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Many recent articles highlight the data revolution in healthcare, an offshoot of the vast amount of digital medical information that has now accumulated in electronic medical records (emrs), and present it as an opportunity to create a learning healthcare system. The generally proposed vision is for a population data - driven knowledge system that generalizes from every patient s life, disease and treatment experiences to impute the best course of action for diagnosis, prognosis and treatment of future patients . There have also been many articles focusing on the risk that nave use of big data (or data in general) poses . As stated by zak kohane of harvard medical school, big data in healthcare cannot be a simple, blind application of black - box techniques: you really need to know something about medicine . If statistics lie, then big data can lie in a very, very big way . This paper will discuss the general issue of data in critical care with a focus on the big data phenomenon that is sweeping healthcare . With the vast amount of digital medical information that has accumulated in emrs, the challenge is the transformation of the copious data into usable and useful medical knowledge . We are experiencing a rapidly expanding collection of vast amounts of clinical data from routine practice and ambulatory monitoring . Clinicians must already make sense of a diverse variety of data input streams in order to make clinical decisions . Data from our everyday activities (financial transactions, cellphone and internet use, social media posts), the environment, and even the local government promise to provide even more clinically relevant information (figure 1), but to what end? And how can increasing amounts of data be incorporated into a system of already overburdened clinicians?figure 1 where big data in healthcare come from (figure courtesy of yuan lai). Where big data in healthcare come from (figure courtesy of yuan lai). The bottom line is that pertinent quality data add tremendous value, which accounts for their unreasonable effectiveness. There is no way to minimize undesirable variability in practice without the data to substantiate the standardization . The volume and variety of increasingly available big data can allow us to interrogate clinical practice variation, personalize the risk - benefit score for every test and intervention, discover new knowledge to understand disease mechanisms, and optimize processes such as medical decision making, triage and resource allocation . Clinical data have been notorious for their variable interoperability and quality, but a holistic use of the massive data sources available (vital signs, clinical notes, laboratory results, treatments including medications and procedures) can lead to new perspectives on challenging problems . While the wetware of the human mind is a wonderful instrument for this purpose, we must design better data systems to support and improve those components of this data integration process that exceed human abilities . Decisions in the intensive care unit (icu) are frequently made in the setting of a high degree of uncertainty, and clinical staff may have only minutes or even seconds to make those decisions . The increasing need for intensive care has spiked the ratio of icu beds to hospital beds as the icu plays an expanding role in acute hospital care . But the value of many treatments and interventions in the icu is unproven, with many standard treatments being ineffective, minimally effective, questionably effective, or even harmful to the patient . In a setting where the effects of every intervention are subject to patient and clinical context - specific factors, the ability to use data for decision support becomes very attractive and closer to essential as increasing complexity transcends typical cognitive capabilities . An example of collected data being used to infer high - level information is the icu scoring systems in use today . Icu scoring systems, such as apache (acute physiology and chronic health evaluation), mpm (mortality probability model), and saps (simplified acute physiology score), are all based on the use of physiologic and other clinical data for severity adjustment (table 1). While these scores are primarily used to assess and compare icu performance (e. g., by examining the ratio of actual - to - predicted outcomes) they also have use as short - hand indicators of patient acuity . But scoring system value depends not only on the accuracy of the underlying data, but also on clinical trust in the reliability of the data and the predictions based on that data . In 2012, scoring systems were used in only 10% to 15% of us icus, despite demonstrated good discrimination and calibration .table 1 a comparison of intensive care unit (icu) scoring systems (from with permission) icu scoring system timing of data collected physiological values other required data total data elements required original reported mortality prediction performance saps iiiprior to and within 1 hour of icu admission10age, six chronic health variables, icu admission diagnosis, icu admission source, los prior to icu admission, emergency surgery, infection on admission, four variables for surgery type26auc = 84.8% (n = 16,784)apache ivfirst icu day (1632 h depending on time of admission)17age, six chronic health variables, icu admission diagnosis, icu admission source, los prior to icu admission, emergency surgery, thrombolytic therapy, fio2, mechanical ventilation32auc = 88.0% (n = 52,647)mpm0-iiiprior to and within 1 hour of icu admission3age, three chronic health variables, five acute diagnosis variables, admission type (e. g., medical - surgical) and emergency surgery, cpr within 1 h of icu admission, mechanical ventilation, code status16auc = 82.3% (n = 50,307)saps: simplified acute physiology score; mpm: mortality prediction model; apache: acute physiology and chronic health evaluation; auc: area under the curve; cpr: cardiopulmonary resuscitation; los: length of stay . A comparison of intensive care unit (icu) scoring systems (from with permission) saps: simplified acute physiology score; mpm: mortality prediction model; apache: acute physiology and chronic health evaluation; auc: area under the curve; cpr: cardiopulmonary resuscitation; los: length of stay . In practice, clinical prediction must be motivated by the needs of clinical staff, and this must be driven in large part by perceived utility and an increase in technical comfort amongst clinicians . Some of the biggest opportunities for big data to make practical gains quickly are focused on the most expensive parts of current clinical practice: reliable, predictive alerting and retrospective reporting analytics for high - cost patients, readmissions, triage, clinical decompensation, adverse events, and treatment optimization for diseases affecting multiple organ systems . Icu physicians have embraced the value of collecting and storing electronic clinical records, and this has led to partnerships between industrial and academic entities . For example, the commercial apache outcomes database has gathered partial physiologic and laboratory measurements from over 1 million patient records across 105 icus since 2010 . The philips eicu archives data from participating icus, and has collected an estimated database of over 1.5 million icu stays . As an ongoing provider, the eicu adds more than 400,000 patient records per year to its stores, and these data are also commercially available to selected researchers via the eicu research institute . In contrast to these commercial databases, the multiparameter intelligent monitoring in intensive care (mimic) database is open and publicly accessible (figure 2). Over the past decade, the mimic database has collected clinical data from over 60,000 stays in beth israel deaconess medical center icus, including clinical notes, physiological waveforms, laboratory measurements, and nurse - verified numerical data .figure 2 the mimic database . Ssa: social security administration (figure courtesy of the laboratory of computational physiology, massachusetts institute of technology). Ssa: social security administration (figure courtesy of the laboratory of computational physiology, massachusetts institute of technology). Medicine is ultimately based on knowledge, and each of the many ways to establish knowledge has certain advantages and pitfalls . Here, we focus on the randomized controlled trial (rct), observational studies and what we have termed dynamic clinical data mining (dcdm) (figure 3).figure 3 dynamic clinical data mining . Emr: electronic medical record (figure courtesy of kai - ou tang and edward moseley, from with permission). Emr: electronic medical record (figure courtesy of kai - ou tang and edward moseley, from with permission). Rcts are the gold - standard for clinical knowledge discovery . But 65 years after the first rct was published, only 1020% of medical decisions are based on rct - supported evidence . When examining the validity of a variety of medical interventions, about half of systematic reviews report insufficient evidence to support the intervention in question . The reality is that the exponential combinations of patients, conditions and treatments cannot be exhaustively explored by rcts due to the large cost of adding even small numbers of patients . Furthermore, the process of performing rcts often intentionally or inadvertently excludes groups of patients, such as those with particular co - morbidities or medications, or of certain ages or ethnic groups . Thus, when trying to make a real decision under practice conditions, the rct conclusions may simply not be applicable to the patient and situation in hand . This was the driver for the concept of dcdm in which the user of an emr would be automatically presented with prior interventions and outcomes of similar patients to support what would otherwise be a completely subjective decision (see below). These include the heterogeneity of treatment effect of red blood cell (rbc) transfusion, the impact of pre - admission selective serotonin reuptake inhibitors on mortality in the icu, the interplay between clinical notes and structured data on mortality prediction, optimization of heparin dosing to minimize the probability of over- and under - anticoagulation, long - term outcomes of minor troponin elevations in the icu and the association between serum magnesium and blood pressure in the critically ill, to name a few . But these observations may be specific to the beth israel deaconess medical center and need to be validated using databases from other institutions . Others have examined institution - specific databases, and these studies have yielded findings that have been translated into practice: a recent study at seattle children s compared a wide range of performance metrics and translated results into prioritized departmental and enterprise - wide improvements . Celi, zimolzak and stone described an operational vision for a digitally based, generalized decision support system that they termed dynamic clinical data mining . The proposed system aggregates individual patient electronic health data in the course of care; queries a universal, de - identified clinical database using modified search engine technology in real time; identifies prior cases of sufficient similarity as to be instructive to the case at hand; and populates the individual patient s emr with pertinent decision support material such as suggested interventions and prognosis, based on prior treatments and outcomes (figure 3). Some of the most clear - cut arguments for big data in healthcare are in conjunction with the formulation of fully digitized prevention and pharmacovigilance processes (figure 4). Clinicians of the future will have to work with user friendly versions of these tools to make timely and informed decisions about the drugs their patients are receiving . In a more general sense, clinicians will have to begin to consider an individual emr as only part of a patient s record with the remainder of the record consisting of the two - way relationship of the patient s emr with the entire population database . The essential starting point of the individual patient can be enhanced by the knowledge present in population - level databases, and the resulting information combinations and comparisons used to make informed clinical decisions . In turn, the information accumulated from individuals benefits the healthcare of the entire population.figure 4 clinical care optimization: a big data model for efficient targeting of tests and treatments and vigilance for adverse events (figure courtesy of kai - ou tang and edward moseley, from with permission). Clinical care optimization: a big data model for efficient targeting of tests and treatments and vigilance for adverse events (figure courtesy of kai - ou tang and edward moseley, from with permission). National pharmaceutical benefits manager, express scripts, can predict which patients may fail to take their medication 12 months in advance, with an accuracy rate of 98%; ibm is modifying their famed watson system (in tight collaboration with clinicians) for predicting different types of cancer . 23andme s database has already been used to find unknown genetic markers for parkinson s disease and myopia, and their acquisition of $1.3 million in national institute of health funding has shown additional confidence in their goals . More recently, the open data movement has been quietly sweeping almost every industry, including the specialized domain of healthcare . It calls for data sharing, and by its very nature, requires a degree of accountability as well as collaboration across disciplines never seen before . At the forefront of the open data movement in healthcare glaxosmithkline (gsk) announced that it would make detailed data from its clinical trials widely available to researchers outside its own walls, stunning the scientific community . For a company that spends $6.5 billion a year on research and development, it was a sharp turn away from a historic system of data secrecy . In may 2013, it then invited others to join clinicalstudydatarequest.com, where gsk and six other drug makers have already uploaded data from nearly 900 clinical trials . The following month, the medical device company, medtronic, teamed up with yale university and shared its clinical trials data through the yale university open access data (yoda) project . Other important trends in open data are crowdsourcing, data marathons and hackathons, which leverage several newly available phenomena . These include combining publically available, detailed, and de - identified emrs with crowdsourcing techniques and coordinated hackathons to capture, organize and integrate stakeholder user input from a necessary variety of input sources (figure 5). The traditional approach to knowledge discovery involves publication in peer - reviewed journals by a very circumscribed group of contributors . This process excluded a number of potentially valuable contributors, such as full time clinical physicians, nurses, medical trainees, and patients, among others.figure 5 beyond open big data: addressing unreliable research (figure courtesy of kai - ou tang). Beyond open big data: addressing unreliable research (figure courtesy of kai - ou tang). Hackathons are large - scale events that contemporaneously bring together (physically and/or by teleconferencing) large groups of qualified individuals to collectively contribute their expertise towards a common problem set . Crowdsourcing also focuses large groups of qualified individuals towards a common problem, but allows those individuals to do so asynchronously and in a mobile manner using phones, tablets, laptops and other devices to contribute from any location . With such tools, individual clinical encounters this amalgamation of individual knowledge should allow each clinician to address gaps in their knowledge, with the confidence that their decisions are supported by evidence in clinical practice . In january 2014, the inaugural critical data marathon and conference was held at the massachusetts institute of technology . In the data marathon, physicians, nurses and pharmacists were paired with data scientists and engineers, and encouraged to investigate a variety of clinical questions that arise in the icu . Over a 2-day period, more than 150 attendees began to answer questions, such as whether acetaminophen should be used to control fever in critically ill patients, and what the optimal blood pressure goal should be among patients with severe infection . This event fostered collaboration between clinicians and data scientists that will support ongoing research in the icu setting . The associated critical data conference addressed growing concerns that big data will only augment the problem of unreliable research . Thought leaders from academia, government and industry across disciplines including clinical medicine, computer science, public health, informatics, biomedical research, health technology, statistics and epidemiology gathered and discussed the pitfalls and challenges of big data in healthcare . The consensus seemed to be that success will require systematized and fully transparent data interrogation, where data and methods are freely shared among different groups of investigators addressing the same or similar questions . The added accuracy of the scientific findings is only one of the benefits of the systematization of the open data movement . Another will be the opportunity afforded to individuals of every educational level and area of expertise to contribute to science . From a broader analysis of big data, we can try to understand larger patterns by comparing the strength of many signals in large populations . There is a critical need for collaborative research amongst many groups that explore similar questions . The association between data sharing and increased citation rate, and an increasing commitment by companies, funding agencies and investigators to more widely share clinical research data point to the feasibility of this move . The prospect of using big data in an open environment may sound overwhelming, but there have been key steps to encourage this cultural transformation . For example, the centers for medicare and medicaid services (cms) have begun to share data with providers and states . As the largest single payer for health care in the united states, cms has used its vast store of data to track hospital readmission rates in the medicare program (importantly finding a rapid decline in readmission rates in 2012 and 2013), and combat medicare fraud (in its first year the system stopped, prevented, or identified an estimated $115 million in improper payments). As large amounts of shared data become available from different geographic and academic sources, there will be the additional benefit from the collection of data from sources with different viewpoints and biases . While individual researchers may not be aware of their own biases or assumptions that may impact reported results, shared exploration of big data provides us with an inherent sanity check that has been sorely lacking in many fields . In a recent analysis of data - driven healthcare by the mit technology review, the authors noted that medicine has entered its data age . Driven by the promise of an estimated $300 to $450 billion a year, companies of all sizes are beginning to fight in earnest to capture and tame the data explosion . Key innovations fall into three major areas: more and more data, especially resulting from mobile monitoring; better analytics using new machine learning and other techniques; and meaningful recommendations that focus on prediction, description, and prevention of poor health outcomes (that are finally captured in an easily accessible format). The mass of new data rests primarily in the proprietary hands of large entities like insurance companies and care providers . For example, the genomics company 23andme is famously creating a huge database of genomic data, moving from over 700,000 records towards their goal of tens of millions . Some countries with centralized healthcare systems like in addition, smaller companies like welldoc and ginger.io are beginning to focus on rampant cell - phone penetration to get into the health - data market . Mobile phones can now seamlessly acquire daily patient metrics on meals, exercise, call patterns and other behaviors; welldoc uses these data to recommend personalized insulin doses based on patients daily habits, and ginger.io monitors patients with mental illnesses for the kinds of actions that might indicate a need for help . Other companies provide physical attachments to mobile devices that enrich the possible data types available: cellscope sells an attachment to support remote otoscopy; alivecor provides electrocardiogram (ekg) signals; propeller health attaches to an inhaler to record pertinent data; and there are a slew of others for nearly every imaginable data need . But bigger data require better methods, and better machine learning techniques for clinical data have been a long time in coming . The most intuitive argument (that more data from which to learn cannot be worse, so must be better) is true: there have been empirical demonstrations that predictive models built from sparse, fine - grained data see marginal gains in predictive performance even to massive scale . But there is another less intuitive argument for bigger data: certain rare trends or behaviors simply may not be observed in sufficient numbers without employing big data . Dubbed the heavy tail of data, these rare behaviors are even more difficult to observe as we add more features to our datasets . Intuitively, we can think of datasets as a set of samples out of a larger space; for example, a circle inscribed within a square gets most of the area, leaving only the corners out . But as we move from inscribing a circle within a square, to inscribing a sphere within a cube, the ratio of space in the corners increases (figure 6). Repeat this to a higher dimension and most of the volume of the cube will be concentrated in its (many) corners . But it is these rare instances (sometimes appropriately referred to as corner cases) of behaviors or patient characteristics that machine learning cannot reliably analyze with historically available data sample sizes . The big data explosion is finally offering data at a scale large enough to overcome the risks of higher - dimensional spaces when working with healthcare data issues.figure 6 the data space and corner cases (figure courtesy of yuan lai). The data space and corner cases (figure courtesy of yuan lai). Along with big data s promise, there have been warnings of over confidence and disaster, labelled by lazer et al . As big data hubris the warning parable told to illustrate this is google s flu trends . In 2008, google launched its flu trends, which used the search terms typed into google to track the progression of influenza epidemics over time . However, this approach was subsequently revealed to have suffered from several known data analysis pitfalls (e. g., overfitting and concept drift) so that by 20122013, the prevalence of flu was being greatly overestimated . Other oft - cited risks include misleading conclusions derived from spurious associations in increasingly detailed data, and biased collection of data that may make derived hypotheses difficult to validate or generalize . But avoiding spurious conclusions from data analysis is not a challenge unique to big data . A 2012 nature review of cancer research found reproducibility of findings in only 11% of 53 published papers . There is concern that big data will only augment this noise, but using larger datasets actually tends to help with inflated significance, as the estimated effect sizes tend to be much smaller . If researchers have large amounts of data that severely oversample certain populations or conditions, their derived hypotheses can be incorrect or at least understandably difficult to validate . The way that current literature is designed, generated, and published creates sequential statistically significant discoveries from restricted datasets . It is not uncommon in the scientific literature to get a different story for a variable s (vitamin e, omega-3, coffee) relationship to outcome (mortality, alzheimer s, infant birth - weight) depending on what is adjusted for, or how a population was selected . There is little meaning to exploring the impact of one variable for one outcome: it is the big picture that is meaningful . The benefits of the data explosion far outweigh the risks for the careful researcher . As target populations subdivide along combinations of comorbid conditions and countless genetic polymorphisms, as diagnostic and monitoring device including wearable sensors become more ubiquitous, and as therapeutic options expand beyond the evaluation of individual interventions including drugs and procedures, it is clear that the traditional approach to knowledge discovery cannot scale to match the exponential growth of medical complexity . Rather than taking turns hyping and disparaging big data, we need organizations and researchers to create methods and processes that address some of our most pressing concerns, e. g., who is in charge of shared data, who owns clinical data, and how do we best combine heterogeneous and superficially non - interoperable data sources? We need to use big data in a different way than we have traditionally used data collaboratively . By creating a culture of transparency and reproducibility

Odorant binding proteins (obps) were identified almost three decades ago (vogt and riddiford 1981), but their roles in insect olfaction are still a matter of considerable debate . That obps are involved in odorant reception was disputed after odorant receptors (ors) were demonstrated to respond to semiochemicals when expressed in heterologous systems these expression systems, however, have limitations in addressing the role(s) of obps in olfaction . The heterologous expression system that uses drosophila empty neurons (dobritsa et al . 2003) includes surrogate obps, i.e., obps expressed in the ab3 sensilla, whereas in non - insect cell systems1 (forstner et al . 2009) odorants are solubilized with organic solvent or with the addition of recombinant obps . Thus, ultimately the role(s) of obps in insect olfaction must be addressed by examining insects with reduced levels (knockdowns) or devoid of a test obp (knockouts). In drosophila, analysis of a mutant defective for expression of an obp revealed that dmelobp76a (aka lush) is required for the activation of pheromone sensitive neurons by (e)-11-vaccenyl acetate and associated behavior (xu et al . 2005), but other insect species are not amenable to this type of genetic manipulation . Previously, we employed the empty neuron system of drosophila to express the pheromone receptor from the silkworm moth, bombyx mori, bmoror1 alone or co - expressed with a pheromone - binding protein, bmorpbp1 (syed et al ., we demonstrated clearly that pbps enhance the sensitivity of the insect olfactory system (syed et al . Recently, it was shown that addition of a recombinant pbp to a heterologous system that expresses a pheromone receptor from antheraea polyphemus increases both sensitivity and selectivity (forstner et al . 2009). Given that our previous attempts to knockdown pbp expression in the silkworm moth were unsuccessful (leal and ishida, unpublished data), we explored knocking down obp expression in mosquitoes . We then focused on cquiobp1, which is highly expressed in the antennae of the southern house mosquito culex pipiens quinquefasciatus (= cx . Recently, cquiobp1 was shown to bind a mosquito oviposition pheromone (mop) (laurence and pickett 1982) in a ph dependent manner and to be expressed in antennal sensilla sensitive to this pheromone (leal et al . 2008). In the present study, we used cquiobp1 as a target in rna interference (rnai) experiments to examine its function in the reception of oviposition attractants . Mosquitoes injected with double strand rna (dsrna) showed reduced levels of cquiobp1 transcripts as well as reduced antennal responses to mop, skatole, and indole when compared to water - injected controls interestingly, antennal response to nonanal, a major host cue detected with extremely high sensitivity by cx . These findings suggest that cquiobp1 is involved in the detection of multiple oviposition attractants and plays a key role in the sensitivity of the mosquito olfactory system . Cquiobp1 rna interference full - length cquiobp1 dsrna was synthesized by in vitro transcription from purified pcr product that contained t7 promoter sequences in inverted orientations and purified by using rneasy minelute cleanup kit (qiagen). Approximately 100 nl (350 ng) of dsrna were injected through the intersegmental thorax membranes into 1-to-48 h - old cx . Quinquefasciatus female mosquitoes with a microinjector system minj-1 (tritech research, los angeles, ca, usa). Dsrna - injected, water - injected, and non - injected mosquitoes were generated . Individual female heads were dissected in liquid nitrogen 4 d post - injection, rna from each head was extracted with rneasy mini kit (qiagen), and individual cdnas were synthesized from 0.1 g of rna using 100u superscript ii reverse transcriptase (invitrogen). Real - time quantitative pcr (qpcr) was carried out by using express sybr greener qpcr supermix universal (invitrogen) in a final volume of 20 l . Reactions were run with a standard cycling program, 50c for 2 min, 95c for 2 min, 40 cycles of 95c for 15 s, and 60c for 1 min, on an ab7300 real - time pcr system (applied biosystems). Cquiobp1 expression was normalized to the expression levels of an endogenous control, the ribosomal protein that encodes gene s7 (cquirps7). Relative quantification analysis based on the comparative ct method (ct) was performed using ab7300 system sds software (applied biosystems). Non quantitative pcr was carried out from the same cdnas by using 2u gotaq dna polymerase (promega) in a final volume of 25 l . Quinquefasciatus female was mounted on a syntech eag platform equipped with micromanipulator-12 and a high - impedance ac / dc preamplifier (syntech, germany). Chloridized silver wires in drawn - out glass capillaries filled with 0.1% kcl and 0.5% polyvinylpyrrolidone (pvp) were used for reference and recording electrodes . The recording electrode accommodated the two antennae of the excised head after the tips of the antennae were clipped to provide a better contact . Preparation was bathed in a high humidity air stream flowing at 20 ml / s to which a stimulus pulse of 2 ml / s was added for 500 ms . Any change in antennal deflection induced by the stimuli or control puffs was recoded for 10 s. indole and 3-methyl indole (skatole) were purchased from acros (usa) and were 95% pure; nonanal (99%) was from sigma - aldrich; racemic 6-acetoxy-5-hexadecanolide (mop) was a gift from bedoukian research incorporated, usa . Chemicals were dissolved in dichloromethane (dcm), wt / vol, to make a stock solution of 10 g/l and decadic dilutions were made . An aliquot (10 l) of a stimulus was loaded onto a filter paper strip, the solvent was evaporated for 30 s, and the strip was placed in a 5 ml polypropylene syringe from which various volumes were dispensed . Data presented are from a pool of mosquitoes injected and tested in three different batches on different days . In each session, eag responses of at least three of rnai - treated and water - injected mosquitoes were recorded . We employed a combination of rt - pcr and real - time quantitative pcr (qpcr) to examine mrna levels of cquiobp1 in heads of rnai (dsrna - injected) and control (water - injected, non - injected) mosquitoes using cquirps7 as a control gene . Rt - pcr analysis showed a clear reduction of cquiobp1 transcript levels in dsrna - injected mosquitoes, as compared to water - injected and non - injected mosquitoes (fig . We then examined by electroantennogram (eag) the responses of sham - and rnai - treated female mosquitoes to oviposition attractants . Silencing the cquiobp1 gene clearly affected antennal responses to mop and indole, a putative oviposition attractant (millar et al . 1c), which confirmed the trend observed by a semi - quantitative method (fig . Dsrna - injected mosquitoes displayed reduction of cquiobp1 transcript levels (average 59.9%) when compared to both water - injected (sham - treated) mosquitoes (average 97.3%) and non - injected controls (normalized to 100%). Dsrna - injected individuals displayed significant reduction of cquiobp1 transcripts (47% to 65%) (fig . Furthermore, water - injected and non - injected mosquitoes displayed almost equivalent levels of cquiobp1 transcripts, thus demonstrating that rnai treatment is responsible for the observed reduction of cquiobp1 mrna levels (fig . This partial silencing of cquiobp1 shown by qpcr analysis demonstrates the feasibility of significantly reducing even highly expressed olfactory genes like obps by using the rnai approach . 1b) also suggests that 50% transcripts reduction is enough to generate reduced responses to several semiochemicals . 1pcr and eag data . A rt - pcr analysis indicating that cquiobp1 transcripts were reduced in rnai - treated females (rna1 & rna2) when compared to the transcript levels in water - injected (water) and non - injected (non) females . B eag traces recorded from antennae of water- and rnai - treated female mosquitoes challenged with mop (100 g), indole (10 g), and nonanal (10 g). Bars on the top of traces indicate the duration of the 500 ms stimulus . C relative expression of cquiobp1 by qpcr using express sybr green er. Rnai - treated, water - injected, and non - injected mosquitoes (each n = 5). D, e, f dose - response eag curves for skatole, indole, and nonanal, respectively (n 10). The scale for skatole (d) and indole (e) graphics is the same, but the high sensitivity of nonanal (f) required a different scale pcr and eag data . A rt - pcr analysis indicating that cquiobp1 transcripts were reduced in rnai - treated females (rna1 & rna2) when compared to the transcript levels in water - injected (water) and non - injected (non) females . B eag traces recorded from antennae of water- and rnai - treated female mosquitoes challenged with mop (100 g), indole (10 g), and nonanal (10 g). Bars on the top of traces indicate the duration of the 500 ms stimulus . C relative expression of cquiobp1 by qpcr using express sybr green er. Rnai - treated, water - injected, and non - injected mosquitoes (each n = 5). D, e, f dose - response eag curves for skatole, indole, and nonanal, respectively (n 10). The scale for skatole (d) and indole (e) graphics is the same, but the high sensitivity of nonanal (f) required a different scale finally, we compared the responses of sham- and rnai - treated female mosquitoes to various doses of these oviposition - related compounds . Eag responses of rnai - treated females to mop were below the detection limit, but the dose required to generate consistent eag signals with water - treated or untreated mosquitoes was high (100 g). In contrast, reduction of cquiobp1 transcripts led to a significantly reduced response to skatole (n = 10, p <0.05) at all doses tested (fig . Likewise, eag responses to indole by rnai - treated females were significantly lower than the responses recorded from water - treated female mosquitoes at all doses tested (fig . Lastly, we observed an apparent trend towards smaller eag responses to nonanal by rnai - treated compared water - treated female mosquitoes, but the differences were not significant (fig . The simplest explanation for these findings is that obps play an important role for the sensitivity of the insect s olfactory system . Although we were not able to completely silence cquiobp1, probably because of the high level of transcription, the partial knockdown clearly affected antennal response to physiologically relevant compounds . Previously, we demonstrated by in vitro assays that cquiopb1 binds mop in a ph - dependent manner, and we showed its expression in antennal sensilla sensitive to this oviposition attractant (leal et al . These rnai experiments are the first evidence in vivo that cquiobp1 is involved in the reception of culex mosquito oviposition attractants . Although it is tempting to speculate that cquiobp1 is selective because responses to nonanal were not significantly different in sham- and rnai - treated mosquitoes (fig . 1f), the level of transcript reduction achieved by our rnai treatments may not be high enough to affect eag responses of semiochemicals such as nonanal for which the olfactory system responds with remarkable sensitivity (syed and leal 2009). By contrast, the reduced levels of cquiobp1 transcripts affected the responses of compounds with higher thresholds, thus allowing us to conclude that cquiobp1 is indeed involved in the detection of oviposition attractants, and that high levels of obps expression are essential for the sensitivity of the insect s olfactory system.

