However, although 13 carbohydrate binding module families have been reported to contain starch-binding domains, only starch-binding domains from carbohydrate binding module family 20 have been well studied and introduced into plants successfully.Starch-binding domains from carbohydrate binding module family 20 have been used as a tool for starch engineering. Previous studies showed that Microbacterium aurum, were expressed in the tubers of a wild type potato cultivar  and an amylose-free (amf) potato mutant.In this study, two fragments, the tandem CBM25 domain and the tandem CBM25 with multiple fibronectin type III (FN3) domains of the α-amylase enzyme from 2 and FN3 protein were successfully accumulated in the starch granules of both Kardal and amf transformants. The accumulation of (CBM25)2 protein did not result in starch morphological alterations in Kardal but gave rise to rough starch granules in amf, while the FN3 resulted in morphological changes of starch granules  but only at a very low frequency. The starches of the different transformants did not show significant differences in starch size distribution, apparent amylose content, and physico-chemical properties in comparison to that of untransformed controls.The (CBM25)These results suggest that the starch-binding domains from carbohydrate binding module family 25 can be used as a novel tool for targeting proteins to starch granules during starch biosynthesis without side-effects on starch morphology, composition and properties.The online version of this article (10.1186/s12896-017-0406-x) contains supplementary material, which is available to authorized users. Starch is the most important and abundant storage carbohydrate in plants and exists in the form of discrete granules in higher plants such as wheat, rice, maize, potato, and pea. Starch granules are mainly composed of two α-glucan polymers, a mostly linear amylose 20-30%) and a highly branched amylopectin (70-80%) . Starche0-30% andMicrobial extracellular hydrolytic enzymes that catalyze the degradation of insoluble polysaccharides, such as glycogen, starch, and cellulose, typically possess a modular architecture referred to as carbohydrate-binding modules (CBMs) which target cognate catalytic modules to specific polysaccharide structure , 6. To dexpression of starch binding domain fusion proteinsin planta resulted in altered starch granule structures and properties [Escherichia coli glycogen branching enzyme in potato resulted in severe morphological changes in starch granulesexpression of an engineered granule-bound  [Expression of an amylosucrase gene in potato results in larger starch granules with novel properties [Until now, only SBDs from CBM family 20 have been well studied  and introperties –17. For granules . Expressoperties . Moreoveoperties .Microbacterium aurum. This α-amylase enzyme is responsible for the formation of numerous small pores in starch granules when it was incubated with potato starch [It is still unknown whether the SBDs of other CBM families can be used to target proteins to starch granules and whether they have other different biochemical properties in comparison to CBM20s. A multi-domain α-amylase enzyme composed of a catalytic α-amylase domain, multiple fibronectin type III domains, and a tandem carbohydrate binding domain belonging to the CBM family 25, was isolated from o starch . The tano starch .In this study, the effects of the tandem CBM25 domain on starch granules were studied and the potentiality of using this tandem CBM25 domain as tool for anchoring proteins into starch granules during starch biosynthesis was assessed.2 (the tandem CBM25 domain sequence) and pBIN19/FN3 (tandem CBM25 with multiple fibronectin type III domains) were transformed into wild type potato  and amylose-free potato (amf), respectively. Thirty independent kanamycin-resistant transformant clones from each transformation were transferred to the greenhouse for tuberization and further analysis. During the growth in the greenhouse, the morphology of transgenic plants did not show detectable differences when compared with that of untransformed control plants. The morphology of tubers, the tuber yield, and the starch yield of all transformants were comparable with that of untransformed controls (data not shown).Two constructs Fig. , which a2 and FN3, in potato tubers was determined by semi-quantitative RT-PCR. Results showed that tubers of transgenic plants possess the mRNA transcripts of the expressed fusion proteins 52 and FN2 and FN3 proteins in both Kardal and amf potato starches was analyzed by Western dot blot. An N-terminally engineered RGS(His)6-tag allows the detection and classification of the accumulation of the His-tagged fusion proteins in starch granules from transformants expressing different constructs. The Western dot blot results showed that the His-tag fusion proteins can be detected in (CBM25)2 and FN3 transformant series both in Kardal and amf backgrounds (data not shown).The expression of (CBM25)2 and FN3 respectively. Starch granule bound proteins were extracted from different transformants and were analyzed with SDS-PAGE and subsequent Western blotting immuno-detection with anti-RGS(His)6 antibodies. As shown in Additional file 2 and FN3 transformed plants and bands were undetectable in both untransformed control Kardal and amf starches. These results indicate that (CBM25)2 fused with poly-His-tag and FN3 fused with poly-His-tag fusion proteins have been targeted to the starch granules successfully.As predicted, the molecular masses of the His-tagged fusion proteins were 22,954 Da and 59,283 Da for (CBM25)2 and FN3 proteins were accumulated in starch granules of transformants in both Kardal and amf backgrounds. In order to investigate whether the accumulation of fusion proteins in starch granules affect the starch granule morphology, starch granules of each transformant were investigated by both light microscopy and electron scanning microscopy (SEM).The (CBM25)2 and FN3 proteins did not affect starch granule morphology in Kardal background. Most of the transformants did not show any starch granule morphological alteration in KD-(CBM25)2 and KD-FN3 transformant series in comparison with that of untransformed control. However, 2 out of 30 KD-FN3 transformants, KD-FN3-04 and KD-FN3-07, showed an altered starch morphological phenotype. Starch granules from these transformed plants showed a helical shell-shaped structure at a very low frequency (less than 1%) which was observed when starch was stained with iodine. Further investigations with SEM revealed the feature of these structures in more detail ail Fig. . As showail Fig.  have smoail Fig. . Further5ail Fig.amf background, the expression of both proteins did not result in severe alterations in starch granule morphology. The light micrographs showed that the amf-(CBM25)2 and amf-FN3 transformants did not show starch morphological alterations (data not shown). However, SEM microscopy revealed that the surface of starch granules from both amf-2CBM25 and amf-FN3 transformants were rough, especially in the higher expressors such as amf-2CBM25-29 and amf-FN3-10 2 and 13 out of 18 transformants in amf-FN3 that showed rough surface granules albeit at a low percentage. Moreover, there was one transformant (amf-FN3-15) that showed amalgamated starch granules 2 and amf-FN3 transformants were also present at a low frequency (about 5%) in the highest expressors (amf-(CBM25)2-29 and amf-FN3-04).To investigate the frequency of starch granules with altered morphology, the number of altered granules was scored by counting a population of 300 starch granules in triplicate for selected transformants which have the highest fusion protein accumulation level. The results from these quantification analyses showed that the helical starch granules were present at a very low percentage (less than 1%) in KD-FN3-04 and KD-FN3-07 transformants. The starch granules with rough surface in 2 and FN3 protein accumulation in starch granules on starch physico-chemical properties, such as apparent amylose content, mean granule size and granule size distribution, and starch granule melting behavior (Tonset and ΔH), was measured. These results are summarized in Table amf-(CBM25)2, KD-FN3, and amf-FN3 transformants and their corresponding controls.The impact of (CBM25)M. aurum were expressed in amylose containing and amylose-free potatoes, respectively, to test the potentiality of the tandem CBM25 domain as a tool to target proteins into the starch granules during starch biosynthesis.In this study, the tandem CBM25 sequence and the tandem CBM25 with repeated fibronectin type III domain sequence from amf genetic backgrounds in this study  [in planta by using SBDs. In this study, the expression of the tandem CBM25 did not affect starch composition (apparent amylose content) and starch physico-chemical properties  . These asex 1-1) , 16. Thiamf-(CBM25)2 and amf-FN3 transformants. The rough surface granule phenotype in this study and the amalgamated starch granules which were only observed in amf-FN3-15 are similar to the starch morphological phenotypes which were reported in the double CBM20 tranformants in amf background [2 and FN3 protein might interfere with the starch granule assembling process to some degree to give rise to starch morphological alterations, though at a very low rate.The accumulation of the tandem CBM25 domain in starch granules neither lead to severe starch morphology alterations nor affected the starch granule size distribution, but there are some altered starch granules at a very low frequency were observed in this study. For instance, the helical starch granules were only observed in 2 out of 30 KD-FN3 transformant plants at a very low frequency (less than 1%) and the rough surface granules (approximately 5%) showed in both ckground . These sIn the 13 CBM families which contain SBDs, the structure and property of CBM20 and CBM25 have been thoroughly characterized . Althougamf backgrounds [amf-FN3-15 with similar amalgamated starch granule phenotype suggesting that the accumulation level of (CBM25)2 could lower than (CBM20)2, although this cannot be confirmed by the comparison of these two proteins accumulation level due to two different antibodies were used for Western Blotting detection. Moreover, the helical granules which were observed in two KD-FN3 transformants have never been observed before in any of the transgenic potato starches. Since the mRNA expression level of FN3 in both transformants is quite high comparing with that of other transformants, the expression of FN3 could affect genes involved in starch assembling process and give rise to these helical starches, though at a very low rate. However, this needs to be investigated further.The absence of amalgamated granules may be due to the fact that the double CBM25 has less binding sites than the double CBM20. It was proposed by Nazarian and co-workers  that thekgrounds . HoweverSince the incorporation of the tandem CBM25 in starch does not affect physico-chemical properties of starch granules, in particular gelatinization of starch, and it is supposed to deposit in all the regions of the starch granule, the tandem CBM25 domain can be a better tool than CBM20 to anchor proteins into starch granules in order to maximize the potential for the effector proteins. This study shows that CBM25 is a very good  tool to anchor effector proteins into starch granules for starch bioengineering.2 tandem sequence and the (CBM25)2 with repeated fibronectin type III domain sequence of the α-amylase from M. aurum., were cloned in frame to the GBSSI promoter and its transit peptide sequence with a RGS(His)6-tag to facilitate antibody detection. The two constructs, named pBIN19/(CBM25)2 and pBIN19/FN3 were made in pBIN19 expression binary vector. These constructs were made to express (CBM25)2 and FN3-(CBM25)2-3FN3 fusion proteins in potato plants. To obtain the pBIN19/(CBM25)2 plasmid  in the pUC19/SBD2 plasmid [2 plasmid. Similarly, the other fragment was cloned into the same pUC19/SBD2 plasmid with the primers 5′-AGCCCATGGTGCGTGCACCGAC -3′ and 5′-ATCGGATCCTTACGCCGAAGTACCTGCC -3′, for FN3-(CBM25)2-3FN3 amplifications. The 5′ end of the coding regions in all