accept clinician or expert opinion as a replacement for scientific evidence for estimating a treatment's efficacy and safety, but to better understand how the effectiveness and safety of a treatment varies across the patient population (referred to as heterogeneity of treatment effect [HTE]) so as to make optimal decisions for each patient.Although "evidence-based medicine" has become the dominant paradigm for shaping clinical recommendations and guidelines, recent work demonstrates that many clinicians' initial concerns about "evidence-based medicine" come from the very real incongruence between the overall effects of a treatment in a study population  and deciding what treatment is best for an individual patient given their specific condition, needs and desires (the task of the good clinician) -7. The aThe conventional method of examining whether treatment effects vary in a trial population is to divide patients into subgroups based on potentially influential characteristics. The main problem with the conventional approach is that there are too many characteristics that can potentially influence treatment effect. This leads to myriad subgroup analyses which are typically both underpowered and vulnerable to spurious false positive results due to multiple comparisons. For these reasons, subgroup analyses are usually "exploratory" and rarely actionable, leaving the clinician to assume that all patients meeting trial inclusion criteria should be similarly treated.Herein, we propose a framework that directly addresses the problem of multiplicity in two ways. First, our framework prioritizes the analysis and reporting of multivariate risk-based HTE, over conventional "one-variable-at-a-time" subgroup analysis. This recommendation is based on an understanding that HTE emerges from just a few fundamental risk dimensions. These dimensions--which include the risk of the primary study outcome (the main focus of our proposed approach), competing risk, the risk of treatment-related harm and direct treatment-effect modification -8--can oWhen considering whether a patient is likely to benefit from a therapy, the most relevant measure of treatment effect is the absolute risk reduction (ARR) (see Appendix 1) of a treatment  ,11. It iIndeed, because a minority of high-risk patients may account for most trial adverse outcomes and because even a small degree of treatment-related harm can nullify or outweigh benefits in low risk patients, it does not take extreme assumptions to produce scenarios in which almost all individuals ,12,13 inWhile these examples illustrate cases in which the absence of risk-based analysis will result in harmful (or merely wasteful) over-treatment, under certain circumstances the opposite may also be the case; a treatment's effect may be null overall, even though it provides substantial benefit in a patient subgroup  ,15.Although the degree of heterogeneity in risk shown in Tables Recent research has demonstrated that, even when there are large and clinically important differences in treatment effects across risk groups, conventional subgroup analyses (which assess HTE "one-variable-at-a-time") are inadequate to detect these differences across risk subgroups because they do not account for the fact that patients have multiple variables that determine risk simultaneously ,9,21-24.There are better alternatives to one-variable-at-a-time subgroup analyses. Multivariable subgroup analysis is theoretically possible, and has been shown to be potentially useful, but staSeveral recent papers have addressed important considerations when conducting and interpreting subgroup analyses ,30,32-40Although its importance was highlighted over a decade ago, reportiThe precise approach for presentation is not important, as long as it allows the reader to understand the distribution of predicted baseline risk (or the risk score of a risk index) in the study population. "Table Finally, including this information in "Table absolute risk reduction varies across the study population even when relative risk reduction is constant  It allows us to understand how In reporting risk stratified results, readers should be provided with the information needed to easily determine the amount of variation in ARR/NNT and RRR. An approach to presenting these results to a general readership is shown in Table primary subgroup analysis as those subgroup comparisons that are well justified  so as to yield potentially actionable results appropriate for guiding clinical care. Therefore, all primary subgroup comparisons must be fully specified and justified a priori.Here we define The number of comparisons made in the primary subgroup analysis should be kept small in number to minimize false positive results, since each additional subgroup comparison decreases the usefulness of the other primary subgroup analyses and should therefore exact a statistical penalty (see recommendation #5). Often, no single variable subgroup analysis  will be indicated as part of the primary subgroup analysis. Rather, these should generally be conducted as exploratory (secondary) analyses (see recommendation #4), unless: 1) there exists previous empirical evidence from observational studies or exploratory subgroup analyses in prior clinical trials; or 2) there are highly compelling reasons to believe the patient attribute is likely to importantly influence the relative treatment effect (such as time to treatment with time-sensitive therapies or biomarkers that are strong candidates to be specific targets of therapy [e.g. estrogen receptor positivity in breast cancer]).post-hoc changes in variable construction to better "fit the data". By conducting primary subgroup analysis that are few in number, fully pre-specified, hypothesis-driven and more statistically robust (see recommendation #5), examinations of HTE can produce strong and actionable evidence regarding which patients are most likely to benefit from treatment.Prespecification of primary subgroups should include explicit definitions and categories of the subgroup variables, including cut-off thresholds for continuous or ordinal variables where these are used, and the anticipated direction of the effect modification. While it is ideal that analyses should be pre-specified at the time of trial initiation ,27, it iAlthough we propose making a clear distinction between primary and secondary subgroup analyses, it would be a mistake to forgo secondary analyses. Secondary analyses can explore evidence of unexpected relationships between individual patient attributes and treatment effects. Although exploratory analyses are an important part of scientific discovery, it is critically important to understand that such analyses are mainly appropriate for hypotheses generation, which can then be tested  in future studies. Although medical journals may be reluctant to report "exploratory" analyses, it would be quite easy to routinely include secondary subgroup analyses in an electronic appendix to be published online with the main results of a clinical trial, making them available to the scientific community and for future meta-analyses while keeping them distinct from the primary results.all subgroup analyses, including multivariate-risk, primary and secondary subgroup analyses, and the paper must state that the primary subgroup analyses conducted were pre-specified. Because statistically significant benefit is likely to be absent in small subgroups, the correct analysis is not to test the significance of the treatment effect in one subgroup or another, but whether the effect differed significantly between subgroups. Work by Brookes et al suggests that the most statistically robust approach to assessing HTE is using interaction terms in regression models ) patients in a trial, calculated as (CER - EER)/CER. Moreover, we use the term "net RRR" in this paper to emphasize that we are assessing the overall treatment benefit .The number of patients who need to be treated, on average, to prevent 1 additional bad outcome; calculated as 1/ARR.1. Evaluate and report on the distribution of risk in the overall study population and in the separate treatment arms of the study by using a risk prediction model or index.