Minimally invasive surgery was first described by wickham in 1987 and refers to surgical techniques that are less invasive than open surgery for the same purpose . Conventional open, laparoscopic, robot - assisted laparoscopic, and video - assisted minilaparotomy surgery (vams) have been performed as minimally invasive renal surgery . This surgical technique was performed through minilaparotomy and patients who underwent it recovered quickly . More than 600 cases of living donor nephrectomy have been conducted successfully, and this technique is also widely used to manage renal malignancy . Many studies have compared the cost - effectiveness of laparoscopic and robot - assisted renal surgeries with that of open surgery . Compared the costs of open surgery and robot - assisted laparoscopic radical prostatectomy for prostate cancer . They noted that robot - assisted laparoscopic prostatectomy was more expensive than open surgery in terms of medical supply and operation costs . Reported that laparoscopic living donor nephrectomy with low complication rates was a cost - effective renal surgery . However, there has been no research on the cost - effectiveness of minilaparotomy kidney surgeries such as vams . Therefore, this study aimed to compare the cost - analysis of vams versus open, laparoscopic, and robot - assisted laparoscopic radical nephrectomy (rn) surgery under korean medical insurance . Twenty patients with suspected renal cell carcinoma who underwent vams, open, laparoscopic, or robot - assisted laparoscopic rn between january 2008 and december 2010 were selected . The patients sampled for this study were treated between 2008 and 2010 while the insurance system applied, and the most recent 20 cases not subject to the exclusion criteria were selected . Patients who met the following criteria were excluded: 1) those who underwent another surgery apart from rn, 2) those who incurred additional medical fees owing to postoperative complications, 3) those who underwent rn during hospitalization in another department, and 4) those whose final pathological finding was not renal cell carcinoma . Patient information (age, gender, body mass index [bmi], and length of hospital stay) was retrospectively collected from medical records . Tumor stage was based on the american joint committee on cancer tumor, nodes, metastasis staging, 7th edition . Four items considered to be related to the surgery were compared from the itemized statements: procedure and operation, anesthesia, laboratory testing, and medical supply fees . Items such as room and meal charges and medications, which were regarded as being minimally related to surgery, were excluded . Surgery was defined as a medical service directly performed by doctors with their hands or tools . Laboratory test fees refer to costs associated with extracting and testing specimens to diagnose a disease or ascertain its progression . Anesthesia fees refer to the costs of anesthesia for a surgery or treatment associated with alleviating pain . Medical supplies refer to the costs of materials used in a test or a surgery . Criteria for insured and uninsured costs were based on benefit coverage criteria prescribed by the health insurance review and assessment service . For laparoscopic rn, routine disposable laparoscopic equipment was used . For robot - assisted laparoscopic rn, the da vinci robot (intuitive surgical inc ., 18.0 (ibm co., armonk, ny, usa). To determine the significance of the differences observed between the means of continuous variables, student's t - test was used . To determine the significance of the differences observed between the rates of categorical variables, fisher's exact test was used . There was a significant difference in patient age and bmi (p<0.05) between the laparoscopic and the vams group . There was no significant difference in tumor sizes or stage distributions between the vams group and the other three groups (table 1). Patient costs (meanstandard deviation) were 2,023,791240,757, 2,024,246674,859, 3,603,557870,333, and 8,021,902330,157 korean won (krw, the currency of south koea) for the vams, open, laparoscopic, and robot - assisted rn groups, respectively . Among them, the sum of the insured costs was 1,904,627231,957, 1,798,127645,602 (p=0.634), 3,039,769711,792 (p<0.01), and 899,668323,508 (p<0.01) krw in the vams, open, laparoscopic, and robot - assisted rn groups, respectively, whereas the sum of the uninsured costs was 119,16324,581, 226,119215,009, 563,788487,798 (p<0.01), and 7,122,23456,117 (p<0.01) krw, respectively (table 2). In the vams group, medical supply fees accounted for the highest portion of total costs at 38.63% (insured costs were 33.43% and uninsured costs were 5.20%), followed by procedure and operation fees at 29.99% (insured costs were 29.99%). Procedure and operation fees in the open rn group, medical supply fees in the laparoscopic rn group, and procedure and operation fees in the robot - assisted laparoscopic rn group accounted for the largest percent at 33.19% (insured cost at 33.19%), 60.51% (insured cost at 45.3% and uninsured cost at 15.08%), and 88.24% (insured cost at 0.98% and uninsured cost at 87.26%), respectively (fig . 1). There was a significant difference between the vams and open rn groups in the laboratory test (insured) and surgical material fees (insured and uninsured; p<0.05). Medical supply fees were the item with the greatest difference between the laparoscopic and the vams groups (p<0.05). There was likewise a significant difference between the groups in terms of laboratory test fees (insured; p<0.05). In the robot - assisted laparoscopic rn group, procedure and operation fees had the greatest difference compared with those of the vams group . Laboratory test costs (insured) and medical supply costs (insured) were also significantly different from those of the vams group (p<0.05). There was no significant difference in total cost between the vams and the open rn groups (p=0.998). There was a significant difference in the sum of insured costs, uninsured costs, and total costs between the vams and the laparoscopic rn group (p<0.01). With patients placing importance on quality of life and decreased postoperative pain, demand for minimally invasive surgery is increasing . Furthermore, along with the development of imaging and operative equipment, surgical techniques have undergone much improvement . Four minimally invasive surgical techniques are being used for kidney surgery in the urological field: laparoscopic surgery, minilaparotomy surgery, robot - assisted laparoscopic surgery, and percutaneous cryotherapy or ablation therapy . In 1990, clayman et al this surgical technique, compared with conventional open surgery, caused less postoperative pain and required a shorter hospital stay and time to return to normal life . In 2001, guillonneau et al . Subsequently, other studies reported good functional and oncologic outcomes in patients undergoing this surgical technique . For the minilaparotomy technique, yang et al . Reported the first living donor nephrectomy using vams, and since then, data on safety and clinical usefulness from more than 600 cases of nephrectomy have been reported . Currently, vams is used for diverse renal surgeries including radical, partial, and living donor nephrectomies . The clinical usefulness of percutaneous techniques has been verified by many reports, but they have limits in that they are applied to selected patient cases only . Conventional open, laparoscopic, robot - assisted laparoscopic, and vams have been performed for renal masses . Vams is a minilaparotomy technique in which an endoscope is used and a technique of internal traction is applied with a piercing retractor . It leaves minimal operation - related scars owing to the surgical window available through minilaparotomy . For a certain surgical technique to become widely used, it should be associated with advantages in terms of cost - effectiveness, patient benefits, and postoperative outcomes . However, there has been no study on the cost - effectiveness of vams compared with other surgical techniques for rn . For comparison and analysis, we divided patients who were diagnosed with renal cell carcinoma and underwent rn into the open, laparoscopic, robot - assisted laparoscopic, and vams rn groups . To research the cost - effectiveness of surgical techniques, it is necessary to evaluate complications from such procedures, because complications affect total cost . Therefore, only four direct cost items related to surgery were compared and analyzed: procedure and operation, anesthesia, laboratory testing, and medical supply costs . In this study, items such as room and meal charges related to the length of stay were excluded from the evaluation of the cost - effectiveness of surgical techniques . In korea, the cost of ward stay is approximately 10,000 krw per day, which is inexpensive and therefore may lead to longer hospital stays . According to our study results, vams was more cost - effective than laparoscopic and robot - assisted laparoscopic rn (p<0.01) (table 2). The greatest difference in medical supply fees was between the vams and laparoscopic rn groups (p<0.01). In korea, changes in the benefit coverage criteria of health insurance in 2006 enabled medical supply fees in laparoscopic surgery to be covered by health insurance . However, such a difference between the two groups in medical supply fees was probably due to fees for the disposable device (e.g., autosuture multifire endo gia 12 mm [covidien plc, dublin, ireland]) that is currently used and which is expensive (more than 100,000 krw). Disposable devices (e.g., floseal hemostatic matrix [baxter healthcare co., hayward, ca, usa], harmonic scalpel [ethicon endo - surgery, cincinnati, oh, usa]) are expensive and are rarely used in open or vams rn . This increases the cost of laparoscopic and robot - assisted laparoscopic rn, making them more expensive compared with the open or vams group . Laboratory testing (insured) fees were less in the vams group than in the laparoscopic rn group (p=0.037), which is related to the shorter length of stay in the former group . Among the itemized costs, the greatest difference in produced and operation fees (uninsured) was between the vams and robot - assisted laparoscopic rn groups . In robot - assisted surgery, many reusable devices (e.g., endowrist [intuitive surgical inc ., sunnyvale, ca, usa]) were used . Those devices are reusable several times with cleansing and sterilization; thus, it was not feasible to charge this cost for each surgery . At most hospitals, the maintenance cost for reusable devices is included in the uniform procedure and operation fee . Disposable devices were not charged separately, and the cost was also included in the uniform fee . Therefore, the cost of medical supplies for the robot - assisted laparoscopic rn group can seem to be lower than the costs for other groups . Currently, the price of the da vinci robot ranges from 1.5 to 1.75 million dollars and maintenance costs from 112,000 to 150,000 dollars . This is why procedure and operation fees are more expensive in the robot - assisted laparoscopic rn group than in the vams group . Laboratory test fees were greater in the open than in the vams group because of the former group's longer length of hospital stay . The mean total costs of laboratory tests in the immediate postoperative 5 days were almost the same in all groups; after that period, the cost increase was proportional to the length of hospital stay . Medical supply fees were greater in the vams group than in the open rn group . This is due to the use of an endoscope and a disposable device 12 mm visiport plus (tyco healthcare, norwalk, usa) accompanying it . Nevertheless, there was no significant difference in the total cost between the open rn and vams groups . Judging from the study results thus far, vams seems to be more cost - effective than laparoscopic and robot - assisted laparoscopic surgeries . Comparison of vams with open surgery showed no significant differences in costs between them, proving that vams is a competitive modality in renal minimally invasive surgery . In addition to direct costs, hamidi et al . Compared and analyzed social costs after discharge, including costs resulting from complications in laparoscopic donor nephrectomy . When a patient undergoes a surgery, other costs such as medication and room and meal charges are incurred in addition to the direct costs related to the surgery . After discharge, patients may incur indirect costs such as sick leave, copayments for health care, and hiring fees for home work . Our study compared only costs directly related with surgery and therefore was unable to predict outcomes resulting from the incurrence of other costs . Surgeons who have not yet overcome the associated learning curve tend to have higher complication rates than do experienced surgeons . In this study, the surgeries of the vams group were conducted by experienced surgeons, which suggests that their complication rates would not be significantly different from those of the patients who underwent an open surgery . Although the learning curve of vams is not very steep, it is not a common technique; therefore, a large - scale multi - center study is necessary . Finally, this study only examined rn, which does not represent all vams procedures . Recent medical advancements, including abdominal ultrasonography, have resulted in increased discovery rates of small renal masses . The standard method for treating small renal masses is shifting from radical to partial nephrectomy . To fully research the cost - effectiveness of vams from different aspects, studies on other surgical techniques such as partial nephrectomy and pyeloplasty in addition to rn are necessary . Furthermore, the procedure has cost - effectiveness advantages compared with laparoscopic and robot - assisted laparoscopic rn.

The clinical utility of most conventional chemotherapeutics is limited either by the inability to deliver therapeutic drug concentrations to the target tissues or by severe and harmful toxic effects on normal organs and tissues . Liposomes are small, spherical, and enclosed compartments separating an aqueous medium from another by phospholipid bilayer . Many hundreds of drugs, including anticancer and antimicrobial agents, chelating agents, peptide hormones, enzymes, proteins, vaccines, and genetic materials, have been incorporated into the aqueous or lipid phases of liposomes, with various sizes, compositions, and other characteristics, to provide selective delivery to the target site for in vivo application . Several techniques, such as the bangham, detergent - depletion, ether / ethanol injection, reverse phase evaporation, and emulsion methods, have been reported for preparing liposomes with high - entrapment efficiency, narrow particle size distribution, and long - term stability.17 recently, some alternative methods including dense gas and supercritical fluid techniques have been introduced for liposome preparation without using any organic solvent.1,79 due to the differences in preparation methods and lipid compositions, liposomes can be classified according to their lamellarity (uni- and multilamellar vesicles), size (small [100 nm], intermediate [100250 nm], or large [250 nm]), and surface charge (anionic, cationic, or neutral).1012 in clinical studies, liposomes show improved pharmacokinetics and biodistribution of therapeutic agents and thus minimize toxicity by their accumulation at the target tissue.13,14 liposomes were first discovered by bangham in 1965 and the first liposomal pharmaceutical product, doxil, (ben venue laboratories, inc bedford, oh) received us food and drug administration (fda) approval in 1995 for the treatment of chemotherapy refractory acquired immune deficiency syndrome (aids)-related kaposi s sarcoma.1315 currently, there are about twelve liposome - based drugs approved for clinical use and more are in various stages of clinical trials (tables 1 and 2).1362 most liposomal drug formulations, such as doxil and myocet (gp - pharm, barcelona, spain), are approved for intravenous application.63 other administration routes such as intramuscular delivery have been approved for delivery of surface antigens derived from the hepatitis a or influenza virus (epaxal [berna biotech ltd, berne switzerland] and inflexal v [berna biotech espaa sa, madrid, spain]).37,38 oral delivery has also been examined; however, this is more troublesome due to the potential for liposome breakdown following exposure to bile salts.64 liposomes dispersed in aqueous solution generally face physical and chemical instabilities after long - term storage.65 hydrolysis and oxidation of phospholipids and liposome aggregation are the common cause of liposome instabilities . According to the literature, many methods have been investigated for the stabilization of liposomes, such as lyophilization, freezing, and spraying drying . In commercial liposome - based drugs (table 1), ambisome (gilead sciences, inc, san dimas, ca), amphotec (ben venue laboratories, inc, bedford, oh), myocet, visudyne (novartis pharma ag, basel, switzerland), and lep - etu (liposome - entrapped paclitaxel easy - to - use in general, freeze - drying increases the shelf - life of liposomal formulations and preserves them in dried form as lyophilized cakes to be reconstituted with water for injection prior to administration.66 furthermore, cryoprotectants need to be added to maintain particle size distribution of liposomes after the freeze - drying - rehydration cycle . Various types and concentrations of sugars have been investigated for their ability to protect liposomes against fusion and leakage during lyophilization processes.66 in commercial liposome lyophilized products, lactose has been used as a cryoprotectant in the formulations of amphotec, myocet, and visudyne, and sucrose was added in the formulations of ambisome and lep - etu to increase liposome stability during lyophilization . Interestingly, these commercial lyophilized products showed similar shelf - life in comparison with other liposome products (eg, suspension and emulsions) and hence lyophilization may not have the expected effect on liposome stability . In 1998, clemons and stevens compared the potency and therapeutic efficacy among the different lipid - based formulations of amphotericin b (amphotec, ambisome, and abelcet (sigma - tau pharmasource, inc, indianapolis, in)) for the treatment of systemic and meningeal cryptococcal disease.67 their work indicated that the therapeutic efficacy of amphotec and ambisome was superior to that of abelcet, by up to ten - fold, in survival and in clearing infection from all organs . In these three commercially available lipid - based formulations of amphotericin b, amphotec and ambisome are both lyophilized products and abelcet is formulated as a suspension . Therefore, lyophilization may not extend the shelf - life of products but may increase therapeutic efficacy in vivo . Similar results were also reported in our previous studies.70 we investigated the stability of the sirna - loaded liposomes in suspension and lyophilized powder form up to 1 month postmanufacture.68 following formulation, the sirna - loaded liposomes were stored at either 4c or room temperature . The particle size and zeta potential of sirna - loaded liposomes remained unchanged in both storage conditions . However, sirna entrapment efficiencies were observed to have decreased slightly after 1 month in storage for both suspension (90% 83%) and lyophilized powder (94% 84%) forms . Surprisingly, the gene - silencing efficiency of sirna - loaded liposomes in aqueous solution showed 80% reduction following 1 month of storage at either 4c or room temperature . This was in contrast to liposomes prepared in the lyophilized powder form where 100% of the gene - silencing efficiency was retained following storage at either 4c or room temperature for 1 month . Although therapeutic efficiency of liposome - based drugs may vary depending on the choice of lipids, the preparation technique, physico - chemical characteristics of the bioactive materials, and overall charge of the liposome, lyophilization is useful for the long - term storage of liposome - based drugs . Liposome delivery systems offer the potential to enhance the therapeutic index of anticancer drugs, either by increasing the drug concentration in tumor cells or by decreasing the exposure in normal host tissues . Doxorubicin is an anthracycline widely used to treat solid and hematological tumors, but its major drawback is its related cardiotoxicity . In cardiotoxicity, positively charged doxorubicin s affinity for negatively charged cardiolipin, a lipid abundant in heart tissue, is thought to be involved in drug localization in the heart tissue.69 therefore, doxorubicin - loaded liposomes were developed to combat aggressive tumors, like breast and ovary metastatic cancers and kaposi s sarcoma . Myocet and doxil were the first - approved liposome - based drugs for cancer treatment . Both products contain doxorubicin but are different, particularly in the presence of polyethylene glycol (peg) coating (figure 1). In pharmacokinetic studies of doxorubicin - loaded liposomes, free doxorubicin had an elimination half - life of 0.2 hours and an area under the plasma concentration time curve (au) of 4 g h ml in patients as compared with 2.5 hours and 45 g h ml for myocet and with 55 hours and 900 g h ml for doxil, respectively.25 the particle size of myocet is about 190 nm and doxil is about 100 nm . Both liposome products have longer circulating half - life in blood as compared with the free drug, but doxil has a much longer circulation time in blood than myocet . Generally, the blood circulation time of liposomes (t1/2) increases with decreasing size, negative charge density, and fluidity in the bilayer or peg surface coating . In a phase iii head - to - head comparison of free doxorubicin vs myocet in patients with metastatic breast cancer, similar results were presented in first - year survival rate (64% vs 69%) and progression - free survival (3.8 vs 4.3 months), but myocet had low incidence of cardiac events (13% vs 29%), mucositis / stomatitis (8.6% vs 11.9%), and nausea / vomiting (12.3% vs 20.3%).70,71 therefore, myocet tends to reduce drug - related toxicity (eg, cardiotoxicity) rather than to enhance antitumor efficacy . Similar to myocet, doxil had a better safety profile, including reduction of cardiotoxicity (3.9% vs 18.8%), neutropenia (4% vs 10%), vomiting (19% vs 31%), and alopecia (20% vs 66%) in a phase iii trial of metastatic breast cancer, whereas its progression - free survival times (6.9 vs 7.8 months) and overall survival times (21 vs 22 months) demonstrated equivalent efficacy to conventional doxorubicin.72 however, palmar - plantar erythrodysesthesia (48% vs 2%), stomatitis (22% vs 15%), and mucositis (23% vs 13%) were found to be more often associated with doxil than free doxorubicin . Lipo - dox (tty biopharm company ltd, taipei taiwan) is the second generation of pegylated liposomal doxorubicin, composed of distearoylphosphatidylcholine (dspc) and cholesterol with a surface coating of peg.27 dspc, which has two completely saturated fatty acids (both stearic acids), has high phase - transition temperature (tm), 55c, and good compatibility with cholesterol . Normally, lipid bilayer has two thermodynamic phases: gel or liquid - crystal phase . At temperature <tm, the lipid membrane is in the gel phase, which is relatively rigid and tight because the lipid molecules have lower energy of random motion and the hydrocarbon chains are fully extended and closely packed . Liposomes composed of phospholipids like dspc have higher stability compared with others containing unsaturated fatty acid (egg phosphatidycholine [pc]) or fatty acids of shorter or not uniform carbon chains like hydrogenated soy pc (hspc). In a phase i clinical study, lipo - dox achieved the most prolonged circulation half - life (65 hours).73 however, tseng et al demonstrated that there were no differences in survival between free doxorubicin only (median survival time of 23 days) and lipo - dox (medium survival time of 23.5 days) in a murine b - cell lymphoma model.74 in patients with metastatic breast cancer, the median time to disease progression of 163 days represented the result of lipo - dox treatment and the median duration of response in responding patients (286 days) are comparable with those of doxil treatment.75 neutropenia, stomatitis, and skin toxicity were reported in many cases of lipo - dox administration . For lipo - dox, stomatitis appeared at doses of 30 mg / m and reached dose limit at 50 mg / m.27 in contrast, doxil reached dose limit at 80 mg / m and hence lipo - dox had higher incidence of severe stomatitis than doxil . In comparison with myocet (the non - pegylated form of liposomal doxorubicin), doxil and lipo - dox (both pegylated forms of liposomal doxorubicin) both showed significant incidence of stomatitis and this is mainly due to the long circulation properties of pegylated liposomes.27,71,72 the new generation of doxorubicin - loaded liposomes are thermosensitive liposomes (tsls), which release their encapsulated drugs in regions where local tissue temperatures are elevated.76 compared with non - tsls that remain stable and do not release drug in the physiologic temperature range, tsls undergo a gel - to - liquid crystalline phase change when heated that renders the liposomes more permeable, releasing their encapsulated drugs . Thermodox (celsion corporation, lawrenceville, nj), a proprietary tsl encapsulation of doxorubicin, has recently begun phase iii clinical trials for the treatment of hepatocellular carcinoma.77 thermodox is composed of dipalmitoylphosphatidylcholine (dppc), monostearoylphosphatidylcholine (mspc), and polyethylene glycol 2000-distearoylphosphatidylethanolamine (peg 2000-dspe) in 90:10:4 molar ratio.49,50 in the design of tsls, it is necessary to choose a phospholipid that has a gel - to - liquid crystalline phase transition temperature (tc) in the temperature range of clinically attainable local hyperthermia (41c 42c). The mechanism behind tsls is the temperature - induced membrane instability at the tc of the used lipids . Dppc with a tc = 41.5c is an ideal lipid according to temperature - triggered technology.78,79 for liposomes composed of dppc alone, the rate of release and the amount released are relatively small . By incorporating a small amount of lysolipids, such as mspc or monopalmitoylphosphatidylcholine, into dppc liposomes, tc is shifted down slightly and membrane instability and drug release rate is significantly enhanced at tc . In vitro release studies, monopalmitoylphosphatidylcholine - containing tsls released about 45% of encapsulated doxorubicin in bovine serum at 42c in a few seconds (20 seconds), while pure dppc liposomes released only 20% over 1 hour.79 banno et al demonstrated that the presence of mspc, rather than peg 2000-dspe, in dppc liposomes would give rise to the rapid drug - release profile in vitro, suggesting that lysolipid is the more important component in determining the rate of tsl content release.80 indeed, banno s in vivo data showed that the presence of 9.6 mol% mspc in tsl could result in more rapid elimination of the encapsulated doxorubicin (t1/2 = 1.29 h), compared with the formulation without lysolipid (t1/2 = 2.91 h). In 2007, dromi et al compared the accumulation of doxorubicin in mice tumors among free doxorubicin, doxil, and thermodox.50 results showed that over time, doxorubicin gradually increased in tumors when both doxil and thermodox were used but not with free doxorubicin . At 24 hours after administration, doxorubicin concentrations in tumors were found to be significantly higher with doxil than thermodox . Thermodox is currently under evaluation in clinical trials and hence the therapeutic efficacy of thermodox is still unknown . Daunorubicin is classified as an anthracycline anticancer drug in the treatment of leukemia and a wide variety of solid tumors, but its major drawbacks are myelosuppression and cardiotoxicity.81 daunorubicin has also been incorporated into liposomes for the formulation of liposomal anticancer chemotherapy drugs . Daunoxome (gilead sciences, inc) is a commercial liposomal formulation of daunorubicin in which the drug is entrapped into small unilamellar vesicles (45 nm) composed of dspc and cholesterol in 2:1 molar ratio . In animal studies with tumor models in mice, daunoxome increased tumor uptake of daunorubicin ten - fold when measured against free drug (2470.5 vs 245.1 g hr / ml for 048 hours).82 furthermore, clinical pharmacokinetic studies have demonstrated that daunoxome was 36-fold higher in auc (375.3 vs 10.33 g hr / ml) in comparison with conventional daunorubicin.83 in a phase iii trial of daunox - ome versus a conventional combination of doxorubicin, bleomycin, and vincristine (abv) in aids - related kaposi s sarcoma, the efficacy of daunoxome was comparable to that of vincristine . Response rates (25% vs 28%), time to treatment failure (115 vs 99 days), and overall survival (369 vs 342 days) were similar on both treatment arms.84 moreover, patients treated with daunoxome experienced less alopecia (8% vs 36%) and neuropathy (13% vs 41%) and their cardiac function remained stable taxol (paclitaxel) is a marketed product for the treatment of ovarian, breast, non - small cell lung cancer, and aids - related kaposi s sarcoma.40 however, paclitaxel is only sparingly soluble in water and, therefore, intravenous administration depends on the use of the non - ionic surfactant cremophor el (polyethoxylated castor oil) to achieve a clinically relevant concentrated solution . Unfortunately, cremophor el increases toxicity and leads to hypersensitivity reactions in certain patients.85 the lep - etu formulation of paclitaxel is being developed to potentially reduce toxicities associated with taxol by eliminating the drug formulation component polyoxyethylated castor oil . Lep - etu formulations composed of 1,2-dioleoyl - sn - glycero-3-phosphocholine (dopc), cholesterol, and cardiolipin in 90:5:5 molar ratio were prepared by the modified thin - film hydration method . Dopc, a zwitterionic natural phospholipid, is chosen as one of the lipid components in the lep - etu formulation because of a low tc (22c) and hence dopc can form more flexible liposomes to entrap highly hydrophobic molecules . Moreover, liposomes containing cardiolipin reportedly reduced cardiotoxicity associated with doxorubicin by altering the pharmacokinetics and tissue distribution of the drug and hence cardiolipin may also exert similar results in lep - etu.86 fetterly et al evaluated the maximum tolerated dose, dose - limiting toxicities, and pharmacokinetics of liposome - encapsulated paclitaxel (lep - etu) in comparison with taxol.87,88 the maximum tolerated dose of lep - etu was 325 mg / m in a phase i study of patients with locally advanced or metastatic carcinoma.88,89 this dose is higher than that achieved with taxol, which is typically delivered at a dose range of 135 to 200 mg / m . The major toxicity to administration of paclitaxel is neuropathy . In the phase i study, neurotoxicity occurred in 5 of 12 patients (42%) treated with lep - etu at 325 mg / m . Although a direct comparison with taxol is not possible, neutropenia was seen in 53% of metastatic breast cancer patients treated with 250 mg / m taxol as demonstrated by winer et al.89 therefore, the neuropathy caused by lep - etu appears to be no worse than that reported for taxol within 3 weeks of treatment . Following lep - etu administration, the auc of paclitaxel in patients with advanced or metastatic carcinoma was improved (8.2 to 6.16 g hr / ml) with increasing dose (135 to 375 mg / m), which is similar to taxol . Although similarities exist between the plasma pharmacokinetics of the two formulations, the clinical evidence obtained from the phase i study shows lep - etu can be administered safely at higher doses than taxol.88,89 another liposome formation of paclitaxel is endotag-1.4244 the formulation of endotag-1 is prepared by 1,2-dioleoyl-3-trimethylammonium propane (dotap), dopc, and paclitaxel in 50:47:3 molar ratio . Dotap is a cationic synthetic lipid, which comprises one positive charge at the head group . The use of cationic lipids to enhance gene delivery has been studied extensively, but their application in clinic is relatively unexplored . Recently, there has been great interest in cationic liposomes, mainly due to their inherent ability to selectively target tumor vasculature . This selective affinity of cationic liposomes to tumor vasculature provides an opportunity for the development of many anti - angiogenic and anticancer formulations based on cationic liposomes.42 endotag-1 is the first formulation of cationic liposomes carrying paclitaxel in clinical trial . For commercial storage, endotag-1 formulations are lyophilized, and they are reconstituted with water for injection directly prior use . In preclinical programs, endotag1 - 1 inhibited tumor growth also in taxol - resistant animal tumor models such as b16 melanoma and sk - mel 28 melanoma . Endotag-1 demonstrated a strong antivascular effect on the preexisting tumor vasculature and affected several tumor microcirculatory parameters . In a phase ii trial of patients with pancreatic adenocarcinoma who were not candidates for surgery, endotag-1 in combination with gemcitabine substantially extended overall survival compared with gem - citabine alone.90 median survival in patients who received gemcitabine alone was 7.2 months, whereas it was up to 9.4 months in those who received combination treatment of endotag-1 plus gemcitabine . After 6 and 12 months of treatment, survival rate was superior for all endotag-1 doses plus gemcitabine compared with gemcitabine alone . The 12-month survival rates in patients given the two higher doses of endotag-1 (22 and 44 mg / m plus gemcitabine) were 36% and 33%, respectively, compared with 17.5% in those given gemcitabine alone . Combination treatment with endotag-1 plus gemcitabine was well tolerated and led to substantially more prolonged survival rates compared with standard therapy in this phase ii trial . Further clinical studies are warranted to demonstrate a statistically significant survival benefit associated with endotag-1 plus gemcitabine in advanced pancreatic cancer . The incorporation of viral membrane proteins or peptide antigens into liposomes has been shown to potentiate cell - mediated and humoral immune response, and generate solid and durable immunity against the pathogen . Virosomes are reconstituted virus liposomes, constructed without the genetic information of the virus making them unable to replicate or cause infection.91,92 the lipid layers of virosomes, composed of dioleoyl phosphatidylethanolamine (dope) and dopc, are employed to mimic viral membrane for vaccine delivery . Epaxal and inflexal v are both vaccine products using the virosome - based antigen delivery system for commercial use (table 1). For the production of inflexal v, the influenza viruses, grown in hens eggs, are first inactivated with beta - propiolactone . The influenza surface antigens, hemagglutinin and neuraminidase, are then purified and mixed with the phospholipid lecithin to form virosomes . Due to the virosomal technology, hepatitis a virus (hav) vaccine epaxal, and influenza vaccine inflexal v are highly efficacious by mimicking natural viral infection . The use of virosomes to deliver hepatitis a or influenza antigens stimulates a strong immune response of immunocompetent cells . In contrast to other commercially available hav vaccines, epaxal is an aluminium - free vaccine based on formalin - inactivated hepatitis a (strain rg - sb) antigen - incorporated virosomes . In a clinical study by usonis et al, seroprotection rates were 100% in all infants and children at 1 and 12 months after primary vaccination with epaxal.35 in contrast, the seroprotection rate after vaccination with the aluminium - containing vaccine havrix (glaxosmithkline biologicals rixensart, belgium) was 67.7% in infants with pre - existing maternal anti - hav antibodies, and a booster vaccination was required for complete seroprotection . Moreover, epaxal was generally well tolerated by infants and children, with no serious systemic or local events reported after either primary or booster vaccination . For inflexal v, most studies have shown inferior efficacy or ineffectiveness on clinical parameters for these vaccines compared with the nonadjuvanted, split - virus, or subunit seasonal vaccines.93 kanra et al, compared the immunogenicity and safety of inflexal v in children with a split influenza vaccine, fluarix (glaxosmithkline biologicals, dresden, germany).94 both vaccines were well tolerated and could induce effective immune responses in children . Interestingly, the virosome - adjuvanted influenza vaccine showed greater immunogenicity (88.8% seroconversion rates for h3 n2) over the split influenza vaccine (77.5% seroconversion rates for h3 n2) in unprimed children . In essence, virosomal techniques may not be able to give superior protective immunity in clinic but play an important role in preventing morbidity and lethality associated with vaccine . Verteporfin is a hydrophobic chlorin - like photosensitizer, which has been shown to be highly effective for photodynamic therapy in vivo . However, verteporfin also has a tendency to undergo self - aggregation in aqueous media, which can severely limit drug bioavailability to biological systems . It is important to introduce verteporfin into the bloodstream in its monomeric form and hence verteporfin was encapsulated in liposomes (visudyne) for intravenous drug delivery.2931 the lipid layers of visudyne are composed of unsaturated egg phosphatidylglycerol and dimyristoyl phosphatidyl choline in 3:5 molar ratio . Visudyne was the only drug approved by the fda for the photodynamic treatment of age - related macular degeneration . Visudyne treatment prevents the growth of the destructive blood vessels without hurting the surrounding tissues . Phase i and ii clinical trials were conducted for 609 patients with age - related macular degeneration.95,96 after 12 months of treatment, the group treated with visudyne (6 mg / m body surface area) had statistically better visual acuity, contrast sensitivity, and fluorescein angiographic outcomes than those who had placebo treatment (5% dextrose in water). At the examination 12-months posttreatment, 246 (61%) of 402 eyes assigned to verteporfin compared with 96 (46%) of 207 eyes assigned to placebo had lost fewer than 15 letters of visual acuity from baseline . In subgroup analyses, the visual acuity benefit of verteporfin therapy was clearly demonstrated (67% vs 39%) when the area of choroidal neovascularization, caused by age - related macular degeneration, occupied 50% or more of the area of the entire lesion . However, chowdhary et al reported that visudyne was readily destabilized in the presence of relatively low concentrations of plasma.29 therefore, the aim of future investigation of liposomal formulations in ophthalmology is to develop stable liposome structures for extending the plasma circulation time following intravenous injection . Since the first liposomal pharmaceutical product, doxil, received fda approval in 1995, liposomes have been widely applied as drug carriers in clinic . Until now, several important types of liposomes, such as pegylated liposomes (doxil and lipo - dox), temperature sensitive liposomes (thermodox), cationic liposomes (endotag1 - 1), and virosomes (expal and inflexal v) have been investigated for clinic use . In contrast with liposomal - based drugs on the market (table 1), liposome - based drugs in clinical trials (table 2) focused more on the types of delivered drugs (eg, cisplatin, blp25 lipopeptide, grb2 antisense oligodeoxynucleotide, bacteriophage t4 endonuclease 5, etc) and therapeutic applications (from topical delivery systems to portable aerosol delivery systems). New liposomal formulations, such as pegylated liposomes, may extend blood circulation time, vary drug distribution in the body, and hence reduce the possible side effects related to the drugs (eg, cardiotoxicity). However, pegylated liposomes (doxil and lipo - dox) displayed significant incidence of stomatitis in clinical trials, which may be related to pegylation . Moreover, some of the new generation liposomes showed only comparable or even poor therapeutic efficiency compared with free drug or conventional vesicles in clinical trials . In comparison with doxil, thermodox displayed significantly weaker doxorubicin accumulation in mice tumors at 24 hours after administration.50 endotag-1 plus gemcitabine and endotag-1 plus paclitaxel achieved excellent therapeutic effect in two phase ii clinical trials in pancreatic cancer and triple receptor - negative breast cancer, but endotag-1 therapy alone in triple receptor - negative breast cancer resulted in poor survival rate (34%) and median progression - free survival time (3.4 months) in comparison with paclitaxel (48% and 3.7 months).97 spi-077, the first liposomal formulation of cisplatin, had limited clinical efficacy in a phase ii clinical trial of advanced non - small cell lung cancer, even though spi-077 demonstrated enhanced cisplatin tumor accumulation in preclinical models.98 similar to spi-077, a phase ii study of liposomal annamycin in the treatment of doxorubicin - resistant breast cancer had no detectable antitumor activity.99 although new liposomal - based drugs have been well studied in preclinical animal models, these liposomal pharmaceutical products may be unable to provide promising therapeutic effects in clinical trials . For future development of liposomal - based drugs, the comparison of drug circulation time in blood, drug accumulation in tissues, and possible toxicity between conventional vesicles and new generations of liposomes should be investigated in preclinical animal models . Furthermore, there should also be focus on the clinical therapeutic effects and toxic side effects of liposomal lipid composition.