constructs carried a RGS(His)6 tag to facilitate protein detection and purification. All constructs in pUC19 were later digested with HpaI-BamHI and cloned into the same position in pBIN19 vector containing potato granule-bound starch synthase I (GBSSI) promoter and its transit peptide for tuber expression and amyloplast targeting and a NOS terminator, respectively. The pBIN19/(CBM25)2 and pBIN19/FN3 were assembled from the following fragments: (1) GBSSI promoter and transit peptide, (2) RGS(His)6-(CBM25)2 or RGS(His)6-FN3-(CBM25)2-(FN3)3, and (3) a NOS terminator. The predicted molecular masses of the RGS(His)6 containing proteins were 22,954 Da and 59,283 Da for RGS(His)6-(CBM25)2 and RGS(His)6-FN3 respectively, excluding the transit peptide. The accuracy of all constructs were controlled by sequence analysis.Two DNA fragments, the (CBM25) plasmid , giving Agrobacterium tumefaciens strains LBA4404 harboring the expression cassette constructs  and amylose-containing potato plants (wild-type) were used for transformations. Two constructs 2 refers to the (CBM25)2 domain; FN3 refers to (CBM25)2 with repeated fibronectin type III domain. KD-UT and amf-UT refers to two untransformed controls respectively, and xx stands for the clone number. Plantlets grown on MS30 selection medium were harvested, multiplied and 5 plantlets of each clone was subsequently grown in pots in the greenhouse to generate tubers.cts Fig.  was usedcts Fig. , which aStarches were isolated according to the method by Huang et al. . Briefly6-tag fusion proteins accumulated in the transgenic starch granules was measured by Western dot blot analysis. For determining the amount of fusion proteins, 50 mg of (transgenic/control) starches were boiled for 5 min with 1 mL of 2× SDS sample buffer containing 5% β-mercaptoethanol (v/v). After cooling to room temperature, equal amount of the supernatants (500 μL) was applied to a Hybond ECL transfer membrane  using the S&S manifold-I dot blot system . To detect expression of recombinant His-tagged proteins, a monoclonal anti-RGS(His)6-tag antibody was obtained from Qiagen . Protein fractions were electroblotted onto nitrocellulose membrane. Probing and detection of Western-dot blots were performed as described by Ji et al. [6-tag (Qiagen) according to instruction of manufacturer.The amount of RGS(His)i et al. ..The SDSi et al.  and the Relative expression of mRNA was determined by Semi-quantitative RT-PCR analysis as described by Nazarian et al. . The ubiA combination of light microscopy  and scanning electron microscopy  were used to investigate the granule morphology of starch granules as described by Huang et al. .The apparent amylose content of starch granules were measured using the method by Hovenkamp-Hermelink et al. . TheonseOne-way analysis of variance (ANOVA) was carried out to compare the statistical difference in starch apparent amylose content (%AM), median granule size(d50), and starch gelatinization temperature of the transformants and controls. In Table


International Journal of Molecular Sciences accepted nominations for Young Investigator and Travel Awards 2017. Over 200 nominations were received and were evaluated by a panel of judges comprised of International Journal of Molecular Sciences editorial board members.With the goal of recognizing outstanding contributions to the field of molecular sciences by young investigators under the age of 40 (by 31 December 2016), and early-career investigators, which includes postdoctoral students and PhD students, and assisting the early-career investigators in attending international conferences in 2017, last year the We are excited to announce the winner of the Young Investigator award: Dr. Rob W.J. Collin who will be awarded 2000 Swiss Francs; and the following winners for Travel Awards, Dr. Yi Ma, Dr. Miranda Ween, and Dr. Reza M. Zadegan who will be supported with up to 800 Swiss Francs each towards their travel expenses to attend international conferences in 2017.Xenopus intermediate pituitary, under the supervision of Prof. Dr. Gerard J.M. Martens. After obtaining his PhD degree, he changed gears to the field of Human Genetics, and as a post-doctoral researcher, he was involved in the identification of several novel disease-causing genes for inherited hearing impairment  and inherited (vitreo)retinal diseases . Since 2009, Dr. Collin has moved his scientific activities towards the development of novel genetic therapies for retinal diseases, in particular those focusing on correcting pre-mRNA splicing defects. Supported by a prestigious VENI grant from the Netherlands Organization for Scientific Research, and an Individual Investigator Award from the Foundation Fighting Blindness USA, amongst others, he and his group have developed an antisense oligonucleotide-based therapeutic strategy for the future treatment of CEP290-associated LCA. In 2010, he was a visiting scientist in the lab of Prof. Dr. Jean Bennett, at the F.M Kirby Center for Molecular Ophthalmology, Scheie Eye Institute in Philadelphia, PA, USA.Dr. Rob W.J. Collin is an Associate Professor at the Department of Human Genetics, Radboud University Medical Center in Nijmegen, The Netherlands, and is affiliated to the Donders Institute for Brain, Cognition and Behaviour. In 2000, Dr. Collin obtained his M.Sc. degree in Chemistry and in 2006, he successfully defended his doctoral thesis entitled “Exploring the role of Alzheimer’s amyloid-β precursor protein APP and its relatives in tdy1) mutant, which accumulates excess levels of sugars and starch in leaves. She cloned Tie-dyed1, a novel gene that expresses in phloem cells including sieve elements and companion cells. TDY1 is localized on the endoplasmic reticulum (ER) membranes involved in phloem unloading in maize. The findings provide insights into managing carbohydrate for yield improvement and biofuel production. Dr. Ma then switched to studying Ca2+ associated signaling in plant cells. She is working on identifying Ca2+ conducing channels that are involved in different signaling transduction pathways, such as BR signaling, plant innate immunity and meristem development. She has demonstrated that different Ca2+ sources could be responsible for different pathways. Dr. Ma is investigating Arabidopsis plants expressing an optogenetic cAMP sensor to monitor cAMP generation in responses to various environmental cues. Dr. Yi Ma, Post-Doctoral Research Scientist at University of Connecticut, USA. Dr. Ma obtained her Ph.D in Plant Biology from the Pennsylvania State University in 2008 under the supervision of Professor David Braun. Her Ph.D research was focused on carbohydrate partitioning in maize. She was working on the characterization of a tie-dyed1  group. Dr. Zadegan believes that nucleic acid-based materials are ideal candidates for interdisciplinary bio-nanomaterials science, and it is hence their coding, synthesis, and exploration of their unique properties that forms the basis of the research program he plans to establish. His current research focuses on synthesizing innovative biomaterials for a range of applications, with particular emphasis on nanostructured materials and devices and on developing alternative digital memory storage technologies given the likelihood that demand will outpace capacity and production of current technologies.International Journal of Molecular Sciences’ editorial board members and editorial staffs, we wish to congratulate these four outstanding scholars for their accomplishments.On behalf of the


Valsalva retinopathy is a common condition but retinal holes secondary to Valsalva retinopathy are rarely reported. The author believes this to be the first report to describe multiple retinal holes after hyaloidotomy for Valsalva retinopathy. Valsalva retinopathy is a common condition but retinal holes secondary to Valsalva retinopathy are rarely reported. We report a case of Valsalva retinopathy with multiple retinal holes after YAG hyaloidotomy. To the best of our knowledge, this is the first reported case of multiple retinal holes in the posterior pole following YAG hyaloidotomy for Valsalva retinopathy.A 25-year-old male presented with sudden loss in vision of right eye (RE) following lifting heavy load. The presenting best corrected visual acuity (BCVA) in his RE was 20/200 and left eye (LE) was 20/20. Fundus evaluation of RE revealed well circumscribed dome shaped premacular haemorrhage about 3 disc diameters in size. Since the patient was very apprehensive and requested aggressive treatment, YAG laser hyaloidotomy/membranotomy was done with Zeiss Visuals® YAG III machine with a single shot of 8 mJ applied over inferonasal border of the subhyaloid haemorrhage. At 2-week follow-up, the premacular haemorrhage was noticeably absorbed but he developed 2 full thickness retinal holes near the inferotemporal border of premacular haemorrhage along with empty cavity as bubble over macula. At 4 weeks, the full thickness retinal holes increased to 5 in number . OpticalIntraoperatively, brilliant blue was used for staining, and the ILM was intact, but superficial sheen like dome shaped detachment suggestive of thickened ILM was present over the macular area. After PPV, though the fundus image shows persistence of empty bubble/cavity , there wValsalva retinopathy occurs in young healthy adults following a Valsalva maneuver. The prognosis for patients given a diagnosis of only Valsalva retinopathy is generally good. YAG hyaloidotomy is a relatively safe procedure with very good safety profile. It is noninvasive, inexpensive outpatient procedure and very effective treatment option for large subhyaloid haemorrhage in comparison to other treatment options like vitrectomy, pneumatic displacement. In the past, the application of Nd-YAG laser in the posterior segment was limited to releasing tractional vitreous bands and other pathologic vitreous attachments, especially in cases with tractional retinal detachment due to diabetic or sickle-cell retinopathy and other complicated retinal detachments. The high levels of energy up to 1000 mJ) applied to treat these conditions could result in serious complications such as retinal and/or choroidal haemorrhage and retinal perforation. However no such events have been reported following YAG hyaloidotomy for subhyaloid haemorrhage, probably due to the fact that the energy used is very low and also the entrapped blood acts as a cushion protecting the underlying retina. To the best of our knowledge, the development of multiple retinal holes in the posterior pole following complete resolution of Valsalva retinopathy by YAG hyaloidotomy has not been previously reported in the literature. Kim et al. 000 mJ ap reportedThere are several possible mechanisms that could explain retinal hole formation following YAG hyaloidotomy.First, the retinal holes could be due to the direct photo-disruptive effect of the YAG laser. The entrapped blood is believed to act as a cushion, dampening the disruptive impact of the ND: YAG laser burst. In small haemorrhages, the protective dampening effect may be insufficient.Secondly, the thickened internal limiting membrane (ILM) observed after resolution of the premacular haemorrhage may have created a tangential traction on the retina.Thirdly, the massive haemorrhage puts the ILM under high tension, which may make ILM hard to reattach to the retina as discussed by Zou et al.  and MeyeIn our case, the second and third hypothesis might explain the pathology of retinal holes since, during PPV, the ILM over previous subhyaloid/sub-ILM bleed was found to be partially detached. Moreover the visual acuity and retinal findings stabilized after PPV with ILM peel. After PPV, the fundus image shows persistence of empty bubble/cavity over the macula which might be due to pigmentary changes secondary to the entrapped sub-ILM bleed. Moreover, there is resolution of hyperreflective convex cavity in the post-PPV OCT. We need a long term follow-up to see if the cavity/bubble like appearance disappears in subsequent follow-up.Multiple retinal holes secondary to Valsalva retinopathy have been rarely reported and their mechanism needs further understanding. This case illustrates the possibility of retinal hole formation for Valsalva retinopathy.


