INK4a as a possible diagnostic marker of cervical cancer. To evaluate whether the specificity of p16INK4a expression in dysplastic and neoplastic cervical epithelium is sufficient for such application we undertook a broader immunochistochemical registration of this protein with a highly p16INK4a-specific monoclonal antibody.Cervical carcinomas are second most frequent type of women cancer. Success in diagnostics of this disease is due to the use of Pap-test . However Pap-test gives significant portion of both false-positive and false-negative conclusions. Amendments of the diagnostic procedure are desirable. Aetiological role of papillomaviruses in cervical cancer is established while the role of cellular gene alterations in the course of tumor progression is less clear. Several research groups including us have recently named the protein p16Paraffin-embedded samples of diagnostic biopsies and surgical materials were used. Control group included vaginal smears of healthy women and biopsy samples from patients with cervical ectopia. We examined 197 samples in total. Monoclonal antibody E6H4 (MTM Laboratories, Germany) was used.INK4a-positive cells. Overexpression of p16INK4a was detected in samples of cervical dysplasia (CINs) and carcinomas. The portion of p16INK4a-positive samples increased in the row: CIN I – CIN II – CIN III – invasive carcinoma. For all stages the samples were found to be heterogeneous with respect to p16INK4a-expression. Every third of CINs III and one invasive squamous cell carcinoma  were negative.In control samples we did not find any p16INK4a is typical for dysplastic and neoplastic epithelium of cervix uteri. However p16INK4a-negative CINs and carcinomas do exist. All stages of CINs and carcinomas analyzed are heterogeneous with respect to p16INK4a expression. So p16INK4a-negativity is not a sufficient reason to exclude a patient from the high risk group. As far as normal cervical epithelium is p16INK4a-negative and the ratio p16INK4a-positive/ p16INK4a-negative samples increases at the advanced stages application of immunohisto-/cytochemical test for p16INK4a may be regarded as a supplementary test for early diagnostics of cervical cancer.Overexpression of the protein p16 Cervical cancer makes up about 10–12% of total women cancers [The main screening test for cervical cancer is the cytological smear staining technique developed by G. Papanicolaou  and knowHistological analysis of a biopsy sample, more laborious in preparation and study as compared with that of a cytological smear, is also not absolutely efficient owing to a substantial rate of interobserver discrepancies among expert pathologists examining the same material .Infection with human papilloma viruses (HPV) belonging to so-called high-risk group is the main risk factor of cervical cancer incidence . To deteINK4a for a possible supplementary marker of dysplastic and neoplastic cervical epithelium lesions. This protein belongs to the group of cyclin-dependent kinase Cdk4/6 inhibitors [INK 4a (synonyms: MTS 1, CDKN2, INK4a/ARF). Gene INK4a plays an important role in the regulatory pathway Cdk-Rb-E2F. The product of this gene p16INK4a prevents pRb phosphorylation by inactivating Cdk4/6; pRb keeps on binding E2F transcription factors and as a result cells stay in G1 phase not passing to DNA replication. In various tumor types INK4a as a bona fide tumor suppressor undergoes homozygous deletions, is inactivated by point mutations, LOH or hypermethylation; p16INK4a expression is reduced or ceases under such conditions or the protein function may be impaired [For the recent years several research groups ,6-16 inchibitors  and is eimpaired .INK4a and its protein becomes of no importance for a cell so far as they function upstream of the site of breakage. Cells with thus inactivated pRb pass cell cycle checkpoint G1/S without any obstacle.Peculiarity of cervical carcinomas is due to the ability of HPV oncoprotein E7 to interact with pRb and inactivate it . As a reINK4a commonly found in human permanent cell lines  [INK4a protein as a marker of premalignant and malignant cervical epithelium cells. Functionally active gene RB was shown to be able to negatively regulate the expression of INK4a on a transcriptional level, but details of this negative feed-back loop remain obscure [Reciprocallity between status of pRb and that of p16ultures) ,20,21 asultures) ,22,23 se obscure .INK4a as a marker of dysplastic and neoplastic alterations in cervical epithelium cells we analyzed the expression of this protein utilizing a highly p16INK4a – specific monoclonal antibody. We examined 197 samples in total. The materials studied included: 1) samples of normal epithelium of healthy women , 2) diagnostic biopsy samples from patients with cervical ectopia, 3) samples of CINs of various stages, 4) samples of invasive cervical cancer, 5) samples from different normal utery body and cervix tissues from women with gynecological diseases not associated