A 60-year - old male patient was referred to an otorhinolaryngology clinic due to a lump on the left side of his jaw, which had grown in 2 months . Ultrasound sonography test examination revealed a cystic mass that was 2417 mm in size with smooth contours . Multiple echogenic and reactive lymph nodes with partially visible hila were visualized in the neighboring upper jugular chain, with the largest being 1610 mm in size . Following a neck magnetic resonance imaging and a preliminary diagnosis of wt, left superficial parotidectomy materials were sent for pathologic examination in two pieces, which were 53.22 cm and 4.531.2 cm in size . Cross section analysis showed an off white - yellowish, well - contoured nodular tumor with a bleeding center of 42.52.2 cm . Microscopic examination indicated that the tumor had epithelial components with basaloid and oncocytic columns of cells neighboring lymphoid components (fig . In addition to the lymphoid follicles with distinct germinal centers, infiltration of large neoplastic cells with bizarre and extremely atypical morphology was seen in the lymphoid component (figs . 2, 3). 4b), leukocyte common antigen, igg, cd138, mum1, and focal positivity for kappa . Staining for lambda, igm, iga, cd3, cd5, cd10, cd15, cd56, epithelial membrane antigen, bcl2, bcl6, cyclind1, s100, pancytokeratin, cytokeratin 20, human melanoma black 45, actin, and desmin were negative . Latent epstein - barr virus (ebv) was shown to be negative in tumor cells by using ebv - encoded rna chromogenic in situ hybridization . Due to these findings, the patient was diagnosed with " wt and cd30 positive diffuse large b - cell lymphoma in the parotid gland . " Following the lymphoma diagnosis, a full body screen was performed . In addition to these findings, the left suprarenal gland showed two nodular mass lesions, which were assessed as likely adenomas; however, this preliminary diagnosis was not confirmed by histopathology . The patient was stage 3a and received six courses of rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone (r - chop) therapy . During 6-month follow - up, the patient was free of disease . Wt is the second most common type of salivary gland tumor . In 10 - 15% of cases, it is bilateral, and it accounts for 70% of all bilateral salivary gland tumors.2 the male / female ratio is 1.6/1, and it typically develops in the 6th and 7th decades . Smoking increases the risk of developing wt.5 microscopically the tumors are typically composed of proliferative epithelial components accompanied by lymphoid stroma with lymphoid follicles that have distinct germinal centers . Histogenesis of the lymphoid stroma in wt has been a topic of discussion for many years . Lymphoid stroma can arise as a cell response to epithelial neoplasms or as a normal lymph node due to residue held by the epithelial neoplasm.5,6 the most widely accepted hypothesis suggests that wt is a neoplasm that develops in the heterotopic salivary gland ductus within or around the parotid lymph nodes.7 transformation to carcinoma in wt is a well - known phenomenon; however, the development of lymphomas from wts is very rare.4,8 although some cases contain a normal residual lymphoid component, in others cases the lymphoid component contains entirely neoplastic lymphoid cells.4 in the present case, non - neoplastic lymphoid tissue was also present in the neighboring areas . The pathogenesis of malignant transformation of wt remains unclear; however, exposure to radiation is of particular interest, as the relationship between previous radiotherapy and lymphomas arising from wts has been determined by some authors.4,5,9 chronic immune sialadenitis is thought to play an important role, independent of the presence of sjgren syndrome symptoms.4,7,10 in this case, there was no history of radiotherapy or sialadenitis, but a history of smoking may have provoked the development of wt . Saxena et al.1 state that because the lymphoid stroma of wt is part of the systemic lymphoid tissue, in patients with lymphomatous spread of wt, disseminated disease is present during the staging either at the time of the diagnosis or after . In the present case, with screening techniques, lymphadenopathies of a pathologic size were found in the inguinal and iliac regions . Some researchers suggested that although the relationship between wt and lymphoma could be coincidental, it might also be of a pathogenic nature . According to the latter statement, a single agent can affect different tissues or one tumor could trigger the formation of another . From this point of view, the epithelial component is a continuous antigenic stimulator for the lymphoid component, which provides the stimulus for the development of lymphoma.1,6,8 according to this theory, the frequently observed reactive follicular hyperplasia in wt may be histological evidence of chronic antigen stimulation.1 it has been suggested that the lymphomas seen with wt are typically non - hodgkin lymphomas; however, there are a few cases reporting hodgkin's lymphomas.11,12 the majority of non - hodgkin's lymphomas in wt are follicular lymphomas . Dlbcl, small lymphocytic lymphoma, extranodal marginal zone lymphoma of mucosa associated lymphoid tissue, and mantle cell lymphoma have also been reported.4,6,8,9 a small number of t - cell lymphomas such as peripheric t - cell lymphoma and t - cell lymphoblastic lymphoma have also been described in wt.4,8,13 in summary, malignant lymphomas in wt are very rare . The presented case is a diffuse large b - cell lymphoma expressing cd30 positivity . To the best of our knowledge this is the first case in literature describing dlbcl with expression of cd30 in wt.

They almost always require open reduction and internal fixation . Due to the increase in the emergence of native bone setters, these fractures are increasingly been managed by these spurious bone setters using native splints . As a result the choice of implants used can be either a dynamic condylar screw plate (dcs) orproximal femoral nail (pfn). Here we have used a surgical grade 316 l stainless steel proximal femoral anatomical locked compression plate (pf - lcp). We analyzed 13 patients with established non unions of subtrochanteric fractures treated in our centre by the use of the pf - lcp . All our patients were followed up by serial radiographs at 6, 12, 18, 24 weeks and thereafter at 6 months interval . Union was achieved in 11 out of 13 patients at 12 weeks whereas two patients had delayed union which eventually healed at 18 weeks and 24 weeks . The average harris hip score at 1 year follow - up was excellent in eight, good in four and fair in one patient respectively . We conclude that in complicated non - unions, the use of pf - lcp has a definite positive role in the management of such cases . While inter - trochanteric malunite frequently, subtrochanteric fractures most often end in non - unions . The interposing soft tissues along with the displacement means that these fractures necessitate open reduction . Also to complicate matters, there has been a surge in the number of traditional bone setters who use native splints with massages . Hence, the frequency of non - union subtrochanteric fractures has increased in the recent past . The implant of choice has traditionally been either dcs plates or pfn . In our study clinical picture of the anatomical pf - lcp with proximal screws showing divergent screws and various angles (95, 120 and 135 degrees) we analyzed 19 consecutive patients with non - unions of subtrochanteric fractures who presented to our clinic . All patients underwent open reduction with removal of interposing fibrous tissue, freshening of the edges and anatomical reduction . The pf - lcp was used with proximal 6.5 mm locking cancellous screws and distally using both cortical and locked screws . Primary bone grafting was done in two patients (seinsheimer type iv) i.e patients s. no . 2 and 12 [table no . 2] to maintain poesteromedial cortical contact . Wound closure and suture removal done as per standard guidelines . All patients were started on non - weight bearing walking for 6 weeks . Then weight bearing was started as tolerated . Eleven out of 13 patients started full weight bearing by 12 weeks with 2 patients walking full weight bearing at 18 and 24 weeks respectively . The functional assessment was done using the modified harris hip score and results were tabulated (table 2). Serial radiographs were taken at 6, 12, 18, 24 weeks follow - up and thereafter at 6 months interval . Two patients (case no . 2 and 12) had delayed unions which healed eventually at 18 and 24 weeks respectively . They were both type iv seinsheimer fracture pattern with loss of posteromedial cortical contact . They were primarily grafted and this could be a possible reason for the delayed union . There was one patient who had one case of wound dehiscence which required secondary suturing under local anaesthesia (case no.9). At one year follow - up, all our patients were ambulatory full weight bearing, walking without any aid and were doing well . The functional assessment showed excellent results in eight [fig . 2, 3 & 4], good in four and fair in one patient respectively . We do not routinely advise or perform implant removals for any of our patients due to social and financial constraints . Pre op x ray showing type v seinsheimer fracture non - union with smooth edges post op x ray at 1 year follow - up showing complete fracture union with implant insitu in good position a: clinical photo at 1 year follow - up showing excellent function of hip movements figure 4b: clinical photo at 1 year showing no limb length inequality . . The earlier used proximal femoral side plates namely dcs and the newly introduced pf - lcp have their own advantages in select cases . Shukla et al reviewed 60 patients treated with i m nailing and reported a union rate of 95% . They also reported a higher malunion and non - union rate in those patients treated by closed reduction than those treated by open reduction (3 and 1 in open versus 6 and 2 in closed reduction group). They also concluded that the complication rate was higher in those fractures fixed in varus (> 10 degrees) at the fracture emphasizing that correct anatomical alignment is of paramount importance in achieving union . In our study, all our patients underwent open reduction and anatomical reduction was achieved in all our patients . Hence, we had a comparable union rate with no varus collapse or implant failure . Bartonincek et al used the double angled blade plate with valgus osteotomy in his series of 15 patients and achieved a union rate of 93.33% which is comparable to our study . One patient had an implant failure due to a repeat fall and required revision surgery . The average harris hip score improved from 73 pre - operatively to 92 following surgery . In our study, the average harris hip score following union was 89 which is comparable . Pelet et al compared gamma nail versus side plate and reported 100% healing with gamma nail with 2 failures in the side plate group . However though we have used only anatomical pf - lcp and achieved comparable union rates . However weight bearing was delayed till about 12 weeks in 11 out of 13 patients (radiological union). Liporace et al reported a case report of using a femoral fixator distractor over a i m nail to achieve length in a patient with limb length discrepancy . In our study, we were able to restore limb length to within 0.5 cm of the opposite normal side in all our patients . Giannoudis et al reported a new diamond concept of treating non union subtrochanteric fractures using local injection of growth factor (rhbmp-7), ria (reamer irrigator aspirator) and mesenchymal growth factors (msc). He concluded that in addition to the above, preventing varus malalignment at the fracture is the keystone to allow fracture healing and prevent implant failure . Muller et al reported a careful usage of additional circlage wiring to provide stability to the fracture site treated by i m nail . In our study, we ensured anatomical reduction along the posteromedial cortex was achieved to prevent varus collapse at the fracture leading to implant pull out . Pugh et al compared first generation nails to second generation nails and preliminary reports by them suggested a slight biomechanical advantage for the second generation nail over the first generation nails . In our study, we have obtained results which are comparable to the i m nail with fewer complications . Omalley et al showed in 46 patients of unstable trochanteric fractures treated by intra medullary devices that there was on an average a 7 mm lateral shift of the distal femoral shaft (i.e wedge effect). As a result all of those patients had a varus malignment (neck shaft angle of 129 degrees versus 133 degree in the opposite normal hips) but the fracture eventually united . In our study, we ensured a near anatomical neck shaft angle and supported the postero - medial cortex with graft when required (case no.2 & 12) to ensure that no varus collapse occurs . Seyham et al compared the outcomes of proximal fractures using pfna and intertan nails and concluded that the rate of proximal screw back - out and varus collapse was significantly higher in the pfna than in the intertan group . In our study, we did not report any varus collapse or implant pull out in any of our cases . Niu et al conducted a survey among aaos members about the preferred choice of implant for proximal femur fractures . He concluded that although both intramedullary devices and plate fixation devices produced equal results with regard to fracture healing, the implant of choice in the current scenario is the i m device due to ease of surgery and biomechanical stability over the plate devices . In our study however, we have shown that in select complicated cases, these newer pf - lcp have proved to be as efficient and stable as i m devices . Muller et al showed by a comparative study between pfn and dhs, a significantly higher rate of screw cut - out was seen in dhs group compared in the pfn group . The pf - lcp that we have used in our study has the advantage of having three locked screws in place of one dhs screw at 95,120 and 135 degrees to offer increased stability with a negligible cut out risk . In our study, we did not include a control group treated by either a pfn or dhs implant . However, we compared our results with the results of other authors [3, 7, 9, 10] who used either pfn or dhs as the standard implant of choice for such fractures . The results in our study show promising outcomes in favour of the pf - lcp, but our study group is small (13 patients) and we need to have a bigger study group and include more patients . Although the gold standard remains intramedullary devices for such fractures, we have concluded from our study that the anatomical proximal femur locked plates (pf - lcp) is able to provide comparable results with those of i m devices . The potential advantages of this implant over the other side plates are as follows: three locked screws in the proximal fragment at various angles namely 95, 120 and 135 degrees providing multi planar stability [fig . 1 & fig . 2] no loss of bone as no reaming is done as with dcs screws anatomical so no pre - contouring is required provision of combi hole to use either locking or cortical screw to achieve plate to bone contact distally . Can be safely used with fracture extension into greater trochanter (entry point for nail). We therefore conclude that pf - lcp is a valuable tool in the arsenal of every orthopaedic surgeon . We believe that with the right patient selection, this implant provides a similar result and outcome to that offered by intramedullary devices . Although the conventional and current implant of choice is intramedullary nailing (im / il nail) following open reduction, the use of the pf - lcp has produced results similar to those of i m nails . Hence, for the appropriate patient choice, the pf - lcp is a newer and proven implant to use for excellent outcomes.