New England Journal of Medicine (NEJM) is today the highest ranked general medical journal. It is unknown if there exists institutional bias favoring publication of articles originating from Harvard University, since the NEJM is produced by the Massachusetts Medical Society with close connections to the Harvard University. We examined if studies originating from the Harvard University published in the NEJM were noninferior in terms of citation rates compared to articles with an origin outside Harvard University. We evaluated original research articles published in the NEJM in 2000 up until June 2001. A two-sample noninferiority test based on the primary endpoint of citations was performed. Twenty-two studies were affiliated to the Harvard University and 280 studies were not affiliated to the Harvard University. The mean number of citations for Harvard affiliated studies was 625  and for non–Harvard affiliated studies 493 . The mean difference was not statistically different between affiliations, but fulfilled the requirements for noninferiority . In summary, citation rates were comparable between studies origination from the Harvard University compared to non-Harvard Institutions. Based on these results there appears to be low risk of institutional bias in the publishing process of original studies in the NEJM.Recently, in the four top journals of humanities, an institutional bias towards publication of authors from Harvard and Yale was shown. The  New England Journal of Medicine (NEJM) is today the highest ranked general medical journal, with a steadily increasing impact factor (IF) over the last 20 years that has now reached 72 in IF , where the IF is based upon the number of citations to that journals recent published articles divided by the number of published articles the two preceding years. According to this, the Garfield . This inNEJM should optimally ensure publication of only the most impactful papers, and the base for publication decision should rely primarily on scientific merit and novelty. Recently, in the four top journals of humanities, an institutional bias towards publication of authors from Harvard and Yale was shown . The articles were gathered consecutively and manually from the webpage www.nejm.org. Institutional affiliation based on first and last author were registered and categorized as Harvard or non-Harvard affiliation. The affiliation to Harvard of either the first or last author categorized the research as pertaining to Harvard. Citation rates, as of August 2017, for each article were retrieved from www.nejm.org. Data was extracted by one author. Study sample size was determined through power calculation based on pilot data from the first 3 months of 2000 in the Journal. A two-sample noninferiority test based on the primary endpoint of citation rates was performed using a power of 90% with a 2.5% error rate and a delta value of 200. Implementing a sampling ratio of 5 the numbers of articles needed in each group was 14 articles from the Harvard University and 280 non-Harvard based studies. We estimated that we needed to include articles from January 2000 up to June 30 2001. A two-sample noninferiority test based on the primary endpoint of citations was performed with a power of 90% and type I error rate of 2.5% with non-inferiority (Δ) set to 200 citations. Non-parametric Mann–Whitney’s U test was used to compare differences between continuous variables. Analyses were performed in STATA Version 13.1 . Descriptive summary statistics were presented with 95% confidence interval.We evaluated original research articles published in the NEJM year 2000 up until June 2001 was identified. Twenty-two studies were affiliated to the Harvard University and 280 studies were not affiliated to the Harvard University. The mean number of citations for Harvard affiliated studies was 625 , Δ 200).A total of 302 original articles published in the NEJM had a first or last author affiliated to the Harvard University. Based on these results there appears to be a low risk of institutional inequality in terms of impact of the articles published in NEJM publications from the Harvard University compared to publications to other institutions.In total, eight percent of all articles published in the NEJM publications are affiliated to Harvard, this skewed proportion with origin from NEJMs home institution might suggest evidence for institutional equality. Previous studies related to citation rates have focused on factors related to higher citation, where e.g. for-profit funded research and articles related to cancer/cardiovascular disease are associated with higher citation rates (Kulkarni et al. NEJM despite its home institution. Furthermore, this study ensure a rigid editorial process for the acceptance of articles in NEJM.Data from the humanities have suggested an institutional bias with a higher proportion of the authors affiliated to Yale and Harvard more likely to publish in the top ranked journals (Piper and Wellman NEJM to a particular institution. It is unclear if these finding can be generalized to other fields, or more specialized journals.The strength of this study is pertinent to the fact that the study was powered for the primary endpoint—noninferiority in citation rates. This is to our knowledge the first study to assess home institutional bias related to citation rates. Furthermore, we chose articles published from 2000 and 2001 to ensure a sufficient time to be cited, and less vulnerable to trends in citing. Few general medical journals are so strongly linked as NEJM were associated with Harvard University. However, we found no evidence of home institution bias between studies affiliated to Harvard and those not affiliated to the Harvard University with regards to citations rates.We conclude that eight percent of the studies in


To examine the feasibility of using the MyotonPRO digital palpation device in measuring the transverse stiffness of tendon tissue.Experimental study.The MyotonPRO was used to measure the stiffness and related properties of ballistics gel in comparison with an external materials testing system (PCB electronics). The device was then used to measure the same properties of avian Achilles tendons before and after the removal of the overlying skin and subcutaneous tissue. Next, the test-retest reliability of the Achilles and patellar tendons was determined in humans. Finally, the stiffness of the Achilles tendon was measured before and after competitive running races of varying distances .The MyotonPRO demonstrated a high degree of consistency when testing ballistics gel with known viscoelastic properties. The presence of skin overlying the avian Achilles tendon had a statistically significant impact on stiffness (p<0.01) although this impact was of very small absolute magnitude . In healthy adults of normal body mass index (BMI), the reliability of stiffness values was excellent both for the patellar tendon  and the Achilles tendon . In the the field study, men had stiffer tendons than women (p<0.05), and the stiffness of the Achilles tendon tended to increase following running (p = 0.052).The MyotonPRO can reliably determine the transverse mechanical properties of tendon tissue. The measured values are influenced by the presence of overlying skin, however this does not appear to compromise the ability of the device to record physiologically and clinically relevant measurements. The MyotonPRO  is a handheld, digital palpation device which has been used to measure the mechanical properties of muscles and other soft tissue . Using sThe repeatability and reliability of the device have been tested on various muscles in several intra and inter-session studies,–7 but ne3 molds and allowed to set at 4˚C for 12 hours. The mass of each gel was measured and the amount was adjusted (depending on the gel to water ratio) to ensure that the mass of each gel was 10g. Each gel was molded around a small aluminum jig, sized 5 cm x 5 cm x 2.5 cm, on which a piezoelectric accelerometer  was mounted. The mold was removed, ensuring that the gel was the only mass above the accelerometer. To characterize the biomechanical parameters of the gels using the piezoelectric accelerometer, the gel was raised 5 cm off a rigid table and released; on landing, oscillations along the vertical axis were measured by the accelerometer. Each test consisted of five trials. The reproducibility of this manner of testing was assured by examining the variability of measured responses. Biomechanical values obtained by the accelerometer were compared to the MyotonPRO by leaving the mounting jig in place during subsequent tests and leaving the gels in the moulds, so as to measure the oscillation values of the same collective system in both tests. The MyotonPRO was programmed to automatically take 5 measurements, each separated by 2 seconds to allow for the oscillations in the gel to dissipate before the next test began, with a tap time of 15ms.To create simulated soft tissue phantoms, ballistics gels of different consistencies  were prepared using commercially-produced gelatin powder  and water. As the gf was calculated from its definition:Based on the accelerometer output, the same mechanical and viscoelastic properties displayed by the MyotonPRO were derived  as folloWe assume an initial undamped vibration, in which case the angular frequency ω is related to stiffness K and mass m:Rearranging :K=ω2m3):K=4π2 T using  and m isFollowing this initial study, we examined the potential effect of the layer of skin and subcutaneous tissue which lie directly over the tissues whose properties are to be measured by the MyotonPRO. Two fresh (unfrozen) whole chickens were commercially obtained, and the bilateral Achilles tendons were used . Before testing, the samples were marked on the skin using a felt-tipped pen in one centimeter increments, starting from the calcaneal bone and moving proximally to define a set of consistent probing sights. These sites coincided with measuring directly over the Achilles tendon (site 1), where the tendon begins branching towards the medial and lateral gastrocnemius muscles (site 2), where the tendon begins inserting into the muscles (site 3), continues inserting (site 4), finishes inserting (site 5), and finally the last two points were over the gastrocnemius muscles themselves (sites 6 and 7). At each site, 5 measurements were taken before moving to the next. The default testing pattern settings of the device were used with a 0.8 second interval between taps and a tap time of 15 ms. The layers of skin and subcutaneous tissue were removed afterwards in a single layer using a surgical scalpel, and the thickness of this skin and associated tissue was measured with digital calipers . The same testing sites were then re-measured directly on the Achilles tendon or its associated muscle. The anteroposterior thickness of the Achilles tendon was also measured 1 and 2 cm proximal to its insertion with digital calipers.10 healthy adults  were recruited to examine the same-day test-retest reliability of the MyotonPRO with reference to the Achilles and patellar tendons. To be included, subjects had to be 19 to 50 years of age, fluent in English, and recreationally active. Subjects were excluded if they had any health or medical conditions which could affect the patellar tendon. All subjects provided written, informed consent. The height and weight of subjects were measured, and they were asked how many days / week of moderate to vigourous activity they engage in. To measure the stiffness of the patellar tendon, subjects were seated in long sitting (legs outstretched and relaxed), and the device was positioned perpendicular to the skin in the middle of the patellar tendon by manually palpating the insertions and lateral borders of the tendons. To measure the stiffness of the Achilles tendon, subjects were seated on a raised stool with the leg and foot hanging freely (hip and knee at approximately 90° of flexion). The testing protocol (number and spacing of taps) was identical to that used for the in vitro study. For each tendon, two measurement sessions were held on the same day with the same tester, separated by a minimum of 3 hours.Sixy-six recreational runners  were recruited at community-organized races in the Vancouver area during the summer of 2016. A booth with information about the study was placed near the starting line, and investigators recruited participants who approached the booth. All participants provided written, informed consent for measurement before and after the start of the race. A single investigator took bilateral measures of tendon stiffness before and after the race, using the same device, and using the protocol described in the reliability study described above. Participants provided the following information; height and weight (self-reported), average number of running days per week, average weekly miles run, and current medications (over last 48 hrs). To be included, participants had to be 18 years of age or older and fluent in English, participate in moderate or vigorous physical activity for a minimum of 30 minutes at least three times per week, and already be signed up to participate in the race. Exclusion criteria were: genetic disorders with known or possible influence on musculoskeletal properties; recently (within 12 months) experienced or currently have acute or chronic musculoskeletal disorders; recently (within 12 months) experienced a partial or full tear of the Achilles or patellar tendons.Descriptive statistics  were generated to summarize the measurements of ballistics gel obtained with the MyotonPRO and the external reference device. To determine if there was a statistically significant difference in the measured stiffness of avian tendons with and without the presence of skin, a three-way within subject ANOVA test was conducted with the following effects: (1) skin/no skin, (2) testing site, and (3) left/right leg. To examine the reliability of using the MyotonPRO for assessing the biomechanical properties of the human Achilles and patellar tendons, intraclass correlation coefficients were calculated for each dependent variable. To see if baseline Achilles tendon stiffness correlated with the type of race being run (as an indirect indicator of training status), a Spearman’s correlation coefficient was calculated. To examine for potential changes in Achilles tendon stiffness following running, a repeat measures ANOVA was run. Finally, to determine whether tendon stiffness differed between men and women at baseline, an independent t-test was performed (including both patellar and Achilles tendons).The output of the MyotonPRO was compared to the values obtained through external measurement with a piezoelectric accelerometer, with regard to two biomechanical parameters of interest (K and D). The results from both testing methods for gels of varying consistencies are shown in The skin thickness over the avian Achilles tendon was consistent, measuring 1.2 +/- 0.2 mm without significant variation across all 7 test sites. Achilles tendon thickness measured 5.1 +/- 0.2 mm, which is identical to the thickness of the asymptomatic, adult human Achilles tendon.  