with dysplastic lesions of epithelium  and 6) samples of cells from 3 cervical carcinoma cell lines. We also compare our data with the results presented by other groups working in similar directions [To estimate the applicability of p16rections ,12-16.INK4a is typical for some samples of dysplastic and neoplastic epithelium of cervix uteri. We have not found at least a single sample overexpressing p16INK4a among control samples. The portion of p16INK4a-positive samples increases in the following row: CIN I – CIN II – CIN III – invasive carcinoma. However p16INK4a-negative CINs and carcinomas have also been found. All stages of CINs and carcinomas analyzed turn out to be heterogeneous with respect to p16INK4a expression: side by side with the samples which express p16INK4a in 25% of cells or more we detect samples which are stained poorly or lack any staining. So p16INK4a-negativity does not seem to be a sufficient reason to exclude a patient from the high risk group when results of Pap-test, HPV detection by PCR or histological investigation warn about possibility of poor prognosis. As far as normal cervical epithelium is p16INK4a-negative and the ratio p16INK4a-positive/ p16INK4a-negative samples increases at the advanced stages of CINs and carcinomas application of immunohisto-/cytochemical test for p16INK4a may be regarded as a supplementary  test for early diagnostics of cervical cancer.We demonstrate in the present work that overexpression of the protein p16Immunohisto-/immunocytochemical study was performed on 197 samples in total. Those included 6 samples from normal epithelium of healthy women , as well as the following surgical and diagnostic biopsy materials: 37 samples from patients with cervical ectopia, 113 samples of CINs of different stages including cancer in situ, 26 samples of invasive cervical cancer (21 squamous cell carcinomas and 5 adenocarcinomas), 12 samples of normal tissues from uterus body (myometrium) and cervix from patients with different gynecological diseases, 3 cervical cell line samples taken for positive control (see below). Apart from 9 smears  the rest 188 materials were paraffin-embedded histological blocks. The quality of smears turned out to be satisfactory for immunochemical analysis Fig.  and 1d.Neutral formalin-fixed paraffin embedded samples of biopsies and surgery materials were received from archives of N.N.Blokhin Cancer Research Center (Moscow), P.A. Gertzen Institute of Oncology (Moscow), Central Clinical Hospital (Moscow) and Fourth Clinical Hospital (Poltava, Ukraine).For immunohistochemical analysis 4–5 μm serial sections were transferred on Histobond slides with adhesive layer (SMT Geraetehandel GmbH, Germany). The first section was stained with hematoxylin-eosin for traditional morphological analysis and verification of diagnosis by not less than two independent pathomorphologists.Presence of high risk HPV in cervical CIN and carcinoma cells was verified by PCR . Some ofVaginal normal epithelium smears obtained during regular examination from healthy women were transferred on HistoBond slides. Absence of abnormal cells was confirmed in Cytology Department of Cancer Research Center on a parallel slide. Smears were fixed for 5 min in 10% formaldehyde, washed with flowing water, and processed for further development as described for deparaffinized histological slices . Cells oINK4a-specific monoclonal antibodies E6H4 (MTM Laboratories AG, Germany) according to protocol by Klaes et al [Immunohistochemical staining was carried out using p16es et al .INK4a in earlier immunocytochemical studies with the same antibody [INK4a-positive one in our previous studies (on preceeding cuts). The analysis of the given slide series was carried out only if the positivity of the control sample was confirmed. Thus neither slide series in the present study was completely p16INK4a-negative.1). In the beginning of the study as a whole cells of three cervical cell lines were stained first. They were SiHa (HPV16-positive), C33a and HT-3 (both HPV-negative); all of them had been characterized as expressing the protein p16antibody . 2). OneINK4a-expressing material was included into every slide series meant for staining (as in variant 3 of positive controls, – see above) which was processed in a usual way but PBS was applied instead of p16INK4a-specific antibody. The results were regarded as valid if this slide was negative. 