Ensuring the highest quality of health care for all stroke patients is important in the current climate of scarce resources and the increasing burden of stroke to the health sector . There is a strong international momentum to improve the quality of acute stroke management.1 this is supported by high level evidence that now underpins many acute stroke interventions, including several provided by allied health professionals.2 although much of the current research on quality in stroke care has focused on factors that may influence medical interventions,37 allied health professionals are similarly interested in ways to implement best practice care.8 allied health professionals are members of multidisciplinary stroke teams and contribute to patient care from early in acute admission, through the stroke rehabilitation phase, and beyond . The professional composition of acute stroke teams may vary internationally . In the australian context of this study, allied health members include physiotherapists, occupational therapists, speech pathologists, social workers, dietitians, and psychologists.2 several researchers suggest that patient age is a determinant of the quality of medical and allied health care patients receive following acute stroke.35,913 we have previously reported that age and gender, on their own, are not related to an overall index of allied health care quality.14 further investigation is now required to determine whether patient age and gender are associated with individual measures of allied health care, and further, whether other variables, such as comorbidity, prestroke independence, and stroke severity, are putatively associated with allied health care . If there are differences in allied health care provided to patients with acute stroke, it is important to understand why care might differ, so that quality improvement strategies can be effectively targeted at problem areas . This paper explores demographic and stroke - related factors (predictor variables), including patient age, which may be associated with individual measures of quality of care provided to acute stroke patients by allied health professionals . Our aim was to provide systematically determined information to guide clinical quality audits and targeted quality improvement strategies in stroke care . Ethical considerations and our sampling framework have been reported in detail previously.14 in summary, we conducted a retrospective clinical audit of medical records for 300 acute stroke patients from three metropolitan tertiary hospitals in adelaide, south australia, australia . Sampled patients had been consecutively admitted to hospital prior to august 2009, and the audit was conducted between november 2009 and april 2010 . We previously reported on an overall index of 20 performance indicators of allied health service quality, identified from a literature review (listed in table 2).14,15 although several of these indicators relate to interdisciplinary elements of stroke care which may be shared within a stroke team, the focus of this study is the ability of allied health professionals to contribute to this work, because this is largely unexplored . In our earlier study, quality of care was determined by per patient compliance with all 20 process indicators.14 in the current study phase, compliance with each process indicator was considered individually and associations were explored with predictor variables . Allied health professionals of interest in our research were from physiotherapy, occupational therapy, speech pathology, dietetics, social work, and psychology . Previous clinical audits and literature reviews of stroke provided awareness of the demographic and clinical variables that could be extracted retrospectively from medical records.1315 these variables are captured by stroke clinicians to assist diagnosis and clinical management, or for service monitoring . Data were extracted from medical records on patient age, gender, premorbid levels of independence and accommodation type, english proficiency, comorbidity levels, weekend or weekday admission, stroke unit admission, initial stroke severity, length of stay in the acute hospital, and process indicator compliance . Many of these demographic and clinical variables have been associated with care quality in the stroke literature, especially for medical care,14 or as predictors of stroke outcomes . However, none of these predictor variables have previously been well explored for their influence on stroke care by allied health professionals . In addition to the evidence discussed above regarding age - related differences in care, researchers have reported associations between gender and stroke care quality.1618 stroke severity is strongly linked to survival and discharge destination outcomes,19,20 and a priori reasoning suggests that it may prompt allied health care processes, such as swallow assessment, in patients with obvious risks of poor outcome . Stroke severity may also influence the ease with which specific care, such as early rehabilitation, can be achieved . Admission over a weekend has previously been reported to influence care standards and patient outcomes following acute stroke.12,21 the scarcity of allied health staff at the research sites over weekends suggested that day of admission may alter care . Patient outcomes following stroke have been associated with previous levels of independence and accommodation,22,23 comorbidity levels,24,25 and length of stay in the acute hospital.26,27 these factors may influence allied health staff decisions regarding care, for example, the priority given to early rehabilitation interventions . Factors such as length of stay may also influence the achievability of some care processes for patients . We considered english proficiency in our study because it has previously been linked to stroke outcomes and the quality of health care patients receive.28,29 a simple causal pathway was constructed to assist in our understanding of how to undertake the analysis of the putative predictors of the allied health indicators of care . This approach was based on the causal modeling theory of rothman and greenland.30 we called this a simple causal pathway because we had no understanding at this point of the ongoing influence of early predictor variables on other variables which become important along the pathway . We undertook a series of analyses to understand the relationships between the putative predictor variables and each care process indicator, using our causal pathway as an analysis model . Univariate logistic regression models were constructed between: adherence with individual process indicators and age; adherence with individual process indicators and non - age predictor variables; the association of age with other predictor variables; and the association between non - age variables . Data were analyzed using sas proprietary software (v 9.2; sas institute, cary, nc). Correlations between variables were expressed as relative risks, odds ratios (or, as appropriate), and 95% confidence intervals (ci). We report relative risks for the first two of the analyses because we were examining associations between independent care predictors with dependent variables (indicators of care quality derived from cross - sectional observational data). We reported or for the third and fourth analyses because we were examining the association between independent variables . As reported in our earlier paper, age was most appropriately dichotomized as younger (<75 years) and older (75 + years) patients.14 stroke severity on admission was determined by retrospectively extracting data from medical records to complete a national institute of health stroke scale (nihss) for each patient . The nihss is a widely used, valid, and reliable measure of stroke severity.31,32 it is also reliable and valid when data are extracted retrospectively from patient medical records.33,34 based on previous stroke studies, nihss scores were divided into three groups for analysis, ie, mild strokes (nihss <8), moderate severity strokes (nihss 816), and severe strokes (nihss> 16).35 comorbidity levels were measured using the charlson comorbidity index (cci), which is a summary score of the existence or absence of 17 medical conditions, weighted to account for disease severity.36 this index has been validated as a predictive comorbidity index for patients with stroke . It has been used in previous stroke outcome studies and has also been validity and reliability tested for retrospective data extraction.37,38 comorbidity information was extracted from the medical records to complete a cci for each patient . Based on analysis reported in previous studies, patient cci scores were dichotomized as low comorbidity levels (cci 1) vs high comorbidity levels (cci> 1).38 patients admitted between 1600 hours on a friday and 2400 hours on a sunday, when access to allied health professionals was scarce, were recorded as weekend admissions . Admission directly from the emergency department to a stroke unit was recorded in binary terms (yes = 1, no = 0). Nonaphasic patients were recorded as not proficient in english if there was evidence that assistance had been required with language translation, or if limited english or similar was found in the medical records . Premorbid dependence level was recorded as independent or dependent, according to whether assistance was required with activities of daily living or instrumental activities of daily living.39 premorbid accommodation was recorded as a private home or a residential care facility (nursing home or hostel). Length of stay data (in days) was broadly classified for analysis . For univariate analysis, length of stay was dichotomized into shorter stay (<12 days) and longer stay (12 days). The cut point of 12 days was the mean length of stay for the data set and was also the average length of stay for acute stroke patients at the three data collection hospitals in 2007/08 and 2008/09.40 to provide more detailed consideration of the possible influence of length of stay on care, analysis considered length of stay in three groups divided at the data tertiles (<4 days, 49 days, and 10 days). We previously reported on an overall index of 20 performance indicators of allied health service quality, identified from a literature review (listed in table 2).14,15 although several of these indicators relate to interdisciplinary elements of stroke care which may be shared within a stroke team, the focus of this study is the ability of allied health professionals to contribute to this work, because this is largely unexplored . In our earlier study, quality of care was determined by per patient compliance with all 20 process indicators.14 in the current study phase, compliance with each process indicator was considered individually and associations were explored with predictor variables . Allied health professionals of interest in our research were from physiotherapy, occupational therapy, speech pathology, dietetics, social work, and psychology . Previous clinical audits and literature reviews of stroke provided awareness of the demographic and clinical variables that could be extracted retrospectively from medical records.1315 these variables are captured by stroke clinicians to assist diagnosis and clinical management, or for service monitoring . Data were extracted from medical records on patient age, gender, premorbid levels of independence and accommodation type, english proficiency, comorbidity levels, weekend or weekday admission, stroke unit admission, initial stroke severity, length of stay in the acute hospital, and process indicator compliance . Many of these demographic and clinical variables have been associated with care quality in the stroke literature, especially for medical care,14 or as predictors of stroke outcomes . However, none of these predictor variables have previously been well explored for their influence on stroke care by allied health professionals . In addition to the evidence discussed above regarding age - related differences in care, researchers have reported associations between gender and stroke care quality.1618 stroke severity is strongly linked to survival and discharge destination outcomes,19,20 and a priori reasoning suggests that it may prompt allied health care processes, such as swallow assessment, in patients with obvious risks of poor outcome . Stroke severity may also influence the ease with which specific care, such as early rehabilitation, can be achieved . Admission over a weekend has previously been reported to influence care standards and patient outcomes following acute stroke.12,21 the scarcity of allied health staff at the research sites over weekends suggested that day of admission may alter care . Patient outcomes following stroke have been associated with previous levels of independence and accommodation,22,23 comorbidity levels,24,25 and length of stay in the acute hospital.26,27 these factors may influence allied health staff decisions regarding care, for example, the priority given to early rehabilitation interventions . Factors such as length of stay may also influence the achievability of some care processes for patients . We considered english proficiency in our study because it has previously been linked to stroke outcomes and the quality of health care patients receive.28,29 a simple causal pathway was constructed to assist in our understanding of how to undertake the analysis of the putative predictors of the allied health indicators of care . This approach was based on the causal modeling theory of rothman and greenland.30 we called this a simple causal pathway because we had no understanding at this point of the ongoing influence of early predictor variables on other variables which become important along the pathway . We undertook a series of analyses to understand the relationships between the putative predictor variables and each care process indicator, using our causal pathway as an analysis model . Univariate logistic regression models were constructed between: adherence with individual process indicators and age; adherence with individual process indicators and non - age predictor variables; the association of age with other predictor variables; and the association between non - age variables . Data were analyzed using sas proprietary software (v 9.2; sas institute, cary, nc). Correlations between variables were expressed as relative risks, odds ratios (or, as appropriate), and 95% confidence intervals (ci). We report relative risks for the first two of the analyses because we were examining associations between independent care predictors with dependent variables (indicators of care quality derived from cross - sectional observational data). We reported or for the third and fourth analyses because we were examining the association between independent variables . As reported in our earlier paper, age was most appropriately dichotomized as younger (<75 years) and older (75 + years) patients.14 stroke severity on admission was determined by retrospectively extracting data from medical records to complete a national institute of health stroke scale (nihss) for each patient . The nihss is a widely used, valid, and reliable measure of stroke severity.31,32 it is also reliable and valid when data are extracted retrospectively from patient medical records.33,34 based on previous stroke studies, nihss scores were divided into three groups for analysis, ie, mild strokes (nihss <8), moderate severity strokes (nihss 816), and severe strokes (nihss> 16).35 comorbidity levels were measured using the charlson comorbidity index (cci), which is a summary score of the existence or absence of 17 medical conditions, weighted to account for disease severity.36 this index has been validated as a predictive comorbidity index for patients with stroke . It has been used in previous stroke outcome studies and has also been validity and reliability tested for retrospective data extraction.37,38 comorbidity information was extracted from the medical records to complete a cci for each patient . Based on analysis reported in previous studies, patient cci scores were dichotomized as low comorbidity levels (cci 1) vs high comorbidity levels (cci> 1).38 patients admitted between 1600 hours on a friday and 2400 hours on a sunday, when access to allied health professionals was scarce, were recorded as weekend admissions . Admission directly from the emergency department to a stroke unit was recorded in binary terms (yes = 1, no = 0). Nonaphasic patients were recorded as not proficient in english if there was evidence that assistance had been required with language translation, or if limited english or similar was found in the medical records . Premorbid dependence level was recorded as independent or dependent, according to whether assistance was required with activities of daily living or instrumental activities of daily living.39 premorbid accommodation was recorded as a private home or a residential care facility (nursing home or hostel). Length of stay data (in days) was broadly classified for analysis . For univariate analysis, length of stay was dichotomized into shorter stay (<12 days) and longer stay (12 days). The cut point of 12 days was the mean length of stay for the data set and was also the average length of stay for acute stroke patients at the three data collection hospitals in 2007/08 and 2008/09.40 to provide more detailed consideration of the possible influence of length of stay on care, analysis considered length of stay in three groups divided at the data tertiles (<4 days, 49 days, and 10 days). Mean age at stroke onset was 74.7 years (standard deviation [sd]: 13.5, range 18100 years). The mean length of stay in acute care was 12.5 days (sd: 15.6, range 198 days). The sample was proportionally balanced for gender . Despite similar mean ages for males and females, a larger proportion of females were in the older age groups, with 72% females aged 75 years or older, compared with 53% of males . A greater proportion of females suffered a moderate or severe stroke (28%) than males (18%). For the whole sample, there were weak relationships between increasing age and increasing stroke severity (r = 0.21) and comorbidity levels (r = 0.20). Compliance with each process indicator was generally poor (table 2, columns 2 and 3). For 16 of the process indicators (80%), the outcome of univariate logistic regression models, associating process indicator adherence with age, is reported as relative risks in table 2, column 4 . Only one process indicator had a significant association with age, where patients younger than 75 years were significantly more likely to receive first mobilization within 24 hours of stroke onset than older patients . Compliance with 12 of the 20 process indicators (60%) was significantly correlated with non - age variables . The only variables which were not associated with any process indicator compliance were previous accommodation type and english proficiency . For 30% of the process indicators significant correlations were found between patient age, and the predictor variables of stroke severity, comorbidity levels, premorbid accommodation, premorbid independence level, gender, english proficiency, and length of stay . In summary, compared with younger patients, patients 75 years or older were significantly more likely to have a moderate - to - severe or severe stroke (or: 1.8, 95% ci: 1.13.2 and or: 2.9, 95% ci: 1.46.1, respectively), to have higher comorbidity levels (or: 2.5, 95% ci: 1.54.2), to have lived in residential care (or: 2.6, 95% ci: 1.16.2), or been previously dependent (or: 6.2, 95% ci: 3.212). Older patients were also more likely to be female (or: 2.2, 95% ci: 1.43.6), to have a length of stay of 59 days (or: 0.6, 95% ci: 0.30.9), and to have poor english proficiency (or: 3.2, 95% ci: 1.19.7). Females were less likely than males to have been previously independent (or: 2.2, 95% ci: 1.43.7), more likely to have a moderate or severe (nihss 8) stroke (or: 0.4, 95% ci: 0.20.6), and a length of stay 10 days (or: 0.4, 95% ci: 0.20.7). Patients who suffered a moderate - to - severe stroke (nihss 8) were more likely to have lived previously in residential care (or: 0.3, 95% ci: 0.10.7), to have high comorbidity levels (or: 0.6, 95% ci: 0.40.98), and to have a length of stay 10 days (or: 2.6, 95% ci: 1.54.7). Compared with patients having low comorbidity, high comorbidity levels were associated with previous residential care (or: 8.3, 95% ci: 2.035.6), and previous dependence (or: 4.1, 95% ci: 2.18.0). Patients were less likely to be admitted to a stroke unit if they were previously dependent (or: 5.5, 95% ci: 2.711.3) or living in residential care (or: 8.5, 95% ci: 3.024.3). Patients with poor english proficiency were more likely to be dependent prior to their stroke (or: 2.9, 95% ci: 1.36.9). Patients admitted on a weekend were less likely to have a short length of stay (<4 days) or long length of stay (10 days) compared with weekday admissions (or: 0.4, 95% ci: 0.20.8 and or: 0.6, 95% ci: 0.31.0, respectively). There was also a trend for less likelihood of stroke unit care if admitted on a weekend . This analysis also demonstrated the potential redundancy in considering some non - age variables for their relevance to quality of allied health care . For example, an association between previous accommodation and previous independence was impossible to assess because all patients in residential care were, by default, also dependent . When this is considered in the light of earlier findings, previous independence may be the more important predictor variable because it is associated with process indicator compliance and has a stronger correlation than accommodation, with age . The complex confounding associations between the various non - age predictor variables are illustrated in figure 2 . In figure 3 we revisit our initial causal pathway, adding in the associations found between adherence to allied health process indicators, and the early predictor variables captured in patient demographic and stroke event data . This new pathway summarizes the journey for patients admitted with acute stroke and the multiple factors that can impact on the care they receive from allied health professionals . Mean age at stroke onset was 74.7 years (standard deviation [sd]: 13.5, range 18100 years). The mean length of stay in acute care was 12.5 days (sd: 15.6, range 198 days). The sample was proportionally balanced for gender . Despite similar mean ages for males and females, a larger proportion of females were in the older age groups, with 72% females aged 75 years or older, compared with 53% of males . A greater proportion of females suffered a moderate or severe stroke (28%) than males (18%). For the whole sample, there were weak relationships between increasing age and increasing stroke severity (r = 0.21) and comorbidity levels (r = 0.20). Compliance with each process indicator was generally poor (table 2, columns 2 and 3). For 16 of the process indicators (80%), the outcome of univariate logistic regression models, associating process indicator adherence with age, is reported as relative risks in table 2, column 4 . Only one process indicator had a significant association with age, where patients younger than 75 years were significantly more likely to receive first mobilization within 24 hours of stroke onset than older patients . Compliance with 12 of the 20 process indicators (60%) was significantly correlated with non - age variables . The only variables which were not associated with any process indicator compliance were previous accommodation type and english proficiency . For 30% of the process indicators significant correlations were found between patient age, and the predictor variables of stroke severity, comorbidity levels, premorbid accommodation, premorbid independence level, gender, english proficiency, and length of stay . In summary, compared with younger patients, patients 75 years or older were significantly more likely to have a moderate - to - severe or severe stroke (or: 1.8, 95% ci: 1.13.2 and or: 2.9, 95% ci: 1.46.1, respectively), to have higher comorbidity levels (or: 2.5, 95% ci: 1.54.2), to have lived in residential care (or: 2.6, 95% ci: 1.16.2), or been previously dependent (or: 6.2, 95% ci: 3.212). Older patients were also more likely to be female (or: 2.2, 95% ci: 1.43.6), to have a length of stay of 59 days (or: 0.6, 95% ci: 0.30.9), and to have poor english proficiency (or: 3.2, 95% ci: 1.19.7). Females were less likely than males to have been previously independent (or: 2.2, 95% ci: 1.43.7), more likely to have a moderate or severe (nihss 8) stroke (or: 0.4, 95% ci: 0.20.6), and a length of stay 10 days (or: 0.4, 95% ci: 0.20.7). Patients who suffered a moderate - to - severe stroke (nihss 8) were more likely to have lived previously in residential care (or: 0.3, 95% ci: 0.10.7), to have high comorbidity levels (or: 0.6, 95% ci: 0.40.98), and to have a length of stay 10 days (or: 2.6, 95% ci: 1.54.7). Compared with patients having low comorbidity, high comorbidity levels were associated with previous residential care (or: 8.3, 95% ci: 2.035.6), and previous dependence (or: 4.1, 95% ci: 2.18.0). Patients were less likely to be admitted to a stroke unit if they were previously dependent (or: 5.5, 95% ci: 2.711.3) or living in residential care (or: 8.5, 95% ci: 3.024.3). Patients with poor english proficiency were more likely to be dependent prior to their stroke (or: 2.9, 95% ci: 1.36.9). Patients admitted on a weekend were less likely to have a short length of stay (<4 days) or long length of stay (10 days) compared with weekday admissions (or: 0.4, 95% ci: 0.20.8 and or: 0.6, 95% ci: 0.31.0, respectively). There was also a trend for less likelihood of stroke unit care if admitted on a weekend . This analysis also demonstrated the potential redundancy in considering some non - age variables for their relevance to quality of allied health care . For example, an association between previous accommodation and previous independence was impossible to assess because all patients in residential care were, by default, also dependent . When this is considered in the light of earlier findings, previous independence may be the more important predictor variable because it is associated with process indicator compliance and has a stronger correlation than accommodation, with age . The complex confounding associations between the various non - age predictor variables are illustrated in figure 2 . In figure 3 we revisit our initial causal pathway, adding in the associations found between adherence to allied health process indicators, and the early predictor variables captured in patient demographic and stroke event data . This new pathway summarizes the journey for patients admitted with acute stroke and the multiple factors that can impact on the care they receive from allied health professionals . This paper provides new data regarding the possible predictors of allied health care quality for patients with acute stroke . The sample is robust because it is appropriately powered and derived from a consecutive sample of stroke patient records . Based on our findings, we suggest that the quality of acute stroke care contributed by allied health in multidisciplinary settings could be improved . This is the first known study to examine a range of individual processes of care by allied health professionals and the factors which may relate to compliance with these processes . The findings suggest a complex relationship between variables which may be related to the provision of best practice by allied health professionals caring for acute stroke patients . We acknowledge that the generalizability of the findings for some variables chosen in our study may be limited by international variations in health care systems and policy . Length of stay data and admissions directly to a stroke unit, for example, are both particularly influenced by local contexts . Variability in the roles of stroke team members must also be taken into account when interpreting our results . For example, in the study settings, speech pathologists and dietitians made a strong contribution to team decisions regarding enteral feeding (process indicator 12), but this may not be an allied health role in some settings . Furthermore, we recognize that, as part of a multidisciplinary team with shared roles and responsibilities, the work of the allied health professions can be difficult to consider separately . Correlates were found for older age, including increased stroke severity, higher comorbidity levels, previous residential care accommodation, previous dependence, female gender, poor english proficiency, and longer length of stay . These predictor variables were age proxies in our sample and may be stronger predictors of care decisions than patient age per se . Some medical literature suggest that the age of an acute stroke patient is a determinant of the quality of medical care for stroke.35,912 in allied health care, we suggest that other factors may be at work . Patient age had a strong correlation with only one quality process indicator (early first mobilization), and this process indicator was even more strongly correlated with stroke severity . Non - age variables were more frequently correlated with process indicator compliance (twelve indicators) than was patient age . Stroke severity was the most frequent predictor variable (seven process indicators), with length of stay the second most common predictor (five process indicators). This analysis also demonstrated the lack of importance of some non - age variables, such as previous residential care accommodation data made redundant by data on previous independence . It is possible that systematic variations between professions may contribute to age - related differences in the medical care provided following stroke, which do not apply to allied health care . It is recognized, for example, that older patients are under - represented in some of the primary stroke research which guides evidence - based medical diagnostics and interventions.3 patients over 80 years have been excluded from many thrombolysis trials,41 and similar age exclusions are reported for secondary prevention stroke medications.42 the evidence base for allied health stroke care is still in early development and may therefore have less influence on which patients receive particular elements of care . As well as practicing within the biomedical framework adopted by medical practice, many areas of care provided by allied health professionals also fit within a biopsychosocial model.43 these differences may result in different clinical reasoning processes and decision - making by the separate professions . Allied health professional decision - making regarding the care delivered to patients with stroke has not been well explored . There may be complex influences on the decisions they make about the care they provide to patients with acute stroke, underpinned by their perspectives of the role of non - age predictor variables on patient outcome . Our causal pathway (figures 1 and 2) suggests that many factors cannot be adjusted because they are a priori to the stroke . Ensuring the highest quality of allied health care for all stroke patients is important in the current climate of scarce resources and the increasing burden of stroke to the health sector . The associations identified between independent variables, including patient age, indicate that there are unlikely to be simple explanations for why some patients receive recommended care and others do not . To understand fully the important factors influencing the quality of care provided to acute stroke patients by allied health professionals will require further investigations into their perspectives on the capacity of stroke patients to improve, and how they make care decisions.

Different modalities of neuromodulation such as repetitive transcranial magnetic stimulation (schlaepfer et al ., 2003; george, 2010), vagus nerve stimulation (kosel and schlaepfer, 2003; schlaepfer et al ., 2008b), and magnetic seizure therapy (lisanby et al ., 2001; kayser et al ., 2010) have been proposed and systematically studied in psychiatric different disorders (schlaepfer et al ., 2010). Both clinically and scientifically the most promising method of neuromodulation might be deep brain stimulation (dbs). Dbs refers to the stereotaxic placement of unilateral or bilateral electrodes connected to a permanently implanted neurostimulator (schlaepfer and lieb, 2005b). The exact neurobiological mechanisms by which dbs exerts effects on brain tissue are not yet fully understood (hardesty and sackeim, 2007). Various mechanisms have been discussed, on the neuronal level, excitatory and inhibitory processes might play a role (mcintyre et al ., 2004). Today, it is unknown which part of the neuron (e.g., cell body, axon) is primarily modulated by dbs . Certainly, the stimulation volume is not a fixed area around the electrode and the effect on neuronal tissue is variable . Stimulation parameters (frequency, amplitude, pulse width, duration) also clearly have an impact on the effect (ranck, 1975). With commonly used parameters, a relatively large volume of neural tissue side effects in dbs are either related to the operation itself (e.g., bleeding, local infections at the chest) or to the stimulation (e.g., elevation of mood, anxiety, motor slowing). Fortunately, the safety of the stereotactic operation technique has been extremely improved in the last years with the help of neuroimaging . On the other hand, dbs has many advantages over traditional therapy methods: clinical effects can be achieved without irreversible lesioning, stereotactic operation is the most minimal neurosurgical method and electrodes can be completely removed if necessary . Furthermore, dbs offers the opportunity to continuously adjust stimulation variables for each patient in order to optimize therapy . The patient can turn off stimulation immediately if side effects occur . Dbs is the only neurosurgical method that allows blinded studies for therapy control . In comparison to antidepressant medication, nor side effects such as extrapyramidal effects, weight gain, that substantially effect compliance and patient s quality of life, are reported . Also no long - time side effects as in antidepressant treatments (geddes et al ., 2003; furukawa et al . Nonetheless, dbs can be associated with side effects due to stimulation that are transient and can be counteracted by a change in stimulation parameters (see table 1). But until it has been proven that dbs has the same clinical effect as pharmacotherapy, the latter together with psychotherapy must be the first treatment choice . Thus, dbs could become an exciting method in the treatment of depression and obsessive compulsive disorder (ocd) and offers unique possibilities to gain more insight into the underlying neurobiology of psychiatric disorders . Different modalities of neuromodulation such as repetitive transcranial magnetic stimulation (schlaepfer et al ., 2003; george, 2010), vagus nerve stimulation (kosel and schlaepfer, 2003; schlaepfer et al ., 2008b), and magnetic seizure therapy (lisanby et al ., 2001; kayser et al ., 2010) have been proposed and systematically studied in psychiatric different disorders (schlaepfer et al ., 2010). Both clinically and scientifically the most promising method of neuromodulation might be deep brain stimulation (dbs). Dbs refers to the stereotaxic placement of unilateral or bilateral electrodes connected to a permanently implanted neurostimulator (schlaepfer and lieb, 2005b). The exact neurobiological mechanisms by which dbs exerts effects on brain tissue are not yet fully understood (hardesty and sackeim, 2007). Various mechanisms have been discussed, on the neuronal level, excitatory and inhibitory processes might play a role (mcintyre et al ., 2004). Today, it is unknown which part of the neuron (e.g., cell body, axon) is primarily modulated by dbs . Certainly, the stimulation volume is not a fixed area around the electrode and the effect on neuronal tissue is variable . Stimulation parameters (frequency, amplitude, pulse width, duration) also clearly have an impact on the effect (ranck, 1975). With commonly used parameters, a relatively large volume of neural tissue side effects in dbs are either related to the operation itself (e.g., bleeding, local infections at the chest) or to the stimulation (e.g., elevation of mood, anxiety, motor slowing). Fortunately, the safety of the stereotactic operation technique has been extremely improved in the last years with the help of neuroimaging . On the other hand, dbs has many advantages over traditional therapy methods: clinical effects can be achieved without irreversible lesioning, stereotactic operation is the most minimal neurosurgical method and electrodes can be completely removed if necessary . Furthermore, dbs offers the opportunity to continuously adjust stimulation variables for each patient in order to optimize therapy . The patient can turn off stimulation immediately if side effects occur . Dbs is the only neurosurgical method that allows blinded studies for therapy control . In comparison to antidepressant medication, nor side effects such as extrapyramidal effects, weight gain, that substantially effect compliance and patient s quality of life, are reported . Also no long - time side effects as in antidepressant treatments (geddes et al ., 2003; furukawa et al . Nonetheless, dbs can be associated with side effects due to stimulation that are transient and can be counteracted by a change in stimulation parameters (see table 1). But until it has been proven that dbs has the same clinical effect as pharmacotherapy, the latter together with psychotherapy must be the first treatment choice . Thus, dbs could become an exciting method in the treatment of depression and obsessive compulsive disorder (ocd) and offers unique possibilities to gain more insight into the underlying neurobiology of psychiatric disorders . The main focus of studies on the underlying neurobiology of major depression (md) has focused on the description of biological differences between patients and healthy subjects such as alterations of monoaminergic or endocrine systems . The relative importance of the various biological changes has not been elucidated; correlation with specific symptoms of the disease has rarely been attempted . Psychotropic drugs work by altering neurochemistry to a large extent in widespread regions of the brain, many of which may be unrelated to depression . In contrast to some neurological disorders, the pathological interplay of several brain regions contributes to the behavioral, emotional, and cognitive symptoms of psychiatric disorders . Metabolic studies suggest that different symptoms are mediated by different brain regions (berton and nestler, 2006; yurgelun - todd et al ., 2007; krishnan and nestler, 2008) a convincing network - model of depression integrating biochemical, electrophysiological, imaging, and animal studies, has been described by mayberg (1997). According to this model, depression results from a dysregulation of limbic cortical connections: pathological changes in dorsal brain regions (including the dorsolateral prefrontal cortex, inferior parietal cortex, and striatum) were associated with cognitive symptoms (e.g., apathy, anhedonia, hopelessness, deficits in attention, and executive function), changes in ventral areas (hypothalamic pituitary adrenal axis, insula, subgenual cingulate, and brainstem) contribute to the vegetative and somatic aspects of depression (e.g., sleep disturbance, appetite, endocrine dysregulation). This model underlines the role of the rostral cingulate cortex in regulating the network (mayberg, 1997). The involvement of further regions in depression is discussed: the hippocampus contributes to memory deficits, the nucleus accumbens was associated with anhedonia and lack of motivation, the amygdala plays a role in the processing of aversive stimuli and avoidance (berton and nestler, 2006). Obsessive compulsive disorder is characterized by obsessions (anxiety - provoking thoughts) and compulsions (repeated, time - consuming behaviors; stein, 2002). As in most psychiatric disorders, a complex interplay of genetic factors, neurotransmitter changes and psychosocial characteristics contribute to the development of this disease . Dysfunctions in a network connecting the cortex and basal ganglia are supposed to underlie ocd . Imaging data demonstrated changes in orbitofrontal cortex, anterior cingulate cortex and caudate nucleus in ocd (baxter, 1990). Emerging evidence suggests that different alternations of the ocd circuitry subserve different symptom subtypes (kopell and greenberg, 2008). It has been hypothesized that an over activation of the direct pathway of the cortico - striatal pallidal thalamic cortical loop leads to intrusive thoughts (baxter et al ., 2001). These novel conceptualizations of both ocd and md, brought about mainly by advances in functional neuroimaging but also electrophysiological and molecular studies and their synthesis have paved the road to hypothesis - guided studies on targeted reversible neuromodulation with dbs in these disorders . The subgenual cingulate cortex (brodmann area cg25) has probably dysfunctional connections to the dorsal and ventral compartments of the emotion regulation circuit in depression (mayberg, 1997). The subgenual cingulate cortex modulates negative mood states (mayberg et al ., 2005b). It has been involved in acute sadness and in antidepressive treatment effects (mayberg et al . The rostral part of the cingulate cortex seems to play a key role in modulating the network of depression (mayberg, 1997). (2005b) could demonstrate, that 2 months after surgery, 5/6 patients met the response criterion [baseline score in the hamilton depression rating scale (hdrs) minus 50%], after 6 months, four patients showed sustained response . Different neuropsychological parameters that were impaired at baseline were significantly improved . A reduction in the pathological hyperactivity in this region has also been demonstrated using positron emission tomography (pet) in this study . During the blinded sham stimulation phase (n = 1), the patient s condition worsened considerably . No adverse events due to stimulation were observed (mayberg et al ., 2005b). (2009) investigated the use of dbs at the ventral capsule / ventral striatum (vc / vs). The vc / vs was targeted, because former studies targeting the vc / vs in ocd patients (nuttin et al ., 1999; greenberg et al ., 2006) showed improvement not only for ocd symptoms but also for depressive symptoms . This finding was supported by the fact that the vs has complex architecture and includes structures such as the bed nucleus of the stria terminalis and the nucleus accumbens, which are regions believed to be involved with stress - related and reward motivation components of depression (forray and gysling, 2004; epstein et al ., 2006). Once stimulation was titrated to therapeutic benefit and the absence of adverse effects, patients received significant improvements in depressive symptoms measured by the hdrs . Responder rates of 40% at 6 months (n = 15) and 53.3% at last follow - up (mean last follow - up of 23.5 14.9 months) receiving continuous dbs stimulation are referred . Remission rates were reported 20% at 6 months and 40% at last follow - up with the hdrs . So the results of this study suggest that dbs of the vc / vs could also provide benefit in highly treatment - refractory patients with depression . However, since the larger contacts of the vc / vs leads have twice the surface area of standard leads used in other dbs applications, more frequent battery replacements or rather implanting recharging batteries should be considered (malone et al ., 2009). We selected the nucleus accumbens as target for dbs because of its prominent role in the reward system . The nucleus accumbens is known to act as motivational gateway between systems involved in motor control and limbic systems in charge of emotion processing; especially the ventral striatum is uniquely located to modulate other regions of the brain (schlaepfer et al ., 2008a). By targeting one site in a network of brain regions implicated in processing of affective stimuli, it was possible to manipulate anhedonia in particular . It could be demonstrated that modulation of this structure was associated with changes in the symptoms of anhedonia and mood in three depressed patients . Normalization of brain metabolism in fronto - striatal networks as result of stimulation was also observed (schlaepfer et al . Results from a total of nine patients in this study show acute as well as long - term antidepressant effects of dbs at this target have been published recently, demonstrating a responder rate of 50% (bewernick et al ., the habenula has been proposed recently as target for dbs in depression (sartorius and henn, 2007). Animal data and imaging studies have shown, that this regions controls serotonergic fibers from the dorsal raphe nuclei and noradrenergic fibers from the locus coeruleus (winter et al . The authors hypothesize that over activation of the habenula is related to depression and recently reported on the course of depression after dbs to the habenula in a case report (sartorius et al ., 2010). Another putative target site for md has been proposed very recently, the medial forebrain bundle (coenen et al ., 2011). Magnetic resonance diffusion tensor imaging (dti) can visualize distinct functional circuits in the living human brain on the basis of the anisotropy of the brain tissue . This technique has been applied to an analysis of the different dbs sites for md and lead to the hypothesis - guided development of yet another site with hypothetically greater efficacy and even less unwanted effects . Single - case studies in ocd patients with comorbid depression have shown antidepressant effects: bilateral stimulation of the ventral nucleus caudatus in combination with nucleus accumbens for ocd led to remission of depression (hdrs_17 it was supposed that dysregulation of the connection between unspecific thalamic system and orbitofrontal cortex plays an important role in the development of depression (jimnez et al ., 2005). Therefore, bilateral stimulation of the lower thalamus stem was performed one depressed patient and led to remission (hdrs 42 10). Unfortunately, these regions are very large and not well circumscribed in relation to this disease . Thus the size of cortex region that needs to be modulated would be too large (lipsman et al ., 2007). In most studies, the anterior limb of the internal capsule was the target for either unilateral or bilateral stimulation (anderson and ahmed, 2003; gabriels et al ., 2003; nuttin et al ., 1999; nuttin et al ., 2003; all studies reported on promising results ranging from response to complete remission . In terms of side effects, some studies reported on induced, directly stimulation related symptoms of hypomania which all ceased completely after reduction of stimulation intensity . Zona incerta has been studied at three patients with parkinson s disease and comorbid ocd (mallet et al ., 2002; the subthalamic nucleus was stimulated in a study (malone et al ., 2009), this group included 16 patients and received significant lower symptoms of ocd . In a recent ocd study targeting the subthalamic nucleus, ocd symptoms were significantly reduced after the 3-months double - blind stimulation phase compared to the double - blind sham stimulation phase (mallet et al ., 2008). Both studies refer to possible associated risk of serious adverse events (mallet et al ., 2008; malone et al ., the nucleus accumbens and nucleus caudatus were target in one case study with comorbid depression (s above). Unilateral stimulation of the nacc in a well - designed, controlled study lead to somewhat less impressive but significant improvements results in 10 patients (huff et al ., 2010). The stimulation of the vc / vs led to a significant improvement in 50% of the patients side effects related to the stimulation were transient hypomania and increased anxiety, which could be counteracted by parameter change (greenberg et al ., 2006). Recently results of bilateral dbs to the nucleus accumbens in ocd with an open 8-month treatment phase, followed by a double - blind crossover phase with randomly assigned 2-week periods of active or sham stimulation, ending with an open 12-month maintenance phase have been published (denys et al ., 2010). Nine of the 16 patients were classified as responders, indicating that bilateral stimulation of the nucleus accumbens may be an effective and safe treatment in patients with highly refractory ocd . In summary, promising effects for different targets have been demonstrated, but as worldwide sample sizes are small, it is too early to select one favorable target if there is any . As ocd is a heterogeneous disease, there might be different optimal targets for different symptom clusters . The high mortality, low quality of life, and the social burden of inadequately treated serious psychiatric illness favor the use of dbs for treatment - resistant patients . The potential benefit to the understanding of pathological principles in mental disorders is evident (schlaepfer and lieb, 2005a; fuchs, 2006; ford, 2007; synofzik and schlaepfer, 2008, 2010). Fundamental ethical concerns are generally applicable to all clinical interventions (e.g., pharmacotherapy, psychotherapy) including dbs in neurological disorders . Foremost, are patients able to give conformed consent? It has been demonstrated that depressed patients show few impairments in decision - making capacity related to clinical treatment research (appelbaum et al ., 1999). Another concern is, how far human nature may ethically be manipulated (fuchs, 2006). Long - term effects of dbs cannot be evaluated yet, but in comparison to pharmacotherapy, brain stimulation is a more specific and reversible intervention . More problematic is the danger of misuse, such as for mind control or for over - enhancement of normal (healthy) cognitive function (brain doping; fuchs, 2006; ford, 2007). As clinical researchers in psychiatry, our aim is to help patients to lead a normal life, including normal cognitive function and personal autonomy . More practical ethical concerns are the availability of alternative treatment methods (e.g., pharmacotherapy, ect, psychotherapy). Taking to account that dbs is used only with treatment - resistant patients, who have already shown no benefit with other treatment approaches currently available, the apparent reversibility of dbs and its robust potential benefits, as described by prior pilot studies, are strong ethical arguments for considering dbs treatment for resistant psychiatric disorders (synofzik and schlaepfer, 2008, 2010). However, there are also some notable risks with dbs, particularly intracerebral bleeding and wound infection and its efficacy is not yet formally and extensively established in controlled trials . Therefore, until the dbs treatment method is scientifically validated; obligatory standards for patient inclusion and exclusion criteria as well as the selection of targets are needed . (2009), recommending 16 key points for guiding research and protecting the safety and rights of research subjects, as well as nuttin et al . (2002) to form a separate committee with only distant access to the individual patient or no direct involvement to the study for reviewing patient selection . It is our belief, that despite any committee review might it be as thorough and exhaustive as possible the clinical responsibility remains with the patient s clinicians and cannot be shared by review committees . So from our point of view further research regarding obligatory standards in dbs is needed . This is by no means unique to dbs, but this area is particularly vulnerable to bias because of an excessive reliance on single - patient case reports (schlaepfer and fins, 2010). Until cohort studies are routinely performed, the possibility will remain that only positive results will be published at the expense of negative data that might also have important implications . Balanced publishing of results is even more important taking to account, that patients and public understanding of the risks and benefits of dbs is strongly shaped by media (racine et al ., 2007). There are no fundamental ethic objections to its use in psychiatric disorders, but until substantial clinical data is available, mandatory standards are needed for patient and target selection, quality of research center, and study protocol . It is very important to point out that in the actual stage of research; dbs for psychiatric diseases is clinical research on therapeutics . The benefit of this method has to be proven first, until dbs will be available for many patients . Before, much more information about the therapeutic effect, individual predictors of response, possible short and long - time side effects, and neuroethical issues have to be gained . Deep brain stimulation is a unique and very promising method for the treatment of therapy resistant psychiatric patients . Nonetheless, the duration of the battery limits the choice of stimulation parameters, increases the risk of infection, and raises treatment costs . A particular advantage of dbs is, that it allows recording signals from the stimulating electrodes (cohen et al ., 2009a,2009b,2009c) and combining these data with functional neuroimaging in order to map the spatiotemporal unfolding of dbs - elicited whole brain activity will lead to a much broader knowledge on functional and dysfunctional circuits processing affective stimuli revealing fundamental mechanisms of brain function . 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.