Whilst t2, and average number of days engaged in exercise per week was 2.0 +/-2.1. For the Achilles tendon, the reliability (intra class correlation coefficient) of the measured parameters were: frequency (0.96), decrement (0.94), stiffness (0.96). The intraclass correlation coefficients for the patellar tendon were: frequency (0.96), decrement (0.86), stiffness (0.96).The average age of participants was 22.2+/-2.7 years. BMI was 22.5+/-2.9 kg.mThe average age of participants was 42 years ± 14, BMI 23 ± 2.3. From the demographic information presented by race-type , it can The MyotonPRO, when tested on soft-tissue phantom materials with known properties, was capable of quantifying dynamic stiffness (K), and logarithmic decrement (D). The device was capable of acquiring values across the range gels tested, as can be seen in While there was a statistically significant difference in stiffness between measurements made with or without the skin overlying the tendon and/or muscle, the difference was small and consistent across the measured sites (approximately 2.5%), such that the device was still able to detect changes in stiffness along the length of the muscle-tendon unit even in the presence of skin. We do not know why the inclusion of skin resulted in a slight increase in stiffness values. Nevertheless, the influence of skin did not have a meaningful impact on the measured value, at least in the in vitro study performed here. Changes in (tensile) stiffness of the Achilles tendon following acute resistance training programs are in the order of +30%,  and lossThe field confirmed a number of previously reported findings, e.g. stiffer tendons in men than women. There was a small increase in Achilles tendon stiffness after running of longer duration. The type of race  was significantly (but weakly) correlated with Achilles tendon stiffness. This could indicate either an effect of training (marathon runners reported greater frequency and length of running), or of age . The reliability of measurements from the patellar and Achilles tendons in a small group of healthy young adults was excellent. Further work is required to discover normal values in a larger population of healthy and pathological tendons, and with individuals of varying skin type and body composition.Tendon mechanical properties can be quantified with the MyotonPRO device.In individuals with normal BMI, the trends in, and region-specific properties of, the Achilles and patellar tendons can be monitored for relative changes with the MyotonPRO device.Future studies are needed to determine the utility of the MyotonPRO in people with higher levels of subcutaneous adiposity.S1 FigError bars represent the standard deviation.(DOCX)Click here for additional data file.S1 TableData are shown as mean +/- SD. Tendon and muscle were significantly different for all measured parameters.(DOCX)Click here for additional data file.S2 TableBMI: body mass index.(DOCX)Click here for additional data file.


Biochemia Medica journal from 2011 to 2017, in its „golden era” and expansion of its quality. It was a great experience and pleasure to have learned from her and to have been a part of such a successful development of our Journal. I would like to thank her for giving me the opportunity to continue as the new appointed Editor-in-Chief. I do also thank the Croatian Society for Medical Biochemistry and Laboratory Medicine’s (CSMBLM) Executive Board and the Editorial board of the Biochemia Medica for their support.Professor Ana-Maria Simundic was the Editor-in-Chief of the Biochemia Medica at the top position among some of the most esteemed Croatian scientific journals and in the first quartile within the Medical laboratory technology category of the Journal Citation Report   the Journal already met the inclusion criteria and has been accepted for indexing in the National Library of Medicine/Medline bibliographic database since the beginning of 2012 (Biochemia Medica journal.I would like also to emphasize the irreplaceable role of former and current Journal editors, as well reviewers and authors and their merits in the successful expansion of the Therefore I would like to thank Prof Simundic for everything she has done. In the years of her mandate she was a driving force continuously dedicated to the Journal growth. To honour her merits, I have appointed her as the Journal Senior Editor. I’m convinced she still has a lot of energy, enthusiasm and fresh ideas to support our Journal to further flourish and grow in relevance, impact and recognition.I’ll do my best to apply all that I have learned from her and I will strive to continue along the same path. I’m sure that this will be possible because of successful and confident team that I have in the Journal Editorial Board.


To reduce some problems of traditional graft, we devise a modified multiple branched graft for repair of Crawford extent II and III thoracoabdominal aortic aneurysm (TAAA).We described a modified multiple branched graft for Crawford extent II and III thoracoabdominal aortic aneurysm (TAAA) repair in 8 patients, Which comprised a main graft and three branches, and the third branch was bifurcated into two limbs.Our initial experience demonstrated that this modified multiple branched graft may make the thoracoabdominal aortic aneurysm(TAAA) repair easier and safer. In the traditional graft replacement of thoracoabdominal aortic aneurysm (TAAA), a straight graft is usually used, and several aortic patches containing the orifices of intercostal, celiac, superior mesenteric, and renal arteries are sutured to the openings in the straight graft. Recently, presewn tetrafurcate graft was used for TAAA repair, and clinical results showed this tetrafurcate graft could effectively short the ischemic time of the reimplantated visceral organs and facilate anastomotic hemostatisis , 2. TherThe modified multiple branched graft was constructed by suturing three grafts to the openings in a straight graft in an end-to-side fashion with running 4–0 polypropylene. Therefore, it comprised a main graft and three branches. The first branch was perpendicular to the other two branches, and the third branch was bifurcated into two limbs Fig. .Fig. 1ThThe sizes and attachment of the main graft and three branches were showed in Fig. Patient was in the right lateral decubitus position with the lower body slightly tilted to the left, and a left thoracoabdominal incision was performed. The cardiopulmonary bypass was established by a venous cannula placed in the right atrium through the left femoral vein and 2 arterial return cannulas inside both femoral artery and ascending aorta. If the proximal thoracic descending aorta was not involved by the aneurysm and was long enough for both clamping and anastomosis , proximal aortic anastomosis was performed under mild hypothermic cardiopulmonary bypass and beating heart. otherwise, it was performed using an open technique with profound hypothermic circulatory arrest.During our modified multiple branched graft replacement of TAAA, the proximal aortic anastomosis was performed first. After a proximal aortic clamp was placed just distal to the left subclavian artery or profound hypothermic circulatory arrest was established, a distal aortic clamp was positioned above the diaphragm. The aorta was transected proximal to the diseased segment and the proximal end of the choiced modified multiple branched graft was cut to the appropriate length. Then, the anastomosis between the proximal aorta and the proximal end of the modified multiple branched graft was performed with a continuous 4–0 polypropylene suture. As this proximal aortic anastomosis was completed, the air was evacuated from the graft, and a graft clamp was placed under this proximal aortic anastomosis.Next, the distal aortic clamp was repositioned just above the ostia of the visceral arteries. The T6 to T12 intercostal arteries were isolated with a full-thickness patch of aorta. After this aortic patch was sutured to the first branch of the modified multiple branched graft, the graft clamp was released and replaced below the first branch to permit perfusion of those implanted intercostal arteries. During the graft clamp movement, air was evacuated from the graft. Then, the distal aortic clamp was repositioned above the aortic bifurcation. Orifices of celiac, superior mesenteric, and right renal arteries were joined at a single aortic patch, and this aortic patch was anastomosed to the distal end of the main graft. Thereafter, the graft clamp below the first branch was removed and air was evacuated from the graft, and both second and third branches were individually clamped. When this step was completed, perfusion to the viscera and right kidney was restored. The second branch was anastomosed to the left renal artery, and then the blood supply was restored to the left kidney after the second branch clamp removal and air evacuation Finally, the third branch was anastomosed to the normal distal abdominal aorta or it’s two limbs to the bilateral iliac arteries after the third branch or it’s limbs were trimmed in the suitable length.From April 2009 to December 2014, the modified multiple branched graft was used in 8 patients with Crawford extent II 3 patients) and III (5 patients) TAAA . The cardiopulmonary bypass time, spinal cord ischemic time, visceral and right renal ischemic time and the left renal ischemic time were 176 ± 52 min (102–207 min), 16.3 ± 4.3 min (13–19 min), 16.5 ± 4.3 min (13–20 min), 25.8 ± 6.2 min (24–31 min), respectively. Performing all anastomotic hemostasis was easy as all the suture line was completely external exposed. No patient required a reopening to correct excessive post-procedural bleeding. Prolonged intubation (›48 h) was required in 2 patients. Renal failure requiring dialysis occurred only in 1 patient. Paraplegia or paraparesis did not develop postoperatively in any patient. No patient had clinical evidence for postoperative hepatic or intestinal ischemia. All were discharged from the hospital and were followed up. The follow-up period was 32.7 ± 9.9 months . Their postoperative computed tomographic scans showed that all modified multiple branched grafts were patent and not kinked (Fig.  patientsOur modified multiple branched graft was specially designed for TAAA repair. It provided a branch for attachment to the vital intercostal arteries, and it’s all branches could easily conform to the different directions of the celiac, superior mesenteric, and renal arteries. Therefore, compared with the presewn tetrafurcate graft designed for arch replacement, our modified multiple branched graft might be more suitable for T AAA repair.In the present technique, orifices of celiac, superior mesenteric, and right renal arteries were joined at a single aortic patch, and this aortic patch was anastomosed to the graft. Compared with the separate attachment technique in which each visceral or renal artery was anastomosed to the different branch of the multiple branched graft, our visceral patch technique could sensibly reduce the time for anastomosis and the ischemic time of viscera, consequently could simplify the operation. However, visceral patch aneurysm might develop. Fortunately, this visceral patch aneurysm didn’t occur in our patients during the follow-up. During the operation, we kept the residual aortic wall of the visceral patch as less as possible, which might contributed to our present results. Surely, the long-term fate of those visceral patches should be carefully evaluated, but the prevalence of patch aneurysm is expected to be acceptable because the straight graft and patch technique for TAAA repair provides satisfactory long-term fates of the visceral patches .Our present modified multiple branched graft may make TAAA replacement easier and safer. Although the preliminary outcomes were encouraging, rigorous long-term follow-up and further extensive clinical use are necessary to completely evaluate the efficacy of this modified multiple branched graft.