2). As an intrinsic negative control served adjacent to CIN or carcinoma normal tissues including stromal elements. In neither case did we find any staining in these tissues (fig. 1). One more serial cut made from p16ues fig. .INK4a was expressed in nuclei and/or in a cytoplasm.In addition to four categories of staining defined by Klaes et al. ,- poor , sporadiINK4a-specific staining of cervix uteri normal, dysplastic and cancer cells are presented in Fig. Various types of p16INK4a  may be detected but in a cytoplasm in the majority of cells while in a number of cells both in nuclei and cytoplasm, why in some cervical cell cultures it is found solely in cytoplasm and in other cervical cell lines – in nuclei also. We did not find at least a single sample with an exceptionally nuclear staining; similar were the results by other investigators [INK4a-specific staining varies to such a degree we scored as positive every sample in which the staining was expressed either in a cytoplasm or in both nuclei and cytoplasm.We did not register any staining in either of 6 smear samples taken from healthy women Fig. . An examtigators . With keThe data of the analysis of the cervical epithelium preparations stained with monoclonal antibodies E6H4 are summarized in Table INK4a-positive cells were observed with low frequencies: 34 samples were negative and 3 ones (8,1%) were stained poorly.In all 37 samples from patients with cervical ectopia p16INK4a-negative. In 7 samples (about 14%) sporadic or focal  were attributed to sporadic Fig , focal oive Fig. .INK4a-positive cells  stained poorly, 3 (21.4%) stained sporadically, 4 (28.4%)-focally and 5 (35.8%) expressed diffuse staining.As to invasive cancers, only 1 out of 26 samples (3.8%) lacked p16lls Fig. . One samlls Fig. . Among 1INK4a expression was more pronounced in cells belonging to a more advanced lesion  the results of staining with p16es Table .INK4a by monoclonal antibodies shows that the overwhelming majority of invasive cervical carcinoma samples differ from normal cervical epithelium of healthy women. We found no cases of sporadic, focal or diffuse staining with E6H4 antibodies among 6 vaginal smears from healthy women as well as among 37 samples from patients with cervical ectopia including those in which ectopically localized cervical epithelium koilocytes or condyloma had been registered. In addition, in 11 samples of normal glandular and stromal cervical tissues and one sample of uterus body normal myometrium tissue which were obtained from patients with gynecological disorders p16INK4a was not expressed at all.Immunochemical detection of p16INK4a-expressing. However in 2 samples not expressing any p16INK4a or expressing it poorly high-risk HPV DNA sequences were detected by both PCR and Southern blot hybridization. These data are in a good agreement with those by Klaes et al., who described two samples of p16INK4a-negative but HPV-positive cervical cancer [INK4a in less than 1% of cells . DCS-50.1/H4-NA29 (Oncogene Research Products, Cambridge, MA), 2). 375P (Biogenex Laboratories, San Ramon, CA), 3). ZJ11 and JC8 (NeoMarkers, Freemont, CA), 4) 05–418 (Upstate Biotechnology, Lake Placid, NY) and 5). J175–405 (PharMingen, San Diego, CA). The results of the comparative experiments by Klaes at al [Monoclonal antibodies E6H4 originally described by Klaes et al  had beenINK4a-positivity  in a comparatively small number of CIN I and CIN II samples (13–14 %). Among CINs III the portion of such samples increased up to 54,2%, with diffuse staining in every sixth case.We observed strong p16The data we have obtained for CINs of all stages rather differ from the results by Klaes et al. . All of INK4a expression in dysplastic and neoplastic cervical epithelium in the course of progression.Nevertheless the coincidence between our results and the data by Klaes et al  concerniINK4a-negative in control group. Similar was the situation in the reference group: 12/12 negative. Among CINs I, CINs III and invasive carcinomas these indices made up 32/51 (63 %), 8/24 (33%) and 1/26 (4 %) respectively.This trend is especially evident in our study when negative cases only are taken into consideration. All 6 samples were p16INK4a when detected immunohistochemically may be regarded as a marker of dysplastic and neoplastic lesions in cervical epithelium. Positive correlation between p16INK4a expression and morphological stage of the disease on the same slide (when combined cases with both dysplastic and neoplastic lesions were found) also favors this inference.The data presented herein allow us to conclude that hyperexpression of p16INK4a was suggested to be performed on cytological smears [INK4a to become rather widely used not only as an addition to surgery but also for regular examinations in outpatient clinics. In this connection it seems important to estimate frequencies of a feasible false-negativity of the test.In a number of recent communications immunochemical staining for p16l smears ,13-15. CINK4a-negative invasive carcinoma samples , to utilization of different types of monoclonal antibodies, to different criteria used by different research groups for the results interpretation, etc.Keeping in mind that dysplastic lesions of all stages frequently regress and do not convert into invasive cervical carcinomas , we summINK4a expression among previously developed tests for early detection of cervical carcinomas. In this connection the following points deserve mentioning. A pathologist in the course of common histological investigation