If left untreated, ureteropelvic junction obstruction (upjo) can lead to hydronephrosis and progressive impairment of renal function . With success rates exceeding 98%, currently, several studies have reported on the high success rate of redo pyeloplasty . However, to our knowledge, the factors affecting functional outcomes after redo pyeloplasty have not yet been reported . Accordingly, the aim of this retrospective study was to evaluate changes in differential renal function (drf), as a functional outcome, in children who underwent redo pyeloplasty for the management of failed pyeloplasty and to outline the factors associated therewith . With approval from the institutional review broad of severance hospital (4 - 2014 - 0081), medical records were obtained from a database of patients who had undergone redo pyeloplasty between january 2002 and november 2010 at severance hospital in seoul, korea . During this period, a total of 21 children underwent redo pyeloplasty by a single surgeon (s.w.h .) At sevrance hospital . The initial pyeloplasties were performed at our institution in 11 children, and the remaining procedures were performed at other institutions . Information on preoperative drf and renal cortical thickness (rct) was not available for 3 patients who had undergone renal scintigraphy or ultrasound at other institutions, and these patients were excluded from the analysis . Failure of initial pyeloplasty was judged by either obstructive symptoms or signs . The decision to perform redo pyeloplasty depended on the presence of symptoms (e.g., urinary tract infection, flank pain), functional loss (deterioration of drf of more than 5%), and an aggravated obstruction pattern on a renogram or a huge urinoma . The patients were followed up postoperatively by use of serial ultrasound and renal scintigraphy for evaluating long - term functional outcomes . Follow - up ultrasound was performed at 4 to 6 weeks after the operation and was then repeated every 1 to 6 months thereafter, according to the results of a previous study . The degree of hydronephrosis was graded from 0 to 4 according to the society for fetal urology (sfu) classification scheme . Rct was measured in the sagittal plane at the level of the midkidney, as described by moghazi et al . . The measurement was obtained over the medullary pyramid, perpendicular to the capsule, and as the shortest distance from the base of the medullary pyramid to the renal capsule . Statistical comparisons of continuous variables in patient demographics were carried out by using the mann - whitney u - test . The wilcoxon signed rank test was used for paired comparisons of before and after the operation . The characteristics of the patients enrolled in this study af ter initial pyeloplasty are summarized in table 1 . All patients showed at least persistent or mild increases of hydronephrosis on ultrasound, with results on postoperative renal scintigraphy consistent with an obstruction . The mean interval between operations (between initial pyeloplasty and redo pyeloplasty) was 13.6710.33 months . The causes of redo pyeloplasty included persistent obstruction on renography related to worsening hydronephrosis or a huge urinoma on ultrasound or the development of symptomatic obstruction, such as urinary tract infection and recurrent pain . With a mean follow - up period of 44.8328.86 months both showed increased drain output and a huge urinoma on an ultrasound after the first pyeloplasty . Thus, we first attempted ureteral stent insertion, which failed . Within about 1 week, redo pyeloplasty was performed . Was determined on the basis of viability and fibrotic changes in the upj, as well as the presence of perinephric tissue . Drf on renal scintigraphy worsened after the initial pyeloplasty in 6 patients, who showed deterioration of renal function (decrease of more than 5%); was stable in 11 patients; and slightly increased in 1 patient . The mean drf of diseased kidneys before and after initial pyeloplasty was 45.77%6.05% and 38.72%15.44%, respectively . At approximately 6 months after redo pyeloplasty, the mean drf increased to only 40.50%15.12%, a difference that was not significant . After redo pyeloplasty, prevention of further functional deterioration was recorded in two - thirds of the patients but not in the remaining one - third (fig . When we evaluated hydronephrosis grade with serial ultrasound after redo pyeloplasty, all patients showed an improvement in hydronephrosis grade compared with that before redo pyeloplasty . The mean ages were 55.5072.1 months in the decrease in drf group and 55.5047.15 months in the no decrease in drf group (p=0.616). The mean follow - up duration between operations was 13.6612.40 months in the decrease in drf group and 13.666.77 months in the no decrease in drf group (p=0.682). The mean drf before initial pyeloplasty was 45.16%5.60% in the decrease in drf group and was not significantly different from that (46.08%6.41%) in the no decrease in drf group (p=0.604). Gender, hydronephrosis grade, and operation type (dismembered vs. nondismembered; stented vs. unstented) were not statistically different between the two groups . Ddrf was calculated as the difference in drf between before and after initial pyeloplasty . In the decrease in drf group, the mean ddrf was -23.00%12.31% . In the no decrease in drf group, the mean ddrf was 0.91%4.62% . In the decrease in drf group, drf was significantly decreased between before and after initial pyeloplasty (p=0.028); in the no decrease in drf group, the difference was not significant (p=0.397). Drct was calculated as the difference in rct between before and after initial pyeloplasty . In the decrease in drf group, the mean drct (-3.562.9 mm) was higher than that in the no decrease in drf group (-0.410.27 mm), a significant difference between the two groups (p<0.001). Additionally, we calculated rdrf as the difference in drf between before and after redo pyeloplasty, as a reflection of the level of recovery of drf after redo pyeloplasty . In the decrease in drf group, the mean rdrf was 1.16%2.99% . In the no decrease in drf group, it was 2.08%3.23% . The difference in rdrf between the two groups was not significant (p=0.541) (table 2). Finally, we noted a significant positive correlation between drct and ddrf (differences between before and after the initial operation; p<0.001; r2 linear=0.716). Meanwhile, patients with a decline in drf of more than 5% showed greater decreases in rct (fig . The patient showed no change in hydronephrosis grade (sfu grade 3) and reported experiencing flank pain after redo pyeloplasty . Therefore, we performed double j stent insertion at 1 month after the redo operation . Drf on renal scintigraphy worsened after the initial pyeloplasty in 6 patients, who showed deterioration of renal function (decrease of more than 5%); was stable in 11 patients; and slightly increased in 1 patient . The mean drf of diseased kidneys before and after initial pyeloplasty was 45.77%6.05% and 38.72%15.44%, respectively . At approximately 6 months after redo pyeloplasty, the mean drf increased to only 40.50%15.12%, a difference that was not significant . After redo pyeloplasty, prevention of further functional deterioration was recorded in two - thirds of the patients but not in the remaining one - third (fig . Before redo pyeloplasty, 14 patients were hydronephrosis grade 4 and the others were hydronephrosis grade 3 . When we evaluated hydronephrosis grade with serial ultrasound after redo pyeloplasty, all patients showed an improvement in hydronephrosis grade compared with that before redo pyeloplasty . The mean ages were 55.5072.1 months in the decrease in drf group and 55.5047.15 months in the no decrease in drf group (p=0.616). The mean follow - up duration between operations was 13.6612.40 months in the decrease in drf group and 13.666.77 months in the no decrease in drf group (p=0.682). The mean drf before initial pyeloplasty was 45.16%5.60% in the decrease in drf group and was not significantly different from that (46.08%6.41%) in the no decrease in drf group (p=0.604). Gender, hydronephrosis grade, and operation type (dismembered vs. nondismembered; stented vs. unstented) were not statistically different between the two groups . Ddrf was calculated as the difference in drf between before and after initial pyeloplasty . In the decrease in drf group, the mean ddrf was -23.00%12.31% . In the no decrease in drf group, the mean ddrf was 0.91%4.62% . In the decrease in drf group, drf was significantly decreased between before and after initial pyeloplasty (p=0.028); in the no decrease in drf group, the difference was not significant (p=0.397). Drct was calculated as the difference in rct between before and after initial pyeloplasty . In the decrease in drf group, the mean drct (-3.562.9 mm) was higher than that in the no decrease in drf group (-0.410.27 mm), a significant difference between the two groups (p<0.001). Additionally, we calculated rdrf as the difference in drf between before and after redo pyeloplasty, as a reflection of the level of recovery of drf after redo pyeloplasty . In the decrease in drf group, the mean rdrf was 1.16%2.99% . In the no decrease in drf group, it was 2.08%3.23% . The difference in rdrf between the two groups was not significant (p=0.541) (table 2). Finally, we noted a significant positive correlation between drct and ddrf (differences between before and after the initial operation; p<0.001; r2 linear=0.716). Patients without deterioration of renal function showed almost no change in rct . Meanwhile, patients with a decline in drf of more than 5% showed greater decreases in rct (fig . During the follow - up period, we observed one complication associated with redo pyeloplasty . The patient showed no change in hydronephrosis grade (sfu grade 3) and reported experiencing flank pain after redo pyeloplasty . Therefore, we performed double j stent insertion at 1 month after the redo operation . Since anderson and hynes reported on the first successful dismembered pyeloplasty in 1891, many advances have been made in the surgical management of upjo . However, the basic surgical principles have remained largely the same, including the meticulous preservation of the ureteral blood supply, construction of a widely patent and watertight anastomosis, and careful tissue handling . These principles have allowed dismembered pyeloplasty to be successful in relieving upjo in up to 98% of cases . Even when patients are optimally managed, however, pyeloplasty fails in a small but steady proportion of patients . Several treatment approaches exist for secondary upjo af ter failed pyeloplasty . Among them, redo pyeloplasty, by use of both open and minimally invasive techniques, appears to be the most effective, with success rates higher than 90% among pediatric patients . Therefore, in the present study, we set out to evaluate changes in drf and rct by use of serial renal scintigraphy and ultrasound . In doing so, we found that, after redo pyeloplasty, drf on renal scintigraphy was similar to that after failed pyeloplasty, reflecting the difficulties of recovering initial renal function . In previous studies, researchers noted that drf significantly improved in children with immediate or delayed pyeloplasty . On the other hand, another study reported that anderson - hynes pyeloplasty had no effect on renal function after surgery and that the increase in renal function at follow - up in infants might be attributable to their normal growth potential . In light of our results nonetheless, prior to conducting this study, we assumed that recovery of renal function after redo pyeloplasty would reflect preservation or improvement in initial drf . However, when we compared two groups of patients divided according to a decrease in drf of more than 5% of initial drf, ddrf was shown to be a factor that significantly contributed to functional recovery after redo pyeloplasty in pediatric patients . We discerned this to mean that severe reductions in renal function after an initial surgery may greatly affect the likelihood of recovering initial renal function after redo pyeloplasty . For detecting severely reduced drf after a failed pyeloplasty, we attempted to assess rct as another factor of recoverability of renal function . Herein, drct was shown to be a significant factor that affected the functional outcome of redo pyeloplasty . Previously, harraz et al . Reported that, after the relief of obstruction, there is a tendency for renal function to recover, irrespective of nephron mass, as determined by cortical thickness . Other investigators have also reported rct as a powerful predictor of renal function . In connection with these reports, we found a positive correlation between ddrf and drct in patients who experienced a failed pyeloplasty . Accordingly, we think that drct could be a predictor of ddrf in patients scheduled to undergo redo pyeloplasty, which may help physicians in predicting the likelihood of recovering initial renal function thereafter . Although rct on ultrasound could present bias in the outcome measure, standardized measurement of rct with serial ultrasound would be helpful to determine the benefits of a secondary operation . Additionally, we evaluated changes in hydronephrosis after redo pyeloplasty . Most patients showed an improvement in hydronephrosis after redo pyeloplasty, although normalization was rare . In primary pyeloplasty, park et al . Reported that both symptomatic cases and delayed improvements in hydronephrosis (i.e., up to 6 months) were identified as risk factors for lack of normalization . Therefore, the possibility of normalization after redo pyeloplasty seems to be lower than that after initial pyeloplasty . Nevertheless, we must acknowledge the limitations of our report, including the inherent drawbacks of the retrospective design and the lack of bias control . Also, the accuracy of using renal scintigraphy as a measure of renal function is in question . Although large - scale studies are needed to draw more definitive conclusions, these are difficult owing to the very low failure rate of pyeloplasty . As strengths of our study, however, the data in our series were collected from patients who underwent redo surgeries performed by a single surgeon and included many variables that might predict drf recoverability after redo pyeloplasty . Accordingly, we believe that our study is important to establishing the concept of a renal functional outcome for predicting improvement after redo pyeloplasty . Such a concept would better equip physicians for proper counseling of patients before surgery and for making successful surgical decisions . Redo pyeloplasty should be considered in cases of failed pyeloplasty in order to preserve renal function and to offer relief from symptoms . In patients who underwent redo pyeloplasty, ddrf and drct were shown to be factors affecting the functional outcomes of this procedure . Meanwhile, in patients who show severe deteriorations in drf or decreases in rct after initial pyeloplasty, recovery of initial drf after redo pyeloplasty may be difficult . Therefore, redo pyeloplasty should be performed before severe deterioration of drf or decreases in rct . Reoperation is a psychologically large burden on the operator, and the reoperation itself is more difficult than the initial operation because of the adhesive surgical field and poor tissue condition of the renal pelvis and ureter . Complicated surgical techniques such as flap surgery or ureterocalicostomy should be applied in some cases . Owing to the rarity of reoperation cases, knowledge about redo pyeloplasty has usually been gained through the experience of an individual surgeon . First, after initial pyeloplasty, the postoperative result is not as simple and conclusive as " surgical failure . " Sometimes, it is not easy for the surgeon to decide on reoperation . Discrepancies may exist in the imaging studies between the sonographic findings and excretion and renal function in the diuretic renogram . Some patients show delayed excretion despite moderate improvement of hydronephrosis . In particular, postoperative transient hydronephrosis could be present and a " wait - and - see " approach is considered because most cases improve spontaneously . In case 1, differential renal function (drf) was 46% and hydronephrosis was grade 3; thus, the " wait - and - see " approach could be considered if the patient did not show flank pain or urinary tract infection . Second, in a very poorly functioning kidney, maybe as the result of obstruction or infection, is it meaningful to perform redo pyeloplasty? 10 and 15, the drf was only 1% and 6%, respectively; thus, functional recovery was not expected in these cases . In my experience, functional improvement can be achieved only in the case of an acute high - grade obstruction . Double j stenting and follow - up evaluation of functional change could be an option to predict functional restoration after the operation . Finally, the author concluded that recovery of drf after redo pyeloplasty is difficult in patients who show severe deteriorations in drf or a decrease in renal cortical thickness after the initial pyeloplasty . The title of this article implicates the author's conclusive mind that delayed redo pyeloplasty fails to recover lost renal function . The authors suggest that one should not hesitate to perform reoperation in cases of postoperative findings such as sonographic changes and loss of renal function . Although it is not easy for surgeons to recommend reoperation during follow - up, it is worse to delay the decision for reoperation in cases showing definite deterioration . Eventually, the deterioration causes superimposed urinary tract infection and flank pain and finally leads to decreased renal function . We acknowledge the limitations of this study, especially the unaccounted for compounding surgical factors such complicated surgical field conditions and the location and degree of stricture, which were unavoidable owing to the study design . Despite this limitation

The hydatid cyst is a zoonosis caused by adult or larval stages of tapeworms belonging to the genus echinococcus granulosus . The tapeworm stage is harbored in the intestine of carnivores such as dogs, which constitute the definitive host, and the eggs are passed in the feces of the infected carnivores and ingested by herbivores such as sheep, which comprise the intermediate host . Larvae emerge from the eggs in the intestine; and after invasion to the blood vessels, they can migrate into almost every part of the body . The usual destination is the liver via the portal tract, but sometimes the larvae pass through the liver barrier and reach the lungs and all the other viscera, where they transform into small cysts . Echinococcosis / hydatidosis is one of the most important zoonotic diseases inasmuch as it occurs in different parts of iran . Adult worms have been recovered from dogs, jackals, and wolves, but human cases have been reported from hospital archives by pathological reports of surgically proven cases in different geographical areas of the country . In nearly all the previous reports, the liver was the most common location of the hydatid cyst, followed by the lung, with the approximate occurrence rates of 70% and 12%, respectively . There is a small number of reports of higher incidence rates of lung involvement in iran, but such cases are very unusual . The reported incidence in children has been a point of controversy in a few previous investigations, reporting incidence rates of 41 - 70% for the lung and 43 - 48% for the liver hydatid cyst . Although most reported iranians with echinococcosis had cysts in their lungs and livers, more unusual cyst locations were also recorded . In a few previous reviews on hydatidosis form iran, unusual body sites such as the heart, orbit, brain, muscle, salivary gland, bone, urinary tract, and pancreas were reported . The aim of this paper is to provide an overview of the published cases of the hydatid cyst in unusual body sites from iran to delineate the most important demographic findings and locations of the disease in this hyperendemic country . The published cases of the hydatid cyst in unusual body sites from iran were reviewed via a search in pubmed, scopus, google scholar, iranmedex, scientific information database (sid), magiran, and irandoc (1990 - 2011), using the keywords of hydatid cyst and iran and echinococcus granulosus and iran . The following inclusion criteria were employed: 1) articles must be written in english and farsi; 2) articles must have been published between 1990 and 2011; 3) studies must be from iran and contain case report(s), diagnosing the hydatid cyst in unusual locations (i.e. Other than the liver and lung); and 4) cases must have been pathologically confirmed postoperatively . In the last 20 years, about 463 cases of the hydatid cyst located in different parts of the body, excluding the liver and lung, have been published from iran . The published cases of the hydatid cyst with unusual locations from iran the most common locations were the central nervous system (brain, spinal cord, and orbit), musculoskeletal system, heart, and kidney, whereas some less common locations were the spleen, pancreas, appendix, thyroid, salivary gland, adrenal gland, breast, and ovary . Most of the published cases were reported from tehran (as a referral center for the whole country); nevertheless, other centers such as khorasan, azerbaijan, fars, isfahan, and yazd also reported unusual locations of the hydatid cyst . Central nervous system in the last 20 years, about 256 cases of the hydatid cyst in the brain, spinal cord, and orbit have been reported form different geographical areas of iran . There are two reviews by abassioun et al . Who reported 69 cases of the brain hydatid cyst . These patients were 3 to 50 years of age, with a slight male preponderance . Among these 69 reported cases, 5 cysts were in the posterior fossa, 2 in the cerebellum, one in the cp angle, one in the fourth ventricle, one in the pons, and 59 cases in the brain parenchyma . The hydatid cyst of the orbit in the above - mentioned review was detected in 28 patients, with an age range of 5 to 54 years . Abassioun et al . Also reported 36 cases of the spinal hydatid cyst, both intra and extradural, 20 of which were male and 16 cases were female patients . Apart from the above reviews, 105 other intracranial hydatid cysts were reported in 73 males and 32 females, with an age range of 5 to 60 years . Most of the intracranial hydatid cysts were within the brain hemisphere, and the most common presenting symptoms were headache and vomiting . As a rule, the hydatid cyst of the brain tends to be solitary and spherical . Serologic tests are not diagnostic, and imaging studies such as computed tomography (ct) scan and magnetic resonance imaging (mri) are necessary for preoperative diagnosis . There were 11 cases of the spinal hydatid cyst; they were all adults above 20 years of age and presented with signs and symptoms related to cord compression such as low back pain, radicular pain, and paraparesis . The majority of the spinal hydatid cysts were extradural, and primary intradural hydatid cysts were very rare . Aside from the aforementioned review, the orbital hydatid cyst was rarely reported form iran: there were only 8 cases, all presenting in childhood . The reported symptoms were visual impairment and proptosis, and anatomically most of the orbital cysts were in the intraconal space because most branches of the ophthalmic artery supply the intraconal space . Musculoskeletal system in the last 20 years, the skeletal hydatid cyst has been reported in 44 patients, comprised of 28 males and 16 females with an age range of 5 - 71 years (mean age=41.5 years). The locations of the skeletal hydatid cysts were varied such as the maxillary sinus, mandible, knee, long bones, and ilium . The clinical manifestations of the osseous hydatid cyst may take a long time to become obvious, and that is when the cyst is detected by swelling, pathologic fracture, and secondary infection . The bone hydatid cyst is polycystic in contrast to other non - osseous locations, which is because of the absence of adventitia around the cyst . The diagnosis of the osseous hydatid cyst is based on imaging modalities such as ct scan . The hydatid cyst involvement of the skeletal muscle is even less common than that of the bone . In our review of iranian cases, we found 11 reported patients, 8 males and 3 females with an age range of 22 - 80 years (mean age=29 years), with the hydatid cyst of the skeletal muscle . The reported locations were in the latissmus dorsi, gluteal muscle, cervical muscles of the paraspinal area, and thigh . The most common presenting symptoms were painless swelling, causing symptoms secondary to the compression effect on the adjacent organs . Radiological studies, including mri, are the mainstay of the preoperative diagnosis of the skeletal muscle hydatid cyst . Cardiovascular system the third most common unusual location of the hydatid cyst reported from iran is the cardiovascular system, with 42 cases having been reported in the last 20 years . The cases comprised 25 males and 17 females with an age range of 8 to 73 years (mean age=29.5 years). Most of the cardiac hydatid cysts were located in the ventricular wall, and the most common presenting symptoms were angina, dyspnea, and palpitation, in consequence of the pressure effects of the cyst on the coronary and conducting system . Likewise, only 2 cases of the intrapericardial, and endocardial, hydatid cysts were reported from iran . The vascular hydatid cyst in the aorta and superior vena cava with invasion to the myocardium was reported in a study from iran . There were reports of very infrequent asymptomatic cases of the hydatid cyst of the heart detected during ekg evaluations for another surgery . Serologic tests are positive in about 50% of the patients, but transesophageal echocardiography (tee) is known as the imaging procedure of choice for the diagnosis of the cardiovascular hydatid cyst . Kidney and urinary tract our investigation yielded 31 published cases, 23 males and 8 females with an age range of 9 to 73 years (mean age=44 years), of the hydatid cyst of the kidney and urinary tract . Among these cases, 29 patients had the renal hydatid cyst and 2 had the bladder wall hydatid cyst . There is no serologic and immunological test pathognomonic for the diagnosis of the renal hydatid cyst, but ultrasonography and, in particular, ct scan can be of great help . There were 20 cases of the splenic hydatid cyst from iran in 13 males and 7 females with the reported age ranging from childhood to 75 years . The splenic hydatid cyst exhibits a variety of clinical features, requiring a high index of suspicion for diagnosis . Uterus, ovary, and fallopian tube there were 9 published cases, with a mean age of 50 years (mean age=34 - 84 years), of the ovarian hydatid cyst from iran . The uterine hydatid cyst is extremely rare, and only one case was reported from iran with the accompanied involvement of the fallopian tube in a 25-year - old female, who presented with lower abdominal pain . The diagnosis was made after laparotomy for the evaluation of the cause of the symptoms . The most popular methods of diagnosis are ultrasonography, ct scan, and mri, all of which are much more sensitive than immunologic tests . In the last 20 years, 6 patients, 4 males and 2 females with a mean age of 34.5 years, have been reported with the pancreatic hydatid cyst . This cyst usually manifests as an epigastric mass, recurrent acute pancreatitis, chronic pancreatitis, and obstructive jaundice . Complications of the pancreatic hydatid cyst depend on the relationship between the cyst and the pancreatic duct . The methods of choice for the diagnosis of the pancreatic hydatid cyst are ct scan and mri . There were 9 published cases, 4 males and 5 females with a mean age of 16.5 years, of the hydatid cyst of the salivary gland: 7 in the parotid gland and 2 in the submandibular gland . Eight cases of the breast hydatid cyst were published from iran, all in the female breast with a median age of 40.7 years . The most common presenting symptom was a well - defined palpable breast mass, which can be confirmed by mammography and ultrasonography . In the last 20 years, only 4 cases of the thyroid hydatid cyst have been reported from iran, all in females between 17 and 35 years of age (mean age=14.3 years). The patients with the thyroid hydatid cyst presented with pressure symptoms and signs of dyspnea, hoarseness, goiter, and dysphagia . Clinically, the thyroid hydatid cyst presents with a solitary mass, mimicking a thyroid cystic nodule . The diagnosis can be made by fine needle aspiration (fna) and isotope scanning . The adrenal hydatid cyst in iran was reported in only 2 cases: a 49-year - old female and a 42-year - old male . The adrenal hydatid cyst is mostly asymptomatic and is incidentally found by imaging; on rare occasions, however, it can cause hypertension . Another case was reported, presenting with vague flank pain with a primary diagnosis of a renal tumor, for which surgery was undertaken . There was only one reported case of the appendiceal hydatid cyst from iran, diagnosed after laparotomy in a 47-year - old male worker presenting with vague abdominal pain . Seven cases, 5 males and 2 females with a mean age of 28.7 years, of the mediastinal hydatid cyst were reported from iran . Omentum and retroperitoneum seven cases of the mesenteric, diaphragmatic, omental, pelvic, and retroperitoneal hydatid cyst have been reported from iran in the last 20 years . These cases may remain asymptomatic until reaching a large size, and the clinical signs vary according to the site . The parapharyngeal hydatid cyst in a 41-year - old female, and the nasolabial hydatid cyst in an 11-year - old adolescent, were the last two extremely rare case reports in this review from iran . Hydatid disease is a unique parasitic disease that is endemic in many parts of the world . This parasitic disease is a significant public health concern in iran, as an endemic country, rendering a review of the published cases of hydatid disease from this hyperendemic country vitally important . In hydatid disease, the liver and lung are the most common involved organs, but the disease can be seen in any organ of the body . The rates of the localization of hydatid disease in different body organs vary in the literature . All the published cases in iran included in this review are based on hospital experiences proven postoperatively by pathological examination . Our results demonstrated that the most common locations of the hydatid cyst, after the lung and liver, were the central nervous system, orbit, musculoskeletal system, cardiovascular system, kidney, and urinary tract . There were also reports of the spleen, uterus, ovary, pancreas, salivary gland, breast, adrenal, appendix, mediastinum, omentum, and retroperitoneum hydatid cysts . The clinical manifestations in the hydatid cyst of most parts of the body are too nonspecific to make a diagnosis based on the signs and symptoms before surgery . In all of the previous reports from iran and all around the world, it has been shown that serologic tests have many false - negative results, but imaging modalities such as ultrasonography, ct scan, and mri have been the methods of choice, especially the latter, which has been the diagnostic method of choice for the preoperative diagnosis of the hydatid cyst in most unusual locations . The best treatment for the hydatid cyst is surgical excision, accompanied by postoperative medical therapy . The next part of this review presents the salient points of each unusual site of the hydatid cyst extracted from the most recently published literature . Central nervous system, spinal cord, and orbit the cerebral and spinal cord hydatid cysts are very rare . Indeed, the existing literature contains about 300 articles, accounting for 2 - 3% of all the cases of hydatidosis . The most common location is the intraparenchymal supratentorial, and the most common presenting symptoms are headache and weakness in the previous reports from other parts of the world, which is very similar to the cases published from iran . In the last 20 years, 256 cases of the central nervous system hydatid cyst have been published from iran . This cyst site accounted for the third common site of the hydatid cyst after the lung and liver . According to the recent literature, this cyst accounts for about 1% of all the cases of the hydatid cyst . In this location, the intravertebral discs are usually preserved because the disease tends to progress beneath the periosteum and ligaments . The orbital hydatid cyst accounts for about 1 - 2% of the cases in the previous literature and is most commonly detected in childhood . Musculoskeletal system osseous hydatid disease and muscular hydatidosis are uncommon and account for 0.5 - 4% and 0.5 - 2.5% of all hydatidosis cases, respectively (in endemic areas). The most common locations of the osseous hydatid cyst are the vertebra, pelvis, and long bones in the previous records from other parts of the world . However, in the published cases form iran, there were 55 cases with variable locations such as the long bone, mandible, maxilla, and pelvis . Muscle involvement of the hydatid cyst is reported as an uncommon location, because of high lactic acid, which is not a suitable environment for the parasite . Cardiovascular system the heart and large blood vessels also have been reported as the common unusual body sites of the hydatid cyst in endemic areas of the world, accounting for 0.5 - 2% of all the reported cases . The diagnostic method unique for this part of the body is echocardiography, which has been claimed as the method of choice for the diagnosis of the cardiac hydatid cyst . Nonetheless, ct scan and mri are also helpful in other parts of the body . Kidney and urinary tract the kidney is the most common location in the urinary tract and has been reported in about 2 - 3% of all cases of the hydatid cyst . In many of the previous reports from other parts of the globe, the kidney is reported as the third common site of the hydatid cyst after the liver and lung . In our survey of the published cases from iran, however, the renal hydatid cyst was the fourth most common location of the hydatid cyst . The clinical symptoms are nonspecific, and the only interesting and diagnostic symptom reported is hydatiduria . The hydatid cyst of the urinary bladder is even less common, and only 2 cases were published from iran . This cyst can also present with hydatiduria and is, otherwise, extremely difficult to diagnose before surgery . Less than 2 - 5% of the cases of the hydatid cyst have been reported from the spleen . Many of the reported splenic hydatid cysts worldwide are asymptomatic, and a very small number of patients show nonspecific left upper quadrant pain . Uterus, ovary, and fallopian tube the ovary is the most common site of hydatidosis in the female genital tract, but overall it is extremely uncommon (less than 1%). The clinical presentations are very nonspecific, and making a correct preoperative diagnosis is very difficult . There were only 9 cases of the ovarian hydatid cyst published from iran . The uterine hydatid cyst is even less common than ovarian hydatidosis, and its occurrence is exceptional . The clinical presentation of this cyst is also very nonspecific, and it is difficult to diagnose the cyst before surgery . Only one case of the uterine hydatid cyst was reported from iran . The hydatid cyst of the fallopian tube is most often accompanied by the ovary hydatid cyst and can cause infertility and spontaneous rupture of the tube . The pancreatic hydatid cyst is very uncommon and accounts for less than 1% of the cases . There are reports from iran and other parts of the world about the diagnosis of the salivary gland hydatid cyst via fna cytology . This cyst is reported to be capable of causing anaphylaxis and dissemination, but there are increasing numbers of reports on the diagnosis of the salivary gland hydatid cyst via fna, without any complications . The breast involvement of the hydatid cyst is rare, with a reported incidence of 0.27% . Mammography, ct scan, and mri can help to diagnose the breast hydatid cyst before surgery . However, there are rare case reports of preoperative diagnosis by fna cytology without complications . The hydatid cyst of the thyroid is very rare and clinically presents like a simple colloidal cyst . For all the reports of the role of fna in the diagnosis of the thyroid hydatid cyst, as is the case in the salivary gland and breast, its application is controversial . The adrenal hydatid cyst is most often asymptomatic, but reports of hypertension are also available . In our survey, only 2 cases of the adrenal hydatid cyst were reported from iran; both patients underwent surgery with the impression of the adrenal cyst . The hydatid cyst of the appendix is exceptional, and fewer than 10 cases have been reported worldwide . The mediastinal hydatid cyst is uncommon but it should be included in the differential diagnosis of the mediastinal cyst in endemic parts of the world . Our findings yielded 7 cases from iran, presenting with cardiac or respiratory problems . Omentum and retroperitoneum the omental and retroperitoneal hydatid cysts are very uncommon, but these cysts can become huge in size . The hydatid cyst can present in any part of the body and no site is immune . These unusual locations often produce nonspecific symptoms; consequently, it is advisable that the hydatid cyst be considered in the differential diagnosis of all cysts of the body, especially in endemic countries such as iran.