Objective: The objective of this article is to review the methods currently used for the bolstering of skin grafts and compare their advantages and disadvantages with those of the dry, sterile surgical scrub brush. We report a series of cases performed at a single institution and compare the cost-effectiveness, application, and limitations of this method with other options for skin graft bolstering. Methods: A PubMed search using the parameters “(bolster) AND skin graft” was conducted, yielding 85 results. A total of 40 publications met the criteria for our literature review. The costs of the foam bolsters utilized as stents for skin grafts were obtained from the Central Supply and Resource Division of the University of Louisville Hospital for a cost analysis. The cost per square centimeter of each bolster material was calculated. Results: At $0.003/cm2, the 3M Reston foam is the most inexpensive of the 3 bolster materials analyzed. The dry, sterile surgical scrub brush has a similar cost at $0.006/cm2 but carries the advantage of sterility. The material cost of negative pressure wound therapy is $0.47/cm2, and the cost of the system as a whole makes it a much more expensive alternative. In 6 patients with defects of varying size and location, the scrub brush bolster showed a near 100% graft take and no complications. Conclusions: The dry, sterile surgical scrub brush presents a readily available and low-cost option for the stenting of small skin grafts and should be considered a viable method in the armamentarium of available skin graft bolsters. Objective: Skin grafting is a commonly used and dependable method on the reconstructive ladder. Success in skin grafting requires a suitable donor site and postoperative prevention of factors that can cause graft failure, namely, shear, fluid accumulation, and infection. The ideal dressings minimize graft movement, apply pressure to prevent minimal fluid from building underneath the graft, and keep the site clean to minimize the amount of bacterial exposure. The methods of graft dressings have evolved over the years, and a wide range of supplies are available for that purpose. Traditional methods utilize a cotton or gauze bolster secured by silk ties, whereas new innovations such as the wound VAC  allow for negative pressure therapy. A commonly used material for graft immobilization at our institution is Reston self-adhering foam .This method was first discussed by Weiner and Moberg,They conclude that this method creates the ideal stent, which has specific characteristics. These characteristics are 1) consistent reliability in achieving 100% graft take, (2) case and expediency of surgical application, (3) technical control of the pressure exerted by the stent, (4) uniform distribution of the pressure over the entire graft bed, (5) intrinsic elastic properties that exert pressure in a desired physiologic range, and (6) immediate accessibility to stent material. consisteOf particular concern to us is the requirement of immediate accessibility to stent material. While Reston foam has many advantages, it also requires sterilization prior to use. However, the manufacturer does not recommend sterilizing Reston foam and discourages its use as a postoperative compression dressing.,4-The use of sponge from a dry, sterile surgical scrub brush has been previously described and presents an inexpensive and readily available alternative to other foam products.1A PubMed search using the parameters “((bolster[Title]) AND graft[Title]) AND skin” was performed, yielding only 7 results. The search was then expanded using the parameters “(bolster) AND skin graft,” which yielded 85 results. A filter of “human’ subjects only” was applied, leaving 71 results. Results were reviewed and our discussion is limited to immobilization methods used for the broad application of common skin grafts. Publications referencing bolsters created only for use in specific graft sites or discussing the impregnation of bolsters with antibiotics or other fluids were excluded.These exclusions left a total of 40 publications.The cost of 3 foam bolsters utilized for skin grafts was obtained from the Central Supply and Resource Division of the University of Louisville Hospital for a cost analysis. These products are the BD CareFusion dry, sterile surgical scrub brush,A series of 8 cases using the dry, sterile surgical scrub brush as a bolster for skin grafts was performed at the University of Louisville Hospital.D.G. was an 84-year-old man with a growing lesion on the right temporal scalp that was found to be a melanoma by punch biopsy. He was taken to the operating room for wide local excision, which left an initial defect measuring 5 × 5 cm. An adjacent tissue rearrangement was performed that minimized the defect to 2 × 2 cm, which was then covered with a split-thickness skin graft. He had no complications from the procedure, and his skin graft healed well. Final pathology, however, showed a focus of melanoma at one of the margins, so he was taken back to the operating room for reexcision. This left a defect measuring 4 × 3 cm, which was subsequently covered using a split-thickness skin graft seen in -14,The tie-over-bolster technique is one of the oldest methods for bolstering skin grafts. Individual sutures with long tails are placed along the periphery of the graft site, and a bolster is placed on the graft. This bolster is typically made using a nonadherent dressing layered on top with a soft, pliable, and absorbent material such as cotton balls or sterile gauze. The sutures are then tied over the top of the bolster to secure it in place. This method can be considerably time-consuming, and the tightness of the sutures over the bolster can create uneven pressure across the graft bed, as well as excess tension on the edges where the sutures are placed. To address these issues, modifications of the tie-over-bolster method were developed, including various suture methods such as running sutures or those placed in specific patterns.10,5,6,4The use of foam for skin graft immobilization has been previously described.1-Vacuum-assisted closure (VAC), a relatively newer technology, is particularly effective for use on large grafts, areas that are more susceptible to fluid accumulation such as the perineum and areas that are difficult to bolster with other methods such as large hand or foot burns. This technique uses a polyurethane sponge and applies a negative pressure, helping suction away any fluid that has accumulated. Studies have found that this technique allows for an excellent graft take with decreased local edema and has compared favorably with standard bolster dressings.17-A variety of other materials have been also used to cover new skin grafts. A unique method of internal bolstering has been characterized for wounds where the skin graft lies in a cavity.24Reston foam is an inexpensive bolster sold in nonsterile packaging that is not safe to be sterilized in an autoclave. This creates a potential risk for contamination and subsequent infection. They also come only in one size, which can become problematic in terms of storage in facilities with limited space such as a surgery center. In addition, Reston foam has limited utility other than for bolstering, whereas the surgical scrub bush can be used for its primary purpose in the operating room environment.Negative pressure therapy is certainly the most expensive method. The sponge itself is more expensive than the 2 alternatives, and it also requires the use of the proprietary impermeable adhesive dressing and the device to create the vacuum. This adds significant cost on a daily basis, since at our institution there is a daily rental fee. Portable machines exist, which allows their use in both inpatient and outpatient settings.The use of foam from the surgical scrub brush is not without its limitations, the most obvious being size. Dimensions are approximately 82-mm long, 48-mm wide, and 19-mm thick. This makes it ideal for use on smaller grafts; however, for wounds larger than the area of the sponge, multiple sponges can be used, but the uniformity of the bolster pressure may be at risk.The dry, sterile surgical scrub brush presents a readily available and low-cost option for the stenting of small skin grafts and should be considered a viable method in the armamentarium of available skin graft bolsters.


