FTO and obesity was first described in a GWAS for type 2 diabetes FTO has since become one of the most solidly confirmed risk factor for polygenic obesity in humans; yet, information about how FTO affects metabolism is still scarce. Bioinformatic analyses suggest FTO codes for a Fe(II)- and 2-oxoglutarate–dependent nucleic acid demethylase Genome-wide association studies (GWAS) are a laborious but powerful tool to identify genetic risk factors associated with complex polygenic traits such as obesity Fto is either eliminated Fto in energy metabolism but are inconsistent as to whether Fto modulates caloric intake, energy expenditure, or both. In 2009, global lack of Fto was reported to result in a lean phenotype as a consequence of increased energy expenditure Fto causes perinatal lethality and growth retardation, which may give rise to secondary effects that are unrelated to the mechanism by which variation in FTO affects human metabolism Fto (367F) show no signs of perinatal lethality or growth retardation; they are lean, exhibit normal food intake and, when normalized by body weight, show increased energy expenditure Fto are obese, hyperphagic, and exhibit normal energy expenditure when corrected for body fat or lean tissue mass FTO alleles are associated with increased food intake, but not energy expenditure  mice. An important step in solving these questions has now been taken by Roger Cox and colleagues. In the current issue of PLOS Genetics, McMurray et al. In summary, despite intense scientific discussion about whether Fto primarily affects energy expenditure or food intake Fto leads to perinatal lethality, growth retardation, and a lower body weight that is accompanied by decreased body fat and lean tissue mass. However, in contrast to previous reports, the authors convincingly show that there is no difference in energy expenditure when the data are interpreted correctly, i.e., using a regression approach that takes into account potential confounding by differences in lean body mass. Several review articles have recently highlighted this issue Fto ko mice, whereas the ratio between CO2 production and O2 consumption  was decreased, suggesting that Fto ablation promotes protein and/or fat utilization.In their manuscript, the authors recapitulate that germline loss of Fto at the time of sexual maturity. These adult onset Fto ko mice showed no increased lethality or growth retardation but had a lower body weight accompanied by a decreased lean mass and, interestingly, an increased body fat mass. No changes were observed in energy expenditure or total food intake, but, similar to the germline Fto ko, RER decreased in adult onset Fto ko mice, an effect also noted in a recent human study To circumvent the challenge of perinatal lethality and growth retardation, McMurray et al. used tamoxifen-inducible ubiquitin-cre mice to delete Fto deletion was recently reported to recapitulate the phenotype of the germline Fto ko mice Fto in the mediobasal hypothalamus (MBH). Interestingly, these adult onset hypothalamic Fto ko mice showed no change in total body weight or body composition compared to sham controls but displayed a slightly decreased body weight gain that was accompanied by decreased food intake without any change in energy expenditure or RER. Taken together, these data indicate that although perturbation of Fto signaling in the MBH can impact food intake, sites other than the hypothalamus may be more important for Fto's influence on body composition and energy homeostasis.As central nervous system (CNS)-specific In summary, Cox and colleagues with their current publication have made several important contributions that allow for a better understanding and potentially improved targeting of Fto signaling in the control of energy homeostasis. The authors make a convincing case that Fto may not directly affect energy expenditure in mice, thereby also shedding some light on a complex methodological question. The authors furthermore show that adult, rather than perinatal, loss of Fto is well tolerated, enabling the analysis of Fto effects without the confounding factors associated with perinatal lethality or growth retardation. The authors also show that lack of Fto in the hypothalamus explains only a small part of the phenotype observed in the global Fto ko mice, indicating that Fto promotes its biological effects through other, non-hypothalamic pathways. Finally, the observation that RER is decreased in the germline and adult onset Fto ko mice points to a role of Fto in regulating peripheral metabolism and substrate utilization. The current paper by Cox and colleagues along with the other studies reviewed here highlight both the considerable challenges of, and the need for, careful and often time-consuming functional studies before the value of GWAS candidate genes can be truly appreciated.


The association between attachment and mental health symptoms in adolescents in a post-conflict low resource setting has not been documented.We investigated the relationship between parent and peer attachment and posttraumatic stress, depression and anxiety symptoms in a sample of 551 adolescents aged 13–21 years old. Attachment quality was assessed using the Inventory of Parent and Peer Attachment (IPPA). Post-traumatic stress, depression and anxiety symptoms were assessed using the Impact of Events Scale Revised (IESR) and Hopkins Symptom Checklist for Adolescents (HSCL-37A) respectively. Gender differences in attachment relationships were determined using independent t-tests. Multivariate logistic regression was used to assess whether attachment relationships were independently associated with posttraumatic stress, depression and anxiety symptoms. Hierarchical linear regression analyses were conducted to explore the moderating role of war-related trauma.Our analyses revealed gender differences in attachment to parents, with males reporting stronger attachment than females. Parental attachment was protective against depression and anxiety symptoms but not posttraumatic stress symptoms after adjusting for potential confounders. Alienation by parents was independently associated with an increase in these mental health symptoms while peer attachment was not associated with any of these symptoms. However, in situations of severe trauma, our analyses showed that peer attachment was significantly protective against post-traumatic stress symptoms.Secure parental attachment is associated with better psychosocial adjustment in adolescents affected by war. Further, adolescents with secure peer attachment relationships in situations of severe war trauma may be less likely to develop posttraumatic stress symptoms. Interventions to enhance peer support in this post conflict setting would benefit this vulnerable population. There is worldwide recognition of adolescence as a period of rapid significant transformation in all aspects of functioning. Changes in psychosocial function include increasing reliance on peers for intimacy and social support and decreasing time spent with parents For example, the brutal civil war between the Ugandan Government forces and the Lord's Resistance Army (LRA) rebels over a twenty year period targeted children and adolescents who were forcefully abducted and forced to commit atrocities Early research focused primarily on the effect of war-related factors including internal displacement, abduction, death of loved ones and loss of property on mental health. Subsequent research has emphasized the importance of identifying explanatory mechanisms and protective factors, such as social support, resilience, coping and attachment style The extant research shows that females are more attached to their peers than males; whereas males are more attached to parents than females Stressful events have been found to moderate the relationship between attachment and mental health outcomes in a few empirical researches In this paper, first, we explore gender differences in attachment relationships. Second, we assess whether attachment relationships were independently associated with post-traumatic stress, depression and anxiety symptoms. Lastly, we explore the moderating role of war-related trauma in the association between attachment and mental health symptoms. We hypothesize that 1) there would be gender differences in attachment relationships, 2) that secure attachment (defined as high scores of attachment) would be significantly protective against mental health symptoms and 3) stressful war events would moderate the association between attachment and mental health symptoms.This study was approved by the Ethics Committee at the faculty of Psychology and Educational Sciences of Ghent, Gulu University Research Ethics Committee, and the Uganda National Council of Science and Technology. Permission and informed written consent was obtained from all head teachers of participating secondary schools. On the day of the interviews, research assistants explained the purpose of the study (which had been previously explained in writing to parents when we obtained written permission from each head teacher) to each head teacher and adolescents saying that the study was trying to understand adolescents' experiences during the war and their effects. Because of the difficulty of obtaining written informed consent from each parent, the approved procedure for obtaining consent was such that head teachers consented on behalf of adolescents whose parents did not return the written information leaflets, indicating no objection to the study and their child's participation. No parent returned the leaflets and no head teacher declined to consent. The IRBs specifically reviewed and approved this method of consent/assent. Study participants less than 18 years old provided oral assent and those 18 years old and above provided informed written consent. Those who declined or withdrew participation were not required to give reasons. Study participants were given pens as a gift for participation and opportunities for support and referral for mental health services were available to all participants.Study participants were school-going adolescents recruited from seven out of fourteen government and private-operated secondary schools in Gulu district situated in Northern Uganda. Prior to 2006, the district had been the epicenter of over 20 years of armed conflict between the Ugandan Government and the LRA rebel group. Of the 14 schools in Gulu Municipality, we contacted seven schools, with additionally stratification by single/mixed-sex schools. The seven schools were selected for three reasons: 1) they had a representative number of private and public schools with a large number of enrollments, 2)students' characteristics were comparable to all students in the Gulu municipality area, and 3) the school head teachers were willing to participate in the study. All students from the second and third year of secondary school were included in the sampling frame, because we hoped to follow-up participants before they completed secondary education from their respective schools.Study data were collected between August and September 2010. We compiled age-specific class lists in the selected schools and consecutively recruited 13–21 year olds. The eligibility criteria required participants to be in their second or third year of secondary education, aged between 13 and 21 years and had the ability to comprehend study procedures and provide informed consent/assent. Research assistants reviewed the study questionnaires with local mental health staff and teachers and pretested with non-participating students to ensure local validity. Research assistants distributed study questionnaires to students who were present in class on a given day and were eligible to participate in the study. All questionnaires were anonymous and self-administered in English, the official language used in all Ugandan schools. Participants completed their questionnaires in class during regular school hours, with the help of trained research assistants. The entire set of questionnaires took approximately an hour for the participants to complete. Finally, the convenience sample consisted of 600 students from the two classes, and 551 of them completed their questionnaires.A standardized socio-demographic questionnaire was used to obtain study participants' age, gender, ethnicity, living situation, marital status of parents and whether their parents were still alive or not.Past childhood adverse events were assessed using the Adverse Childhood Exposure (ACE) questionnaire War-related trauma was measured using a locally developed Stressful War Events (SWE) questionnaire. This 17-item questionnaire was designed specifically for war-affected adolescents in this region, and included questions referring to a specific