usually registers some morphologic features such as zones of active mitotic divisions, multipolar mitoses, vicinity of condilomas and other formations. However when performing an immunocytochemical analysis on a smear a cytologist cannot bring in a correlation with morphological structure results of staining with p16INK4a-specific antibodies in separate cells. According to the results of the present study about 33% of CINs III as well as about 5% of invasive squamous cell carcinomas of cervix uteri do not differ from normal cervical epithelium with respect to p16INK4a expression. Thus immunochemical staining for p16INK4a  does not seem to be the approach that can help to fully overcome absolutely all existing ambiguities of cervical cancer early diagnostics.It seems important to realize the proper place of immunocyto-/ immunohistochemical analysis of p16INK4a the study by Agoff et al [INK4a – specific antibody E6H4. So far as endometrial cells may occur on vaginal smears the test does not seem to enable one to fully avoid false positivity.As to possible sources of false positivity of immunochemical detection of the protein p16INK4a encoded by tumor suppressor gene INK4a is a characteristic of displastic and neoplastic alterations of cervical epithelium. The portion of p16INK4a-positive samples increases in the following row: CIN I – CIN II – CIN III – invasive carcinoma. All stages of CINs and carcinomas analysed are heterogeneous with respect to p16INK4a expression: side by side with the samples which expressed p16INK4a in 25% of cells or more we detected samples which were stained poorly or lacked any staining. According to the data we present herein p16INK4a-negative cervical neoplasms and carcinomas do exist. Thus the lack of p16INK4a-positive cells in samples from different types of cervical lesions should not be regarded as a sufficient reason for excluding a patient from the high-risk group. Despite this as far as normal cervical epithelium is p16INK4a-negative and the ratio p16INK4a-positive/ p16INK4a-negative samples increases at the advanced stages of CINs and carcinomas application of immunohisto-/cytochemical test for p16INK4a may be regarded as an additional  test for early detection of precancerous lesions in cervical epithelium.Overexpression of the protein p16none declaredF.K., D.S., G.V. and G.F. contributed to study conception and design; E.K. and A.B. delt with sample obtaining and preliminary diagnosis; Yu.A., G.F. and V.E. were independent pathologists who confirmed the diagnosis; G.V., L.Z. and D.G. performed immunohistochemical staining and analysis; A.B. carried out HPV typing; G.V. drafted the manuscript. All authors read and approved the final version.The pre-publication history for this paper can be accessed here:Data on high risk HPV genome detection by PCR in CIN I and CIN II samples. the data are presented on high-risk HPV genetic material detection in 9 CIN I and 9 CIN II samples.Click here for file


Haemophilus influenzae, Moraxella catarrhalis, and Streptococcus pneumoniae. Staphylococcus aureus is also frequently isolated while atypical bacteria are thought to cause up to 10% of exacerbations. Antibacterial resistance is increasing worldwide and little surveillance data exist concerning pathogens isolated from patients with AECB.Antimicrobial therapy is considered an important component in the medical management of most patients with acute exacerbation of chronic bronchitis (AECB). The three predominant bacterial species isolated are nontypeable This study examines the prevalence of antibacterial resistance in isolates obtained from patients with clinically diagnosed AECB. A total of 3043 isolates were obtained from 85 centres in 29 countries, between 1999–2003, and were tested against the new ketolide telithromycin and a panel of commonly used antibiotics.S. pneumoniae isolates, 99.9% were susceptible to telithromycin, but only 71% were susceptible to erythromycin and 75.3% to penicillin. Of the H. influenzae isolates, 99.6% were susceptible to telithromycin. 11.7% of these isolates produced β-lactamase. Almost 10% of S. pneumoniae were multidrug-resistant; 99.0% of these isolates were susceptible to telithromycin. Telithromycin also demonstrated good in vitro activity against M. catarrhalis (MIC90 = 0.12 mg/L) and was the most active compound against methicillin-susceptible S. aureus (98.9% susceptible).Of the Telithromycin demonstrated similar or better activity against the bacterial species investigated than the other agents, with the most complete coverage overall. These species are the predominant causative bacterial pathogens in AECB and thus the spectrum of activity of telithromycin makes it a potential alternative for the empirical treatment of AECB. The World Health Organization (WHO) estimates that chronic obstructive pulmonary disease (COPD) is the fourth leading cause of death worldwide. In the year 2000, it was estimated that 2.74 million people died from