Intraoperative Transit Time Flowmetry is currently recommended to assess graft patency during coronary artery bypass grafting (CABG), especially in presence of haemodynamic instability or inability to wean the patient from cardiopulmonary bypass, new regional wall motion abnormalities, or significant ventricular arrhythmias. The VeriQ™ system is one of the currently available systems, which detects imperfections that may be corrected by graft revision. In this case report, multivessel coronary spasm (CS) post-CABG interferes with these intraoperative parameters misleading initially into false results. Cardiac surgeons should bear in mind the limit of VeriQ in distinguishing between graft failure and CS. Angiography may be considered in patients with decreased graft flow despite revision of anastomosis and vasodilatory treatment for the definitive diagnosis. Intraoperative Transit Time Flowmetry (TTFM) is currently recommended to assess graft patency during coronary artery bypass grafting (CABG), especially in presence of haemodynamic instability or inability to wean the patient from cardiopulmonary bypass, new regional wall motion abnormalities, or significant ventricular arrhythmias. TTFM is effective in detecting imperfections that may be corrected by graft revision. This may reduce the incidence of graft occlusion and may reduce perioperative morbidity and mortality .The VeriQ system (MediStim ASA) is one of the currently available systems, which uses specially designed probes, which deliver a bidirectional ultrasound beam across a target vessel, and the system analyses the returning signal to calculate the blood flow through the vessel at a default filter setting of 20 Hz. A real-time flow waveform is displayed, together with the mean graft flow (MGF) in ml/min and derived values such as pulsatility index (PI). This information can be used to determine whether flow through the graft and its anastomoses is acceptable or not. MGF ≤ 20 ml/minute and/or a pulsatility index ≥ 5 predict technically inadequate grafts that need immediate revision before leaving the operating theatre. Coronary spasm post-CABG can potentially interfere with these intraoperative parameters misleading into false results [A 71-year-old diabetic man was admitted to the Oxford Heart Centre within 48 hours from an episode of angina at rest. Coronary angiogram demonstrated severe left main stem stenosis and three vessels coronary artery disease, with a preserved left ventricular systolic function. The patient underwent off-pump CABG using skeletonized left internal mammary artery (LIMA) to the LAD and long saphenous vein (LSV) grafts to the OM and PDA arteries. After completion of the all three grafts, there was excellent flow in the arterial but not in the vein grafts. TTFM measurements with a mean arterial pressure of 80 mmHg were as follows: LIMA to LAD: MGF 83 ml/min and PI 1.4; LSV to OM: MGF 8 ml/min and PI 5.1; LSV to PDA: MGF 9 ml/min and PI 4.4 Figures .At the end of the procedure the patient developed significant ECG ST depression. The sternotomy was reopened and all grafts were revised. LIMA to LAD was found to be widely patent but both vein grafts had minimal flow with no distal run-off. The patient's conditions were stabilised with the use of inotropes and intra-arterial balloon pump (IABP). An urgent angiography confirmed the patency of all three grafts with wide spread evidence of spasm to native coronary arteries Figures .The patient was started on glycerine trinitrate infusion; the adrenaline and noradrenaline were weaned successfully with complete ST resolution and he was discharged home on the 8th postoperative day with fully controlled diabetes and on 10 mg of isosorbide mononitrate, once daily, as a secondary prevention of coronary spasm for 3 months.The intraoperative assessment of graft flow with TTFM and Doppler techniques has been largely accepted and is recognized by 2014 ESC-EACTS guidelines on myocardial revascularization. TTFM is a useful tool towards the right assessment of graft patency and flow but in rare occasions can be misleading and it may fail to detect the real cause of poor flow through the grafts. Furthermore, interpretation can be challenging in sequential grafts and T-grafts –7.The assessment of the graft patency using VeriQ during coronary spasm can be misleading and can provide, as in our case, false positive results, which if not promptly identified can be the cause of increased mortality and morbidity.Perioperative CS is a potentially, life-threatening condition, which if not early detected and successfully treated can be catastrophic. Its prevalence during CABG is reported to range from 0.8 to 1.3% and has been documented in patients undergoing on- and off-pump CABG. Main risk factors for CS are smoking, hyperlipidaemia, advanced age, diabetes, chronic renal impairment and factors related to anaesthesia such as insufficient general anaesthesia, stimulation of the vagal nerve, hyperventilation, hypoxia, and use of large doses of catecholamines [The case described here represents also an extraordinary example of how, despite a generalized CS, the LIMA graft was somehow protected. It is well known how the particular structure of LIMA wall makes it less prone to spasm, even though not immune, compared to other arterial grafts. Endothelial integrity and its pronounced capacity of releasing nitric oxide may also play a significant role in preventing LIMA spasm. In this particular case, the LIMA was harvested in skeletonized fashion, questioning whether minimal thermic injury could effectively contribute to protecting the arterial graft against vascular spasm , 10.Pharmacological treatment of CS includes the administration of nitrates and calcium antagonists. Cardiovascular support devices such as IABP can also be very helpful in managing the acute phase of CS. If medical therapy and IABP are not proven to be sufficient, extracorporeal membrane oxygenation may also become necessary to salvage the patient , 11.This case describes the occurrence of CS following off-pump CABG in a male patient with a poor controlled diabetes. TTFM measurements suggested impaired vein graft glow, but subsequent coronary angiography confirmed graft patency with significant CS.Cardiac surgeons should bear in mind the limit of VeriQ in distinguishing between graft failure and CS. Angiography may be considered in patients with decreased graft flow despite revision of anastomosis and vasodilatory treatment for the definitive diagnosis. The treatment for CS during CABG remains debated; time and vasodilators seem to be the most appropriate way of addressing this rare but dangerous clinical condition.


CTNS gene. Main dysfunction is a defective clearance of cystine from lysosomes that leads to accumulation of cystine crystals in every tissue of the body. There are three different forms: infantile nephropathic cystinosis, which is the most common form, juvenile nephropatic, and non-nephropathic cystinosis. Mostly, first symptom in infantile nephropathic cystinosis is renal Fanconi syndrome that occurs within the first year of life. Another prominent symptom is photophobia due to corneal crystal deposition. Cystine depletion therapy with cysteamine delays end-stage renal failure but does not stop progression of the disease. A new cysteamine formulation with delayed-release simplifies the administration schedule but still does not cure cystinosis. Even long-term depletion treatment resulting in bypassing the defective lysosomal transporter cannot reverse Fanconi syndrome. A future perspective offering a curative therapy may be transplantation of CTNS-carrying stem cells that has successfully been performed in mice.Cystinosis is a rare autosomal recessive lysosomal storage disorder caused by mutations in the  CTNS gene on chromosome 17p13, which encodes the lysosomal cystin transporter cystinosin  infantile nephropathic cystinosis, which is the most common and severe form; (ii) juvenile nephropathic cystinosis, which is characterized by later onset of symptoms and slower progression; and (iii) non-nephropatic cystinosis, with a mainly ocular manifestation, also known as adult form. Each form shows different mutations in the TNS gene . CystinoTNS gene .in utero. First symptoms occur within the first year of life, usually presenting as renal Fanconi syndrome, a dysfunction of the proximal tubule that leads to polydipsia, polyuria, dehydration, proximal renal tubular acidosis, urinary loss of electrolytes, and growth retardation. In the urine, glucosuria and aminoaciduria can be found. In the case of glucosuria and normal serum glucose levels, one should always think of renal glucosuria or Fanconi syndrome. Glucosuria is the only parameter to be detected by urine dipstick in the Fanconi tubulopathy. The high protein turnover in the proximal tubule may explain why Fanconi syndrome is the first symptom of cystinosis.Neonates are clinically asymptomatic at birth with normal birth-weight and normal length, even though cystine accumulation already starts Without treatment end-stage, renal failure occurs at a median age of 10 years. About 95% of cystinosis patients suffer from this type , 8. HistPatients with the juvenile type of nephropathic cystinosis develop symptoms at an older age, often presenting with more unspecific symptoms than patients with infantile cystinosis like nephrotic syndrome or mild proximal tubulopathy, but not necessarily the complete picture of Fanconi syndrome. End-stage renal disease may occur. Most patients are diagnosed in the second decade of life, when onset of photophobia leads to ocular examination and cystine crystals in the cornea can be found. This form accounts for approximately 5% of all cases of cystinosis , 10.This type presents only with ocular symptoms, as deposits are limited to cornea and conjunctiva and is also known as the adult form of cystinosis. Of note, there might be a continuum between milder forms of cystinosis, since non-nephropathic and juvenile forms have been described within one family. Therefore, renal function of every patient with non-nephropathic cystinosis should be monitored closely , 11.CTNS gene   . The mos17 (p13) . Up to nTNS gene , 14. Mosrelation , 16–18. relation .Cystine is a disulfide of the amino acid cysteine. It is generated by lysosomal protein hydrolysis. Because no enzymatic dysfunction was found in cystinotic cells, research focused on defect transporter proteins leading to the identification of the seven-domain transmembrane protein cystinosin, which provides the transport of cystine from lysosomes to cytoplasm . DefectiNonetheless, there is a different susceptibility of cell types to cystine accumulation with renal cells being especially susceptible. This is the reason why cystinosis presents primarily with renal symptoms (see above). Firstly impaired tissue is the proximal tubule leading to renal Fanconi syndrome, which is the major symptom of cystinosis. A characteristic histopathological sign is the so-called swan neck deformity, which describes the loss of proximal tubular cells. Electron microscopy shows cystine crystals in the tubular cells , 21, 22.Probably, the subjectively most impairing early problem is photophobia due to corneal deposition of cystine crystals  or ascorbic acid with moderate success . The cysCysteamine has been available as a commercial drug since 1997 in an immediate-release formulation that demands a strict 6-h administration schedule to maintain effective plasma levels. A new delayed-release formulation has been available since 2013 in the USA and since 2014 in Europe which must only be administered twice daily. Both formulas use cysteamine bitartrate since the bitartrate formulation needs lower doses to maintain plasma levels than cysteamine hydrochloride or phosphocysteamine . The new2/day with a gradually increasing application schedule avoids side effects as lethargy, hyperthermia, and rash  impaired chaperone-mediated autophagy ; (ii) reCTNS-carrying stem cells. Stem cells from wild-type donors were transplanted into irradiated CTNS-knockout mice (The most promising approach to cure cystinosis is the transplantation of hematopoietic out mice . Whereasout mice . The redout mice .Transplantation of hematopoietic stem cells was still effective in older mice, suggesting that stem cell therapy might still be an option even if tissue injury is already manifested. The exact mechanism of stem cell therapy remains unclear. It is possible that stem cell therapy protects healthy tissue from being harmed by cystine crystals or that damaged tissue is being reversed . FurtherThe above-mentioned recommendations of structured transition programs , 49 mustOver the last decades, our knowledge and understanding of cystinosis has improved continuously. This led to new therapy options and simplified medicine formulations, which dramatically improved life expectancy and life quality of cystinosis patients. But still there is no curative therapy. The new approach of stem cell transplantation gives hope to become a curative treatment that would mean another big step for cystinosis patients to further improve life expectancy and quality.SB and LW were responsible for concept and creation of this manuscript. Both authors revised the manuscript and approved the final version to be published.LW has received travel grants and speaker’s honoraria of Raptor Pharmaceuticals, Horizon Pharma, and Chiesi GmbH. SB has received travel grants and speaker’s honoraria of Orphan Europe declares no conflict of interest.