• Report on the distribution of predicted risk (or risk score) in the study population overall and by treatment arm.• Risk reporting should allow readers to assess the full distribution of the study population either graphically  or by including information on the mean, standard deviation, median and interquantile ranges.2. Primary subgroup analyses should include reporting how relative and absolute risk reduction varies in a risk-stratified analysis.any analysis of treatment-effect has begun) and preferably externally developed.• The risk prediction model should be pre-specified  subgroup analyses separately from primary subgroup comparisons.• Secondary subgroup analyses must be reported separately from primary subgroup analyses and clearly labeled as exploratory .5. All analyses conducted must be reported and statistical testing of HTE should be done using appropriate methods (such as interaction terms) and avoiding overinterpretation.• Reporting must include results for all subgroup analyses conducted and the paper must state that primary subgroup analyses conducted were pre-specified and reported.• Statistical comparisons should be limited to reporting for statistical significance of treatment heterogeneity between subgroups using interaction terms. .• Statistical comparisons should be corrected for the number of primary subgroup analyses performed.Predictive models for some commonly used outcomes in clinical trials; references for 95 prognostic models.Click here for file


This is the case of an 18 year old active duty soldier withsymptoms of exertional chest pressure and syncope who was found tohave anomalous origin of the left main coronary artery (LMCA) fromthe right coronary cusp (RCC) traveling partially between thegreat vessels before taking a septal approach between the leftventricular outflow tract (LVOT) and the right ventricular outflowtract (RVOT). Anomalous origin of coronary arteries is a rarecondition that carries an increased risk of angina, myocardialischemia, and sudden cardiac death (SCD). Surgical treatment ofsuch anomalies with both high and lower risk features can bechallenging, and traditional benefit from surgical correction maynot be achieved due to complex anatomy. As evident by our patient,this rare condition even though benign from sudden deathstandpoint could be debilitating despite best efforts andavailable resources. This is the case of an 18-year-old active duty soldier with symptoms of severe gastroenteritis and exertional chest pressure that radiated to his neck and left arm relieved by rest. These symptoms prevented him from participating in sports throughout high school. Although, the patient described one episode of near syncope following a two-mile run in which he became very lightheaded but never lost consciousness.  Imaging evaluation began with a transthoracic echocardiogram which revealed a normal left ventricular ejection fraction with no regional wall motion abnormality. With the patient history and presentation, a subsequent ECG-gated cardiac CT angiogram was obtained to evaluate the coronary artery origins. This study demonstrated an anomalous origin of the left main coronary artery (LMCA) from the right coronary cusp (RCC) travelling partially between the great vessels before taking a septal approach between the left ventricular outflow tract (LVOT) and the right ventricular outflow tract (RVOT)  is 0.15% . AnomaloThe anatomic course of an anomalous LMCA beyond the origin is what determines the extent of symptoms and risk. Traditionally, when an LMCA originates from the RCC, it takes one of four courses: retroaortic, anterior free wall, interarterial, or septal . Eighty Identification of anomalous origin of coronary arteries is highly related to the index of clinical suspicion. We can presume that current suspicion is generally low, given that sudden cardiac death is often the symptom that alludes to the diagnosis . In a reOnce identified, the patient should be placed on strict bed rest, and prompt surgical evaluation, by centers with experience in treating anomalous coronary arteries, should occur , 5. SurgThe typical surgical modality for an interarterial course involves relocation of the anomalous artery from between the great vessels to around them in order to remove the compressive shear forces of the great vessels on the coronary artery. More conservative medical management is used for patients with a septal course. Our patient's anomaly followed a septal course where conservative approach would have been recommended but due to severity of symptoms surgical intervention was deemed prudent. Relocation of the artery would have been the ideal surgical procedure, but with most of the LM course septaly, the only available option was bypass grafting with LIMA to LAD. Patient's left circumflex anatomy with no obtuse marginal targets limited bypass grafting to this territory. Given competitive flow, graft patency and maturation, even in the setting of an arterial graft, was of great concern. However, arterial graft matured as was evident on repeat angiography and patient's persistent symptoms were most likely related to the lateral wall unrevascularized territory. Patient's septal course is deemed benign from sudden cardiac death perspective and thus no intracardiac defibrillator placement was attempted.Anomalous origin of coronary arteries is a rare condition that carries an increased risk of angina, myocardial ischemia, and sudden cardiac death (SCD). This condition does not have a high prevalence in the US, however, when present can have catastrophic results . Many paSurgical treatment of such anomalies with both high and lower risk features can be challenging, and traditional benefit from surgical correction may not be achieved due to complex anatomy. As evident by our patient, this rare condition even though benign from sudden death standpoint could be debilitating despite best efforts and available resources.


Theseclimate changes are anticipated to have a long-term impact on marine andterrestrial ecosystems. Rising sea levels are predicted to flood low-lyingcoastal regions, and fresh water resources could become scarce leading to developmentof desert-like regions. This will greatly affect the survival of fragile plantspecies, wild animals, and other ecosystems all of which could directly orindirectly affect survival and or spread of pathogens and their vectors. Although these changes will undoubtedlyhave an impact on human health, the uncertainties in climate models, as well aspredictive epidemiology, hamper accurate predictions on the impact of global warmingon public health. In addition, the absence of experimental models thatdemonstrate dose dependent effects between climate change and disease givesammunition to those in doubt. As a joint Institute of Medicine/National Academyof Science Committee concluded in 2001, we know that there is a relationshipbetween climate change and infectious disease, but these links aredisease specific and location specific, and we cannot yet predict these impactsat anything other than coarse temporal and spatial scales. Thus, the impact onhuman health is still unclear, and climate change may increase the prevalence ofparticular infectious diseases in some regions, while decreasing the prevalencein others. There are currently 137 publications in PubMed using the keywords“infectious diseases” and “global warming.” The majority of which werepublished in the last few years, and this attests to the increasing interest inthis aspect of public health. However, most data so far are observational, and thepredictive understanding of the impact of disease is based on mathematicalmodeling. Other sources of data include retrospective time-series analyses inspecific locations, or use the periodic El Nino Southern Oscillation (ENSO)phenomenon as a surrogate for long-term change. Since controls are usuallyhistorical and data are now collected in