COPD worldwide . COPD isResults from a number of placebo-controlled clinical investigations have demonstrated that antibacterial agents are of significant clinical benefit in the treatment of AECB, particularly for those patients with at least two of the three cardinal symptoms of AECB (worsening dyspnoea, increased sputum volume, and increased sputum purulence) and/or severe airway obstruction -13. OtheHaemophilus influenzae, Moraxella catarrhalis, and Streptococcus pneumoniae. Other less frequently isolated potential pathogens are Gram-negative enterobacteria, Haemophilus parainfluenzae, Staphylococcus aureus, and Pseudomonas aeruginosa. Gram negative enterobacteria and Pseudomonas aeruginosa are more frequently isolated in patients with severe underlying disease [Mycoplasma pneumoniae in 1–10%, and Chlamydophila pneumoniae in 4–5%  [Bacteria can be isolated from 40–60% of sputum samples of patients experiencing AECB . The thr disease . Viral iH. influenzae isolates and more than 90% of M. catarrhalis isolates produce β-lactamase and this limits the value of penicillins and some other β-lactams [S. pneumoniae [Amoxycillin, ampicillin, sulfamethoxazole-trimethoprim (trimethoprim-sulphamethoxazole), tetracyclines, and erythromycin are considered first-line antimicrobial therapy for AECB . The cli-lactams . Furthereumoniae . Other aS. pneumoniae [S. pneumoniae with methylase, efflux or ribosomal mutations as the mechanisms of resistance [Telithromycin is the first ketolide available for clinical use. Derivatives of erythromycin-A, the ketolides, like the macrolides, exert their antimicrobial action by binding to the bacterial ribosome. Although both macrolides and ketolides bind strongly to a region of domain V in the 23S rRNA of the ribosome, telithromycin has additional strong binding to a region in domain II to which the macrolides bind weakly . Ketolideumoniae . Consequsistance ,23.in vitro antimicrobial activity of bacterial isolates obtained from patients clinically diagnosed with AECB in 3 consecutive years of the PROTEKT study. Using these data, and previously published clinical data, the potential role of telithromycin in the treatment of AECB will be discussed.There is a need for alterative therapeutic options for the treatment of AECB and surveillance data are needed to help determine the suitability of new agents. The PROTEKT (Prospective Resistant Organism Tracking and Epidemiology for the Ketolide Telithromycin) study is an international, longitudinal, antibacterial resistance surveillance study, which was initiated in 1999 to monitor the spread of resistance among respiratory tract pathogens worldwide. Here we analyze the Details of the study design, including the selection of patients and the methodology for the identification of isolates and their storage in the PROTEKT study has been described previously . IsolateS. pneumoniae, 40 H. influenzae, 15 H. parainfluenzae, 20 M. catarrhalis, 25 Streptococcus pyogenes and 20 S. aureus to collect. In years 2 (2000–2001) and 3 (2001–2002), H. parainfluenzae were not collected and 15 extra isolates of S. pneumoniae were collected instead.In Year 1 (1999–2000), each centre had a quota of 60 isolates of S. pneumoniae and S. aureus), ampicillin , amoxycillin/clavulanate, and cefuroxime, three macrolides/azalides; erythromycin, clarithromycin, and azithromycin, the folate synthesis inhibitor; trimethoprim-sulphamethoxazole, the tetracycline; tetracycline and a fluoroquinolone, levofloxacin.The comparator agents used were four β-lactams; penicillin (for S. pneumoniae and for S. aureus are ≤ 1 mg/l is susceptible, 2 mg/l is intermediate, and ≥ 4 mg/l is resistant, and for H. influenzae ≤ 4 mg/l is susceptible, 8 mg/l is intermediate, and ≥ 16 mg/l is resistant [Minimum inhibitory concentrations (MIC) of each antibacterial were determined using the National Committee for Clinical and Laboratory Standards (NCCLS) broth microdilution methodology and lyophilised microtitre plates (Sensititre, Trek Diagnostics) at a central laboratory (GR Micro Ltd., London, UK) . NCCLS besistant .A total of 3043 bacterial pathogens were isolated from patients in 29 countries around the world, with by far the largest number of specimens (1841, 60.5%) coming from Europe (Table S. pneumoniae and H. influenzae formed the majority (1075 and 1037 respectively), followed by M. catarrhalis (536)  Table . Patient50 and MIC90 of the various agents against the five species. Where breakpoints were available the percentage of isolates to the various agents is also included. Telithromycin had similar or better in vitro susceptibility than the comparator agents against all of these species. Activity against S. pneumoniae was particularly good, with telithromycin being the most active agent; 99.9% of isolates were classified as susceptible and the MIC90 (0.12 mg/L) was substantially lower than all other compounds tested.Table S. pneumoniae isolates (from 51 and 53 patients in the 30–64 and >64 year old age groups respectively)) were resistant to both penicillin (MIC ≥ 2 mg/L) and erythromycin (MIC ≥ 1 mg/L) and this was reflected in resistance to amoxycillin, cefuroxime, clarithromycin and azithromycin also  H. influenzae isolates were susceptible to amoxycillin-clavulanate, cefuroxime, telithromycin, azithromycin, and levofloxacin. Tetracycline also had good activity with 97.4% of isolates susceptible. Only 11.7% of H. influenzae isolates produced β-lactamase. There were only 60 isolates of H. parainfluenzae and 100% of these were susceptible to four of the eight compounds tested, telithromycin, amoxycillin/clavulanate, cefuroxime and azithromycin. Trimethoprim-sulphamethoxazole and tetracycline were the least active compounds. In terms of MICs, levofloxacin, azithromycin and telithromycin were the most potent compounds against M. catarrhalis with MIC90 values of 0.03 mg/l, 0.06 mg/l and 0.12 mg/l respectively.Over 99% of M. catarrhalis to allow classification into susceptible or resistant categories.There are currently no interpretative NCCLS guidelines available for S. aureus was 335 and of these only 62 were resistant to methicillin (MRSA). Trimethoprim-sulphamethoxazole was the most active compound overall, with 94.9% of all isolates being susceptible. Telithromycin and tetracycline were the next most active with 85.1% and 84.8% of all isolates susceptible. Telithromycin was the most active compound against the MSSA isolates, with 98.9% being susceptible. The susceptibility of MSSA to tetracycline and trimethoprim-sulphamethoxazole was 92.7% and 97.4% susceptible respectively. These three compounds were the only ones to have activity against the MRSA isolates (trimethoprim-sulphamethoxazole 83.9%, tetracycline 50% and telithromycin 24.2%). Less than 10% of the MRSA isolates were susceptible to the remainder of the compounds.The total number of isolates of S. pneumoniae is most frequently isolated in the least severe cases of AECB, whereas H. influenzae is more commonly isolated from moderate to severe cases, with P. aeruginosa occurring in severe hospitalised cases [Pseudomonas spp.  and hence may not be an appropriate empirical therapeutic option for AECB patients with severe underlying disease who are hospitalized for an acute exacerbation.The primary cause of COPD is exposure to tobacco smoke, the major risk factor being cigarette smoking. The demography of the disease in this study and others reflects this, as the majority of patients in this analysis were male and half were elderly (>64 yrs of age) (2). ed cases . TelithrWhether the isolation of a pathogen during AECB represents an infection responsible for the exacerbation has been debated for many years -31. BactS. pneumoniae and hence offers a viable potential option for the empiric treatment of AECB in non-hospitalised patients [Amoxycillin-clavulanate, azithromycin, and levofloxacin have been shown to be effective in the treatment of AECB, however, there is concern regarding their long-term usefulness, because of the development of resistance to these agents among the causative pathogens ,35. Telipatients .in vitro activity against the commonest bacterial pathogens causing AECB. These data also show that telithromycin has the highest overall activity against bacterial isolates from patients with AECB, regardless of species. Almost 10% of S. pneumoniae isolated were resistant to penicillin, macrolides, and at least one of the other antibiotics tested, with only telithromycin and levofloxacin retaining high activity against these isolates (99.0% and 98.1%, respectively). The validity of this finding is strengthened as the isolates were obtained from a large number of patients over a wide geographical distribution.The data in this study demonstrate that telithromycin has high in vitro against Chlamydophila pneumoniae to the other macrolides with the exception of clarithromycin and has similar activity to the fluoroquinolones [Legionella pneumophila infections [In vitro, the activity of telithromycin against L. pneumophila was similar to levofloxacin but better than erythromycin [Mycoplasma pneumoniae as this species lacks a typical bacterial cell wall, the site of activity for these drugs. Telithromycin has been found to have higher activity than doxycycline and levofloxacin against M. pneumoniae [Although atypical pathogens were not examined in the PROTEKT study, telithromycin has been shown to have superior activity inolones . In guinfections . In vitrhromycin . β-lactaeumoniae . As the Telithromycin has been shown to penetrate into respiratory tissues well . The conTelithromycin can be administered once a day for AECB. Clinical studies have demonstrated that 800 mg administered once daily for 5 days was as effective and well tolerated as a 10-day course of amoxycillin/clavulanate (500/125 mg 3 times daily for 10 days), cefuroxime axetil (500 mg twice daily for 10 days) or clarithromycin (500 mg twice daily for 10 days) . Other