Current strategies to improve graft outcome following kidney transplantation consider information at the human leukocyte antigen (HLA) loci. Cell surface antigens, in addition to HLA, may serve as the stimuli as well as the targets for the anti-allograft immune response and influence long-term graft outcomes. We therefore performed exome sequencing of DNA from kidney graft recipients and their living donors and estimated all possible cell surface antigens mismatches for a given donor/recipient pair by computing the number of amino acid mismatches in trans-membrane proteins. We designated this tally as the allogenomics mismatch score (AMS). We examined the association between the AMS and post-transplant estimated glomerular filtration rate (eGFR) using mixed models, considering transplants from three independent cohorts . We found that the AMS has a significant effect on eGFR  that is independent of the HLA-A, B, DR matching, donor age, and time post-transplantation. The AMS effect is consistent across the three independent cohorts studied and similar to the strong effect size of donor age. Taken together, these results show that the AMS, a novel tool to quantify amino acid mismatches in trans-membrane proteins in individual donor/recipient pair, is a strong, robust predictor of long-term graft function in kidney transplant recipients. The article describes a new concept to help match donor organs to recipients for kidney transplantation. The concept relies on the ability to measure the individual DNA of potential donors and recipients. When the data about genomes  of possible donors and recipients are available, the article describes how data can be computationally compared to identify differences in these genomes and quantify the possible future impact of these differences on the functioning of the graft. The concept presented in the article determines a score for each pair of possible donor and recipient. This score is called the allogenomics mismatch score. The study tested the ability of this score to predict graft function (the ability of the graft to filter blood) in the recipient several years after transplantation surgery. The study found that, in three small sets of patients tested, the score is a strong predictor of graft function. Prior studies often assumed that only a small number of locations in the genome were most likely to have an impact on graft function, while this study found initial evidence that differences across DNA that code for a large number of proteins can have a combined impact on graft function. Survival of patients afflicted with End Stage Renal Disease (ESRD) is superior following kidney transplantation compared to dialysis therapy. The short-term outcomes of kidney grafts have steadily improved since the early transplants with refinements in immunosuppressive regimens, use of DNA-based human leukocyte antigen (HLA) typing, and better infection prophylaxis –3. DespiThe HLA is a cluster of genes on the short arm of chromosome 6 and constitutes the major histocompatibility complex (MHC) responsible for self/non-self discrimination in humans. Multiple clinical studies have demonstrated the importance of HLA-matching to improve kidney graft outcome. Therefore, in many countries, including the USA, donor kidney allocation algorithms includes consideration of HLA matching of the kidney recipient and donor. With widespread incorporation of HLA matching in kidney organ allocation decisions, it has become clearer that HLA mismatching represents an important risk factor for kidney allograft failure but fails to fully account for the invariable decline in graft function and failure in a large number of recipients over time. Indeed, only a 15% survival difference exist at 10 years post transplantation between the fully matched kidneys and the kidneys mismatched for both alleles at the HLA-A, B and DR loci [Here, we used exome sequencing to determine the sequences of the HLA as well as non-HLA peptides encoded by the donor organ and displayed on its cell surface, as well as bioinformatics analyses to determine donor sequences not present in the recipient. The allogenomics approach integrates the unique features of transplantation, such as the existence of two genomes in a single individual, and the recipient’s immune system mounting an immune response directed at either HLA or non-HLA antigens displayed by the donor kidney. In this report, we show that this new concept helps predict long-term kidney transplant function from the genomic information available prior to transplantation. We found that a statistical model that incorporates time as covariate, HLA, donor age and the AMS , predicts graft function through time better than a model that includes the other factors and covariates, but not the AMS.The allogenomics concept is the hypothesis that interrogation of the coding regions of the entire genome for both the organ recipient and organ donor DNA can identify the number of incompatible amino-acids (recognized as non-self by the recipient) that inversely correlates with long-term function of the kidney allograft. http://allogenomics.campagnelab.org.) Our approach was designed to consider the entire set of protein positions measured by a genotyping assay, or restrict the analysis to a subset of positions P in the genome. In this study, we focused on the subset of genomic sites P that encode for amino acids in trans-membrane proteins. It is possible that some secreted or intra-cellular proteins can contribute to the allogenomics response, but the set of trans-membrane proteins was considered in this study in order to enrich contributions for epitopes likely to be displayed at the surface of donor kidney cells. While proteins expressed in kidney could appear to be a better choice, the technical challenge of defining a list of proteins expressed by kidney alone, and perhaps only transiently in some kidney cell type exposed to the surface of the kidney, argues against relying on a kidney expression filter. Similarly, we did not consider other sets of proteins, and make no claim that the set of transmembrane proteins is an optimal choice.We have developed and implemented a computational approach to estimate the AMS from genotypes derived for pairs of recipient and donor genomes.  where the allogenomics observation was first made , and a second validation cohort from recipients transplanted in Paris hospitals .In order to test the allogenomics hypothesis, we isolated DNA from kidney graft recipients and their living donors. We assembled three cohorts:  studies , 10 tranKidney graft function is a continuous phenotype and is clinically evaluated by measuring serum creatinine levels or using estimated glomerular filtration rate (eGFR) . In this2 adj. = 0.78, P = 0.002, n = 10) but not at 12 or 24 months following kidney transplantation  but not at 12 or 24 months following kidney transplantation , where T is the time post-transplantation, measured in months, and (1|P) a random effect which models separate model intercepts for each donor/recipient pairs.In the models presented so far, we have considered the prediction of graft function separately at different time points. An alternative analysis would consider time since transplantation, as well as other established predictors of graft function as covariates in the model. This is particularly useful when studying cohorts where graft function was assessed at several distinct time points . To implement this alternative analysis, we fit a mixed linear model of the form: eGFR ~ donor age at time of transplant + AMS + T + (1|P) (Equation 4), comparing model with AMS or without, P = 0.038, χ2 = 4.284, d.f. = 1). In contrast, models that included AMS, but did or did not include the number of ABDR HLA mismatches fit the data equally well , confirming that the effect of AMS was independent of the number of HLA mismatches. The models of equations 3 and 4 include a random effect for the transplant pair (1|P) term. This term models the differences among pairs, such as level of graft function in the days post-transplantation, as well as correlations between repeated measurements for the same recipient. See Fig C in To determine the effect of AMS on eGFR, we compared the fit of models that did or did not include the AMS. We found that the effect of AMS is significant . A similar result was obtained if HLA was also used as a covariate in the model   reflecting the possible donor specific epitopes displayed on the cell surface. We demonstrated that the AMS, which can be estimated before transplantation, helps predict post-transplantation kidney graft function more accurately than HLA-mismatches alone. Interestingly, the strength of the correlation increases with the time post transplantation, an intriguing finding observed in both the discovery cohort and the validation cohorts.We chose the simplest model to test the allogenomics concept and did not restrict the score to contributions from the peptides that can fit in the HLA groove despite their computational predictability . It is pRecent evidence indicates that mutations in splice sites, although rare, are responsible for a large proportion of disease risk . The allWe chose to focus this study on living, ABO compatible (either related or non-related) donors because kidney transplantation can be planned in advance and because differences in cold ischemia times and other covariates common in deceased donor transplants are negligible when focusing on living donors, especially in small cohorts. The selection criteria for deceased donors include consideration of HLA matching, calculated panel reactive antibody and the age of the recipient. Compared to live donors we expect that the range of the AMS in deceased donors will be comparable to that in our discovery cohort composed primarily of unrelated donors. Since many additional factors can independently influence graft function after transplantation from a deceased donor (e.g. cold ischemia time), potentially much larger cohorts may be required in such settings to achieve sufficient power to adequately control for the covariates relevant to deceased donors and to detect the allogenomics effect.While we have not attempted to optimize the set of sites considered to estimate the allogenomics mismatch score, it is possible that a reduced and more focused subsets of amino acid mismatches could increase the predictive ability of the score. For instance, the AMS could be applied to look for genes with a high allogenomic mismatch burden. Such studies would require larger cohorts and may enable the discovery of loci enriched in allogenomics mismatches responsible for a part of the recipient alloresponse against yet unsuspected donor antigens. Their discovery might foster the development of new immunosuppressive agents targeting the expression of these immuno-dominant epitopes. However, our study also raises a novel mechanistic hypothesis: the total burden of allogenomics mismatches might be more predictive of graft function, than mismatches at specific loci, as was previously widely expected .The study was reviewed and approved by the Weill Cornell Medical College Institutional Review Board . The second study involving the French cohort was approved by the Comité de Protection des Personnes (CPP), Ile de France 5, (02/09/2014). Codes were used to ensure donor and recipient anonymity. All subjects gave written informed consent. Living donor ABO compatible kidney transplantations were performed according to common immunological rules for kidney transplantation with a mandatory negative IgG T-cell complement-dependent cytotoxicity cross-match.Briefly, genotypes of donors and recipients were assayed by exome sequencing . Reads were aligned to the human genome with the Last  aligner The HLA genotypes were obtained from the clinical information system. HLA genotypes are performed as part of clinical care in transplantation centers. They are conducted with the SSP and SSO methods.We selected 10 kidney transplant recipients from those who had consented to participate in the Clinical Trials in Organ Transplantation-04 (CTOT-04), a multicenter observational study of noninvasive diagnosis of renal allograft rejection by urinary cell mRNA profiling. We included only the recipients who had a living donor kidney transplant and along with their donors, had provided informed consent for the use of their stored biological specimens for future research. Pairs were limited to those where enough DNA could be extracted to perform the exome assay for both donor and recipient. Subjects were not selected on the basis of eGFR, whose values were collected after obtaining sequence data. The demographic and clinical information of the Discovery cohort is shown in DNA was enriched for exome regions with the TruSeq exome enrichment kit v3. Sequencing libraries were constructed using the Illumina TruSeq kit DNA sample preparation kit. Briefly, 1.8 μg of genomic DNA was sheared to average fragment size of 200 bp using the Covaris E220 . Fragments were purified using AmpPureXP beads  to remove small products (<100 bp), yielding 1 μg of material that was end-polished, A-tailed and adapter ligated according to the manufacturer’s protocol. Libraries were subjected to minimal PCR cycling and quantified using the Agilent High Sensitivity DNA assay . Libraries were combined into pools of six for solution phase hybridization using the Illumina  TruSeq Exome Enrichment Kit. Captured libraries were assessed for both quality and yield using the Agilent High Sensitivity DNA assay Library Quantification Kit. Sequencing was performed with six samples per lane using the Illumina HiSeq 2000 sequencer and version 2 of the sequencing-by-synthesis reagents to generate 100 bp single-end reads (1×100SE).We studied 24 kidney transplant recipients who had a living donor transplant at the NewYork-Presbyterian Weill Cornell Medical Center. This was an independent cohort and none of the recipients had participated in the CTOT-04 trial. Recipients were selected randomly based on the availability of archived paired recipient-donor DNA specimens obtained at the time of transplantation at our Immunogenetics and Transplantation Laboratory. DNA extraction from peripheral blood was done using the EZ1 DNA blood kit (Qiagen) based on the manufacturer’s recommendation.We studied 19 kidney transplant recipients who had a living donor transplant at Tenon Hospital. This represented a third independent cohort. Recipients were selected randomly based on the availability of archived paired recipient-donor DNA specimens obtained either at the Laboratoire d'histocompatibilité, Hôpital Saint Louis APHP, Paris or during patient’s follow-up between October 2014 and January 2015. DNA extraction from peripheral blood was done using the Nucleospin blood L kit (Macherey-Nagel) based on the manufacturer’s recommendation.The Cornell and French Validation cohorts were both assayed with the Agilent Haloplex exome sequencing assay. The Haloplex assay enriches 37 Mb of coding sequence in the human genome and was selected for the validation cohort because it provides a strong and consistent exome enrichment efficiency for regions of the genome most likely to contribute to the allogenomics contributions in protein sequences. In contrast, the TrueSeq assay (used for the Discovery Cohort) enriches 63Mb of sequence and includes regions in untranslated regions (5’ and 3’ UTRs), which do not contribute to allogenomics scores and therefore do not need to be sequenced to estimate the score. Libraries were prepared as per the Agilent recommended protocol. Sequencing was performed on an Illumina 2500 sequencer with the 100bp paired-end protocol recommended by Agilent for the Haloplex assay. Libraries were multiplexed 6 per lane to yield approximately 30 million paired end reads per sample.https://bitbucket.org/campagnelaboratory/allogenomicsanalyses).We determined the minor allele frequency of sites used in the calculation of the allogenomics mismatch score using data from the Exome Aggregation Consortium (ExAC). This resource made it possible to estimate MAF for most of the variations that are observed in the subjects included in our discovery and validation cohort. Data was downloaded and analyzed with R and MetaR scripts  release ESP6500SI-V2 . The ESPhttp://allogenomics.campagnelab.org).Illumina sequence base calling was performed at the Weill Cornell Genomics Core Facility. Sequence data in FASTQ format were converted to the compact-reads format using the Goby framework . Compactr,d) is estimated for a recipient r and donor d as the sum of score mismatch contributions . https://hub.docker.com/r/fac2003/rocker-metar/). Models with random effects were estimated with metaR 1.5.1 and R  or metaR ( package ). Compar package . We distS1 FileThis file provides additional details about method descriptions, additional results, as well as supplementary Table and Figures.(PDF)Click here for additional data file.