war-related traumatic event, such as “Did you experience living in an internally displaced persons' camp?”Post-traumatic stress symptoms were assessed using the Impact of Event Scale–Revised (IES-R) Depression and anxiety symptoms were assessed using the Hopkins Symptom Checklist-37 for Adolescents (HSCL-37A) The quality of parental and peer attachment in adolescence was assessed using the Inventory of Parent and Peer Attachment almost always or always true), 2(sometimes true) and 1 For brevity, and consistent with Gullone et al., the response scale was simplified to a three-point Likert scale of 3 completed the questionnaires. The mean age of the study participants was 16 .7(SD = 1.34); age range 13 years to 21 years. The mean number of traumatic events experienced was 6.5(SD = 3.8) with a range of 0 to 17. Detailed baseline characteristics of the study population are presented in Using simple logistic regression models, we found that there were significant gender differences with regard to maternal and paternal attachment . Males rAlienation by mothers was independently associated with an increase in depression  and anxiety  but not post-traumatic stress symptoms  while alienation by fathers was independently associated with an increase in depression  anxiety  and post-traumatic stress symptoms . Alienation by peers was not associated with any of these symptoms. Interestingly, trustful peer relationships were protective against depression symptoms  while communication with peers was associated with more posttraumatic stress symptoms .The present study aimed to examine the association between attachment and mental health symptoms and to explore the moderating role of war-related trauma in this relationship. We found three major findings. First, there were gender differences in attachment. Overall, males were more attached to their fathers and mothers than females, consistent with findings among non-trauma samples Second, in keeping with our hypothesis, secure parental attachment was protective against both depression and anxiety symptoms. Contrary to the hypothesis, parental attachment was not associated with PTSD symptoms and peer attachment was not associated with any of the mental health symptoms. Specifically, the protective role of secure parental attachment against depression and anxiety symptoms is in keeping with what other studies, although executed in different contexts such as high-income and non-war-affected countries, have found It has been suggested that secure attachment, especially during adolescence may serve as a buffering system in the developmental stage of many internal and external pressures Peer attachment was not protective against any mental health symptoms in our study sample. This finding is consistent with that of other researchers who have found a more robust protective effect of parental attachment than peer attachment against mental health symptoms Lastly, in contrast to our hypothesis, war-related trauma did not moderate the association between parental attachment and any of the mental health symptoms but it moderated the association between peer attachment and PTSD symptoms. Specifically, peer attachment was significantly protective against PTSD symptoms in situations of severe trauma. This finding contradicts previous studies in which severe trauma was reported to diminish positive peer relationships in which feelings of safety and togetherness are created We note that war-related trauma did not moderate the relationship between parental attachment and mental health. Regardless of the level of war-related trauma, parental attachment remained protective against depression and anxiety symptoms. Possible explanations for this could be that the adolescents and their parents maintain strong attachment bonds irrespective of the severity of trauma, thus countering the effect of the stresses the adolescents may face. It is unclear why war-related trauma would significantly moderate the association between peer attachment and PTSD symptoms but not others.These study findings should be viewed within the context of the following study limitations. First, all measures were based on retrospective self-report data, subject to recall and social desirability biases. Second, because we did not measure postwar stressors, we cannot rule out the influence of unmeasured aspects of the current psychosocial environment on the relation between attachment and mental health symptoms. Third, the sample was limited to school-going adolescents, affecting generalizability. Fourth, the study was cross-sectional, making it impossible to conclude a causal or temporal relationship between attachment and mental health symptoms. Fifth, our measure of attachment may not have captured certain aspects of the attachment relationship unique to the African ethnocultural setting, including whether the attachment indices were socially relevant, given that attachment as a concept is understudied in the African context Despite the above mentioned limitations, this study is the first to contribute to the scientific literature on attachment relationships and psychopathology in adolescents in a post-conflict low resource setting. Understanding the role of moderating influences is important for identifying individual differences in the influence of attachment on mental health and for targeting interventions that will hopefully improve mental health outcomes throughout the life span. Additional research is needed to develop more clearly the theoretical model concerning the relationships among war trauma, attachment, and psychosocial outcomes. In particular, there is a need to better understand the mechanism(s) through which attachment may serve as a protective factor against the negative effects of war-related trauma.In conclusion, secure parental attachments are associated with better psychosocial adjustment in adolescents affected by war. Further, adolescents with secure peer attachment relationships in situations of severe war trauma may be less likely to develop posttraumatic stress symptoms. Interventions to enhance peer support in this post-conflict setting would benefit this vulnerable population.


Multiple sclerosis (MS) is a complicated disease characterized by heterogeneous pathology that varies across individuals. Accurate identification and quantification of pathological changes may facilitate a better understanding of disease pathogenesis and progression and help identify novel therapies for MS patients. Texture analysis evaluates interpixel relationships that generate characteristic organizational patterns in an image, many of which are beyond the ability of visual perception. Given its promise detecting subtle structural alterations texture analysis may be an attractive means to evaluate disease activity and evolution. It may also become a new tool to assess therapeutic efficacy if technique issues are resolved and pathological correlates are further confirmed. This paper describes the concept, strategies, and considerations of MRI texture analysis; summarizes applications of texture analysis in MS as a measure of tissue integrity and its clinical relevance; then discusses potentially future directions of texture analysis in MS. Multiple Sclerosis (MS) is characterized by heterogeneous histopathology including inflammatory infiltrates, demyelination, remyelination, axonal damage, and gliosis . ConsequStructural abnormalities that appear regular may be extracted by visual inspection while complex patterns of pathology that are commonly encountered in medical images are difficult to interpret and require the employment of advanced analysis techniques . As an eTexture analysis is an image postprocessing approach that extracts quantitative information from a digital image based on mathematical analysis: it can be applied to any image and is used in fields as diverse as medicine and geology –8 Figur. A two-dNumerous strategies have been proposed for the examination of image texture. Depending on the particular method used to assess interpixel relationships, a variety of dedicated texture features can be derived. Both statistical and spatial frequency-based approaches are used preferably in neurological imaging applications including MS, which are described below . Note thThis approach attempts to characterize image texture using statistical parameters. First-order statistics  provides a global assessment of pixel distribution and is relatively intuitive and self-explaining. Second- or higher-order statistics characterizes local texture properties in an image which is based primarily on the cooccurrence matrix (GLCM)  and run-d  apart along a given direction   . FourteeThe RLM method , 10 quanPixel patterns that create a unique texture in an image also generate a unique frequency distribution at the spatial scale of the pattern. Specifically, fast changing gray level values represent high frequency content. Conversely, low frequencies relate to slow changing or no change gray-level values . IdeallyA few advanced transforms have been developed trying to characterize localized frequencies specific to each pixel location. One of the versatile approaches is the wavelet transform (WT) which characterizes multiscale frequency content  at each spatial location of an image . This flWhile texture analysis is potentially a new tool to identify subtle structural changes in a tissue, there are concerns regarding its robustness to the variations in imaging protocol and MRI scanner. In theory, differences in acquisition parameters, imaging sequences, and the homogeneity of radio-frequency (RF) field cause alterations in pixel arrangements and therefore MRI texture. This potential limit is drawing much attention and has partially confounded the clinical use of texture analysis. On the other hand, few recent studies argued that MRI texture analysis is relatively tolerant to the imaging variables and support further investigation –18.Mayerhoefer et al.  assessedThe robustness of texture analysis seems to be indicated by these investigations. However, the impact of imaging factors was assessed based on the accuracy of texture-associated classifiers. While it is a popular approach in computer-assisted diagnosis, the classification step may have complicated the evaluation process and added difficulty for interpretation. Direct comparison of texture characteristics may be helpful in the future to clarify this issue. Furthermore, it has not been fully investigated whether texture measures are portable between imaging centers; some researchers , 20 suggWhile pathologically different, the activity of many MS lesions cannot be distinguished on conventional MRI based on their appearances. Using a texture-based segmentation approach, Yu et al.  examinedDespite the dominance of multifocal pathology, diffuse abnormalities are observed in the normal appearing white matter (NAWM) and gray matter (NAGM) of MS patients . RecentlGreat potential of texture analysis has also been demonstrated using spectral features derived from the PST. In a longitudinal study, Y. Zhang et al.  analyzedThe demonstration of clinical relevance is important for a potential imaging measure as part of the validation process. Mathias et al.  performeIn a more recent study, Loizou et al.  assessedIt is hypothesized that pathological processes induce ultrastructural changes on the nanometer to micrometer scale, which manifest as pixel pattern changes on the millimeter scale of MR images. While it is not validated in human subjects, pathological correlates of texture analysis has been demonstrated in animal models of MS. Y. Zhang et al.  analyzedGiven its potential as a sensitive measure of tissue integrity and the clinical relevance, MRI texture analysis may be used to evaluate treatment impact in both overt MS lesions and in the disease prone NAWM. In this way, an integrated picture of therapeutic efficacy can be obtained beyond the detectability of lesion number and volume. In a feasibility study of 5 RRMS patients with active lesions, Y. Zhang et al.  investigMRI texture analysis demonstrates great potential in the study of MS. As an image processing strategy, texture analysis shows promise to extract clinically meaningful information from routine conventional MRI. Given its clinical relevance, texture analysis may be an attractive means to characterize disease activity and progression. However, the robustness of texture analysis to imaging protocols must be clarified before a significant clinical effect can be established. Furthermore, despite the promising outcomes in animal models, pathological correlates of texture analysis are subject to confirmation in MS subjects, whereby the role of texture analysis can be further tested as a potential tool of evaluating treatment benefits for MS patients.