cS. pneumoniae isolates from patients with community-acquired pneumonia, it could then only send H. influenzae from patients with AECB to fulfil the quota for this organism. In addition, atypical pathogens were not sampled and they can represent up to 10% of the causative pathogens [Although this study provides valuable information on the overall antimicrobial profile of bacteria causing AECB, care should be taken when interpreting data related to specific demographics. The prevalence of species could not be calculated in this study as a major limitation, inherent to most surveillance studies, is the requirement for collecting centres to fulfil a specified quota of isolates over a defined time period (1 year). If, for instance, a centre managed to fulfil the quota for athogens .in vitro activity against H. influenzae, S. pneumoniae, and M. catarrhalis, respiratory pathogens commonly isolated in AECB. It is as active as or more active than agents that are currently used in this clinical setting. Additionally, although not shown here, telithromycin has better in vitro activity against atypical pathogens than other agents; an important advantage in this clinical setting as these pathogens may represent 10% of AECB associated infections.In summary, the data presented here demonstrate that telithromycin has good in vitro efficacy of newer antibacterial agents. Providing careful surveillance for the development of resistance is maintained, telithromycin currently offers a useful agent in the treatment of AECB.The development of resistance will always be a threat to the usefulness of antibacterial compounds, however surveillance studies such as PROTEKT allow the rapid detection and characterization of resistance mechanisms and highlight the need for and examine the


Industrial development may result in the increase of environmental risks. The enzymatic transformation of polluting compounds to less toxic or even innocuous products is an alternative to their complete removal. In this regard, a number of different redox enzymes are able to transform a wide variety of toxic pollutants, such as polynuclear aromatic hydrocarbons, phenols, azo dyes, heavy metals, etc. Here, novel information on chromate reductases, enzymes that carry out the reduction of highly toxic Cr(VI) to the less toxic insoluble Cr(III), is discussed. In addition, the properties and application of bacterial and eukaryotic proteins (lignin-modifying enzymes, peroxidases and cytochromes) useful in environmental enzymology is also discussed. Chromate reductases are a group of enzymes that catalyze the reduction of toxic and carcinogenic Cr(VI) to the less soluble and less toxic Cr(III). These proteins have recently raised enormous interest because of their central role in mediating chromium toxicity and their potential use in bioremediation and biocatalysis. Chromate (Cr(VI)) is generated as by-product of various industrial processes such as leather tanning, chrome-plating, pigment production and thermonuclear weapon manufacture . Its higPseudomonas putida) and YieF (from E. coli) have been purified and characterized [The chromate-reducing activities have been located in the cell membrane or in the cytoplasm of many bacteria . Their ucterized . These ecterized .The ability of some microorganism and their enzymes to remove toxic pollutants has been recently reviewed -6. The i4 -2) and may be introduced in eukaryotic and bacterial cells by the sulphate transport system [The intensive industrial and agricultural development has been considered as responsible for a widespread contamination of soil, air and groundwater with toxic pollutants, which are harmful for human health and the environment . These ct system . In bactt system . Thus, tWhile chemical methods are expensive at the large scale required to decontaminate waste sites, microorganisms are commonly used for environmental purposes through the exploitation of their natural catalytic activities. Enzymatic treatments have a minimal impact on ecosystems, as they present no risk of biological contamination. Furthermore, enzymes can act over a wide range of pH, temperature and ionic strength and also may be active in the presence of high concentrations of organic solvents in which major pollutant molecules are soluble .Pleurotus, Bjerkandera, Phanerochaete, and Trametes produce extracellular enzymes with ligninolytic activity. These enzymes are often referred to as lignin-modifying enzymes and include mainly Lignin peroxidase, Manganese dependent peroxidase and laccase [c, are able to oxidize organic compounds in the presence of hydrogen peroxide. An interesting feature of these enzymes is their remarkable low specificity towards substrates that arises from their own catalytic mechanism. In vivo, peroxidases use endogenous low-molecular weight compounds, called mediators, to generate free radicals capable to carry out a wide variety of reactions such as oxidations, bond cleavage, hydroxylations, polymerization