Neurocysticercosis is the most common parasitic disease of the central nervous system leading to seizures worldwide . Humans develop cysticercosis when they ingest eggs of the tapeworm taenia solium usually found in fecal - contaminated water or food . Neurocysticercosis (ncc) is endemic to many parts of the world [37] and is becoming an increasingly important cause of seizures in the united states due to immigration from mexico and central and south america [8, 9]. Seizures in ncc most commonly arise as a result of the granulomatous responses to dead cysts in the brain . The granulomatous response is associated with production of several cytokines including t helper 1 (th1) cytokines such as interferon gamma (ifn-), interleukin-2 (il-2), and interleukin-12 (il-12). T. crassiceps infection in mice is an experimental model for t. solium cysticercosis in man [1115]. Intraperitoneal inoculation with 10 cysts of t. crassiceps results in the entire peritoneal cavity of the mouse demonstrating granulomatous inflammation within 36 months . Similar to human infection, minimal granulomatous inflammation is found surrounding live parasites; rather, granulomatous inflammation is initiated when the parasite dies . The mediators contributing to development of granulomas around the dead parasite and production of proinflammatory cytokines are not completely understood . We previously detected substance p (sp) protein within granulomas associated with t. crassiceps infection [16, 17]. We also demonstrated that levels of il-2, ifn-, il-4, and il-10 protein were significantly higher in granulomas from infected wt mice than granulomas from infected spp - knockout or the sp - receptor (neurokinin 1, nk1) nk1-knockout mice [16, 17]. In addition, we detected mrna for il-1, il-1, il-1 receptor antagonist, and tnf- in all granulomas derived from infected wt mice . However, corresponding proteins levels were not assessed nor was the contribution of sp signaling to their mrna and protein production and to granuloma formation . The current studies were aimed at determining if sp and nk1 contributed to granuloma development and/or to production of il-1, tnf-, and il-6 in cysticercosis . Sp stimulates production of proinflammatory cytokines such as of il-1, il-6, and tnf- by human peripheral mononuclear cells, bronchial cells, and astrocytes [1929] sp also contributes to inflammatory processes associated with other infectious diseases . Sp injection induced recruitment of leukocytes into the pleural cavity of mice and into the skin of humans [1929] and stimulated the migration of human fibroblasts and peripheral blood lymphocytes in studies using modified boyden chambers or micropore filter analysis, respectively [1929]. In the current studies, we determined granuloma size and measured levels of il-1, tnf-, and il-6 protein within granuloma obtained from t. crassiceps - infected wt and mice deficient in spp or nk1 . These studies indicate that sp signaling contributes to granuloma development and proinflammatory cytokine production in t. crassiceps infection and suggests a potential role for this mediator in human cysticercosis . Female mice were infected by intraperitoneal inoculation with 10 cysts of the orf strain of t. crassiceps, as described in [16, 17]. Three months following infection, the mice were euthanatized by cervical dislocation under anesthesia using a combination anesthetic sacrifice rodent cocktail ketamine, 25 mg / kg, acepromazine 0.8 mg / kg, xylazine 5 mg / kg intraperitoneally, at a dose of 0.50.7 ml / kg intramuscularly . Granulomas associated with dying cysts were removed from the peritoneal cavity of each of the infected mice that were euthanized . Three groups of mice were included in the experiments: (1) wild type c57bl/6 mice; (2) preprotachykinin or spp - knockout mice (jackson laborotories, maine, usa, bred> 10 generations onto the c57bl/6 background); (3) nk1-knockout mice provided by dr . Joel weinstock, tufts new england medical center, boston, usa, bred> 10 generations onto the c57bl/6 background . Three to 8 infected mice from each of the 3 groups were used for this study; 415 granulomas per mouse group were used for this study . Granulomas associated with parasites were identified visually, removed from the peritoneal cavity, and either used for quantifying cytokine proteins by elisa or used for size determinations . Intact granuloma was obtained from t. crassiceps - infected wt mice (2 granulomas), spp - knockout mice (4 granulomas), and nk1-knockout mice (3 granulomas), fixed with 4% paraformaldehyde, paraffin imbedded and completely sectioned by microtome into 7 micron sections . The area of granuloma within each section was measured using image j software (nih). The volume of granuloma within each section was calculated by multiplying the area times 7 microns and the volume of granuloma within each section totaled to give the total granuloma volume . Cytokine protein levels were determined in 1215 granulomas derived from t. crassiceps infected wt mice, 46 granulomas derived from t. crassiceps infected spp - knockout mice, and 9 - 10 granulomas derived from t. crassiceps - infected nk1-knockout mice . A portion of each granuloma was homogenized in pbs, followed by centrifugation at 16,000 g. total protein in the supernatant was quantitated using the bradford method (cat no . Il-1, il-6, and tnf- protein levels were determined by sandwich elisa (r&d systems, san diego, california) as per manufacturer's instruction . To begin to examine the contribution of sp signaling to granuloma formation in ncc, we measured granuloma volume in mice with normal and deficient sp signaling . The volumes of granulomas from taenia crassiceps infected spp - knockout mice (1.8 0.45 mm) and nk1-knockout mice (1.68 0.40 mm) were reduced by 31% and 36%, respectively, compared to granulomas derived from infected wt mice (2.62 0.28 mm; p <.05 for both; student's t - test; see figure 1). Il-1 is the primary mediator of granuloma formation in the s. mansoni pulmonary granuloma model . Also, intratracheal injection of agarose beads coupled to recombinant il-1 induced pulmonary granulomas in mice . To determine if decreased production of il-1 in spp- and nk1-knockout mice contributed to reduced granuloma size in these animals, we measured il-1 protein levels in the granulomas derived from each group of mice . Il-1 protein levels in granulomas from t. crassiceps infected spp - knockout mice (216 129 ng / mg total protein) and nk1-knockout mice (101 43 ng / mg total protein) were reduced by 48% and 76%, respectively, compared to granulomas from infected wt mice (418 278 ng / mg total protein; p <.05 for both; student's t - test; see figure 2). Thus, sp signaling contributes to il-1 production within granulomas formed in response to dying t. crassiceps cysts . Furthermore, reduced levels of this cytokine likely contributed to reduced granuloma size in spp- and nk1-knockout mice . Tnf- mediates granuloma growth in the s. mansoni pulmonary granuloma model and is required for granuloma formation in a mouse model of tuberculosis . Similar to our findings with il-1, tnf- protein levels in granulomas from t. crassiceps infected spp - knockout mice (96 67 ng / mg total protein) were reduced by 79% compared to levels in granulomas derived from infected wt mice (460 452 ng / mg total protein; p <.05; student's t - test; see figure 3). Tnf- protein levels within granulomas from nk1-knockout mice (345 153 ng / mg total protein) were decreased by 25% compared to levels with granulomas of wt mice; however, this difference did not achieve statistical significance . Thus, sp contributes to tnf - production within granulomas formed in response to dying t. crassiceps cysts . Furthermore, reduced levels of this cytokine likely contributed to reduced granuloma size in spp- and, perhaps, nk1-knockout mice . The failure to detect a significant difference in tnf- protein levels between nk1-knockout and wt mice suggests the possibility that sp - mediated increases in tnf- may occur through binding of sp to other members of the nk family, for example, nk2 or nk3 . Il-6 production in human peripheral blood mononuclear cells, bronchial cells, and astrocytes is increased directly by sp through the action of nuclear factor il-6 (nf - il-6) and p38 mapk, as well as indirectly in response to il-1 and tnf- through the activation of nf-b [26, 27, 34, 35]. Il-6 mediates its acute proinflammatory effects within infected or injured tissues, in part, through upregulation of cxc chemokines, which leads to recruitment of the first wave of inflammatory cells . As we expected from the il-1 and tnf- results summarized above, il-6 protein levels in the granulomas derived from infected spp - knockout mice (28 30 ng / mg total protein) and from infected nk1-knockout mice (50 16 ng / mg total protein) were reduced by 79 and 62%, respectively, compared to levels in granulomas from infected wt mice (130 153 ng / mg total protein; p <.05 for both; student's t - test; see figure 4). Thus, sp signaling either directly or indirectly through the actions of il-1 and tnf- contributes to il-6 production within granulomas formed in response to dying t. crassiceps cysts . The current studies were performed to determine the contribution of sp and its specific receptor, nk1, to granuloma development and proinflammatory cytokine production within granulomas arising in mice infected with t. crassiceps . We demonstrated that the size of granulomas from the t. crassiceps - infected spp - knockout mice and infected nk1-knockout mice were significantly smaller than granulomas from the infected wt mice . Furthermore, proteins levels of il-1, a key mediator of granuloma formation, were significantly lower within granuloma from spp- and nk1- knockout mice compared to granuloma from mice . In addition, compared to granulomas from wt mice, protein levels of tnf-, another key mediator of granuloma formation, were significantly lower in spp - knockout mice and trended in the same direction in nk1-knockout mice . Thus, sp signaling contributes to granuloma formation, in part, through induction of il-1 and tnf-, key mediators of granuloma formation . Substance p and its high affinity receptor, nk1, are known to play an important role in inflammatory responses . Granuloma formation in response to murine schistosomiasis requires binding of sp to its specific receptor . Sp is known to stimulate inflammatory cell infiltration and to induce the production of proinflammatory cytokines such as il-1, il-6, and tnf- by human peripheral mononuclear cells, bronchial cells, or astrocytoma cells [1929]. Our findings extend these observations and indicate that sp signaling contributes to granuloma formation and production of il-1, tnf-, and il-6 protein within granuloma formed in response to t. crassiceps infection . The mechanism by which sp stimulates the production of these cytokines may be by mediating inflammatory cell influx [1924]. Nerves, endothelial cells, and cells of the immune system produce sp [3638]. All of these cells have receptors for sp and are known to respond to sp [3840]. Sp is known to stimulate influx of lymphocytes, monocytes, macrophages, and other immune cells that produce proinflammatory cytokines such as il-1, il-6, and tnf- [1929]. Although there are various studies on the molecular mechanisms by which sp stimulates the production of il-6 and tnf-, there is limited information on the molecular mechanisms by which sp stimulates il-1 production . A study by martin et al . These studies demonstrated that treatment with an intracellular calcium chelator blocked sp - induced il-1 production . Other studies have demonstrated that sp induces tnf - alpha and il-6 production through nf kappa b in peritoneal mast cells . Substance p production of tnf- in peritoneal mast cells is also known to be mediated via p38 and jnk map kinases . Also il-6 production in human peripheral blood mononuclear cells, bronchial cells, and astrocytes is increased directly by sp through the action of nuclear factor il-6 (nf - il-6) and p38 mapk [26, 27, 34, 35]. Preprotachykinin protein is cleaved to form two active neuropeptides, sp and neurokinin a. therefore, sp precursor (preprotachykinin) knockout mice produce neither sp nor neurokinin a. consequently, our results in spp - knockout mice can be attributed to a deficiency in either sp or neurokinin a or both . However, since nk1 binds only sp and not neurokinin a and the results in nk1-knockout mice mirror the findings in sp - knockout mice, we are confident in attributing reduced granuloma formation and proinflammatory cytokine production to the absence of sp signaling and not to reduced or absent neurokinin a signaling . In the current studies, we demonstrated that the granuloma size and the levels of the proinflammatory cytokine, il-1, are lower in the infected nk1-knockout mice compared to those of the infected spp - knockout mice . Besides sp, peptide hormones such as hemokinin can also bind and activate nk1 at sites of chronic inflammation . Therefore, although the current studies suggest that sp may be an important mediator associated with cytokine production, there may be other peptide hormones like hemokinin that also bind and activate the nk1 receptor that may be associated with granuloma and cytokine production . Therefore, it may be possible that in the nk1-knockout mice, the synergistic lack of activity of both sp and hemokinin may have resulted in lower il-1 levels and granuloma size as compared to spp - knockout mice . Granuloma formation by the host in response to agents causing chronic infections is thought to be essential for limiting and eventually clearing infection . However, recent work in zebra fish infected with mycobacterium marinum suggests that granuloma formation contributes to early bacterial growth . Intraparenchymal cysts of ncc are thought to die spontaneously and to elicit a granulomatous response that does not in itself contribute to the demise of the cyst . Rather, we have previously demonstrated that early granuloma formed in response to dying cysts contributes to ncc disease manifestations by producing mediators that induce seizures . The current studies demonstrating that sp signaling contributes to granuloma formation in taenia crassiceps infection, together with other published observations, suggest the possibility that diminishing granuloma formation in ncc by blocking sp, which contributes to granuloma formation and epileptogenic responses, may be beneficial in the treatment of this disease.