The default mode network has been hypothesized based on the observation that specific regions of the brain are consistently activated during the resting state and deactivated during engagement with task. The primary nodes of this network, which typically include the precuneus/posterior cingulate, the medial frontal and lateral parietal cortices, are thought to be involved in introspective and social cognitive functions. Interestingly, this same network has been shown to be selectively impaired during epileptic seizures associated with loss of consciousness. Using a wide range of neuroimaging and electrophysiological modalities, decreased activity in the default mode network has been confirmed during complex partial, generalized tonic-clonic, and absence seizures. In this review we will discuss these three seizure types and will focus on possible mechanisms by which decreased default mode network activity occurs. Although the specific mechanisms of onset and propagation differ considerably across these seizure types, we propose that the resulting loss of consciousness in all three types of seizures is due to active inhibition of subcortical arousal systems that normally maintain default mode network activity in the awake state. Further, we suggest that these findings support a general “network inhibition hypothesis”, by which active inhibition of arousal systems by seizures in certain cortical regions leads to cortical deactivation in other cortical areas. This may represent a push-pull mechanism similar to that seen operating between cortical networks under normal conditions.


Lung cancer is the leading cause of cancer deaths worldwide. microRNAs (miRNAs) are a class of small non-coding RNA species that have been implicated in the control of many fundamental cellular and physiological processes such as cellular differentiation, proliferation, apoptosis, and stem cell maintenance. Some miRNAs have been categorized as “oncomiRs” as opposed to “tumor suppressor miRs.” This review focuses on the role of miRNAs in the lung cancer carcinogenesis and their potential as diagnostic, prognostic, or predictive markers. Lung cancer is the most common invasive cancer and cause of cancer death worldwide  – have been detected and described. miRNAs are usually 18–25 nucleotides long. Depending on the degree of homology to their 3′UTR target sequence, miRNAs induce translational repression or degradation of mRNAs Figure . miRNAs In this review the focus will be on the state-of-the-art knowledge currently available on the clinical significance of miRNAs in lung carcinogenesis and their role as diagnostic, prognostic, and predictive markers in lung cancer.Several studies have identified an important role of miRNAs in the regulation of the cell cycle and carcinogenesis in different organs, including the lung  are known to be highly expressed in normal tissues and downregulated in different types of cancer, including neuroblastoma, sarcoma, glioma, high-risk chronic lymphatic leukemia (CLL), invasive breast cancer, cholangiocarcinoma, and lung cancer  is considered a key regulator of tumor angiogenesis Semenza, . The polRetinoblastoma 1 (Rb1) was the first identified tumor suppressor. Overexpression of miR-192 inhibited cell proliferation in A549, H460, and 95D lung cancer cells by decreasing Rb1 mRNA and protein expression  are expressed at higher levels in the circulating exosomes of NSCLC patients compared to healthy donors . In a recent study miRNA expression in tumor and non-cancerous tissue pairs collected from stage I-III lung squamous cell carcinoma patients treated with neoadjuvant chemotherapy or radiotherapy were analyzed  that were prognostic predictors. Reduced expression of miR-146b was found to be associated with a reduced overall survival in patients undergoing radical surgery for squamous cell carcinoma of the lung  and overall survival (p = 0.039). In another study we extracted total RNA from 18 tissue samples of lung adenocarcinoma and also from non-cancerous tissue from the same patients . Using the median tumor level as cut-off, tumor miR-381 expression significantly correlated with event-free survival (p = 0.003) and overall survival (p = 0.02).In our own study, we extracted total RNA from tumors and matched non-cancerous lung tissue from 23 cases with a pathological diagnosis of lung adenocarcinoma  and the introduction of new therapeutics directly targeting these molecular changes  have changed the therapeutic strategies in lung cancer treatment. Therefore, higher interest in understanding sensitivity and resistance mechanisms toward these new therapeutic approaches is a consequence of this development. Higher expression of miR-126 enhanced cytotoxicity induced by gefitinib in lung cancer cells  is a member of the TNF family that can induce apoptosis in several types of cancer, including lung cancer (Schaefer et al., The role of miRNA expression related to irradiation has been investigated by several groups. A549 cells, which contain lower let-7 levels and higher activated RAS had significant changes in miRNAs as early as 2 h after irradiation (Weidhaas et al., In conclusion, despite a large negative study on the predictive role of miRNAs signatures in NSCLC further studies are warranted on the basis of several preclinical data. As shown in various studies miRNA can modulate the response of lung cancer cells to EGFR TKIs by interacting with the respective signaling pathway. Confirmation of their predictive role in larger clinical trials is needed.Since their discovery in the 1990s miRNAs have increasingly been recognized as key player in carcinogenesis and cancer progression, but also as potential diagnostic markers and biomarkers. In this overview more insights in the involvement of miRNAs in lung carcinogenesis as well as in their role as diagnostic, prognostic, and predictive biomarkers have been summarized. The current evidence on the prognostic and predictive role of miRNAs is at least partially inconsistent. Therefore, prospective trials evaluating the role of miRNAs described to have prognostic or predictive impact in small retrospective analysis should be planned. For this, standardized protocols for the isolation and the analysis of expression levels of miRNAs are needed.For the future, miRNAs from body fluids, especially the blood plasma might be the center of attention. As discussed, numerous studies have identified aberrant miRNA expression profiles in lung cancer. Therefore, miRNAs can potentially be used as biomarkers in the diagnosis and classification of lung cancer. Moreover, miRNA expression levels in blood plasma may be used as a non-invasive confirmatory screening test complementary to the low-dose helical CT screening in the near future.Another interesting research field is the use of miRNAs as therapeutic agents. The miRNA replacement or the anti-miRNAs will possibly become a new strategy for lung cancer therapy. At the moment several challenges have to be resolved before miRNAs could be investigated in clinical trials. One of the main problems is to find a suitable non-toxic delivery system capable of selectively transporting miRNA-based therapeutics to the tumor site. As discussed in the introduction, one single miRNA is able to target more than 100 mRNAs. It is therefore highly questionable if miRNAs as therapeutic tools could be of sufficient specificity.In conclusion, current knowledge on miRNAs in lung cancer has extended our understanding of lung cancer carcinogenesis and provides health care professionals with a new and innovative cancer biomarker. Beside preclinical research, there are several clinical trials evaluating the role of miRNAs as prognostic and/or predictive biomarkers ongoing.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


ABCC6 on chromosome 16 are responsible for the disease. The pathophysiology is incompletely understood. However, there is consent that a metabolic alteration leads to dysfunction in extracellular calcium homeostasis and subsequent calcification of connective tissues rich in elastic fibers. This review summarizes and aims at explaining the variety of phenotypic ocular findings in patients with PXE. Specialized imaging techniques including white light fundus photography, blue light autofluorescence, near-infrared confocal reflectance imaging, high resolution optical coherence tomography, fluorescein and indocyanine green (ICG) angiography have revealed characteristic lesions at the ocular fundus of PXE patients. These include the classic signs of angioid streaks, peau d’orange, comet lesions, and choroidal neovascularizations (CNVs), but also the more recently recognized features such as chorioretinal atrophy, subretinal fluid independent from CNV, pattern dystrophy-like changes, debris accumulation under the retinal pigment epithelium, reticular drusen and a decreased fluorescence on late phase ICG angiography.Pseudoxanthoma elasticum (PXE) is an inherited multi-system disorder characterized by ectopic mineralization and fragmentation of elastic fibers in the skin, the elastic laminae of blood vessels and Bruch’s membrane in the eye. Biallelic mutations in the ATP-binding cassette (ABC) transporter gene  The latter may lead to subretinal choroidal neovascularization (CNV) with a risk for spontaneous hemorrhage and scar formation with subsequent loss of vision. In addition, comets and comet tail lesions in the midperiphery with a variable degree of RPE atrophy represent a unique sign of the condition  and/or development and growth of angioid streaks . This pattern may be observed at the posterior pole very early in the disease and more peripheral in later disease stages. In the latter case, the slightly whitish or opaque fundus reflex may have become more uniform posteriorly to the area of peau d’orange. Peripheral to the peau d’orange region, the fundus reflex is usually darker . The difference between the central and peripheral fundus reflex is more obvious in dark pigmented patients in whom the higher overall fundus pigmentation contrasts better with the more posteriorly located whitish areas. It may remain unnoticed in less pigmented individuals as well as in very late disease stages .Peau d’orange often is assumed to be most pronounced and widespread in the temporal midperiphery. However, there is good evidence that this characteristic fundus finding simply is the most prominent manifestation of a transition zone that in actual fact is present circumferentially, though not symmetrically .Angioid streaks, which are breaks in BM, are the most obvious and most consistently observed funduscopic finding in patients with in PXE  reflectance imaging was found to be superior to other imaging modalities  to documAlthough other ocular diseases such as high myopia and ocular trauma may also lead to breaks in BM, the pattern of break formation is different in those diseases . While mAngioid streaks are not necessarily associated with a noticeable decrease in retinal function, and visual acuity may remain normal even in presence of a streak crossing the fovea. Angioid streaks may occur with or without overt damage to the RPE . ProbablFigures 3D, and 4J) are observed as solitary, subretinal, nodular, white bodies with a tapering white tail extending posteriorly of the comet body pointing toward the optic disk. The body may have some pigmentation at its margin. Sometimes a spray of comets and comet tails can be observed, creating an aspect of “comet rain.” Comets and comet tails are found in the (mid)periphery of the fundus and are the only PXE-related finding that may occur peripheral to peau d’orange . Often, CNV in PXE are classic membranes . Occasionally, eccentric CNV may remain unnoticed due to its