a more biased fashion than before,there is a concern that some of our conclusions reflect an observational biasthat is common when data collection is initiated on new problems that were not previouslyunder rigid observation.Due to increasingCOTotackle global warming, coordinated efforts will have to be taken that do notonly span countries and cultures but also require many fields of scientificexpertise. Effects of global warming are multifactorial and occur at a timewhen many other important confounding variables constantly change. Beyondglobal warming, increasing global mobility, genetic modification ofagricultural products, and usage of reagents that inhibit pathogens can allhave a significant impact on spread and prevalence of infectious diseases. Thiswill make it difficult to establish causality between global warming and impactof infectious diseases. Rigorous scientific conclusions call for experimentalmodels that examine impact of temperature under controlled conditions. Finally,global warming occurs in the general setting of climate change—temperature isnot the only variable that is changing. Rather, rainfall patterns, windpatterns, and other climatologic variables are changing at the same time.Asmuch as we all wish to act fast, and as much as we cry out for an enlightenedpublic consciousness that would be required to press for policy changes thatameliorate the effects of global warming and limit the emission of greenhousegases, our most imminent problem is that we do not have a true scientificunderstanding of the matter yet. In this special issue, Interdisciplinary Perspectiveson Infectious Diseases solicited cross-cutting interdisciplinary articles thattook new and broad perspectives ranging from what we might learn from previousclimate changes on disease spread to integrating evolutionary and ecologictheory with epidemiologic evidence in order to identify key areas for study inorder to predict the impact of ongoing climate. These studies presentinteresting results and analysis of available data. They also highlight howdifficult it is to interpret data at present.Futurestudies should increase retrospective surveys of museum specimens from previoustimes, long lasting unbiased data mining and true experimental work on diseasemanifestation under higher temperatures. Moreover, predictive climate modelsand predictive epidemiology both need to advance, and become coupled together. Thisresearch will likely not meet current output criteria of short-term grantproposals. This problem needs meticulous patient intelligent researches likeDarwin to devote their life to answering these pressing questions. Without suchefforts, the current generation will inevitably benefit at the cost ofgenerations to come.Bettina C. FriesBettina C. FriesJonathan MayerJonathan Mayer


Fixed drug eruption (FDE) due to fluconazole is extremely rare. We recently had a 35-year-old female patient who presented with multifocal bullous FDE due to fluconazole hitherto not reported in the literature.A 35-year-old female, a known case of carcinoma stomach, operated and initiated on post-operative chemotherapy with cisplatin and adriamycin, presented with multiple itchy hyperpigmented elevated oval patches over the face, neck, trunk, upper limbs and lower limbs of three days duration following some medications for sore throat problem (details of the medication were not available at that time). On physical examination, she had multiple (200 in number) asymmetrically distributed, rounded to oval, hyperpigmented, edematous lesions of variable sizes surrounded by a rim of erythema over the body. Many lesions were bullous. She had a similar episode six months ago but at that time had developed only three lesions on the face and neck following oral medication for mouth problem. A diagnosis of multifocal bullous FDE was made. The skin lesions subsided over next one week leaving behind hyperpigmented macules without any intervention. Patch testing with cisplatin and adriamycin was negative. Oral rechallenge test to paracetamol and diclofenac sodium was negative. Subsequently, she was diagnosed to have oral candidiasis in our hospital and was prescribed oral fluconazole 200 mg on day one followed by 50 mg daily for two weeks. Within half an hour of intake of first dose, she developed itching in the skin lesions and in a couple of hours, developed reactivation of FDE lesions . She wasFluconazole is a triazole antifungal. It is fungisatic and is effective against many yeasts and dermatophytes.2Most of the cutaneous side-effects due to fluconazole exist in isolated or a limited number of case reports. Fixed drug eruption due to fluconazole is extremely rare. To the best of our knowledge, there are only eight earlier reports of fixed drug eruption due to fluconazole in the literature.5FDE is characterized by sudden onset of round and/or oval edematous, dusky-red, macules/plaques on the skin and/or mucosa arising precisely over the area of an earlier reaction due to the same drug.6Our literature search on FDE due to fluconazole revealed that all cases reported so far had limited cutaneous or mucosal lesions. In contrast, our patient had extensive generalized lesions with many bullous lesions, a unique presentation of fixed drug eruption due to fluconazole which has not been described in the literature so far. With widespread use of any drug, new adverse effects come to light and hitherto unknown adverse effect may become more common occurrence. We recommend that fluconazole be included in the list of drugs causing multifocal bullous FDE so that similar cases may be diagnosed more often.


Although animal research indicates that BPA can alter several metabolic functions, interpretation of human data has been more controversial. A new study now presents evidence confirming that exposure of human adipose tissue and isolated fat cells to environmentally relevant levels of BPA suppresses release of the hormone adiponectin A high-calorie diet and sedentary lifestyle have both traditionally been linked to metabolic syndrome—the presence of a constellation of metabolic risk factors including insulin resistance, hypertension, and elevated blood sugar and lipid levels—but researchers are now examining environmental factors as additional causes. Adiponectin increases insulin sensitivity and reduces tissue inflammation, so suppression of its release could lead to insulin resistance and increased susceptibility to metabolic syndrome, the authors write.2), an endogenous human estrogen. They used enzyme-linked immunosorbent assay to measure secreted adiponectin. They also used quantitative real-time polymerase chain reaction to compare the expression of estrogen receptors and estrogen-related receptors in these tissues.The study examined three types of adipose tissue samples taken during breast reduction, abdominoplasty, and gastric bypass surgery. The research team incubated each type of tissue for 6 hours in BPA or estradiol (E2. The authors also showed that the dose response to BPA was nonmonotonic, meaning lower doses caused different effects than higher doses. Finally, they report for the first time similar mRNA expression levels for several estrogen receptors in visceral adipose tissue, although the role of these receptors in the suppressive nature of BPA and E2 has yet to be determined.In all three tissue types, exposure to low-nanomolar concentrations of BPA suppressed adiponectin as effectively or more effectively compared with equimolar concentrations of EThe results of the data are limited by the relatively small sample size in each tissue category, as well as the potential unknown effects of age or obesity on tissue responsiveness. However, the authors write that their data present clear evidence that BPA suppresses adiponectin, potentially leading to a much higher risk of developing metabolic syndrome and its resultant adverse health effects. They conclude that with BPA’s persistence in the environment, more research should be done to determine the mechanism by which the chemical suppresses adiponectin.