Most chd prevalence data are based on population - based birth defect registries or clinical symptoms . A few studies have assessed the prevalence of chd at birth by the echocardiographic screening of an in - hospital population . No large - sample, population - based study on chd using echocardiography has been conducted in langfang district . Langfang district in hebei province is one of the prefecture - level cities with an area of 6429 square kilometers, and the population is approximately 4.4 million, mainly to the han nationality . The district governs 11 counties, namely sanhe, dachang, yongqing, yanjiao, bazhou, wenan, guan, guangyang, anci, dacheng, xianghe . In this cross - sectional study, we aimed to investigate the prevalence of chd in langfang district by analyzing data collected by hospitals located in the counties of the district, as supported a public health campaign focusing on chd treatment . This cross - sectional study took place in the langfang district's 11 maternal and child health certificate registries responsible for the diagnosis of chd as commissioned by the health administrative department of district . According to the schedule of the public health campaign, all 3-month - old infants in the district were encouraged to participate, but only those with willingness to undergo echocardiography in the outpatient department received an ultrasound examination . From july 19, 2012 to july 18, 2014, it is reported that there were totally 77,836 3-month - old infants in the district . Among those, 67,718 (87%) joined the campaign and had received an ultrasound examination, whereas the remaining 10,118 did not . The reasons for nonparticipating were not surveyed, but as speculated by the local health staff involved in the public health campaign, feeling unnecessary may be a key reason . Infants diagnosed with chd were followed up at 1 year of age, and their parents were invited to complete a questionnaire then . The study was approved by the general hospital of beijing military region ethics committee (no . 2011 - 98), and written informed consent regarding the the protocol of chd screening in langfang district was signed by the parents of the infants . In this study, diagnosis was made by echocardiography, and in all of the 11 hospitals, the sonosite m - turbo ultrasonic diagnostic instrument equipped with a pediatric probe (frequency 48 mhz) was used for the examination . Cardiac structure and function were observed along the standard parasternal long - axis, short - axis, suprasternal, subcostal, and apical four - chamber views . All infants were scanned by a senior echocardiographic doctor with more than 5 years of echocardiographic experience to ensure quality . Meanwhile, a self - administered standard questionnaire was designed to investigate socio - demographic characteristics, including maternal age, residence, infant gender, birth weight, gestational age, etc . The screening group comprised a pediatrician who was responsible for the clinical examination, an echocardiographic doctor who conducted the echo - diagnosis and a cardiologist who explained the abnormality or outcome . Chd was classified on the basis of the international classification of diseases, ninth revision, and the clinical modification code . Patent foramen oval and atrial septal defect (asd) (defect <4 mm in diameter) were excluded from chd to avoid overestimation . To improve the participation rate, half of the cost of echocardiography (approximately rmb 245 yuan) was supported by the local government, and the maternity and child care institutions prescribed an echocardiography application form for every infant while distributing birth certificates or at the time of vaccination or physical examination . Along with the echocardiography application form, a data collection form was also provided to infants parents . The data collection form was used to collect the demographic information and to record the echocardiography result and referral information . Once the echocardiography was completed, the data will be entered into an online data collection system designed specifically for this public health campaign by trained staff from the maternity and child healthcare institutions . To standardize the diagnosis, echocardiography expert from general hospital of beijing military region are in charge of confirmation of chd and providing technical support . To facilitate reassessment of echocardiography diagnosis, all image graphs were required to be stored in the computer . To avoid misdiagnosis and omissions the data used in this study were directly exported from the data collection system in the form of an excel spreadsheet . The chi - square test was used to compare rates . The value of p <0.05 was considered statistically significant . This cross - sectional study took place in the langfang district's 11 maternal and child health certificate registries responsible for the diagnosis of chd as commissioned by the health administrative department of district . According to the schedule of the public health campaign, all 3-month - old infants in the district were encouraged to participate, but only those with willingness to undergo echocardiography in the outpatient department received an ultrasound examination . From july 19, 2012 to july 18, 2014, it is reported that there were totally 77,836 3-month - old infants in the district . Among those, 67,718 (87%) joined the campaign and had received an ultrasound examination, whereas the remaining 10,118 did not . The reasons for nonparticipating were not surveyed, but as speculated by the local health staff involved in the public health campaign, feeling unnecessary may be a key reason . Infants diagnosed with chd were followed up at 1 year of age, and their parents were invited to complete a questionnaire then . The study was approved by the general hospital of beijing military region ethics committee (no . 2011 - 98), and written informed consent regarding the the protocol of chd screening in langfang district was signed by the parents of the infants . In this study, diagnosis was made by echocardiography, and in all of the 11 hospitals, the sonosite m - turbo ultrasonic diagnostic instrument equipped with a pediatric probe (frequency 48 mhz) was used for the examination . Cardiac structure and function were observed along the standard parasternal long - axis, short - axis, suprasternal, subcostal, and apical four - chamber views . All infants were scanned by a senior echocardiographic doctor with more than 5 years of echocardiographic experience to ensure quality . Meanwhile, a self - administered standard questionnaire was designed to investigate socio - demographic characteristics, including maternal age, residence, infant gender, birth weight, gestational age, etc . The screening group comprised a pediatrician who was responsible for the clinical examination, an echocardiographic doctor who conducted the echo - diagnosis and a cardiologist who explained the abnormality or outcome . Chd was classified on the basis of the international classification of diseases, ninth revision, and the clinical modification code . Patent foramen oval and atrial septal defect (asd) (defect <4 mm in diameter) were excluded from chd to avoid overestimation . To improve the participation rate, half of the cost of echocardiography (approximately rmb 245 yuan) was supported by the local government, and the maternity and child care institutions prescribed an echocardiography application form for every infant while distributing birth certificates or at the time of vaccination or physical examination . Along with the echocardiography application form, a data collection form was also provided to infants parents . The data collection form was used to collect the demographic information and to record the echocardiography result and referral information . Once the echocardiography was completed, the data will be entered into an online data collection system designed specifically for this public health campaign by trained staff from the maternity and child healthcare institutions . To standardize the diagnosis, echocardiography expert from general hospital of beijing military region are in charge of confirmation of chd and providing technical support . To facilitate reassessment of echocardiography diagnosis, all image graphs were required to be stored in the computer . To avoid misdiagnosis and omissions the data used in this study were directly exported from the data collection system in the form of an excel spreadsheet . Chicago illinois, usa). The chi - square test was used to compare rates . The value of p <0.05 was considered statistically significant . Of the 77,836 3-month - old infants who were born during the study, 67,718 were examined by echocardiography (coverage rate: 67,718/77, 836 = 87%), including 61,505 full - term infants and 6213 preterm infants (<37 weeks). A total of 1554 infants were diagnosed with chd during the 2-year (42.5% boys, 57.5% girls). The top five most common cardiac abnormalities were the following: asd (605 cases, 8.93); ventricular septal defect (vsd, 550 cases, 8.12); patent ductus arteriosus (pda, 228 cases, 3.37); pulmonary stenosis (ps, 66 cases, 0.97); and tetralogy of fallot (tof, 32 cases, 0.47). The chd prevalence differed by gender in this study (= 23.498, p <0.001), and there were more females with asd (= 56.62); however, this was not true of vsd (= 0.01) or pda (= 0.86) [table 1]. Regional differences in prevalence were also found (= 24.602, p <0.001); a higher prevalence was found in urban areas (32.2 cases per 1000 live births) than in rural areas (21.1 cases per 1000 live births). There was a significant difference in the prevalence of chd in preterm versus full - term infants (= 133.443, p <0.001). Prevalence of chd in infants of maternal aged 35 years or over was significantly higher (= 86.917, p <0.001). Chd distribution by gender asd: atrial septal defect; vsd: ventricular septal defect; pda: patent ductus arteriosus; ps: pulmonary stenosis; tof: tetralogy of fallot; dorv: double - outlet right ventricle; sv: single ventricle; iaa: interrupted aortic arch; chd: congenital heart disease . Of the 77,836 3-month - old infants who were born during the study, 67,718 were examined by echocardiography (coverage rate: 67,718/77, 836 = 87%), including 61,505 full - term infants and 6213 preterm infants (<37 weeks). A total of 1554 infants were diagnosed with chd during the 2-year (42.5% boys, 57.5% girls). The top five most common cardiac abnormalities were the following: asd (605 cases, 8.93); ventricular septal defect (vsd, 550 cases, 8.12); patent ductus arteriosus (pda, 228 cases, 3.37); pulmonary stenosis (ps, 66 cases, 0.97); and tetralogy of fallot (tof, 32 cases, 0.47). The chd prevalence differed by gender in this study (= 23.498, p <0.001), and there were more females with asd (= 56.62); however, this was not true of vsd (= 0.01) or pda (= 0.86) [table 1]. Regional differences in prevalence were also found (= 24.602, p <0.001); a higher prevalence was found in urban areas (32.2 cases per 1000 live births) than in rural areas (21.1 cases per 1000 live births). There was a significant difference in the prevalence of chd in preterm versus full - term infants (= 133.443, p <0.001). Prevalence of chd in infants of maternal aged 35 years or over was significantly higher (= 86.917, p <0.001). Chd distribution by gender asd: atrial septal defect; vsd: ventricular septal defect; pda: patent ductus arteriosus; ps: pulmonary stenosis; tof: tetralogy of fallot; dorv: double - outlet right ventricle; sv: single ventricle; iaa: interrupted aortic arch; chd: congenital heart disease . A total of 67,718 3-month - old infants were diagnosed using echocardiography in langfang district during 20122014, and 1554 infants were found to have chd . The total prevalence of chd was 22.9, which higher than the previously reported 8, but within the range reported using echocardiography . The order of chd in langfang district as follow: asd, vsd, pda, pa, and tof . The chd prevalence differed by gender, regional, gestational, and maternal age . In this study, we used echocardiography as a diagnosis tool to investigate the prevalence of chd in langfang district in china; the overall prevalence of chd was found to be 22.9 cases per 1000 live births . This result is similar to those found in shanghai (26.6 cases per 1000 live births) and japan (50.3 cases per 1000 live births) but is significantly higher than that found in other reports . The similar findings in the former two studies might be a result of the use of echocardiography as a diagnosis tool . Similarly, some of the differences in results might be caused by differences in methodology (i.e., in the us, assessment might be more accurate because of the assessment of intracardiac deformity rather than auscultation), data source (birth defect registration or clinical assessment), and subject age at time of diagnosis (small muscular vsd; pda has a high spontaneous closure rate, which might decrease the detection rate). The chd prevalence found here (22.9) was determined by echocardiographic diagnosis and is higher than the internationally accepted level of 8 cases per 1000 live births and the published domestic rate (6.64 cases per 1000 live births). To some extent, this result occurred because of more complete supervision by local public health authorities, better monitoring and greater standardization, and the wide application of echocardiography diagnosis . However, this finding also reflects the heavy responsibility of diagnosis for chd and the need for long - term follow - up and observation . Our data indicate that asd is the most frequent type of chd, followed by vsd, pda, ps, and tof, in that order . This result is consistent with a previous report from india, which indicated that asd was the most frequent lesion . However, some researchers have found vsd to be the most frequent type of chd . Some small vsds might close spontaneously, and large vsds present symptoms early, prompting treatment . Many asymptomatic infants with asd were diagnosed for the first time during the screening; this might also be responsible for the higher asd prevalence found in our study . In general, the difference in the prevalence between males and females was significant in this study (= 23.498, p <0.001); there were more female cases of asd . At present, the cause of heart malformation in infants remains unclear and is perhaps related to gestational age, family history, radiation exposure, the use of medication, etc . Previous studies have shown that the prevalence of chd in males and females is approximately the same; however, the prevalence of artery stenosis, tof, and transposition of the great artery is higher in males than in females ., researchers have reported a higher prevalence in urban areas than in rural areas, but the potential risk factors for chd in urban areas are unknown . Regional differences in prevalence were also found in our study; the prevalence was higher in urban areas (32.2 cases per 1000 live births) and lower in rural areas (21.9 cases per 1000 live births). Although urban areas have the advantage over rural areas in terms of size, population, the economy and other aspects, there might be more environmental risk factors in urban environments, such as extensive applications of lead and other heavy metals in industrial and agricultural production or the emission of toxic pollutant gases, all of which increase the prevalence of chd . Second, in rural areas, birth asphyxia, chds, premature birth / low birth weight, pneumonia, and drowning were the five leading causes of death in 1997 . The death rate was also lower in urban areas than in rural areas at that time . In addition, mahle et al . And hunte et al . Suggest that a prenatal diagnosis has a favorable effect on the treatment of patients undergoing staged palliation, reduces early morbidity, and improves the child survival rate . The prevalence of chd in dachang hui autonomous county (19.5 cases per 1000 live births) was below average (22.9 cases per 1000 live births); further large - sample studies are necessary to clarify differences between races . Unfortunately, the number of ethnicities in the current study was too small to yield significant results . Langfang district is mainly rural, reflects the diagnosis of chd at the grass - roots level in china . The surgical survival of part of the chd has reached a higher level, but the understanding and diagnosis of chd remain to be improved at the grass - roots level in china, especially in rural areas and basic - level hospitals . The study is given priority to with the rural population, the data showed that train the doctor of community and township hospitals on chd diagnosis is very important . Researchers have pointed out that in very preterm / low birth weight infants chd are more prevalent than in the general liveborn population, and confer an increased risk of death and serious morbidities independently of other risk factors . Tanner et al . Showed that preterm infants have more than twice as many cardiovascular malformations as do infants born at term and that 16% of all infants with cardiovascular malformations are preterm . Pappas et al . Reported that extremely preterm infants (<1000 g) with congenital heart defect were 0.8% . The date came from the national institute of child health and human development neonatal research network . In this study, we found that prevalence of chd in infants of maternal aged 35 years or over were significantly higher . Advanced maternal age is proposed to be a risk factor of the heart malformation in some studies; miller et al . Found that advanced maternal age 35 years was associated with increased prevalence of several chd . The reason might be caused by increased mutations in the germ cell line because of cumulated cell replications . Similar to maternal age, advanced paternal age is proposed to be a risk factor of chd in the offspring, but the biological mechanism is not clear . The screening team comprised 3 doctors: a pediatrician who was responsible for clinical examination, an echocardiographer who was responsible for screening the chd, and a cardiologist who was responsible for explaining any abnormality or the outcome . Our multidisciplinary clinical practice model consolidated different experts into one team, which directly communicated comprehensive treatment recommendations to parents with chd infants to improve the quality of the infants lives . Early screening not only helps reduce undetected chd but also can provide accurate data for improving the management of chd . First, as a cross - sectional and single center study, the results only reflect the prevalence of chd in langfang district, providing the up - to - date in this geographical region . Second, since not all infants underwent echocardiography, 13% of infants have been missed . Third, we included only live births, and some infants with chd who died before screening were not included . Long - term follow - up is necessary to determine the temporal trends of the prevalence of chd . In conclusions, echocardiography is a reliable and simple imaging examination method that can be used in the diagnosis of chd, particularly for measuring intracardiac structure and blood flow . Currently, echocardiography has become the most important, noninvasive and standard diagnostic method for chd and is helpful in early diagnosis and in reducing mortality.

Renal transplantation rates are low among patients highly sensitized to human leukocyte antigen (hla) because of the high rate of antibody - mediated rejection and subsequent graft loss . It was recently reported, however, that preoperative desensitization using an anti - cd 20 antibody (rituximab) and intravenous immunoglobulin improved transplantation rates in patients highly sensitized to hla . In contrast, the significance of a positive lymphocytotoxic crossmatch in living donor liver transplantation (ldlt) is controversial . Successful ldlt using a liver graft in which the lymphocytotoxic crossmatch was highly positive is reported . The recipient was a 41-year - old woman with end - stage liver disease due to alcoholic liver cirrhosis (model for end - stage liver disease score 21). At the age of 20, she was gravida one, para one . She was considered a candidate for liver transplantation because of repeated episodes of encephalopathy . Because of the severe shortage of cadaveric donor grafts in japan, we planned an ldlt, and her husband was willing to donate his partial liver . The abo blood type was identical, but the t lymphocytotoxic crossmatch titer was over 10,000 and the b lymphocytotoxic crossmatch titer was 128 (complement method with the dilution technique according to the standard national institutes of health technique). In addition, an examination of anti - hla antibodies using fluorescent microspheres revealed that the recipient had donor specific antibodies (b51 and b52). After obtaining written informed consent from the patient and donor and the approval of the intra - institutional committee, we proceeded to the preoperative preparations . For preoperative desensitization, the patient was first infused with rituximab 2 weeks before the scheduled surgery (due to a catheter - associated infection, however, the operation was postponed and ldlt was performed 21 days after initiation of the rituximab therapy). As the antibody to hepatitis b core antigen was positive, entecavir (0.5 mg / day) was administered for 3 weeks preoperatively to prevent a possible hepatitis b virus breakthrough . On postoperative days 1 and 4, 20 mg of anti - cd25 antibody (basiliximab) was administered in addition to the routine methylprednisolone and tacrolimus, as we were anxious about hyperacute rejection . Besides, mycophenolate mofetil (mmf; 2,000 mg / day) was started on postoperative day 7 . The postoperative course was uneventful except for an episode of mild acute cellular rejection (banff score 3) on postoperative day 27, which responded promptly to steroid recycle therapy . The liver biopsy specimen obtained at the time of the acute rejection showed mild infiltration of lymphocytes in the portal area and around the bile ducts . One year after the ldlt, the lymphocytotoxic crossmatch remained negative and the patient has been well with good graft function.fig . Acr acute cellular rejection, alt alanine aminotransferase, mmf mycophenolate mofetil, mp methylprednisolone, pe plasma exchange, tb total bilirubin, pod postoperative day the clinical profile of the present patient . Acr acute cellular rejection, alt alanine aminotransferase, mmf mycophenolate mofetil, mp methylprednisolone, pe plasma exchange, tb total bilirubin, pod postoperative day the impact of a lymphocytotoxic crossmatch - positive liver graft on acute cellular rejection and graft survival remains controversial, both in deceased donor liver transplantation [3, 4] and in ldlt [57]. Some institutions have reported significantly unfavorable outcomes in ldlt recipients with a positive lymphocytotoxic crossmatch [6, 7]. In contrast, our previous results showed that if the titer is low (no more than 32), a positive lymphocytotoxic crossmatch does not adversely affect the graft or survival in patients without desensitization . Although the significance of a quantitative assessment of the lymphocytotoxic crossmatch has not been reported, the high titer in our present patient led to the need for perioperative desensitization to prevent early graft loss due to antibody - mediated rejection . After considering the results in the present patient, we have settled the indication criteria for preoperative desensitization therapy at the titer of 1,000 (t lymphocyte crossmatch). In this patient, therefore, we applied preoperative desensitization using rituximab and plasmapheresis to reduce the high titer of preformed antibodies and b lymphocytes . As a result, the lymphocytotoxic crossmatch was negative after the 3rd plasmapheresis, and negativity was sustained thereafter . Preoperative desensitization using rituximab was introduced in abo - incompatible ldlt in 2003 and has dramatically improved the outcomes of abo - incompatible ldlt . The appropriate dosage of rituximab is still controversial, but many previous studies have reported the administration of 375 mg / m of rituximab 13 weeks before the transplant . Following these successful cases, we planned the administration of 375 mg / m (500 mg / body) of rituximab 2 weeks before the operation [8, 9]. Splenectomy is also considered to be effective to reduce antibody production, as the spleen is the site of antibody production . After the operation, the suppression of t - cell function to prevent the initiation of t - cell - mediated antibody production was regarded as indispensable . We have routinely used tacrolimus and steroid as an immunosuppressive regimen, and in this particular patient, we added basiliximab (postoperative days [pods] 1 and 4) and mmf . Mild acute cellular rejection occurred about 3 weeks after the ldlt, but response to the steroid recycle therapy was prompt, and the lymphocytotoxic crossmatch was negative during this episode . In summary, we report a successful ldlt using a lymphocytotoxic crossmatch highly positive graft . Perioperative desensitization using plasmapheresis and rituximab may provide significant benefits for reducing anti - hla antibodies.

Acute kidney injury (aki), defined as an abrupt drop of renal function within a short period, is a frequent and serious complication in the intensive care unit (icu) or after surgery, with an incidence of 7.7%42% in patients with previous normal renal function.1,2 aki or even a minor increase in serum creatinine level from baseline was independently associated with increased length of hospitalization, health care costs, cardiovascular events, and mortality.3,4 although there have been many clinical studies on the protection of kidney function in patients with critical illness or perioperative care, such as the administration of n - acetylcysteine, atrial natriuretic peptide, and fenoldopam, the results of such interventions are somewhat contradictory or unproven.5 consequently, it is paramount that more attention should be paid to explore effective preventative and therapeutic strategies for the management of aki . Erythropoietin (epo), a 30-kda glycoprotein hormone, is produced by the kidney to regulate the hematopoiesis in bone marrow, and recombinant human epo has been widely used in the treatment of anemia, especially in end - stage renal disease and certain hematologic diseases.6 interestingly, there is considerable evidence indicating that epo acts as a novel renoprotective agent against ischemic, toxic, and septic aki in animal experiments by reducing apoptosis, stimulating cell proliferation and eliciting its antioxidative and anti - inflammatory functions.7,8 recently, a few randomized controlled trials (rcts) analyzed the role of epo to prevent aki in patients within the icu or after surgery who were at high risk of aki.918 however, the results from these trials were inconsistent, partly because they involved single - site studies with small - scale samples . Therefore, we conducted a systematic review and meta - analysis of rcts to determine whether the use of epo in patients with critical illness or perioperative care could ameliorate the incidence of aki and assess its adverse event . This systematic review and meta - analysis was conducted according to the preferred reporting items for systematic reviews and meta - analyses (prisma) statement recommendations.19 a comprehensive search was conducted in medline (through ovid), embase (through ovid), the cochrane central registry of controlled trials, and the web of science from inception to october 2014 . Medical subject headings, entry terms, and text word searches included the following terms: critical illness, critical care, intensive care, icu, severely ill, perioperative care, perioperative period, erythropoietin, epoetin, epo, erythropoiesis stimulating protein, darbepoetin, acute kidney injury, acute renal injury, acute renal insufficiency, acute kidney insufficiency, acute renal failure, acute kidney failure, acute tubular necrosis, aki, arf, and atn . There was no restriction on language or publication date . In addition, other potentially relevant studies were searched from the clinical trials database (http://clinicaltrials.gov/) for completed trials and the references cited in the retrieved articles and pertinent reviews . All titles, abstracts, and full articles were independently searched and evaluated using predesigned inclusion and exclusion criteria by 2 investigators (c.z . And z.c.l . ). Any discrepancies were resolved by consensus with a third investigator (q.m.l .) If necessary, which was infrequent . Studies were included when the following inclusion criteria were met: (1) rcts, (2) adult patients (age 18 years) with critical illness or perioperative care, (3) use of epo for prevention at least in 1 treatment group, (4) control group receiving placebo or usual treatment, (5) reported incidences of aki in both groups, and (6) for more than 1 publication on the same trial, data from the most recent or complete report were used . Exclusion criteria were as follows: (1) nonrandomized or pseudo - randomized design, retrospective study, case report, and case series; (2) enrolled participants undergoing chronic dialysis therapy, nephrectomy, or transplant surgery (heart, liver, or kidney) due to their complex situations; (3) lack of a control group; (4) studies not addressing the target outcome as mentioned above; and (5) use of epo as a treatment agent after the occurrence of aki . Two investigators (q.m.l . And x.x .) Independently extracted data from all eligible trials and assessed the risk of bias . Data included the first author, publication year, nation of origin, study participants, sample size, whether epo was used previously, mean age, proportions of male patients, hypertension, and diabetes mellitus, mean baseline hemoglobin and serum creatinine levels, mean blood transfusion volume, treatment regimens of the epo - based intervention and control groups, definition of aki, and outcomes measured . The primary outcome was the incidence of aki, the secondary outcomes included dialysis requirement, 30-day mortality, and the adverse events . When the study had several dosage intervention arms,14 all epo intervention arms were combined as one arm by weighted means . In the case of missing or incomplete data, the corresponding author of the original trial was contacted by e - mail for additional information . The risk of bias in the eligible trials was assessed according to the cochrane collaboration tool (version 5.1.0),20 which included 7 items: random sequence generation, allocation concealment, blinding of participants and personnel, blinding of outcome assessment, incomplete outcome data, selective reporting, and other bias . In each item, an answer of low risk of bias suggested sufficient and correct information, high risk of bias indicated that the item was reported incorrectly, and unclear risk of bias meant insufficient or unmentioned details for judgment . For dichotomous outcomes (the incidence of aki, dialysis requirement, and mortality), data were pooled as risk ratio (rr) with 95% confidence interval (ci). The between - study heterogeneity was quantified by cochran's q - statistic and the inconsistency index (i). If there was significant heterogeneity among studies (pq - statistic <0.10 and i> 50%), the random effect model (dersimonian and laird method) was adopted to pool the results; otherwise, the fixed effect model (mantel - haenszel method) was used . Subgroup analysis was performed based on (1) entirely perioperative care, (2) no use of epo previously, (3) at least 2 doses of epo, and (4) patients at high risk for aki according to each study . Sensitivity analysis was conducted to assess the influence of individual studies on the pooled estimate of effects by withdrawing 1 study at a time . An asymmetric funnel plot and pegger's test less than 0.05 indicated a significant publication bias . The assessment for the risk of bias all statistical analyses were conducted using the stata / se 12.0 software (stata corporation, college station, tx). A p value less than 0.05 by a 2-sided test was considered to be statistically significant . A comprehensive search was conducted in medline (through ovid), embase (through ovid), the cochrane central registry of controlled trials, and the web of science from inception to october 2014 . Medical subject headings, entry terms, and text word searches included the following terms: critical illness, critical care, intensive care, icu, severely ill, perioperative care, perioperative period, erythropoietin, epoetin, epo, erythropoiesis stimulating protein, darbepoetin, acute kidney injury, acute renal injury, acute renal insufficiency, acute kidney insufficiency, acute renal failure, acute kidney failure, acute tubular necrosis, aki, arf, and atn . There was no restriction on language or publication date . In addition, other potentially relevant studies were searched from the clinical trials database (http://clinicaltrials.gov/) for completed trials and the references cited in the retrieved articles and pertinent reviews . All titles, abstracts, and full articles were independently searched and evaluated using predesigned inclusion and exclusion criteria by 2 investigators (c.z . And z.c.l . ). Any discrepancies were resolved by consensus with a third investigator (q.m.l .) If necessary, which was infrequent . Studies were included when the following inclusion criteria were met: (1) rcts, (2) adult patients (age 18 years) with critical illness or perioperative care, (3) use of epo for prevention at least in 1 treatment group, (4) control group receiving placebo or usual treatment, (5) reported incidences of aki in both groups, and (6) for more than 1 publication on the same trial, data from the most recent or complete report were used . Exclusion criteria were as follows: (1) nonrandomized or pseudo - randomized design, retrospective study, case report, and case series; (2) enrolled participants undergoing chronic dialysis therapy, nephrectomy, or transplant surgery (heart, liver, or kidney) due to their complex situations; (3) lack of a control group; (4) studies not addressing the target outcome as mentioned above; and (5) use of epo as a treatment agent after the occurrence of aki . Two investigators (q.m.l . And x.x .) Independently extracted data from all eligible trials and assessed the risk of bias . Data included the first author, publication year, nation of origin, study participants, sample size, whether epo was used previously, mean age, proportions of male patients, hypertension, and diabetes mellitus, mean baseline hemoglobin and serum creatinine levels, mean blood transfusion volume, treatment regimens of the epo - based intervention and control groups, definition of aki, and outcomes measured . The primary outcome was the incidence of aki, the secondary outcomes included dialysis requirement, 30-day mortality, and the adverse events . When the study had several dosage intervention arms,14 all epo intervention arms were combined as one arm by weighted means . In the case of missing or incomplete data, the corresponding author of the original trial was contacted by e - mail for additional information . The risk of bias in the eligible trials was assessed according to the cochrane collaboration tool (version 5.1.0),20 which included 7 items: random sequence generation, allocation concealment, blinding of participants and personnel, blinding of outcome assessment, incomplete outcome data, selective reporting, and other bias . In each item, an answer of low risk of bias suggested sufficient and correct information, high risk of bias indicated that the item was reported incorrectly, and unclear risk of bias meant insufficient or unmentioned details for judgment . For dichotomous outcomes (the incidence of aki, dialysis requirement, and mortality), data were pooled as risk ratio (rr) with 95% confidence interval (ci). The between - study heterogeneity was quantified by cochran's q - statistic and the inconsistency index (i). If there was significant heterogeneity among studies (pq - statistic <0.10 and i> 50%), the random effect model (dersimonian and laird method) was adopted to pool the results; otherwise, the fixed effect model (mantel - haenszel method) was used . Subgroup analysis was performed based on (1) entirely perioperative care, (2) no use of epo previously, (3) at least 2 doses of epo, and (4) patients at high risk for aki according to each study . Sensitivity analysis was conducted to assess the influence of individual studies on the pooled estimate of effects by withdrawing 1 study at a time . An asymmetric funnel plot and pegger's test less than 0.05 indicated a significant publication bias . The assessment for the risk of bias was performed with review manager software (version 5.3 from http://tech.cochrane.org/revman). All statistical analyses were conducted using the stata / se 12.0 software (stata corporation, college station, tx). A p value less than 0.05 by a 2-sided test was considered to be statistically significant . The initial search yielded 615 citations, of which 72 were duplicate studies that were excluded . After reviewing the titles and abstracts of 543 citations, 516 articles were removed because of irrelevant content . Upon review of the full text of 27 articles, ten eligible rcts with 2759 participants were identified for this meta - analysis.918 flow diagram of article selection approach . The included studies spanned from 2002 to 2014, and with the exception of 2 articles,9,10 the sample size of all other studies was relatively small (63108 participants). Four trials were conducted in korea,12,13,16,17 2 in the united states,9,10 and the others in new zealand,11 switzerland,14 thailand,15 and sweden.18 napolitano et al10 reanalyzed the data from critically ill trauma patients in epo-2 trial,9 which had been included in this meta - analysis, so only the part of epo-3 trial was included in this analysis . The intention to treat of participants in 1 study included aki patients on randomization,11 and for the objective of this meta - analysis, the data of the subgroup not aki on randomization were used in this analysis . One study13 was the follow - up of a previous trial21; therefore, the incidence of aki was extracted from the former, and the baseline data were extracted from the latter . All studies enrolled participants from single - site center except 3.911 with respect to the participants setting, 8 studies were performed in perioperative period, 6 of which were conducted in patients with elective cardiac surgery,1216,18 one assessed patients undergoing thoracic aorta surgery with hypothermic cardiac arrest,17 and the rest one partly included patients with scheduled cardiothoracic surgery.11 baseline clinical characteristics of included studies six studies excluded patients who used epo previously,9,10,13,15,17,18 whereas other studies did not specify this issue . In 3 of the 10 studies, a high risk for developing aki, the definitions of which were not the same, was included in the enrollment criteria.11,14,16 in 8 studies, baseline end - stage renal disease or dialysis was set as a compulsory exclusion criterion.913,15,16,18 when reported, mean baseline hemoglobin levels ranged from 9.3 to 13.1 g / dl,9,10,1215,18 and mean baseline serum creatinine levels varied from 0.92 to 1.35 mg / dl.1316,18 the type of erythropoiesis - stimulating agent used in all of the intervention groups was epo - alpha or -beta, but not darbepoietin . The one - time epo dosage was either fixed as 20,000 units or 40,000 units in 3 studies9,10,14 or was based on participant weight ranging from 100 units / kg to 500 units / kg in the other 7 studies . The participants in 6 studies received only a single administration of epo1214,1618; however, participants received at least 