lower impact on visual function. Before the development of a scar, CNV is the only ocular PXE complication that is currently eligible for treatment. Intravitreal inhibitors of vascular endothelial growth factor (VEGF) are currently most effective in the attempt to prevent or limit fibrovascular scar formation with consequent visual loss  was also described to occur in patients with angioid streaks . PCV mayFigures 4F and 7) are frequently observed in patients with PXE varying between 10%  – a process which, however, has not been well characterized yet. It may initially be observed as patches of atrophy mostly between or along the major vascular arcades, frequently originating within areas of pattern dystrophy. During the subseqent course of the disease, such lesions may grow and – if initially multifocal – become confluent.Chorioretinal atrophy may develop secondary to CNVs, usually surrounding a fibrovascular scar. Atrophy can also occur in the absence of CNV  seem to be more common in PXE patients than in the general population. The reported prevalence ranges from 6–8% (Optic nerve head (ONH) drusen . On OCT, the calcification of BM may appear as increased reflectivity, and the transition zone from calcified to un-calcified areas correlates well with peau d’orange . Angioid streaks have consistently been found to be associated with breaks in BM . There may be differences with regards to the width of the gap, presence or absence of fibrovascular tissue extending through the breaks , and alterations or preservations of the overlying RPE layer  in a subset of patients .Spectral domain OCT has also revealed presence of subretinal fluid in the absence of CNV  and monitor treatment efficacy of intravitreal VEGF inhibition. This is of particular importance because it may be difficult in patients with PXE to distinguish between low-grade leakage, which would mean CNV activity, and staining on fluorescein angiography. However, at late stages, atrophic lesions may occur with or without intraretinal cysts , which sometimes makes it difficult to distinguish between atrophic retinal cystic alterations and true leakage on OCT, too.In daily practice, SD-OCT is a very efficient means to identify neovascular leakage  and, despite the importance of novel techniques such as SD-OCT, still remains the gold standard for detecting and documenting leakage from a CNV in patients with angioid streaks.Fluorescein angiography highlights several features of PXE . In the latter, angioid streaks usually are hyperfluorescent within the area of reduced late phase ICG-fluorescence (see below). Outside this area, they may also appear hypofluorescent or invisible in some cases.Indocyanine green angiography uses NIR light for excitation of the chromophore, which is superior to fluorescein angiography in detecting abnormalities under the RPE. ICG differs from fluorescein amongst others in terms of its much more extensive blood-protein binding, and its limited vascular leakage. ICG angiography is capable to outline angioid streaks much better than fluorescein angiography in the majority of cases . AngioidFigures 4 and 5). There are no related obvious alterations on fundus photography, early phase ICG angiography, or fundus AF. Notably, the spotted pattern of peau d’orange is located more eccentric. It was hypothesized that the reduced late phase fluorescence may be due to BM calcification or a dysfunctional RPE . Comets – and to a lesser extent their tails – typically show a hyperautofluorescent signal. Not all comets can be detected individually on AF imaging . Thus, fundus AF is useful as a non-invasive tool to monitor progression of RPE changes, including chorioretinal atrophy.Fundus AF illustrates RPE atrophy as areas of hypo-autofluorescence, which are often more extensive than the areas of atrophy seen on funduscopy .With NIR reflectance imaging, angioid streaks appear as uniform, well-demarcated dark fissures against a lighter background, even when they remain unnoticed on color imaging . However, those own preliminary observations have not yet been investigated systematically.Recently, confocal NIR reflectance imaging has been shown to be highly sensitive for detecting reticular drusen in patients with age-related macular degeneration. Calcification of Bruch membrane due to PXE also seems to predispose to the development of reticular drusen  syndrome (GGCX (The term  disease , Paget’s disease , congenisyndrome , and mutme (GGCX . The ocuAngioid streaks, the most obvious feature of PXE-related fundus abnormalities, are almost always observed in patients with PXE. The second strongest association appears to be with hemoglobinopathies, including beta-thalassemia and sickle cell disease. Paget’s disease of the bone has been reported to be associated with angioid streaks in 1.4–14%  and peauPseudoxanthoma elasticum may be regarded as a model disease in which calcification of BM leads to a number of secondary effects at the ocular fundus. Of those, the development of CNV is the most vision threatening complication. However, novel therapies using intravitreally applied VEGF inhibitors appear successful in preserving vision over several years . Thus, oThe authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


PLoS Genetics, Blitzblau et al. Meiosis reduces the ploidy of the genome to generate haploid gametes for sexual reproduction. As gametes are portals for the generational transfer of genetic material, it is imperative that the genome is copied accurately and that chromosomes segregate equally into each haploid gamete. Proper chromosome segregation requires the formation of specialized chromosome axes to create and maintain an environment competent for double-strand break (DSB) formation and homologous recombination. Although the fundamental copying mechanism appears to be identical in mitosis and meiosis, the S phase that precedes meiosis (meiS) is at least twice as long as mitotic S phase (mitS) To compare mitS and meiS, Blitzblau et al. performed genome-wide chromatin immunoprecipitation (ChIP) to identify Mcm replicative helicase binding sites in conjunction with microarray analysis to monitor actively replicating origins. Importantly, synchrony was achieved by taking advantage of an ATP analog–sensitive mutant of Ime2, a kinase essential for DNA replication and meiotic entry, allowing for conditional inactivation. The authors found that Mcm bound to a significant fraction of the same origins in both mitosis and meiosis; the few that differed were located near cycle-specific, actively transcribed genes, consistent with studies suggesting competition between replication and transcription machinery Blitzblau et al. identified early meiS replication sites by analyzing replication in the presence of the ribonucleotide reductase inhibitor hydroxyurea (HU), which depletes nucleotide pools and prevents late origins from firing In the course of these experiments, the authors found that meiS is more sensitive to HU and has more robust checkpoint signaling than mitS. To explore whether this is a consequence of reduced nucleotide pools, Blitzblau et al. treated meiotic cells with HU in the absence of ribonucleotide reductase inhibitor SML1 rec8Δ) or in cells that do not induce DSBs (spo11Δ). No significant differences between the replication profiles were observed, suggesting that loading of meiosis-specific proteins and break formation do not regulate meiotic replication timing.It has been proposed that meiS is slowed to facilitate the elaboration of meiosis-specific chromosomal structures and DSB formation  [5]. Blicdc6 mutant was competent for DSB formation, indicating that breaks can occur on unreplicated chromosomes. This is in contrast to a previous study that found that delaying replication delayed break formation cdc6 mutants.To test whether DNA synthesis, in turn, affected axis and DSB formation, the authors examined the association of meiosis-specific axis components (Red1 and Hop1) following replication arrest by HU, depletion of Mcm loading factor Cdc6, or in the absence of B-type cyclins. In all situations, axis proteins were loaded onto chromosomes, suggesting replication is not an absolute prerequisite for axis formation. Blitzblau et al. also found that the S. cerevisiae there is reduced replication capacity during meiS, at least in part due to limiting nucleotide pools. This manifests as delayed firing of a significant fraction of origins and extended S phase; a similar pattern of origin firing has been observed in S. pombeThe current study provides strong evidence that in While the authors conclusively demonstrate that chromosomal axis and DSB formation can occur in the absence of DNA replication and do not directly impinge on replication timing, these processes are nonetheless linked and occur successively in wild-type cells . Thus th


It has been over 10 years since the Institute of Medicine (IOM) re-ignited the patient safety movement in the United States with their publication ‘To Err is Human’. Five years after that publication there were modest improvements in certain indicators like death in low mortality Diagnosis Related Groups (DRGs), iatrogenic pneumothorax, and certain postoperative complications. At that time there was actually worsening in the rates of hospital acquired decubitus ulcers and postoperative deep vein thromboses and pulmonary emboli , and RobJournal of Community Hospital Internal Medicine Perspectives there are reports on specific systems to improve patient safety. The systems cover hypoglycemia, antibiotic stewardship, and hand hygeine. These systems are being implemented in community-based hospitals just as they are in university-associated teaching hospitals. They have the potential to save lives by transforming even average hospitals into what Amalberti et al. have termed ‘highly reliable organizations’  to identify patient risks and avoid errors. It is not hard to see that systems are more reliable than individuals in maintaining vigilance and prevent errors from reaching patients.c.difficile infected patients save hospital days and save lives in any environment. Strong medication reconciliation practices clearly reduce adverse events, prevent re-admissions, and make post-hospital care more effective. Disciplined standardized hand off systems streamline care and avoid adverse events related to pain control, drug interactions, use of medications to which the patient is allergic, anticoagulation medication related errors, and others. These systems do not require a medical school to implement. Any community-based hospital with a commitment to patient care that is safe, effective, efficient, timely, patient-centered, and equitable can implement these steps.The achievement of safe medical care and the creation of a highly reliable organization do not have to depend on the size or governance of an institution. Relatively small projects like the incorporation of a ventilator bundle can reduce the incidence of ventilator-associated pneumonia and reduce the overall utilization of intensive care resources in a community hospital environment . A compr