Conservationists are continually seeking new strategies to reverse population declines and safeguard against species extinctions. Here we evaluate the potential efficacy of a recently proposed approach to offset a major anthropogenic threat to many marine vertebrates: incidental bycatch in commercial fisheries operations. This new approach, compensatory mitigation for marine bycatch (CMMB), is conceived as a way to replace or reduce mandated restrictions on fishing activities with compensatory activities  funded by levies placed on fishers. While efforts are underway to bring CMMB into policy discussions, to date there has not been a detailed evaluation of CMMB's potential as a conservation tool, and in particular, a list of necessary and sufficient criteria that CMMB must meet to be an effective conservation strategy. Here we present a list of criteria to assess CMMB that are tied to critical ecological aspects of the species targeted for conservation, the range of possible mitigation activities, and the multi-species impact of fisheries bycatch. We conclude that, overall, CMMB has little potential for benefit and a substantial potential for harm if implemented to solve most fisheries bycatch problems. In particular, CMMB is likely to be effective only when applied to short-lived and highly-fecund species (not the characteristics of most bycatch-impacted species) and to fisheries that take few non-target species, and especially few non-seabird species (not the characteristics of most fisheries). Thus, CMMB appears to have limited application and should only be implemented after rigorous appraisal on a case-specific basis; otherwise it has the potential to accelerate declines of marine species currently threatened by fisheries bycatch. Bycatch is increasingly recognized as one of the principal threats to many marine vertebrates, including multiple species of sharks, sea turtles, and seabirds www.nativeenergy.com). Compensatory mitigation for marine bycatch (CMMB) is thus the application of an established, albeit controversial Wilcox and Donlan (henceforth W&D) recently proposed a new approach to marine conservation that they suggest would significantly improve the protection of sensitive marine species impacted by fisheries bycatch Puffinus carneipes) on Lord Howe Island off mainland Australia. Because a new approach to solving marine bycatch could have dramatic conservation implications, a more careful analysis of CMMB, and in particular, a thorough consideration of the necessary criteria for this approach to yield substantial and reliable conservation benefits, is essential.W&D have offered a broad outline of how CMMB might function, but provided few details and described only one quantitative case study, which they conducted for the flesh-footed shearwater , CMMB is not a proposal to add a new mitigation measure with substantial costs  to existing regulatory controls on fisheries. Instead, CMMB is a proposal to continue or expand current levels of fishing effort, and thus current bycatch levels, by lessening restrictions on fishing effort in exchange for fees that would fund indirect compensatory mitigation measures.Re-Analysis of a Case Study below and W&D illustrated the use of CMMB with a case study of the FFSH on Lord Howe Island, one of their numerous breeding colonies. The FFSH population is declining, in part due to high mortality  on the longline hooks of the Eastern Tuna and Billfish Fishery (ETBF) http://www.smithsonianmag.com/specialsections/ecocenter/bycatch.html):CMMB offers the potential to substitute a politically difficult management approach to curtailing the number of threatened species killed as fisheries bycatch  with alternate management methods . However, before such a substitution of one management effort with another is applied to a particular fishery, conservation biologists and managers must have some evidence that the compensatory strategy can yield positive outcomes and not result in a net conservation loss. We present five criteria to serve as a systematic way to assess the potential of CMMB as a tool for creating ‘bycatch neutral’ fisheries, as recent media coverage has labeled the CMMB approach  would have to be saved to equal the mortality of one adult in terms of contribution to future population growth Although the continued survival of threatened populations is so basic a criterion that it may seem unnecessary to discuss, it is indeed a major stumbling block for a successful CMMB program. As we note above, examples of possible CMMB programs use enhancement of early life stage survival to balance mortality of older aged individuals in fisheries. Most species identified as critically endangered by bycatch are moderately to very long-lived, including large sharks, seabirds, and sea turtles. The long life spans of most threatened marine vertebrates are combined with delayed reproductive maturity and/or low reproductive rates; these life history traits create the Given the typical long-lived, slow-maturing life history of most species threatened by bycatch , CMMB efforts that increase survival of offspring to compensate for mortality of adults are unlikely to reverse population declines. One of the first and best analyses of this problem – and one that is literally now a textbook example – is for loggerhead sea turtles impacted by bycatch in shrimp trawlers before they are substituted as a bycatch conservation strategy.Other types of mitigation approaches, such as mitigation banking of wetlands, include explicit acknowledgement of uncertainty about the possible outcomes of mitigation and restoration approaches The proposed uses of CMMB have emphasized the funding of land-based mitigation activities, in particular the removal of non-native species from islands W&D have highlighted exotic animal eradications on islands as a feasible and potentially beneficial use of CMMB funding for seabird bycatch solutions. However, for seabirds, a discrepancy exists between seabird species most affected by bycatch  and those most impacted by non-native predators . For these species, comparing the spatial scales at which bycatch and compensatory mitigation occur relative to the geographic range of the affected populations is critical. Industrial fisheries operate in marine ecosystems around the globe; therefore bycatch mortality typically affects susceptible species throughout large parts of their geographic ranges. In contrast, terrestrial threats rarely impact all breeding locations used by a given bird or turtle population.The most likely targets for terrestrial mitigation efforts under CMMB are seabirds and sea turtles The dynamics of many seabird populations currently approximate source-sink population structures Procellaria aequinoctialis). The white-chinned petrel breeds on a small number of sub-Antarctic island groups, but is abundant and widely distributed throughout the southern oceans where it constitutes the majority of seabird bycatch in longline fisheries An example of a source-sink population structure typical of many seabirds is illustrated by the white-chinned petrel (Phoebastria immutabilis), which breeds primarily in the northwestern Hawaiian Islands, United States of America, but also on Guadalupe Island, Mexico Mus musculus), which is not known to prey on Laysan albatross, but see Another seabird example is the Laysan albatross , including the endangered yellow-nosed  and black-browed (T. melanophrys) albatrosses, and the critically endangered leatherback (Dermochelys coriacea) and hawksbill (Eretmochelys imbricata) sea turtles.As presented by W&D, CMMB is a single-species approach to compensate for (or offset) the impacts of bycatch. However, bycatch is virtually always a multi-species problem . A potential risk of the CMMB approach would be to prolong a single species approach, detracting from a more ecologically-meaningful multi-species perspective.In summary, mitigating bycatch for one or a few species while neglecting the impact of fishing practices on many other non-target species is ecologically unsound, and for CMMB to be effective, impacts to other incidentally captured species need to be evaluated and addressed. One of the most encouraging trends in marine conservation has been the cooperation of agencies and managers concerned with different taxonomic groups to craft bycatch control and reduction plans that would benefit multiple impacted species  and for adults (AS), defined as age six or greater (eqn. 1 in bp); 2) the probability of an adult female laying an egg (ep); 3) the probability of a newly-laid egg hatching and the chick surviving to fledge (fp); 4) the probability of both parents surviving the reproductive period (rS), which is a requirement for chick survival to fledging; 5) the probability of the fledgling surviving until one year from egg laying (0S); and 6) the probability that the chick is female (0.5). Bycatch reduces AS and rS, while rats are alleged to depress fp. W&D assessed the influence on the asymptotic annual population growth rate (λ) of eradicating or controlling rats versus reducing bycatch through partial to full fishing area closures. For our comparison, we examined four conditions: status quo , eliminating rats, eliminating bycatch, or eliminating both rats and bycatch.To allow direct comparisons with W&D's reported results, in all our models, we used a deterministic six-stage matrix model with a pre-breeding census, as did W&D. Annual survival is modeled for 5 prebreeder stages . And, although W&D appropriately define rS as the probability that both parents survive the breeding