2 doses in the other studies . Two studies provided supplementary iron therapy to both the intervention and control groups,9,10 and 1 study provided an iron sucrose supplement only to the intervention group.12 there was considerable variation in the definition of aki across these studies, which was not clear in 2 studies.9,10 all ten studies reported randomization, but 7 studies described the methods of randomization,912,14,16,18 and only 4 studies showed the details of concealed allocation.11,13,15,18 all studies reported double blinding and no or few missing outcome data with the reason . Eight studies provided the clinical trial registration number online with a low risk of bias in selective outcome reporting.10,11,1318 because of the unbalanced use of iron supplementation in 2 groups, 1 study exhibited a high risk of bias in the item other biases.12 risk of bias in included studies . A, risk of bias graph demonstrates the percentages of included studies for each item in the tool; (b) risk of bias summary illustrates the review author's judgments with a cross - tabulation for each eligible study . All ten eligible rcts reported that the overall incidence of aki was 10.57% (147 of 1391 participants) in the epo - based intervention group and 10.38% (142 of the 1368 participants) in the control group . Pooled analysis using a fixed effect model showed that there was no significant difference for preventing the development of aki between the epo and control groups (rr, 0.97; 95% ci, 0.791.19; p = 0.782), as shown in figure 3a . Meanwhile, the test for between - study heterogeneity among the included trials was not significant (i = 20.2% and p = 0.257). Forest plots of rr estimates with the corresponding 95% ci for (a) the incidence of aki, (b) dialysis requirement, and (c) mortality in patients receiving epo therapy versus control . The columns of intervention and control were presented as number of events / number of participants . Stratified analyses of studies with entirely perioperative care demonstrated no significant difference between the epo and control groups using a fixed effect model (rr, 0.86; 95% ci, 0.661.12; p = 0.260; i = 33.9%; p = 0.169).1218 among studies that excluded patients with prior epo use, similar result of rr was obtained (rr, 0.89; 95% ci, 0.661.21; p = 0.467; i = 23.3%, p = 0.259).9,10,13,15,17,18 among patients who received at least 2 doses of epo911,15 or were at high risk of aki according to each study,11,14,16 the prevention of aki remained nonsignificant (rr, 0.99; 95% ci, 0.731.35; p = 0.962; i = 44.3%, p = 0.145 and rr, 1.22; 95% ci, 0.891.67; p = 0.215; i the sensitivity analysis after exclusion of 1 study at a time demonstrated that the above pooled result was robust and did not change much depending on any single study (fig . It should be noted that after removing the study,12 which gave iron supplement only to epo intervention group, the overall rr was 1.02 (95% ci, 0.821.27; p = 0.824) without statistical significance . The sensitivity analysis by removing each individual study at a time is shown on the pooled effect size of the incidence of aki . The funnel plot and egger's test analysis indicated that there was no evidence of publication bias for the aki outcome (fig . The funnel plots for publication bias tests of studies assessing the effect of epo on (a) the incidence of aki and (b) mortality . The dialysis requirement was reported in 7 studies11,1318 totaling 590 analyzable patients, and in 3 of these studies, no patient was treated with dialysis in either group.13,14,18 the overall incidence of dialysis was 2.65% (8 of the 302 participants) in the epo - based intervention group and 3.82% (11 of the 288 participants) in the control group . By meta - analysis for 4 studies using a fixed effect model,11,1517 there was no significant difference of mortality between the epo and control groups (rr, 0.72; 95% ci, 0.311.70; p = 0.457) without significant between - study heterogeneity (i = 0%, p = 0.662), as shown in figure 3b . Because there were only 4 articles in the literature with the effective data, the publication bias was not investigated . The ten included studies demonstrated that overall mortality was 11.07% (154 of the 1391 participants) in the epo - based intervention group and 11.40% (156 of the 1368 participants) in the control group . Mortality was ascertained in - hospital in 3 studies,13,15,16 at 30 days in 5 studies,912,14 and unclear in the remaining study.17,18 pooled analysis using a fixed effect model showed that there was no significant difference of mortality between the epo and control groups (rr, 0.96; 95% ci, 0.781.18; p = 0.705) without significant between - study heterogeneity (i = 0%, p = 0.562), as shown in figure 3c . Meanwhile, there was no evidence of publication bias for the mortality outcome (fig . Six studies demonstrated that none of the patients who received the epo intervention suffered from adverse events, which were associated with the use of drug, throughout the study period, such as hypertension, symptomatic thrombosis, myocardial infarction, stroke, headache, and seizures.1216,18 one study did not report adverse events,17 and 1 study reported adverse events for the entire participants without specifically describing the specific group.11 corwin et al9 showed that the incidence of deep thrombophlebitis was 2.15% (14/650) among the epo intervention group and 2.30% (15/652) in the control group without significant difference . Napolitano et al10 reported that the incidence of clinically relevant thrombovascular events was 16.42% (66/402) in the epo intervention group and 12.53% (49/391) in the control group with an rr of 1.31 (95% ci, 0.931.85). The included studies spanned from 2002 to 2014, and with the exception of 2 articles,9,10 the sample size of all other studies was relatively small (63108 participants). Four trials were conducted in korea,12,13,16,17 2 in the united states,9,10 and the others in new zealand,11 switzerland,14 thailand,15 and sweden.18 napolitano et al10 reanalyzed the data from critically ill trauma patients in epo-2 trial,9 which had been included in this meta - analysis, so only the part of epo-3 trial was included in this analysis . The intention to treat of participants in 1 study included aki patients on randomization,11 and for the objective of this meta - analysis, the data of the subgroup not aki on randomization were used in this analysis . One study13 was the follow - up of a previous trial21; therefore, the incidence of aki was extracted from the former, and the baseline data were extracted from the latter . All studies enrolled participants from single - site center except 3.911 with respect to the participants setting, 8 studies were performed in perioperative period, 6 of which were conducted in patients with elective cardiac surgery,1216,18 one assessed patients undergoing thoracic aorta surgery with hypothermic cardiac arrest,17 and the rest one partly included patients with scheduled cardiothoracic surgery.11 baseline clinical characteristics of included studies six studies excluded patients who used epo previously,9,10,13,15,17,18 whereas other studies did not specify this issue . In 3 of the 10 studies, a high risk for developing aki, the definitions of which were not the same, was included in the enrollment criteria.11,14,16 in 8 studies, baseline end - stage renal disease or dialysis was set as a compulsory exclusion criterion.913,15,16,18 when reported, mean baseline hemoglobin levels ranged from 9.3 to 13.1 g / dl,9,10,1215,18 and mean baseline serum creatinine levels varied from 0.92 to 1.35 mg / dl.1316,18 the type of erythropoiesis - stimulating agent used in all of the intervention groups was epo - alpha or -beta, but not darbepoietin . The one - time epo dosage was either fixed as 20,000 units or 40,000 units in 3 studies9,10,14 or was based on participant weight ranging from 100 units / kg to 500 units / kg in the other 7 studies . The participants in 6 studies received only a single administration of epo1214,1618; however, participants received at least 2 doses in the other studies . Two studies provided supplementary iron therapy to both the intervention and control groups,9,10 and 1 study provided an iron sucrose supplement only to the intervention group.12 there was considerable variation in the definition of aki across these studies, which was not clear in 2 studies.9,10 all ten studies reported randomization, but 7 studies described the methods of randomization,912,14,16,18 and only 4 studies showed the details of concealed allocation.11,13,15,18 all studies reported double blinding and no or few missing outcome data with the reason . Eight studies provided the clinical trial registration number online with a low risk of bias in selective outcome reporting.10,11,1318 because of the unbalanced use of iron supplementation in 2 groups, 1 study exhibited a high risk of bias in the item other biases.12 risk of bias in included studies . A, risk of bias graph demonstrates the percentages of included studies for each item in the tool; (b) risk of bias summary illustrates the review author's judgments with a cross - tabulation for each eligible study . All ten eligible rcts reported that the overall incidence of aki was 10.57% (147 of 1391 participants) in the epo - based intervention group and 10.38% (142 of the 1368 participants) in the control group . Pooled analysis using a fixed effect model showed that there was no significant difference for preventing the development of aki between the epo and control groups (rr, 0.97; 95% ci, 0.791.19; p = 0.782), as shown in figure 3a . Meanwhile, the test for between - study heterogeneity among the included trials was not significant (i = 20.2% and p = 0.257). Forest plots of rr estimates with the corresponding 95% ci for (a) the incidence of aki, (b) dialysis requirement, and (c) mortality in patients receiving epo therapy versus control . The columns of intervention and control were presented as number of events / number of participants . Stratified analyses of studies with entirely perioperative care demonstrated no significant difference between the epo and control groups using a fixed effect model (rr, 0.86; 95% ci, 0.661.12; p = 0.260; i = 33.9%; p = 0.169).1218 among studies that excluded patients with prior epo use, similar result of rr was obtained (rr, 0.89; 95% ci, 0.661.21; p = 0.467; i = 23.3%, p = 0.259).9,10,13,15,17,18 among patients who received at least 2 doses of epo911,15 or were at high risk of aki according to each study,11,14,16 the prevention of aki remained nonsignificant (rr, 0.99; 95% ci, 0.731.35; p = 0.962; i = 44.3%, p = 0.145 and rr, 1.22; 95% ci, 0.891.67; p = 0.215; i = 0%, p = 0.805, respectively). The sensitivity analysis after exclusion of 1 study at a time demonstrated that the above pooled result was robust and did not change much depending on any single study (fig . It should be noted that after removing the study,12 which gave iron supplement only to epo intervention group, the overall rr was 1.02 (95% ci, 0.821.27; p = 0.824) without statistical significance . The sensitivity analysis by removing each individual study at a time is shown on the pooled effect size of the incidence of aki . The funnel plot and egger's test analysis indicated that there was no evidence of publication bias for the aki outcome (fig . The funnel plots for publication bias tests of studies assessing the effect of epo on (a) the incidence of aki and (b) mortality . The dialysis requirement was reported in 7 studies11,1318 totaling 590 analyzable patients, and in 3 of these studies, no patient was treated with dialysis in either group.13,14,18 the overall incidence of dialysis was 2.65% (8 of the 302 participants) in the epo - based intervention group and 3.82% (11 of the 288 participants) in the control group . By meta - analysis for 4 studies using a fixed effect model,11,1517 there was no significant difference of mortality between the epo and control groups (rr, 0.72; 95% ci, 0.311.70; p = 0.457) without significant between - study heterogeneity (i = 0%, p = 0.662), as shown in figure 3b . Because there were only 4 articles in the literature with the effective data, the publication bias was not investigated . The ten included studies demonstrated that overall mortality was 11.07% (154 of the 1391 participants) in the epo - based intervention group and 11.40% (156 of the 1368 participants) in the control group . Mortality was ascertained in - hospital in 3 studies,13,15,16 at 30 days in 5 studies,912,14 and unclear in the remaining study.17,18 pooled analysis using a fixed effect model showed that there was no significant difference of mortality between the epo and control groups (rr, 0.96; 95% ci, 0.781.18; p = 0.705) without significant between - study heterogeneity (i = 0%, p = 0.562), as shown in figure 3c . Meanwhile, there was no evidence of publication bias for the mortality outcome (fig . Six studies demonstrated that none of the patients who received the epo intervention suffered from adverse events, which were associated with the use of drug, throughout the study period, such as hypertension, symptomatic thrombosis, myocardial infarction, stroke, headache, and seizures.1216,18 one study did not report adverse events,17 and 1 study reported adverse events for the entire participants without specifically describing the specific group.11 corwin et al9 showed that the incidence of deep thrombophlebitis was 2.15% (14/650) among the epo intervention group and 2.30% (15/652) in the control group without significant difference . Napolitano et al10 reported that the incidence of clinically relevant thrombovascular events was 16.42% (66/402) in the epo intervention group and 12.53% (49/391) in the control group with an rr of 1.31 (95% ci, 0.931.85). In this present meta - analysis of 10 rcts with 2759 participants, we found that compared with placebo, prophylactic epo therapy for patients who are critically ill or under perioperative care was not associated with a significant reduction in the incidence of aki, dialysis requirement, or mortality . Meanwhile, the effect of epo on aki prevention was consistent with the above result for the stratified analyses on patients with entirely perioperative care, no previous epo use, or more than 1 dose of epo . In addition, epo therapy was not associated with adverse events in these studies, which appeared to be safe in this kind of patients . Aki is a frequent and serious complication occurring in the critically ill or surgical patients and is associated with increased length of hospital stay, occurrence of end - stage renal disease, and mortality.22 ischemia and reperfusion injury, inflammation, oxidative stress, apoptosis, etc . Have all been demonstrated as crucial factors in the development of aki.23 recently, results from several animal studies indicated that epo exerts a renoprotective effect against aki induced by cardiopulmonary bypass or sepsis through mechanisms of reducing ischemia / reperfusion injury, inhibiting apoptosis, and alleviating inflammatory responses.8,24,25 however, the benefits of epo in these animal studies were not reproducible in clinical trials or in this meta - analysis first, many patients included in these trials suffered from some comorbidities, such as hypertension, diabetes, dyslipidemia, or ischemic heart disease and had complicated pathophysiological conditions, which might reduce the effects of epo.26,27 second, compared with animal experiments, the dosage of epo in clinical studies is relatively lower, which might be unable to obtain therapeutic effects . Third, the variable time of epo treatment in clinical studies is not the same as animal experiments, and the optimal time has not been established . Only 1 epo intervention study was enrolled in a previous meta - analysis without estimating the risk of aki,28 and 9 additional rcts with over 2600 participants were included into our meta - analysis . The majority of trials in this analysis had good or moderate methodological quality, which indicated that the results were not susceptible to be influenced by the biases of original researches . Meanwhile, most trials investigated the effect of epo on clinically hard end points such as dialysis requirement and short - term mortality . Both the between - study heterogeneity and publication bias were relatively minimal without statistical significance, which made the pooled effect size less likely to be affected . In addition, the appropriate stratified analyses and sensitivity analyses, which removed one study at a time, were performed with consistent results . First, several inclusion trials might not have sufficient sample size with designed only at the single - center level.1217 in the future, more large multicenter rcts with adequately participants will be needed to elucidate the prevention role of epo . Second, there were differences in patient selection, treatment regimen, and the definition of aki across these trials . An accepted uniform epo study protocol would reduce the degree of variation among the studies . Finally, our meta - analysis was based on aggregated data, not on individual patient - level data . As a consequence, the results might be less accurate and could not be adjusted for certain confounding factors, such as age, comorbidities, and laboratory parameters, which might influence the true therapeutic effect of epo . In summary, this meta - analysis, based on currently available rct evidence, suggests that prophylactic epo treatment of patients with critical illness or under perioperative care does not reduce the incidence of aki, dialysis requirement, or death . Considering the limitations of this study, larger scale, well - designed multicenter rct studies using optimal doses and administration times are needed to investigate the role of epo in aki prevention.

Human brain plasticity or neuroplasticity refers to the capacity of the nervous system to modify the organization of the brain structure and function in response to experience . Previous studies suggested that both short - term [2, 3] and long - term training [46] can modulate brain structural changes involved with both the gray matter (gm) and white matter (wm). The candidate mechanisms for these changes are multifaceted and likely include gliogenesis, synaptogenesis, and vascularization in gm, as well as myelination and axonal sprouting in wm . In addition to normal training or experience, a growing body of evidence has accumulated supporting injury - induced functional or structural plasticity at different levels in the adult central nervous system [810]. Previous studies suggest that, at least in primates, plasticity in the cortical representation can occur rapidly as a consequence of peripheral lesions or sensory deprivation [11, 12]. As a drastic limb injury, amputation in humans has been reported to lead to extensive reorganization, most prominently in the primary somatosensory and motor areas, which was suggested to correlate with phantom limb pain (plp) [1316]. Despite extensive neurobiological research, while some authors have argued that cortical reorganization following amputation is triggered by the loss of sensory input [16, 17], others have proposed that the mechanisms should be attributed to the persistent experience of pain . These discrepancies in the literature raise the fundamental question of whether brain reorganization occurs in amputees without plp . On the other hand, it also should not be overlooked that the short- and long - term effects of amputation on the brain may be varied, as plp is usually more common in the initial stage after amputation . One study using automated voxel - based morphometric analysis found that subjects with limb amputation exhibited a gm decrease in the thalamus, which was unrelated to plp . In addition, reduced gm volume in the primary motor or sensory cortices was also observed in patients with amputation or spinal cord injury . In contrast to voxel - based morphometry, the measurement of cortical thickness provides a more direct and meaningful index . Preiler and colleagues found that cortical thickness in upper limb amputees was reduced in the motor cortex but increased in the temporal and parietal lobes . Although gm reorganization was initially the focus of many brain imaging studies, wm changes after limb amputation are increasingly being investigated using neuroimaging techniques, especially diffusion tensor imaging (dti), which provides information about wm tracts and their organization based on water diffusion . Fractional anisotropy (fa) is the most often used dti index of wm integrity, and reduced fa in amputees has been reported in the corpus callosum (cc) and corticospinal tract . Although these studies have been carried out to determine the effects of missing limbs on brain reorganization, little is known about the associations between gm and wm changes after amputation . The purpose of this study was to examine the long - term patterns of brain reorganization following limb amputation . To systematically characterize brain reorganization, we first used a combined tract - based spatial statistics (tbss) and tractography analysis, which enables a precise characterization of both whole - brain wm and specific anatomical fiber tracts, to assess the microstructural changes in patients with unilateral amputation in the lower limb . We then performed surface - based morphometry across the whole brain gm and regions of interest (roi) focusing on the sensorimotor cortices . Seventeen adult patients (13 males and 4 females) with right lower limb amputation were recruited from the prosthetic and orthotic clinics at the department of rehabilitation, southwest hospital in chongqing . Twelve were amputations following traumatic injury and five were due to tumors (2 being melanoma and 3 being osteosarcoma). Exclusion criteria were the following: (1) age at amputation of less than 18 years or more than 60 years; (2) amputation at another part of the body; (3) presence of major systemic disease (e.g., diabetes mellitus, cardiovascular diseases, and inflammation), psychiatric or neurological illnesses; (4) duration between amputation and magnetic resonance imaging (mri) scanning of less than 6 months; (5) presence of plp or stump pain assessed by the five - category verbal rating scale . Eighteen age- and sex - matched healthy controls without neurological or psychiatric diseases and with normal brain mri were recruited from the local community . All the participants were dominantly right - handed as determined by the edinburgh handedness inventory and had a score of 27 or higher on the chinese version of the mini - mental status examination (mmse). The study was approved by the medical research ethics committee of southwest hospital, and written informed consent was obtained from all participants . All of the participants were scanned using a 3.0 tesla imager (tim trio, siemens, erlangen, germany) with a 12-channel head coil . Dti data were acquired using a single - shot twice - refocused spin - echo diffusion echo planar imaging sequence (repetition time = 10,000 ms, echo time = 92 ms, 64 nonlinear diffusion directions with b = 1000 s / mm, and an additional volume with b = 0 s / mm, matrix = 128 124, field of view = 256 248, and 2 mm slice thickness without gap). From each participant 75 axial slices were acquired and the diffusion sequence was repeated twice to increase the signal - to - noise ratio . T1-weighted three - dimensional magnetization - prepared rapid gradient echo images were then collected using the following parameters: repetition time = 1,900 ms, echo time = 2.52 ms, inversion time = 900 ms, flip angle = 9, matrix = 256 256, thickness = 1.0 mm, and 176 slices with voxel size = 1 1 1 mm . The dti data were preprocessed using the fmrib software library (university of oxford, uk). First, the diffusion data were corrected for eddy currents and head motion, and the two acquisitions were averaged . The averaged images were masked to remove skull and nonbrain tissue using the fsl brain extraction tool . First, fa images for all subjects were nonlinearly aligned to a study - specific minimal - deformation target (mdt) brain and resampled to an isotropic 1 mm resolution . The mdt brain was selected as the brain image that minimizes the deformation from other brain images in the group through warping all fa images in the group to each other [29, 30]. Next, the mean fa image was created and thinned to create a mean fa skeleton that represents the centers of all fiber tracts . Clusters showing group differences in the tbss analysis were used as seed masks for multifiber probabilistic tractography in each subject's native space . The steps have been described in detail in our previous articles [32, 33]. For each participant, pdt was run from each voxel in the seed mask to the whole brain using default parameters . The warp fields of nonlinear registration and the inverse versions were used for the translation between the original space and the standard space . For the elimination of spurious connections, the individual tracts in standard space obtained by pdt were arbitrarily thresholded to include only voxels through which at least 25% (1,250) of samples had passed . Each subject's tracts were then binarized and summed to produce group probability maps for each pathway . The group probability maps were also thresholded at 25% (at least 9 of the 35 subjects) to generate the masks for each fiber pathway . The wm labels atlas and tractography atlas implemented in fsl were used for the structural identification . Individual mean fa values of each pathway were then extracted from the standardized whole - brain dti images . All the structural t1 images were analyzed using freesurfer (version 5.3.0, https://surfer.nmr.mgh.harvard.edu/) to create anatomical surface models . The automated processing stream mainly included removal of nonbrain tissue, talairach transformation, segmentation of gray / white matter tissue, intensity normalization, topological correction of the cortical surface, and surface deformation to optimally place the tissue borders . Cortical thickness was calculated as the shortest distance between the gm and wm surfaces at each vertex across the cortical mantle . Moreover, the gm volume in each hemisphere and total intracranial volume (tiv) was also calculated from the freesurfer processing stream . Finally, using the brodmann areas (ba) atlas in freesurfer (https://surfer.nmr.mgh.harvard.edu/fswiki/brodmannareamaps), we measured the individual mean cortical thickness values in the sensorimotor regions, including the bilateral ba 1, 2, 3a, 3b, 4a, 4p, and 6 . In order to avoid the overlap among these labels, group differences in age, years of education, and neuropsychological scores were examined using independent samples t - tests . Randomize tool, which is specifically designed for permutation testing with nonparametric values . Age and sex clusters were reported reaching a significance level of p <0.05, corrected for multiple comparisons across image using the null distribution of the maximum cluster mass (t> 3). Cluster mass is the sum of all statistic values within the cluster and has been reported to be more sensitive than cluster size . Whole - brain vertex - wise group comparisons for cortical thickness were performed on a standardized surface and the data were smoothed using a full - width / half - maximum gaussian kernel of 10 mm on the surface . Regional differences between amputees and controls were assessed using a vertex - by - vertex general linear model controlling for the potential confounding effects of age, sex, and tiv . The statistical analyses were performed with the surfstat toolbox based on random field theory (rft). Clusters were first reported reaching a significant level of rft - corrected p <0.05, and then those reaching a looser significance level of uncorrected p <0.005 were also indicated . Analyses of covariance (ancova) adjusting for age and sex were used to explore the group differences in the mean fa value for each of the fiber tracts generated by pdt and in the mean cortical thickness for each of the selected sensorimotor regions in both hemispheres . Finally, the relationships between the wm and gm changes were investigated using partial correlation analyses (adjusted for age and sex). A false discovery rate (fdr) corrected threshold of 0.05 was considered as significant for these analyses . There were no significant differences in sex ratio, age, education, and mmse scores between the amputees and controls . Compared with controls, the amputees showed a decreased fa in the right superior corona radiata and wm regions underlying the right temporal lobe and left premotor cortex (pmc) (figures 1(a), 1(c), and 1(e); table 2). Pdt from the above clusters revealed that the contributing wm tracts were the commissural fibers connecting the bilateral premotor cortices and the association fibers that exactly overlapped with the inferior frontooccipital fasciculus (ifof) (figures 1(b) and 1(d)). The cluster underlying the left pmc also generated local premotor and transcallosal paths (figure 1(f)). The results of ancova demonstrated that the mean fa values extracted from the thresholded group probability maps in amputees were all significantly reduced (p <0.05, fdr correction for multiple comparisons) in all the fiber tracts (table 3). The gm volume (controls versus amputees: left, 0.25 0.02 versus 0.24 0.03 l, p = 0.13; right, 0.25 0.02 versus 0.24 0.03 l, p = 0.17) and tiv (1.56 0.15 versus 1.51 0.14, p = 0.17) of amputees did not differ significantly from those of controls . The amputees showed a thinning trend (p <0.005, uncorrected) in different cerebral lobules, with the largest one in the left pmc . Smaller clusters of cortical thinning were also noted in the bilateral occipital lobes, the right temporooccipital junction, precentral gyrus, precuneus lobe, the left inferior parietal lobule, and frontal orbital cortex (figure 2; table 4). We did not find any clusters exhibiting thickness increase in the amputees compared with the control group (p <0.005, uncorrected). The results of ancova for the roi confirmed that the cortical thickness was only significantly decreased in the left premotor area (ba 6) in the amputees relative to the controls (2.73 0.14 versus 2.84 0.12; p = 0.02). The difference remained significant (p = 0.03) even when we added tiv as an extra covariate (table 5). No significant associations were found between the cortical thickness in the affected regions (as shown in table 4) and the dti parameters of the fiber tracts generated from the pdt in the amputees . However, partial correlation analyses revealed that the fa value of the ifof (as shown in figure 1(d)) was negatively correlated to the time since amputation (r = 0.55, p = 0.03). In the present study, we explored brain structural reorganization in lower limb amputees without plp . Cortical thickness and fa values were used as measures to evaluate the gm and wm microstructural changes across the whole brain compared with normal controls . As a consequence, we found that patients with amputation at the right lower limb exhibited cortical thinning in the left premotor area and the right visual - to - motor regions . Additionally, the integrity of the fiber tracts connecting the bilateral pmc and those underlying the right visual - to - motor regions was also significantly reduced in the patients . Our study demonstrates that cortical reorganization occurs in lower limb amputees, even in the absence of plp . We observed a thinning trend in different cerebral lobules, especially in the pmc contralateral to the affected side . The pmc encompasses the anterior lip of the precentral gyrus, the posterior portion of the middle frontal gyrus, and the superior frontal gyrus on the superolateral surface of the brain, corresponding to part of ba 6 . The time - specific studies of the pmc and primary motor cortex reflect the distinct roles of the two areas: the pmc is involved in movement selection, whereas the latter is involved in movement execution [44, 45]. The activity of pmc neurons is also responsible for the specification of movement parameters such as amplitude, direction, and speed of movement . Additionally, the pmc also seems to be involved in the control of eye movements and eye - related neural activity or in specific tasks that require eye - limb coordination [46, 47]. As amputation in the lower limb will lead to a lack of movement selection and disorders of movement parameters and coordination, it can be inferred that the gm loss in the pmc following amputation is possibly attributed to long - term use - dependent blockage . Reduced gm volume in the left primary motor cortex had also been reported in patients with right upper limb amputation but was not found in the current lower limb amputees . One possible reason for the discrepancy could be the sample heterogeneity between studies . As the upper limb representation is much bigger than the lower limb in the brain, the morphological changes due to functional nonuse could be less significant for the patients with lower limb amputation . In line with our reports, one previous study, in which 19 of the 28 patients were amputated at the lower limb, also did not find alterations in the primary motor cortex . In addition, reorganization in the primary somatosensory and motor areas after amputation has been suggested to correlate with plp [15, 16]. In our study, the amputees with plp were not included . Therefore, our findings would provide an update on the distinctive patterns of brain plasticity in lower limb amputees without plp . In this study, the pdt approach was used to reconstruct the tracts from the wm skeleton regions characterized by fa decrease in lower limb amputees . Our tbss analysis revealed that right lower limb amputees displayed significant fa reduction in the right superior corona radiata and wm underlying the left pmc . Further fiber tracking generated the transcallosal paths linking the homologous pmc of the bilateral hemispheres . These findings are very consistent with one pioneering dti study, which reported the reduced integrity in the body of the cc in amputees . It is known that unilateral movement requires sequential processing in bihemispheric motor areas . Using transcranial magnetic stimulation, previous studies found that the pmc modulates the activity of contralateral motor areas during the preparatory period of a voluntary movement with the ipsilateral limb [49, 50]. Such modulation is mediated by interhemispheric inhibition through fibers within the cc and enables healthy adults to perform complex motor tasks without the activation of contralateral muscles . Therefore, the fa reduction within the cc connecting the bilateral pmc may reflect adaptive wm modification following the changes of movement patterns, as the transcallosal inhibition function is disused in unilateral lower limb amputees . Beyond the left pmc, smaller clusters of cortical thinning in amputees were also noted, mainly in the brain regions constituting visual - to - motor networks, including the bilateral visual cortices, the right temporooccipital junction, left inferior parietal lobule, and orbital frontal cortex . Functional mri has found that human parietal and temporooccipital cortices constitute the core nodes for cross - modal vision - action representations . Meanwhile, the inferior parietal lobule, particularly in the left hemisphere, contributes to motor attention and is activated in neuroimaging experiments when subjects prepare movements or switch intended movements . Visual - motor transformation also engages the orbital frontal cortex, which becomes active during response preparation and execution . Further functional / structural connectivity studies confirm that the pmc integrates visual and somatosensory information from the intraparietal area to allow effective exchange and elaboration of information . The connections within the neural networks are plastic and are modified in response to injuries [57, 58], training, and treatments . Previous imaging studies demonstrated that stimulation of afferent input could result in functional reorganization and a corresponding structural expansion of the cortical and subcortical areas [2, 60]. Accordingly, the loss of afferent input following limb amputation should cause negative structural alterations with a decrease in gm . Lower limb amputees also display significant fa reduction in the right ifof, which is negatively correlated with the time span after amputation . The ifof connects the inferior frontal lobe to the posterior temporal - occipital regions and provides the main anatomical connections for the ventral (bottom - up) attention system, which is specialized for the detection of behaviorally relevant stimuli . Reduction of wm integrity in the ifof has been reported to be associated with deficits in executive function in patients with chronic trauma . Furthermore, our previous dti study showed that the right hemispheric ifof confers an advantage for the executive function of attention, which is in line with the well - described rightward dominance of visuospatial processing . Interestingly, the amputees presented time - related microstructural abnormalities of the ifof in the right rather than the left hemisphere, indicating the degenerative function of visuospatial processing following amputation . Future studies including neuropsychological assessments should be used to investigate the underlying explanations for the associations between brain wm plasticity and visuospatial function in amputees . The negative findings of gm increase are supported by one mri study but are incongruent with another . The differences might be due to the status of plp, prosthesis use, amputation sites, or time span after amputation . Using a smaller sample size, preiler et al . Found that upper limb amputees with slight plp showed gm increase in regions of the visual stream . They initially hypothesized that it might be a compensatory effect for the lack of sensorimotor feedback and could serve as a protection mechanism against high plp development . However, in their following study using the same patients, a negative association between prosthesis use and cortical volume in the posterior parietal and occipital lobes, which greatly overlap with the regions with gm loss in our findings, was reported . As prosthesis use has been shown to have a beneficial influence on the prevention of cortical reorganization and plp [67, 68], and patients rely less often on bottom - up or stimulus - driven control with increasing prosthesis use; we could speculate that the cortical thinning and fa reductions in the ventral visual stream also reflect adaptive brain plastic changes along with the transformation of human abilities and might be beneficial for the prevention of plp . Although these findings are robust, some limitations of the present study need to be addressed . First, the relatively small sample size in this study may mask subtle differences between groups, especially in the vertex - based cortical thickness analysis across the whole brain . Left lower limb amputation might result in different morphological and functional changes, especially with respect to the contralateral pmc and the structures in the visual stream . It will be of interest to determine whether the individuals with amputation at the left side will demonstrate the analogous changes at the homologous regions of the other hemisphere . Future studies should be performed to confirm the interhemispheric interactions using noninvasive transcranial current or magnetic stimulation . In this study, we combined high - resolution brain structural mri and dti to investigate the existence and extent of cortical and wm plasticity in subjects with right lower limb amputation . In summary, we found specific motor and somatosensory plastic changes in amputees without plp and provided an update on the plasticity of the human brain involving both gm and underlying wm after limb injury.