TP53 tumour suppressor gene. Sufferers are prone to early onset cancers, particularly sarcomas, adrenocortical carcinoma and breast cancer. Cells from LFS sufferers are known to exhibit telomere dysfunction, genomic instability and spontaneous immortalisation. It is hypothesized that these facets of the LFS host are evidence that the host environment is “primed” for carcinogenesis over and above the lack of p53 tumour suppressor function. Further, it is hypothesized that the host presents an ideal environment for "two compartment tumour metabolism" to take place. Evidence from recent studies supports this new view of LFS and suggests that disrupting certain features of the host environment may markedly reduce the incidence of cancer in LFS sufferers.Li Fraumeni Syndrome (LFS) is a rare autosomal dominant hereditary cancer syndrome characterized by germline mutations in the  TP53 tumour suppressor gene. The syndrome is associated with a range of cancers, particularly sarcomas, gliomas, adrenocortical and breast carcinomas as well as other malignancies, particularly during childhood and early adulthood [Li Fraumeni Syndrome (LFS) is a rare autosomal dominant hereditary cancer syndrome characterized by germline mutations in the dulthood ,2. Amongdulthood ,5.The “two compartment tumour metabolism” hypothesis is a new paradigm that describes a metabolic shuttle between autophagic cells in the tumour stroma and tumour cells ,7. The hAt the heart of this relationship between tumour cells and the surrounding stromal tissues is the autophagic response to oxidative stress . Recent In this paper we present the novel hypothesis that many of the features of the "two compartment" model of cancer, including accelerated host aging, are present in the non-cancerous LFS host, and that people with LFS are therefore "primed" for cancer development over and above a simple loss of p53 tumour suppressor function. Evidence for the hypothesis is reviewed, and the clinical implications discussed.biological aging independent of chronological age [Telomeres are regions of nucleotide sequences that cap the ends of each chromosome and serve to protect the chromosome from recombination or degradation. Successive cell division leads to a shortening of telomere lengths, a process that can lead to chromosomal instability and which is associated both with aging and the pathology of a number of diseases, including cancer. In many respects telomere length can be seen as an indicator of ical age -14. Crucical age .Clinical evidence exists that LFS patients have shorter telomeres than age-matched non-LFS individuals . In otheAnalysis of non-malignant fibroblasts and other cells derived from LFS patients has shown that they display unusual patterns of senescence and that some of them are able to undergo spontaneous immortalisation in vitro. Where control fibroblasts from skin biopsies undergo senescence in the normal way in cultures, some of the fibroblasts from a number of LFS patients enter a long period of growth slowdown and replicative senescence during which they alter morphology, suffer chromosomal damage, including aneuploidy and telomeric association, followed by escape from senescence and the resumption of cell division and replication.It should be noted that spontaneous immortalisation of human fibroblasts almost never occurs in cultures from non-LFS patients ,21. FurtEscape from senescence is often associated with the over-expression of telomerase reverse transcriptase (TERT), the enzyme complex that re-synthesizes the telomere ‘caps’ at the end of the chromosome. Increased expression of telomerase is common to many cancers, conversely this enzyme is absent from non-transformed cells . Some tiThis cell-type specific difference is important in that it is a possible factor in the patterns of cancer incidence in LFS. Breast cancer in LFS affected women is the most common form of the disease, occurring in about 50% of female TP53 mutation carriers . Site specific escape from senescence might also explain the prevalence of bone and soft tissue sarcomas, adrenocortical carcinoma and other forms of cancer that are rare in the general population but common in LFS.This differential rate of immortalisation and senescence also leads to a situation where small populations of immortalized epithelial cells, subject to mutation and chromosomal change, are surrounded by populations of cells with reduced telomere lengths and already in senescence or becoming senescent in response to oxidative stress Figure . In the TP53-induced glycolysis regulator (TIGAR) [p53 also plays a role in cellular homeostasis, metabolism and in how cells respond to nutrient deficiency, hypoxia and other stresses. p53 can up regulate oxidative phosphorylation (OXPHOS) by inducing the synthesis of cytochrome c oxidase (SCO2) and down-regulate glycolysis through activation of  (TIGAR) -27.Activated cancer associated fibroblasts undergo transition to an autophagic state according to the “two compartment” hypothesis. Mechanistically, one of the drivers of this transition is an increased rate of oxidative stress due to secreted reactive oxygen species from adjacent cancer cells . There iAnalysis of the redox parameters in blood samples of healthy LFS patients compared to non-carriers of TP53 mutations found that the LFS mutation carriers had significantly increased indicators of oxidative stress, including a four-fold increase in plasma malondialdehyde levels, indicating increased lipid peroxidation . This isCaveolin-1 (cav-1) is the principal structural component of caveolae, plasma membrane invaginations that participate in diverse cellular activities and are abundant in many cell types. Cav-1 regulates critical cell functions including proliferation, apoptosis, cell differentiation, and transcytosis via diverse signalling pathways. Cav-1 knock-out (KO) mice are an established animal model of premature aging, exhibiting shorter life-span, increased glucose tolerance, insulin resistance and other age-related conditions. Additionally cav-1 KO mice show increased oxidative stress and mitochondrial dysfunction, which are also markers of accelerated host aging .A key hallmark of Lisanti’s “two compartment” theory is a loss of stromal cav-1 and a corresponding up-regulation of cav-1 in tumour cells (i.e. the effects of cav-1 are compartment-specific) . Loss ofA recent study by Sherif and Sultan analysed cav-1 expression in non-cancerous LFS fibroblasts and reported that affected family members showed an 88% down-regulation of cav-1 compared to non-affected family members . This neWe have outlined a number of important characteristics of the “two compartment” model and have shown how these exist in the non-cancerous LFS host, as shown in Table Our hypothesis predicts that disrupting the “priming” of the host environment will reduce cancer initiation and progression in LFS sufferers and can be tested by undertaking specific interventions. Specifically, there are three possible targets:• inhibiting senescence in stromal cells• inducing autophagy in malignant cells/inhibiting autophagy in stromal cells• interrupting the metabolic shuttle between stromal fibroblasts and tumour cellsThese three targets alter the host environment in such a way as to disrupt the “priming” towards the two compartment model, and in theory would markedly reduce the risk of developing cancer in LFS sufferers. A number of important results already suggest that these mechanisms can make a significant impact on cancer risk for LFS sufferers.Komarova and colleagues showed that the mTOR inhibitor rapamycin, which is known to inhibit cellular senescence, increased lifespan and decreased the incidence of spontaneous tumours in p53 +/− mice . The effWhile inhibiting senescence is one possible means of interrupting this metabolic shuttle, another possible mechanism is to induce autophagy in the tumour compartment. The “two compartment” model shows that activated stromal fibroblasts respond to the oxidative stress generated by tumours by becoming autophagic and switching metabolism to aerobic glycolysis, which generates high-energy fuels that can drive the growth of tumour cells ,8. HowevFinally, the hypothesis suggests that carcinogenesis and disease progression in LFS is sensitive to the metabolic state of cancer associated fibroblasts and adjacent tumour cells. Mutant p53 is stabilised by increased glucose supply, and high levels of mutant p53 act as an inhibitor of autophagy in cancer cells . ReducinAnother prediction of the hypothesis is, therefore, that cancer incidence in LFS can be reduced by restriction of the supply of glucose. Options for altering the availability of glucose include dietetic alterations or pharmacological interventions. Supporting evidence for a metabolic influence in LFS carcinogenesis is provided by work on p53 +/− mice, which showed that calorie restriction in adult animals delayed the development of cancer .Chief among the pharmacological interventions is the use of the anti-diabetic drug metformin, already in clinical trials in combination with standard chemotherapy agents. Metformin is known to target many of the pathways affected by dietary caloric restriction, including AMPK, mTOR and IGFR . In the In LFS cancer initiation is more likely than in the general population and may be triggered by the genetic instability that results from shortened telomere lengths, which may be exacerbated by high basal levels of oxidative stress, and by a lack of functional p53. Once cancer is initiated the host environment is already in a state where stromal fibroblasts respond to tumour cells by becoming activated and moving into a state of autophagy, mitophagy and switching metabolism to aerobic glycolysis, thereby feeding the tumour cells with the high energy by-products of this form of metabolism. In short, cancer in LFS patients rapidly moves to a state of “two compartment” tumour metabolism.TP53. However, the "two compartment tumour metabolism" hypothesis and the additional data outlined above suggest that p53 loss in the stroma accelerates the process of their recruitment by immortalized epithelial cells to promote tumour formation. Thus malignancy in LFS is associated with cellular senescence in stromal cells in response to increased oxidative stress from epithelial cells, a process which may be regarded as a form of accelerated host aging [To date the common understanding has been that LFS patients are at greater risk of developing malignancies because of the accumulation of secondary mutations over and above the mutated st aging .TP53 function [The hypothesis outlined here is consistent with the patterns of cancer incidence in LFS affected families, for example, the tendency to early onset cancers of specific tissues, such as breast cancer or soft tissue or bone sarcomas, rather than an across the board tendency to all forms of cancer. In particular, it may shed light on the paradox that LFS patients do not show an increased incidence of cancers related to tobacco, environmental toxins or occupation, as would be expected if damaged DNA repair mechanisms were the primary outcome from loss of function . It may This shift in emphasis from a focus on accumulated DNA damage to cell-type interactions and accelerated aging has important therapeutic implications for LFS. Currently there are no cancer prevention strategies in place for LFS sufferers. Newly diagnosed patients are subject to varying levels of surveillance but are offered no practical steps to reduce the risk of developing malignancies other than bilateral risk reducing mastectomy in women. This imposes high levels of stress on patients and their families, particularly for parents of LFS children and in families with extensive cancer histories.The hypothesis outlined here opens the door to active chemo-preventative strategies in terms of autophagy inhibition, steps to reduce oxidative stress and so on. Drugs such as the anti-diabetic drug metformin, the autophagy inhibitor chloroquine and other agents with low toxicity, including anti-oxidants, may also be worthy of further investigation in LFS families.Research is also warranted to ascertain whether shorter telomere length, reduced cav-1 expression or increased oxidative stress have prognostic significance in LFS.The author declares that he has no competing interests.