season, they estimate rS as the probability that just one parent survives. In addition, according to W&D's apparent source for bycatch rates rS during the 5-month breeding season . While rats are known to prey heavily on FFSH congeners on other islands Rattus rattus), typically affects only small burrow-nesting seabirds (<260 g) all egg and chick mortality observed in this population to rat predation is highly questionable. Assuming that rat eradication would boost fp to 1.0 is of even greater concern. In our review of the literature, we can find no reports of long-term mean fp that even approach 1.0 for shearwater colonies, regardless of the presence of rats or other predators (Table 2 in P. griseus) from predator-free Tuhawaiki Island fSrp. Assuming these birds experience the same high bycatch mortality as FFSH, we estimate fp in the absence of rats as 0.748 for Model 2  are unknown. Finally, CMMB's single species perspective is perhaps its most important limiting factor for overall conservation efficiency. Taken together, these concerns cast doubt on the potential of CMMB to alleviate the threat of extinction for most marine species affected by fisheries bycatch.might have worked to save the bald eagle , but the continued use of DDT would likely have resulted in the extinction of other bird species  as bycatch in industrial longline fisheries Using a CMMB approach, the United Sates longline swordfish fishery could be permitted to continue fishing after exceeding the current maximum allowable loggerhead interactions if fees levied for loggerhead impacts were used to reduce loggerhead bycatch in the small-scale Mexican fishery, possibly including payments to forgo fishing in Bahia Magdalena altogether. If this overall reduction in bycatch resulted in a positive growth rate for the endangered Pacific loggerhead, a CMMB approach could potentially meet criteria 1 through 4. Careful assessment of the multi-species impact from both fisheries – the United States longline swordfish and Mexican small-scale – would have to be conducted to assure that compensatory mitigation measures did not result in a net increase of bycatch for any at-risk species in order to satisfy criteria 5 . Most seriously, a CMMB strategy for loggerheads should not result in increased bycatch of the critically endangered Pacific leatherback sea turtle, predicted to go extinct within this century due to high bycatch mortality A second situation where CMMB might merit consideration is as a means of protecting endangered salmon populations. In a less traditional definition of bycatch, individuals of endangered runs are killed ‘incidentally’ by salmon fishing vessels since targeting salmon from only non-endangered runs is impossible. Because salmon runs have been shown to be more threatened by degradation of riparian  habitats than by harvesting, restoration activities such as the purchase of water rights to ensure minimal stream flows or carefully designed hatchery programs, may be able to compensate for substantial adult mortality Our focus here has been on the biological criteria that a CMMB program should meet in order to be seriously considered as a conservation strategy. However, it is also worth returning to the original rationale for CMMB, which is largely an economic one. Essentially, this argument is that the economic expense of direct bycatch reduction is too onerous to be seriously pursued, and thus we need less direct, less expensive methods to conserve the multiple species that are rapidly declining due to high bycatch mortality. While the economic costs of reducing bycatch are substantial, many successful conservation mandates enacted over the past 150 years directly reduced mortality of at-risk species and often had very large economic costs. Among these were The Migratory Bird Treaty Act of 1918, International Convention for the Regulation of Whaling (1946), and the international ban on ivory through the Convention on International Trade in Endangered Species of Wild Fauna and Flora (CITES) (1989). As these past successes show, successful conservation actions can be pursued even when they have substantial economic costs. Thus, in cases where alternative strategies have little likelihood of success, we should not be averse to promoting conservation strategies that impose short-term economic costs but that will actually work.Although our review reaches a pessimistic conclusion about the effectiveness of trading bycatch mortality for terrestrial mitigation activities, we do not disagree that a united analysis of different conservation measures for bycatch-impacted species is needed. Tackling conservation threats both at sea and on breeding sites has long been advocated to promote recovery of threatened and endangered marine species The global problem of fisheries bycatch requires innovative, yet carefully vetted, conservation approaches. Until a detailed plan of how CMMB would be implemented has been released – including details of fee structure, bycatch recording, reporting, and estimation – consideration of this type of approach is premature. The fishing industry removes vast amounts of biomass as bycatch from the ocean each year  and impaSupplement S1Re-evaluation of the W&D model for flesh-footed shearwaters on Lord Howe Island(0.55 MB DOC)Click here for additional data file.


Anthrax has been described as a veterinary disease of minor importance to clinical medicine, causing occasional occupational infections in single cases or clusters. Its potential for rapid and widespread epidemic transmission under natural circumstances has not been widely appreciated. A little-known 1770 epidemic that killed 15,000 people in Saint-Domingue (modern Haiti) was probably intestinal anthrax. The epidemic spread rapidly throughout the colony in association with consumption of uncooked beef. Large-scale, highly fatal epidemics of anthrax may occur under unusual but natural circumstances. Historical information may not only provide important clues about epidemic development but may also raise awareness about bioterrorism potential. Bacillus anthracis. Textbooks have long described anthrax as a veterinary disease of minor medical importance, attributing most human infections to occupational exposures, now less common in industrialized nations. Because anthrax is usually recognized in single cases or small clusters, its potential for rapid and broad dissemination to humans under natural circumstances has not been widely appreciated. Such a potential would have implications for both epidemics and bioterrorism.In late 2001, anthrax bioterrorist attacks in the United States prompted considerable commentary on how little is generally appreciated about the transmissibility of charbon killed 15,000 persons in Saint-Domingue (modern Haiti). The brief description of this epidemic, written by historian Michel-Placide Justin An obscure report claims that an explosive 1770 epidemic of what was called hattes  or pastures were being thinned out daily by a terrible epizootic ["épizootie"], sought to salt or smoke all their ill or dead animals; and they [then] brought them into French establishments. These meats, known as tassau in the colonies, which the Negroes avoided eating when they could get [uncontaminated] salted beef and codfish, spread to the slaves the communicable agent ["germe"] of the disease with which they [the meats] were infected ["infectées"]. A type of epidemic disease ["peste"], called anthrax ["charbon"], spread throughout all the neighboring dwellings of the Spaniards or the routes they frequently used, and in those where the Negroes had bought this tassau. Within six weeks, more than 15,000 white and black colonists perished of this terrible disease, and its ravages did not stop until the government, the magistrates, and the inhabitants themselves had joined all of their efforts to repel the scourge introduced into the colony by Spanish greed."…The unfortunate slaves in the north of Saint-Domingue therefore experienced the most frightful famine. The dependencies of Fort Dauphin, that of Gros-Morne, [and] of Jean Rabel, were devastated. Codfish being entirely unavailable, the Spaniards, whose  “But the numerous and rapid deaths caused by the disease were not all: at least 15,000 Negroes perished of hunger, and the escape of slaves increased in the northern dependency, causing serious fear for the security of the colony…" Although sketchy, this report of possible epidemic anthrax contains interesting details. It notes the precipitating circumstances of an ongoing epizootic and a sudden change in diet to uncooked—smoked or salted—beef. The report also discloses that outbreak investigation linked the distribution of contaminated beef to the geographic spread of human disease. These associations appear consistent with intestinal anthrax, a disease associated with high mortality. However, exact means and determinants of gastrointestinal transmission were not described. Salted or smoked meat likely would have been eaten without cooking, as was then the custom. Since anthrax spores are resistant to 140°F and to a wide range of chemical treatments, the failure of salting or smoking to destroy them would not be surprising.Apparently the overall mortality in the epidemic was high, although the figure of 15,000 deaths may have been only an estimate. Epidemic and vital events data from the epidemic were probably obtained by French officials and sent to Paris, but I am not aware that such data, if they still exist, have been identified by historians. Neither attack rates nor case-fatality rates have