Dear Reader,Drugs—Real World Outcomes for the year, we wish to reflect on another successful year for the journal and for others in the Adis Premier journals portfolio, and to thank all who have contributed to Drugs—Real World Outcomes over the past 12 months.As we approach the end of 2016, and publish our final issue of Drugs—Real World Outcomes in that the journal content is now available on PubMed Central. Another of our open access journals, Drug Safety—Case Reports, is also now available on PubMed Central.An important milestone was reached for Drugs—Real World Outcomes’ top 10 downloaded articles from SpringerLink this year were:As of September 2016, Medicines Management, Medication Errors and Adverse Medication Events in Older People Referred to a Community Nursing Service: A Retrospective Observational Study. Drugs—Real World Outcomes (2016) 3: 13.Elliott, R.A., Lee, C.Y., Beanland, C. et al. Use of Chronic Medications Among Patients with Non-Valvular Atrial Fibrillation. Drugs—Real World Outcomes (2016) 3: 165.Kocis, P.T., Liu, G., Makenbaeva, D. et al. Persistence of Antipsychotic Treatment in Elderly Dementia Patients: A Retrospective, Population-Based Cohort Study. Drugs—Real World Outcomes (2016) 3: 175.Mast, G., Fernandes, K., Tadrous, M. et al. ® Disposable Insulin Delivery Device for Insulin Delivery in Patients with Poorly Controlled Diabetes at High RiskThe Clinical and Economic Impact of the V-Go. Drugs—Real World Outcomes (2016) 3: 191.Lajara, R., Nikkel, C. & Abbott, S. Traditional Anticoagulants and Hair Loss: A Role for Direct Oral Anticoagulants? A Review of the Literature. Drugs—Real World Outcomes (2016) 3: 1.Watras, M.M., Patel, J.P. & Arya, R. Selective Serotonin Reuptake Inhibitors and Night Sweats in a Primary Care Population. Drugs—Real World Outcomes (2015) 2: 29.Mold, J.W. & Holtzclaw, B.J. Drug-Induced Subacute Cutaneous Lupus Erythematosus Associated with Proton Pump Inhibitors. Drugs—Real World Outcomes (2016) 3: 145.Aggarwal, N. 3 Antagonists Really Contribute to Serotonin Toxicity? A Call for Clarity and Pharmacological Law and OrderCan 5-HT. Drugs—Real World Outcomes (2014) 1: 3.Rojas-Fernandez, C.H. Evaluating the Cost-Effectiveness of Prolonged-Release Tacrolimus Relative to Immediate-Release Tacrolimus in Liver Transplant Patients Based on Data from Routine Clinical Practice. Drugs—Real World Outcomes (2016) 3: 61.Muduma, G., Odeyemi, I. & Pollock, R.F. The Risk of Specific Congenital Anomalies in Relation to Newer Antiepileptic Drugs: A Literature Review. Drugs—Real World Outcomes (2016) 3: 131.de Jong, J., Garne, E., de Jong-van den Berg, L.T.W. et al. Drugs—Real World Outcomes over the course of 2016. Their skill and dedication are critical to the continued publication of the journal. The quality of published articles is, similarly, testament to the significant efforts of the peer reviewers, whose commitment ensures that the journal’s content is held to the highest possible standard. We would like to thank the following individuals who acted as reviewers for Drugs—Real World Outcomes in the last 12 months:We offer our sincere thanks to all authors who have contributed articles to Adebowale Dele Ademola, NigeriaKraemer Alwin, GermanyRichard H. Aster, USAPierrick Bedouch, FranceNancy Bernardy, USABenoit Boland, BelgiumMachaon Bonafede, USANeil Brickel, UKMarta Brooks, USAAnette Bygum, DenmarkJohanna Callhoff, GermanyWendy Cheng, USAVictoria Collings, UKRohan A. Elliott, AustraliaBarbara Farrell, CanadaPaula Fresco, PortugalMasahiro M. Fukuoka, JapanChris Gillette, USAB. Joseph Guglielmo, USAZeky Yüksel Gunaydin, TurkeyMark Haggard, UKJesper Hallas, DenmarkMainul Haque, MalaysiaSwapnil Hiremath, CanadaKeith B. Hoffman, USAChun-Ta Huang, TaiwanKlejda Hudhra, SpainSekwon Jang, USASusan Jick, USAPravin Kamble, USAHarparkash Kaur, UKDonald G. Klepser, USAPaul T. Kocis, USASam Kosari, AustraliaRichard Laing, USACecilie Johannessen Landmark, NorwayMarianne Lisby, DenmarkEleanor Lucas, USAHendrika Luijendijk, The NetherlandsAnke H. Maitland-van der Zee, The NetherlandsLouise Mallet, CanadaG. B. John Mancini, CanadaGloria Manso, SpainJohn F. McCarthy, USANatalie McCormick, CanadaAnthony B. Miller, CanadaAndrew Mosholder, USADomenico Motola, ItalyMarco Mula, UKGiorgio Mustacchi, ItalyPaul N. Newton, UKOnyema Ogbuagu, USAJan Palmblad, SwedenJean-Jacques Parienti, FranceTimo Partonen, FinlandKathryn Peri, New ZealandSathirakorn Pongpanich, ThailandValentin Prieto-Centurion, USANeal Ready, USAJenna M. Reps, UKJohn Robst, USAAlbert Roger, SpainJosea Rono, KenyaSabine Ruths, NorwayAlan Schorr, USATodd Semla, USAPasquale Striano, ItalyRoger E. Thomas, CanadaPhilippe Thuillier, FrancePetra A. Thurmann, GermanyJames E. Tisdale, USAGiuliano Tocci, ItalyAntonella Tosti, USARobert Vander Stichele, BelgiumBastiaan Venhuis, The NetherlandsPa-Chun Wang, TaiwanJuanita Westbury, AustraliaPeter K.K. Wong, AustraliaAntoinette A. Wozniak, USAIn addition, we would like to thank the members of the journal’s Honorary Editorial Board, who have acted as peer reviewers and authors, and have provided guidance on journal content, policy and processes:G.C. Alexander, Johns Hopkins University, Baltimore, MD, USAA. Beresniak, Data Mining International, Geneva, SwitzerlandM.L. Berger, Pfizer, Inc., New York, NY, USAH. Birnbaum, Analysis Group, Inc., Boston, MA, USAJ.M. Bottomley, Amygdala Ltd., Letchworth Garden City, EnglandP. Denig, University of Groningen, Groningen, The NetherlandsJ.E. Fincham, Presbyterian College School of Pharmacy, Clinton, SC, USAB. Godman, Karolinska Institutet, Stockholm, SwedenD. Goldsmith, Goldsmith Pharmacovigilance and Systems, New York, NY, USAS. Karve, AstraZeneca, Gaithersburg, MD, USAN.Y. Kirson, Analysis Group, Inc., Boston, MA, USAC. Kozma, CK Consulting Associates, St. Helena Island, SC, USAT. Lasky, MIE Resources, Baltimore, MD, USAA.A. Mangoni, Flinders University, Adelaide, SA, AustraliaS. Mimica-Matanovic, University Hospital Osijek, Osijek, CroatiaA. Modi, Merck, Whitehouse Station, NJ, USAJ.K. Sluggett, Monash University, Parkville, VIC, AustraliaK.A. Swanson, University of Oklahoma, Oklahoma City, OK, USAJ.E Ware Jr., University of Massachusetts, Worcester, MA, USAQ. Zou, The Lewin Group, Falls Church, VA, USAThe Patient (17.08%), Clinical Drug Investigation (15.99%), the American Journal of Clinical Dermatology (13.17%), Drug Safety (13.5%), and Drugs (12.43%).In other portfolio news, mid-2016 saw the release of the ISI Journal Citation Reports and the latest journal impact factors. The majority of our journals saw a rise in impact factor against the previous year. Most notably, five of our journals saw an increase of over 10% in impact factor – PharmacoEconomics—Open. This new journal will be fully open access and will focus on the publication of applied research on the economic implications and health outcomes associated with drugs, devices and other healthcare interventions. It joins our other well respected health outcomes publications, PharmacoEconomics, Applied Health Economics and Health Policy, and The Patient: Patient-Centered Outcomes Research.The Adis journals portfolio will expand in 2017, with the launch of We hope that you have found the articles published throughout 2016 to be both interesting and informative. We have appreciated the high quality of content contributed to the journal this year and look forward to keeping you up to date with topical real-world outcomes in 2017.With best wishes from Dene Peters (Editor-in-Chief) and Kathy Fraser (Deputy Editor).