It is well established that the tumor microenvironment plays a major role in the aggressive behavior of malignant solid tumors. Among cell types associated with tumor microenvironment, tumor-associated macrophages (TAMs) are the most influential for tumor progression. Breast cancer is characterized by having a large population of TAMs, and experimental models have exposed multiple mechanisms by which TAMs interact with and influence the surrounding tumor cells. The process of metastasis involves tumor cells gaining access to the tissue outside the immediate tumor environment and invading the confining extracellular matrix (ECM). Supporting this process, TAMs secrete proangiogenic factors such as VEGF to build a network of vessels that provide nutrition for tumor cells, but also function as channels of transport into the ECM. Additionally, TAMs release factors to decrease the local pro-inflammatory antitumor response, suppressing it and providing a means of escape of the tumor cells. Similarly, hypoxia in the tumor microenvironment stimulates macrophages to further produce VEGF and suppress the T-cell immune responses, thus, enhancing the evasion of tumor cells and ultimately metastasis. Given the multiple roles of TAMS in breast cancer progression and metastasis, therapies targeting these cells are in development and demonstrate promising results. IntroductionTumor-associated macrophagesTAMs and hypoxiaTAMs and angiogenesisTAMs and the tumor matrixTAMs and toll-like receptorsClinical applicationsConclusion1.Tumors of epithelial cell origin grow in a complex and dynamic stroma consisting of various cell types, matrix proteins and soluble factors. This microenvironment provides all the necessary stimuli for tumor viability, growth, and invasiveness. Essential components of this microenvironment are inflammatory cells and the pro-inflammatory cytokines they produce. The role of inflammation in cancer progression was first described by Virchow in 1867 . ProcessThe process of metastasis and invasiveness of tumor cells is complex and determines clinical outcomes of cancer patients. Many studies have identified a link between this process and some of the cellular elements in the tumor microenvironment. Cells in the tumor microenvironment secrete a wide array of products that modulate the behavior of tumor cells in a tumor-enhancing and tumor-suppressing fashion. Of these cells, macrophages have gained a considerable interest in recent years. Macrophages are the most abundant inflammatory cells in the solid tumor microenvironment, and in this review, we examined how macrophages enhance the invasiveness of breast cancer.2.et al, a meta-analysis showed that an increased macrophage density was associated with poor prognosis in more than 80% of breast cancer cases (Tumor-associated macrophages (TAMs) have been described in many solid tumors, including breast cancer. They make up a big proportion of the cellular elements in different tumors. In breast cancer, macrophages can constitute as much as 50% of the cell mass . Multipler cases .et al showed recently that stromal CCL2 is associated with recruitment of macrophages to the breast cancer stroma and plays a role in relapse-free survival  are an integral cellular component of the immune system. These cells play an important role in protection against intracellular pathogens and cancer cells by virtue of the type I immune response they activate. They are ‘primed’ by the cytokine INF-γ for activation either by tumor necrosis factor-α (TNF-α) or (and more importantly) by activation of toll-like receptors (TLRs) via exposure to microbes or microbial products such as bacterial LPS . Once acet al whereby M2 macrophages are divided into three sub-populations depending on the particular stimulus that activates them  in such tumors . Breast or areas . One expor areas ,25. Thisor areas .et al showed that TAMs express VEGF almost exclusively in perinecrotic and poorly vascularized areas in breast cancer  is one of the gene products increased by HIF-1α upregulation in hypoxic conditions. It was found that MIF is released by hypoxic macrophages . Recentlnditions . MIF's snditions ], which Together the above studies reveal that hypoxic conditions drive accumulation of TAMs in necrotic and poorly vascularized areas of breast cancer. Once in the tumor, the microenvironment influences macrophages to enhance the aggressive behavior of tumors. These hypoxia-mobilized pro-tumoral activities of TAMs may serve as potential targets for breast cancer therapy. By interfering at various levels prior to metastatic and invasive tumor activity the progression induced by macrophages may be reversed. For example, since radiation therapy is known to induce hypoxia in tumor beds, blocking VEGF or CCL2 could potentially stop the recruitment of macrophages to these hypoxic tumor areas and slow or stop tumor progression.4.et al found that there was a positive correlation between high mean vessel density and increased macrophage index in the tumor, as well as an inverse relationship between macrophage counts and relapse-free and overall survival , a key chemoattractant of macrophages, makes PyMT mice susceptible to mammary cancer. However, restoring CSF-1 showed that tumor-associated macrophages play a key role in fostering tumor angiogenesis which is an essential step in the tumor progression to malignancy . The growth of tumor cells locally and their ability to invade and metastasize depends partially on how they can get around this matrix as well as by how they can modulate it to help their evasion.TAMs produce several enzymes which can degrade the extracellular matrix (ECM). Such enzymes include several metalloproteinases  as well as urokinase-type plasminogen activator (uPA) that degrade the ECM . Dissoluet al revealed these structures and found that surrounding the tumor there is a dense ring of fibrillary collagen  which raises the question of whether there is a protective role for estradiol in women with breast cancer that would be lost in chemical/physiological menopause, that is mediated through TLRs and tumor-associated macrophages. If this is proven then targeting this pathway may confer protection from disease progression. Indeed, ERα may be related to the downregulation of certain TLRs in breast cancer (Toll-like receptors (TLRs) are a family of transmembrane receptors that recognize conserved molecular patterns of microbial origins. TLRs play an important role in tissue repair and their role in cancer progression is being more appreciated . In breativation . In a mon  is released from apoptotic cells and activates TLR 4 on dendritic cells, stimulating them to function as cross-presenters of antigens (MHC I), thus stimulating T-cell responses ,57.Mutation of TLR4 gene in humans was found to have an increased frequency of metastasis in breast cancer patients . The cou7.Research studying the malignant potential of transformed epithelial cells, such as mammary cells, showed that these cells acquire a malignant potential; however, this alone is not sufficient to render them able to grow and sustain tumor growth unless in a permissive environment . The breet al, trabectedin (Yondelis®) which is a novel antitumor agent of marine origin was found to affect differentiated macrophages as well as freshly isolated TAMs at effective therapeutic doses . Anti-VEGF antibodies such as bevacizumab, can stop this process of vasculogenesis that a tumor mass needs in order to sustain its viability. Additionally, therapies that target VEGF receptor 2 may decrease macrophage infiltration in the tumor microenvironment . This ca®) is of particular interest in the treatment of women with breast cancer. Not only does it prevent demineralization of bones from hormone manipulation therapy and decreases skeletal related events in metastatic breast cancer, but it also increases disease-free survival in young women when given early in the treatment have been reported  would be another way of targeting macrophages in the clinical setting. Activation of TLR-9 by ligands such as CpG-oligodeoxynucleotides has been used in an early clinical trial of lymphoma and non-small cell lung cancer. In an y tumors . Therefo8.The tumor microenvironment is rich in inflammatory cells and their products. Current research done indicates that among these cells, TAMs play a key role in breast cancer progression and invasiveness. Recruited by tumor cells, TAMs are preferentially molded to serve the need of the cancer cells in a pro-tumoral function instead of an anticancer role and as such, potentiate their malignant behavior. More research needs to be done in the field to understand the intricate relationship between macrophages and breast cancer in order to translate the findings into meaningful clinical trials of therapeutics with TAMs as a target.