been documented from this or similar anthrax epidemics in the same era, although eighteenth-century observers were nearly unanimous in indicating a high or universal death rate from intestinal anthrax.Cercle des Philadelphes, of which Benjamin Franklin became a member, had been established and had also begun to study medical and veterinary diseases. Publications of this and other societies describe Haitian epidemics in the early 1770s, but none mention the 1770 outbreak.Had the epidemic occurred several years later, it might have received more thorough official attention. In 1776, Félix Vicq-d'Azyr set up a system of epidemic surveillance and outbreak investigation that operated in France and her colonies until 1794 charbon as "anthrax," the term corresponding to modern anthrax. But in 1770, 10 years before epizootic anthrax had been reasonably well described by Chabert charbon  was sometimes applied nonspecifically to other human diseases producing skin lesions, including not only dark or violaceous lesions of any sort but also plague and smallpox. Justin's sources for the 1770 epidemic report are unknown, but he did not begin to write it until 1822 or 1823, by which time human and animal anthrax had become better understood.The identity of the disease described in Justin's report can be questioned. I have translated the report’s designation of Other possibilities for the cause of the epidemic seem less likely. Smallpox epidemics periodically swept Caribbean islands  appears to have been epidemic in the Caribbean in 1770  Noah Webster speculated that the 1770 epidemic "must have been the real plague" In rare post-Webster medical references to the 1770 epidemic, anthrax has not been questioned. For example, a passing reference in a medical text by anthrax authority Carl von Heusinger Cercle des Philadelphes appear to be excellent early descriptions of anthrax. The author of one of them Also notable with regard to the epidemic's identity are 1775 reports claiming that a less severe epizootic of the same disease recurred in Saint-Domingue in 1772, spread to Guadeloupe, then recurred again in Saint-Domingue in 1773, 1774, and 1775. These subsequent epidemics affected cattle and caused, in humans, both cutaneous lesions, associated with inoculation, and gastrointestinal diseases, associated with ingestion ,14. ThesHistorians have occasionally speculated that large-scale anthrax epidemics occurred in the past , but evLike the Athenian epidemic—considered by Friedrich Prinzing to be anthrax and included by him among the classic "diseases resulting from wars" Historical evidence from "natural experiments," such as the 1770 Saint-Domingue epidemic, should be considered in public health efforts to prevent disease re-emergence and increase awareness about bioterrorism potential. In developing countries, single cases and small clusters of severe and fatal intestinal anthrax still occur, often in association with butchering ill animals to obtain consumable and salable meat before the animals die. Such occurrences underscore the importance of efforts to maintain a safe food supply. If historically recorded and widespread intestinal anthrax transmission via broadly distributed meats is accepted as accurate, this 200-year-old evidence would reinforce the need to be vigilant in maintaining safeguards to prevent accidental and purposeful contaminations of food products.


Indwelling urethral catheter is often used in male spinal cord injury patients to provide drainage to neuropathic bladder. If the balloon of a Foley catheter is inflated in urethra or, when a properly inserted Foley catheter is later pulled and thereby, the Foley balloon comes to lie in urethra, an excessive length of catheter will remain outside the penis. This sign is termed "long catheter sign". Long catheter sign will also be positive when Foley catheter slips out of urinary bladder in situations where Foley balloon is ruptured by a spiky vesical calculus or deflated due to a defective valve.A fifty-year-old Caucasian male with paraplegia at T-5 level had been managing neuropathic bladder by long-term indwelling urethral catheter. During his stay in spinal unit, the patient felt that there had been a tug on the drainage tube when he was being turned during night as part of the routine care for relief of pressure. Next morning, a health professional noticed that a long segment of catheter was lying outside penis. There was no bleeding from urethral meatus. Catheter continued to drain urine, which was yellowish in colour. Urine output was satisfactory. This patient did not develop any clinical feature of autonomic dysreflexia nor was he feeling unwell. In view of positive long catheter sign, radiological studies were performed to check the position of Foley catheter, which confirmed the clinical impression of incorrectly positioned Foley catheter. The catheter was removed; flexible cystoscopy was performed. A 16 Fr, 20 ml balloon Foley catheter was inserted over a 0.032" guide wire. Following this procedure, a considerably shorter length of Foley catheter remained outside the penis.Positive long catheter sign indicates that the Foley catheter is placed incorrectly and needs repositioning urgently. Prompt recognition of long catheter sign and immediate repositioning of Foley catheter will help to prevent complications such as chronic distension of urinary bladder, urine infection, and pressure necrosis of urethra especially if Foley balloon remains inflated within urethra for a long period. In this patient, use of a Foley catheter with 20 ml balloon, and securing the drainage tube to thigh with two straps, helped to prevent inadvertent pull of Foley balloon into the urethra. Management of the neurogenic bladder has the primary objectives of maintaining continence, ensuring low bladder pressure  and avoiding or minimising infection. Options include intermittent urethral catheterisation, indwelling urethral or suprapubic catheterisation, timed voiding, use of external catheter (for men), drug treatment, augmentation cystoplasty and urinary diversion.  Long-terCarers and health professionals tend to assume that urethral catheter drainage is satisfactory in spinal cord injury patients if the catheter is draining clear urine, there is no blood in urethral meatus, and the patient does not develop features of autonomic dysreflexia. In male spinal cord injury patients, the balloon of a Foley catheter may be inflated in urethra quite inadvertently or, a properly inserted Foley catheter may be pulled and thereby, the Foley balloon may come to lie in urethra. If this happens, an excessive length of Foley catheter will be outside the penis. This sign is termed "long catheter sign". Long catheter sign will also be positive when Foley catheter slips out of urinary bladder in situations where Foley balloon is ruptured by a spiky vesical calculus or deflated due to a defective valve. We present clinical images of long catheter sign in a paraplegic patient in order to raise awareness amongst health professionals of this readily recognisable bedside clinical sign.A fifty-year-old Caucasian male sustained paraplegia at T-5 level in 1987 while driving his car, which skidded and crashed. He had been managing his bladder with long-term indwelling urethral catheter. He developed a false passage in posterior urethra. Therefore, he used undergo flexible cystoscopy and change of catheter over a guide wire. He used to have a size 16 Fr. silicone Foley catheters with 10 ml balloon.In 2005, this patient underwent above-knee amputation for pressure sore over left knee joint. He was readmitted to Spinal Injuries Centre in February 2008 for revision of the stump. On one night during his stay in spinal unit, the patient felt that there had been a tug on the drainage tube while he was being turned as part of the routine care for relief of pressure. Next morning, a health professional noticed that a long segment of catheter was lying outside penis. Figure  There waIn view of positive long catheter sign, radiological studies were performed to check the position of Foley catheter . X-ray oCarers and health professionals should look for this simple bedside sign while they attend to a male spinal cord injury patient. Positive long catheter sign indicates that the Foley catheter is placed incorrectly and needs repositioning urgently. Prompt recognition of long catheter sign and immediate repositioning of Foley catheter will help to prevent complications such as chronic retention of urine, urine infection, and pressure necrosis of urethra especially if Foley balloon remains inflated within the urethra for a long period.We hope that these clinical images of long catheter sign in a paraplegic patient will help to raise awareness amongst health professionals of this readily recognisable bedside clinical sign. Further, these clinical images can be used in teaching health professionals, who are involved in the care of spinal cord injury patients in the hospital setting and particularly, in the community.My problem has been solved after cystoscopy and insertion of a larger balloon catheter.This patient was happy to provide written informed consent for publication of this manuscript and accompanying images in Cases Journal. A copy of the written consent is available for review by the Editor-in-Chief of this journal.The authors declare that they have no competing interests.SV spotted "long catheter sign" and performed radiological study and subsequently, cystoscopy. All authors participated in the care of this patient and contributed to the manuscript.