Heavy drinking causes significant morbidity, premature mortality, and other social and economic burdens on society, prompting numerous prevention and treatment efforts to avoid or ameliorate the prevalence of heavy drinking and its consequences. However, the impact on public health of current selective  prevention and treatment strategies is unclear. Screening and brief counseling for at-risk drinkers in ambulatory primary care has the strongest evidence for efficacy, and some evidence indicates this approach is cost-effective and reduces excess morbidity and dysfunction. Widespread implementation of screening and brief counseling of nondependent heavy drinkers outside of the medical context has the potential to have a large public health impact. For people with functional dependence, no appropriate treatment and prevention approaches currently exist, although such strategies might be able to prevent or reduce the morbidity and other harmful consequences associated with the condition before its eventual natural resolution. For people with alcohol use disorders, particularly severe and recurrent dependence, treatment studies have shown improvement in the short term. However, there is no compelling evidence that treatment of alcohol use disorders has resulted in reductions in overall disease burden. More research is needed on ways to address functional alcohol dependence as well as severe and recurrent alcohol dependence. Heavy drinking takes a high toll on society. Other articles in this issue summarize the disease burden and economic cost to society attributable to alcohol use, which provide a powerful incentive to develop and implement ways to reduce them. The focus of this article is on the role of selective  prevention and treatment approaches for heavy drinkers and people with alcohol use disorders (AUDs) in reducing the burden associated with excessive alcohol use. As used here, selective, or clinical, prevention refers to strategies targeted at individuals at higher risk of experiencing adverse alcohol effects, such as screening and brief counseling of heavy drinkers in health care settings or internet-based screening and advice provided to college students. The term “treatment” refers to services for alcohol dependence provided by a professional, such as a counselor, social worker, nurse, psychologist, or physician. Community peer-led support groups such as Alcoholics Anonymous are considered to be distinct from professional treatment services, much like a diabetes support group would be distinguished from endocrinology services. The article focuses on the following three questions: (1) Can selective prevention and treatment reduce the disease burden attributable to heavy drinking? (2) Are some treatment approaches more cost-effective than others? (3) Do gaps exist in the current continuum of care? After addressing these issues, the review suggests research priorities to help close existing gaps and reduce the burden of disease.Screening and brief advice for at-risk  drinkers, commonly known as screening and brief intervention (SBI), is effective at reducing drinking for a year or more and in many studies also has been shown to reduce alcohol-related harms, such as motor-vehicle crashes and driving violations. Its efficacy is supported by numerous randomized controlled trials and multiple meta-analyses; as a result, the U.S. Prevention Task Force has listed it as a Type B recommendation for medical prevention services . The eviSBI also seems to be effective among select groups when delivered through internet-based or computerized applications. In particular, there is strong evidence that digital SBI can effectively reduce drinking and associated consequences among college students . It is nDespite the evidence supporting its effectiveness, SBI is not yet being implemented widely . WidesprThe specific technique is less important than other, mostly unidentified, factors associated with psychotherapy.Each approach works via different mechanisms but produces similar results on average, much like different antidepressants acting through different mechanisms produce similar outcomes in the treatment of depression.Professional treatment only has a small effect in determining outcome compared with other, nontreatment factors, such as social control , natural history of alcohol dependence, and the tendency to revert to usual levels of drinking following resolution of a crisis where drinking had peaked .Estimating the effectiveness and cost-effectiveness of treatment is more complex. Most reviews conclude that treatment is effective at reducing drinking and associated consequences. Multiple behavioral treatment approaches—such as cognitive– behavioral therapy, motivational enhancement therapy, 12-step facilitation, behavioral marital therapy, and community reinforcement—have similar and relatively high levels of short-term success in reducing drinking and associated consequences, at least when treatment is provided by the highly trained, motivated, and closely supervised clinicians participating in clinical efficacy trials . Why theThis last explanation is supported by recent research demonstrating that changes in drinking habits begin weeks before treatment entry . LikewisWhat is clear, however, is that researchers and clinicians do not yet understand how or why some people change in response to treatment and others do not. To address this issue, NIAAA led the way at the National Institutes of Health (NIH) in shifting the focus of behavioral treatment research to identifying the mechanisms of behavior change rather than encouraging more comparisons of different psychotherapy approaches . The NIHThe lack of clarity about what causes change in drinking behavior also results in uncertainty as to whether treatment of alcohol dependence reduces disease burden. The community prevalence of alcohol dependence, which is about 4 percent in any year, has not changed substantially in recent years . Earlier studies found a cost offset of treatment—that is, lower health care costs after treatment than before treatment . More reAnother limitation when estimating the effects of treatment on public health is that relatively few affected people seek treatment. For example, among people who develop alcohol dependence at some point in their lives only 12 percent seek treatment in a specialty treatment program . Among pDespite these limitations, some tentative conclusions can be drawn as to which approaches to treating alcohol dependence are more cost effective. Studies found no significant difference in outcomes between residential and outpatient treatment and no clear relationship between intensity of treatment and outcome . For exaThere are several gaps in the continuum of care that deserve attention, affecting drinkers across the spectrum of alcohol involvement. Recent epidemiological research has demonstrated that alcohol involvement varies along a continuum ranging from asymptomatic heavy drinking , through functional alcohol dependence, and to severe and recurrent alcohol dependence . The conThere currently are few services for at-risk drinkers and people with functional alcohol dependence. In primary medical care, very few patients are screened and positive screening results addressed . FurtherSBI in primary care settings to identify people with AUDs at the milder end of the severity spectrum is effective and may be cost-effective , but manBecause so many hospitalized heavy drinkers have dependence, SBI is much less effective in this group  and its People with functional alcohol dependence likely require more than brief counseling, but there is a major gap in research concerning optimal treatment strategies. Currently, few, if any, services are available for this group because they fall between at-risk drinkers and those with severe recurrent alcohol dependence . Pharmacotherapy  combined with medical management offers an attractive possible approach for this group, and evidence suggests that this combination yields comparable results to state-of-the-art counseling . Such anGaps in treatment also exist for people with severe recurrent alcohol dependence—the group that most people tend to think of when they think of “alcoholism.” A recent exhaustive report examining the current treatment system concluded that “Most of those who are providing addiction treatment are not medical professionals and are not equipped with the knowledge, skills or credentials necessary to provide the full range of evidence-based services to address addiction effectively,” (p. 3) and that “Addiction treatment facilities and programs are not adequately regulated or held accountable for providing treatment consistent with medical standards and proven treatment practices.” , pp. 3–4At this time no solid conclusions can be drawn as to whether current approaches to prevention of and treatment for AUDs reduce the disease burden attributable to heavy drinking, although these strategies have shown positive outcomes in the short term. SBI for at-risk drinkers in ambulatory primary care settings has the strongest evidence for efficacy, and some evidence supports its cost-effectiveness and associated reduction in excess morbidity and dysfunction. However, these benefits do not necessarily indicate that health care costs for these patients are reduced. Widespread implementation of SBI for nondependent heavy drinkers outside of the medical context has the potential to have a large public health impact. For heavy drinkers with more severe conditions , time-limited counseling may improve short-term recovery rates, but its long-term impact is less clear. Moreover, recent research findings have not been widely implemented. Scientifically based, medically anchored treatment approaches may provide a more attractive and cost-effective approach than the current intensive but time-limited treatment. More research is needed on ways to address functional alcohol dependence as well as severe and recurrent alcohol dependence.


MedImmune is the biologics business unit of AstraZeneca with a mission of helping patients with significant unmet medical need by developing innovative medicines. MedImmune has a rich pipeline across five therapeutic areas including oncology, respiratory, inflammatory and autoimmunity, infectious diseases, neurosciences, cardiovascular and gastrointestinal diseases. To realize our vision of personalized healthcare—treating the right patient with the right drug at the right dose, we are applying cutting edge tools such as next-gen sequencing, circulating tumor cells and advanced PK/PD modelling across the pipeline.Fundamental to our goal of developing personalized healthcare is gaining deep understanding of diseases across different populations and specifically in Asians. To this end, we have formed partnerships with Chinese academic institutions, government agencies and industry partners, and have a history of working with scientists/physicians in China to develop medications that target the Asian/Chinese patient population. For example, the AstraZeneca product IRESSA (gefitinib), is already frontline therapy in China for the treatment of patients with locally advanced or metastatic non-small cell lung cancer with an activating mutation in the EGFR gene.Most recently we set up an exciting collaboration with the Shanghai Chest and Renji Hospitals to develop a richly annotated database of lung cancer and hepatocellular cancer patient samples to aid in identifying novel drug targets and developing therapeutic strategies to aid patients. This presentation will provide examples in our pipeline that give us reasons to believe in such approaches, e.g. a type I interferon gene signature for an anti-IFN-alpha or anti-IFNAR monoclonal antibody in patients with systemic lupus erythematosus.MedImmune is committed to helping Chinese patients with significant unmet medical need and we believe collaborations with leading Chinese PIs and innovation are key to our mission.


Drawing upon the ideas of context reinstatement and multiple trace theory, we argue that memory retrieval is driven by internal and/or external factors which recreate these frequency-specific oscillatory patterns which occur during episodic encoding. These ideas are synthesized into a novel model of episodic memory  that provides several testable predictions for future research.The spectral fingerprint hypothesis, which posits that different frequencies of oscillations underlie different cognitive operations, provides one account for how interactions between brain regions support perceptual and attentive processes . Here, w Human episodic memory, the storage, and retrieval of experienced events, is a hallmark of our daily experience. While several factors influence the accuracy of memory retrieval, including the availability of relevant cues, one particularly well-studied factor is similarities between encoding and retrieval. Specifically, memory retrieval is facilitated when it occurs in the original encoding environment , an effeThe hippocampus is a brain region critical to episodic memory  and is tThese core behavioral and neural findings regarding overlap between context and neural patterns of activity between encoding and retrieval, however, leave a fundamental issue unresolved – how are specific cell assemblies formed during encoding selectively reactivated during retrieval via neocortical sensory traces? Two mechanisms utilizing the phase of oscillatory brain activity, cross-frequency coupling and phase synchronization (PS), are hypothesized to underlie these processes. First, the phase of low-frequency activity often modulates the amplitude of high-frequency activity, known as cross-frequency coupling . MTT argues that the hippocampus is constitutively necessary for memory retrieval by providing the spatial contextual information for a specific memory episode . FurtherWe also found evidence for spectral fingerprints in memory retrieval. More specifically, retrieving spatial versus temporal information led to frequency-specific changes in low-frequency PS. Spatial retrieval was characterized by delta-band synchronization and temporal retrieval was characterized by theta-band synchronization, raising the possibility of frequency multiplexing in episodic memory. This finding has led us to explore, from a mechanistic perspective, how spectral fingerprints could be implemented in episodic memory encoding and retrieval. Here, we extend the notion of spectral fingerprints in episodic memory by arguing that frequency-specific oscillations not only act as a medium for inter-regional interaction but also represent part of the episodic engram itself.Figure 1), including synaptic and neuronal resonance  or perceptual features results in spatially distributed patterns of high-gamma oscillatory power  coupled There is also evidence that spatially distributed patterns of phase form part of the content of a stimulus representation. Recoding from monkey frontal and parietal cortices during a working memory paradigm, Gamma activity in turn appears to be related, at least in some cases, to neuronal firing rate  but see Decades of work have established that the hippocampus is necessary for episodic memory encoding  and receMemory encoding requires the formation of arbitrary associations amongst different types of information. These include items, such as who or what, and contexts, such as when or where. Memory models suggest that the hippocampus may be important for the associational, or “binding,” of these disparate types of information , each ofLow-frequency oscillatory activity can dictate the form of synaptic potentiation that is induced, with long term potentiation (LTP) occurring more under conditions of theta activity  and whenSeveral animal studies have found low-frequency phase-locking of single neurons relative to local and distant oscillatory activity relates to visual working memory and/or memory encoding . ComplemAdditional mechanisms exist for the promotion of specific phase relations amongst neuronal ensembles. Phase entrainment  and/or pin vitro while concurrently mimicking an extracellular field via stimulation. The authors found that extracellular fields (particularly below 8 Hz) can phase entrain single neurons and coordinate spiking activity of groups of neurons in the absence of synaptic activity. These results suggest two important inferences. First, ephaptic coupling may provide a mechanism for the hippocampus to coordinate neocortical activity in the absence of structural connectivity, particularly in light of the fact that the hippocampus does not heavily project directly to neocortical areas  creating a positive feedback loop between resonance and plasticity to promote frequency-specific cell assemblies via Hebbian plasticity. Extending the notion of Hebbian plasticity, we therefore suggest that neurons that resonate together may also operate together in functional cell assemblies.These studies have been taken as evidence that hippocampal neurons act as stimulus dependent matched filters which can adaptively alter their frequency response to match the frequency of their inputs . While ain vivo, these studies indicate that frequency-specificity also occurs at the synaptic level of organization in neural circuits over short time scales. Future work employing computational modeling will be necessary to determine how resonance and plasticity interact under conditions of memory encoding and retrieval.Consistent with this idea, computational modeling work indicates that network resonance may even develop in networks of neurons which are not intrinsically resonant . Moreoveh  potentially contribute to variability in oscillatory frequency patterns. The relative contribution of each factor to frequency variability has yet to be fully explored and warrants further investigation. For our purposes, the key point is that frequency-specific memory-related cell assemblies may arise from numerous intrinsic and extrinsic sources contributing to variability in oscillatory brain activity. We argue that the brain may harness this variability in service of episodic memory encoding such that an engram is also manifest in content specific oscillatory brain states.We have synthesized studies across multiple levels of analysis and species, developing an emerging picture of how the hippocampal-neocortical system encodes and retrieves information. The encoding of a novel experience, such as meeting up with an old friend in a new city, is likely to differentially benefit from hippocampal “binding” of arbitrary associations. The encoding of novel experience, in particular, appears to drive hippocampal activity , with inAt the assembly level, hippocampal association of items in context is accompanied by theta-gamma CFC  to inducThe central claim presented here is that frequency-specific patterns of oscillatory activity that occur during encoding are reinstated during memory retrieval. Accordingly, there is evidence for increased CFC  and PS  during mSeveral lines of evidence suggest that the hippocampus may orchestrate the selection of specific cell assemblies during retrieval  by promoThe demonstration of IRFs and similar findings during motor tasks , 2012 prFigure 2) of episodic memory:Drawing upon the ideas of context reinstatement, spectral fingerprints and multiplexing, MTT, and internal receptive fields, we propose the following model ((1) The rhythmic external world and/or rhythmic sensory sampling (active sensing) impose rhythmicity onto sensory inputs. Phase entrainment and phase resetting serve as mechanisms for rhythmic inputs to arrive during periods of heightened local excitability.(2) Rhythmic inputs act as a frequency and phase specific spectral context during encoding and selectively drive synapses and neurons with similar resonant properties. Neurons that resonate together will also operate together in functional cell assemblies.(3) Shared frequency preference amongst neurons, CFC, and PS contribute to the formation of a cellular assembly for a specific engram through Hebbian plasticity and STDP. This encoding process strengthens synaptic connections between neurons in the assembly and also modifies their resonance properties to match that of the assembly.(4) Reactivation of a cell assembly during retrieval is a hippocampally driven process whereby the hippocampus reinstates, largely based on contextual cues, the internal receptive field for a given cell assembly. This process is frequency multiplexed, allowing for the simultaneous reactivation of different assemblies operating at different preferred frequencies.Spectro-contextual encoding and retrieval theory makes several predictions for future research which can be tested using both correlative and causal methods. First, providing retrieval cues based on real-time detection of brain states should augment memory performance. For instance, presenting a retrieval cue during a window in which oscillatory phases match those present during item encoding should selectively facilitate memory performance for the item. This prediction should be testable in existing datasets.Second, SCERT predicts that neuronal ensembles that resonate together also operate together. Although difficult to test at the macroscopic level in humans at present, it is in principle possible to identify several single neurons in humans, identify their frequency and phase preference, and then determine how neurons with similar spectral preferences operate during behavior. Neurons that show multiple frequency and phase-preferences during different behaviors would also provide evidence for frequency multiplexing. Thus, a novel prediction here would be that ensembles representing different components of memory, if stimulated together at the same frequency, could induce novel memories. For example, if one could stimulate representations for “airplane” and “purple stripes” one could create a false memory of a novel purple-striped vehicle even though this had never been experienced before. Although there is evidence to suggest that stimulation can sometimes induce retrieval of remote memories , the verThere are additional predictions that can be made using causal stimulation methods. It should be possible to manipulate memory performance by experimentally controlling the frequencies under which memories are encoded and retrieved. This could be accomplished either by experimentally controlling the frequency of stimulus presentation or via electrical stimulation methods. For instance, stimulating the hippocampus via deep brain stimulation (DBS) during retrieval at a frequency introduced during encoding should facilitate retrieval by reactivating frequency-specific cortical traces. Thus, if recordings determine that a specific spatial context (say a scene) is encoded via 3–5 Hz synchronization between the hippocampus and specific ensembles within neocortex, stimulating the hippocampus in concert with these cortical nodes should enhance recollection of the scene and any previously encoded details with this scene. No studies to date have matched stimulation and recordings in the human brain and so this prediction remains novel and untested. Yet, it provides an important link between oscillatory coherence, cortical, and hippocampal cooperation.Conversely, we predict that inducing a mismatch between encoding and retrieval frequencies will impair memory retrieval by producing a spectral brain state that does not selectively drive the assembly at its preferred IRF. For example, if a scene were encoded via 3–5 Hz coherence between hippocampus and cortex, stimulating either hippocampus or cortex at this frequency, provided this simulation is out-of-phase with the on-going hippocampal activity, will impair contextual retrieval. During retrieval, a similar effect would result from stimulating at a high frequency that is inconsistent with the encoded frequency. In fact, studies using DBS in hippocampus suggest that stimulating the hippocampus at fast frequencies will disrupt encoding of pictures, which is possible if stimulation occurs out of phase with on-going cortical stimulation or at a different frequency all together from what would typically be induced in cortex . Thus, aFinally, episodic encoding should benefit from exogenously induced phase-synchronization between neocortical areas in patients with hippocampal damage or dysfunctional hippocampi. Specifically, inducing neocortical synchronization via methods such as transcranial magnetic stimulation (TMS) or transcranial alternating or direct current stimulation (tACS/tDCS) may facilitate encoding of neocortical memory traces, although these are likely to be more general and semantic in nature. These methods have been used previously to induce human cortical theta PS and causally modulate performance on a simple memory task . To the What are the broader mechanisms responsible for this assembly selection process? We suggest two possibilities to this yet unresolved question. Environmental cues may reactivate a subset of neurons in the cell assembly encoding a specific memory. For instance, seeing a picture of one’s high school prom date may activate neuronal populations or specific oscillatory patterns that represent the person. If neurons which resonate together also operate together, this process may ultimately drive activity in the larger, frequency-responsive assembly representing the entire prom experience. This speculative possibility warrants further studies. Second, in the absence of closely associated or rhythmic environmental cues, it may be possible for intrinsic brain dynamics or top-down processes to recreate oscillatory patterns from encoding via local generators of theta activity as discussed above. Given that many cues are not inherently rhythmic, some other source of rhythmicity may be at play, possibly top-down signals from associational cortical areas or active sensing processes ; these pOur model of memory encoding and retrieval raises a number of intriguing new questions for future research. First, how does sleep-related reactivation fit into our model? Does memory replay reinforce the spectral patterns which were originally present during encoding? Second, what are the constraining conditions for multiplexing in memory ? Third, Finally, unique patterns of oscillatory phase are almost always present in the brain. This activity may be capable of selectively driving assemblies with a specific internal receptive field . Why areIn summary, SCERT argues that memory encoding is subserved by synaptic and neuronal resonance, CFC, and PS such that frequency-specific oscillatory activity both forms cell assemblies and contributes to the episodic engram. We provide evidence that a range of factors, including synaptic and neuronal resonance, sensory, motor, and behavioral factors, contribute to frequency-specific oscillatory dynamics. Implementing the ideas of context reinstatement, we argue that retrieval occurs via the hippocampally driven reinstatement of an engram’s spectral signature, ultimately driving activity in spatially distributed cell assemblies that code for a specific experience.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.