In humans, five different numts cause genetic disease and a dozen human loci are polymorphic for the presence of numts, underscoring the rapid rate at which mitochondrial sequences reach the nucleus over evolutionary time. In the laboratory and in nature, numts enter the nuclear DNA via non-homolgous end joining (NHEJ) at double-strand breaks (DSBs). The frequency of numt insertions among 85 sequenced eukaryotic genomes reveal that numt content is strongly correlated with genome size, suggesting that the numt insertion rate might be limited by DSB frequency. Polymorphic numts in humans link maternally inherited mitochondrial genotypes to nuclear DNA haplotypes during the past, offering new opportunities to associate nuclear markers with mitochondrial markers back in time.The natural transfer of DNA from mitochondria to the nucleus generates nuclear copies of mitochondrial DNA ( Endosymbiosis is germane to eukaryote evolution, and gene transfers from organelles to the nucleus were an important mechanism of genetic variation that helped to forge the prokaryote-to-eukaryote transition Neurosporanumts (pronounced “new-mights”), for nuclear sequence of mitochondrial origin, was coined numt population polymorphism numt variation among human siblings has been found nupts . With the recent eruption of eukaryotic genome data, it is opportune to take a look at the prevalence and properties of numts in sequenced eukaryotic genomes.The story of gene wanderings, from organelles to the nucleus during recent evolutionary time, started with the report of a gene sequence that was present in both the nuclear and the mitochondrial genome in numts are responsible for many instances of misidentification, both in mitochondrial disease studies and phylogenetic reconstruction.Due to their sequence similarity to mitochondrial DNA, Numts are common in humans. As a result, numt variation is continuously mis-reported as mitochondrial mutations in patients numt  was erroneously implicated in causing diseases, such as low sperm motility numt as mitochondrial variation Numts are a major challenge in using mitochondria for these purposes numts, the barcoding approach is unreliable, at least in primates numts are coamplified numts introduce serious ambiguity into the DNA barcoding paradigm as arthropods are one the major phyla studied in taxonomy.Mitochondrial DNA is commonly used as a marker for molecular systematics, phylogeny and for species diagnosis (“DNA barcoding”). The DNA barcoding technique for animals aims to identify organisms by using a short fragment of mitochondrial cytochrome c oxidase I (COI) gene numt. Newer findings even implicate numts in reports of horizontal gene transfer among plants The report that 80-million-year-old dinosaur bones harboured DNA numts using standard data-mining tools. Attempts to identify numts solely with computer methods started with partial genome sequences of plants and yeast Plasmodium, and Caenorhabditisnumts specifically in the human genome numts was reported with values ranging from 286 to 612 depending on the search parameters and depending on how closely related were combined hits into a single numt contig. Later calculations based on numts from both human and chimpanzee suggested an intermediate number of 452 numtsnumts stem from independent insertion events from the mitochondrion, whereas others are the results of tandem duplications numts appear in more copies than recent ones Sequenced eukaryotic genomes can be readily scanned for numt covers 90%  of the human mitochondrial genome numtsnumts inserted into the nucleus decelerate their evolutionary rate and become “molecular fossils” resembling ancestral mitochondrial fragments numt insertion appears to have been more or less continuous over time in the lineages leading to the human genome The largest human numt insertion is ∼5.1–5.6×10−6 per germ cell per generation, or that every two human haploid genomes should be polymorphic for at least two numt loci numt sequence to identify recent numt insertions that appear only in the human genome but not in the chimpanzee genome. Based on whole genome alignments, more than 80% of the numts in the human and chimpanzee genomes were found to be orthologous in that they are present at the same loci in the two species numts stemming from recent numt insertions, deletions, and tandem duplications were also identified. Current estimates have it that there are 40 and 68 species-specific insertions in the human and chimpanzee lineages, respectively Phylogenetic and PCR amplification studies in humans suggest that the rate of numts have been reported in humans so far numts by searching the human dbSNP database for numts that appear in the reference human genome and are missing in the variation data. Overall, about a third of human-specific numts (12/40) are variable  but appear in the variation data.Eight loci that are polymorphic for variable . Ten outnumts not only appears as neutral polymorphism but, more rarely, is also associated with human diseases numt insertion numt insertion into exon 14 of the GLI3 gene causes a premature stop codon, is associated with Chernobyl MCOLN1, eliminated proper splicing of the gene USH1C gene associated with Usher syndrome type IC numtnumt insertions, the mitochondrial genome remains intact in the afflicted individuals.Integration of numts has been estimated in various species including yeasts Numts show not only different frequencies in different genomes, but also different size distributions Numts are abundant in plants, where the longest numt known so far, a 620-kb partially duplicated insertion of the 367-kb mtDNA of Arabidopsis thaliana, was reported Beyond humans, the whole genome repertoire of numt frequency among metazoans so far numts are relatively short. Since the last genome-wide survey encompassing 13 nuclear genomes numt repertoire in 85 fully sequenced genomes including 20 fungi, 11 protists, 7 plants, and 47 animals, for which both nuclear and mitochondrial genomes are available, reporting the number of BLAST nucleotides that were found in the genome (BLASTN of entire mitochondria against the genome using e-score of 0.0001). Some mitochondrial genomes , contain repetitive sequences, such that a single nuclear fragment can be found by BLAST to match multiple mitochondria pieces, a source of differences between tabulations in earlier reports. Each nuclear nucleotide appearing in numt matches multiple mtDNA regions.The honeybee genome is currently the record-holder for Numts are common in all groups that were examined. The numt content of these genomes varies from no detectable numts in eight species to more than 500 kb in three genomes. As noted by Richly and Leister numts is usually less than 0.1%, with the higher proportions of numts appearing in plants and yeast numts. At first sight, 0.1% might not seem like much, but numt sequences are constantly becoming undetectable through mutation and deletion, such that 0.1% represents a steady state level of recently incorporated and detectable numts at any given point in time.Cyanidioschyzon, the absence of numts makes sense, because if an organelle must lyse in order for DNA to escape to the nucleus, then more than one organelle per cell  would be required for the DNA to escape numts in the present releases of several animal genomes, from insects to vertebrates, is an exception in that regard, but annotations can change over time. The highest total numt content was found in the opossum Monodelphis domestica, whose genome sequence contains over 2000 kb of numt nucleotides. However, most opossum numts do not map to known chromosome arms, and some fraction of these may turn out to be true mitochondrial sequences. In plants, the highest numt content appears in Oryza sativa Indica group with more than 800 kb of numts. Among fungi, the highest numt content appears in Phaeosphaeria nodorum with 77 kb, and in protists the highest numt content so far appears in Phytophthora infestans with 111 kb.For organisms that have only one mitochondrion, such as numts one detects can change with search strategy, genome version and level of genome completion. For example, when calculated in 2009, the genome of Arabidopsis has 54% more total numt length (305.6 kb) than it did five years ago (198 kb) numts were initially removed during the annotation process numt content in the Drosophila melanogaster genome has grown from 0.5 kb in 2004 to a current value of 10.3 kb  numtsnumts identified here. Other available assessments of numt content in genomes are shown in The number of  10.3 kb , correspnumt content . Bensasson et al. numts (see below). Early searches detected no such correlations numt content and mitochondrial genome size, even when numt content is normalized by the nuclear genome size. Three different processes can thus contribute to the differences in numts between species—the frequency of mitochondrial transfer, the amount of chromosomal integration, and the dynamics of post-insertion processes, such as duplications and deletions affecting all DNA as part of bulk genome evolution.The data from 85 genomes reveal a strong correlation between genome size and total numts to persist in nuclear genomes, mitochondrial DNA must first physically reach the nucleus, then it must integrate into the nuclear chromosome, with intragenomic dynamics of amplification, mutation, or deletion following. Work so far has focused on the escape of DNA from the mitochondria and on the integration of mtDNA within the nucleus but not on its physical entrance into the nucleus (the notion that nuclear chromosomes should actively pluck mtDNA from the organelle seems unlikely enough to exclude). The current picture is summarized in For S. cerevisiae. Their assay was based on engineering the URA3 gene, which is involved in uracil biosynthesis, from the nuclear genome to a plasmid that is maintained in the mitochondrion. During the propagation of such yeast strains carrying a nuclear ura3 mutation, plasmid DNA that escapes from the mitochondrion to the nucleus complements the uracil biosynthetic defect, restoring growth in the absence of uracil, an easily scored phenotype. The rate of DNA transfer from the mitochondria to the nucleus was estimated as 2×10−5 per cell per generation URA3 gene carrying its own promoter was located on a plasmid, that experimental system only measured relocation of mtDNA into the nucleus and did not measure integration of the plasmid or mtDNA into the chromosome. In addition, it only measured the transport of the entire URA3 gene, while shorter or other mitochondrial fragments went undetected. In a different experimental setup, mtDNA fragments joined to linear DNAs to form circular DNA plasmids. The integration frequency was suggested to be as high as 10−3 to 10−4, or that 1 in every 1,000–10,000 yeast cells might contain a new mitochondrial insertion Thorsness and Fox yme  mutations, lead to an elevated rate of mtDNA escape to the nucleus yme mutants have protein products that are mitochondrion-associated, and it has been suggested that perturbation in mitochondrial functions due to the alteration of gene products affect mitochondrial integrity, leading to mtDNA escape. In the case of the yme1 strain, abnormal mitochondria are targeted for degradation by the vacuole, and this degradation increases mtDNA escape to the nucleus Increased rates of yeast mtDNA escape are observed in different conditions, including in cells that have been frozen and thawed, in cells that were grown in non-optimal temperature, and, when environment favors fermentation, as primary energy source. In addition, mutations in at least 12 nuclear loci called the The appearance of large mitochondrial segments within nuclear genomes including large fragments of non-coding regions numt integration sites, Blanchard and Schmidt numts are inserted into double-strand breaks (DSBs) by the non-homologous end joining (NHEJ) machinery. This was later borne out in an important study on yeast under conditions where homologous recombination was not possible numt integration Based on numt, and these junctions reflect the repair events at each end of the original chromosomal break  always involve small deletions and even in NHEJ reaction with filler DNA the frequency of deletions is significantly bigger  numt losses using a multiple genome alignment when an outgroup is present.Deletion of sertions  and casenumt frequency (at least in species where multiple copies of mitochondria exist), the finding that numt content is strongly correlated with genome size points to the participation of two mechanistically independent processes: integration into the nuclear chromosome and post-insertional processes.Barring a role for differential mtDNA escape into the nucleus as a limiting factor in lineage-specific numts are captured in DSBs, then numts would be predicted to appear more often in bigger genomes than in smaller ones (but at a roughly constant per Mb rate). If true, then numts should be more common in genomic regions that are prone to DSBs. For example, transcription itself can increase DSBs and genome instability numts in introns versus intergenic regions numt frequency should be higher in regions known to be associated with genome instability as in fragile sites, cells that undergo radiation, and in cancer cells.Integration now appears to implicate DSBs. DSBs can arise spontaneously during growth or can be induced by external stimuli such as radiation. Reactive oxygen species (ROS) arising in the mitochondria can also cause nuclear DNA damage numt content is the previously detected negative correlation between DNA loss and genome size Drosophila and Laupala, which vary 11-fold in their DNA content Arabidopsis involves large deletions while DSBR of the tobacco genome, which is 20-fold larger, is associated with insertions numts might show similar patterns; animal genomes with more non-coding nuclear DNA would be expected to have more numts, while ones with less non-coding DNA will tend to lose them. In other words, this mechanism simply entails a genome-wide tendency to lose DNA in small genomes, such that the numt frequency would be independent of DSB frequency, in which case numt frequency might be expected to correlate with noncoding DNA amount.Another possible explanation for the correlation between genome size and Over longer evolutionary timeframes, with DNA continuously being transferred from organelles to the nucleus, one might wonder why any DNA has remained in the organelles at all. The reasons for this have to do with the essential bioenergetic function of the organelle numts that were inserted specifically in the human lineage are polymorphic for the presence versus absence of the insertion among human populations  of those ulations . Of cournumts segregate in populations at frequencies that are consistent with neutral, deleterious, or beneficial effects? While there are good reasons to assume neutrality numts, as well as the potentially beneficial role that numts play in DSBR, indicate that the spectrum of numt mutational effects may be broad. More studies on polymorphism for numts in human genomes should provide incisive clues. With the sequencing of 1,000 human genomes—and 1,000 Drosophila, 1,000 Arabidopsis, and many more after that—the data to test many ideas about the evolutionary dynamics of numts are not far away.Future challenges will include gaining a fuller understanding of post-insertion processes at the population genetic level. For example, do numts can tell us about the history of the species and which populations or subspecies must have had historically overlapping biogeographic distributions. Neanderthal's numts and a scan for Neanderthal mtDNA in a broad sample of human nuclear genome sequences might be an interesting undertaking. An additional fascinating aspect especially in humans, is that polymorphic numts potentially provide much more information than just another segregating marker numt insertion can tell us which nuclear genotypes and which mitochondrial haplotypes coexisted within the same germline at the particular point in time during which the numt was inserted. As such, they offer the opportunity, so far unexplored, to associate nuclear markers with mitochondrial markers back in time and thus to tie mitochondrial with nuclear genome evolution. While recombination within the nuclear genome might put a limit on the detectablility of such associations for numts inserted during the early phases of human evolution, this could still potentially represent a rich source of information about human history and admixture to be gleaned from the 1,000 human genome data, and similar endeavours, when it becomes available.A particularly interesting aspect is that