and demethylation [Several bacterial enzymes that can be used in bioremediation have been described; they include mainly oxidative enzymes such as mono-and dioxygenases but their use is restricted by the need of cofactors, which can only be efficiently regenerated inside the microorganism . In the  laccase , though  laccase . Besideshylation . Severalhylation -10.Strong regulations have been established to push the industrial sector to develop new programs destined to a greater environmental care. Nowadays, industry is strongly dependent on petroleum and its derivatives as a source for raw materials and energy. There are still large reserves of crude oil, which are heavy oils with a high content of sulphur and heavy metals. The use of these fuels generate a great pollution, being one of their most important environmental impacts the formation of the acid rain which takes place by the sulphur oxide production during combustion. Redox enzymes may encounter fields of application not only in the bioremediation of polluted environments, but also in the development of novel clean technologies to avoid or diminish the environmental contamination. Biocatalytic methods for sulphur removal from straight-run diesel fuel have been developed . The remDespite their potential application in bioremediation and clean processes, the activity of oxidative enzymes may be limited, among other factors, by the low bioavailability of the pollutants and by the relatively low operational stability of the enzyme under the environmental conditions required to carry out the bioremediation. Several strategies to increase the catalytic activity of peroxidases have been proposed, including chemical modification of the enzyme ,15 and gMicrobial genomics is a new emerging field that enables us to look at parts of the environment that were, until recently, masked to us. Present estimations suggest that more than 99% of the microorganisms in most environments  are not amenable to grow in pure culture, and thus very little is known about their enzymatic activities. We can now access the genomes of non-culturable microorganisms through creating the "so-called" metagenomic-libraries and identify protein-coding genes and biochemical pathways that will shed some light on their properties and function . New enzThe even more strict regulations on hazard wastes has forced to the development of new environmentally compatible strategies to substitute or complement the conventional ones. Chemical technologies are expensive when applied to large scale and in many cases are technically not feasible. On the other side, by exploitation of the huge diversity of natural activities and metabolic pathways presented by microorganisms, new strategies can be envisaged. The use of oxidative enzymes as biocatalysts for environmental purposes presents a promising potential due to their low specificity and low energetic requirements. However, further characterization of new biocatalysts is needed. The use of novel technologies such as molecular directed evolution may have a large impact in the tailoring and further application of enzymes not only for bioremediation but also for the development of friendly environmental technologies.


Validation of the use of the lognormal model for predicting long-term survival rates using short-term follow-up data.907 cases of laryngeal cancer were treated from 1973–1977 by radiation and surgery (248), radiation alone (345), and surgery alone (314), in registries of Connecticut and Metropolitan Detroit of the SEER database, with known survival status up to 1999. Phase 1 of this study used the minimum chi-square test to assess the goodness of fit of the survival times of those who died with disease to a lognormal distribution. Phase 2 used the maximum likelihood method to estimate long-term survival rates using short-term follow-up data. In order to validate the lognormal model, the estimated long-term cancer-specific survival rates (CSSR) were compared with the values calculated by the Kaplan-Meier (KM) method using long-term data.The 25-year CSSR were predicted to be 72%, 68% and 65% for treatments by radiation and surgery, by radiation alone, and by surgery alone respectively, using short-term follow-up data by the lognormal model. Corresponding results calculated by the KM method were: 72+/-3%, 68+/-3% and 66+/-4% respectively.The lognormal model was validated for the prediction of the long-term survival rates of laryngeal cancer patients treated by these different methods. The lognormal model may become a useful tool in research on outcomes. Literature review  indicateThe lognormal distribution is defined as the distribution of a random variable whose logarithm is normally distributed. The purpose of this study is to validate the use of the lognormal model -4 by estThis model may be useful for randomized clinical trials because it allows the prediction of long-term survival rates several years earlier than is possible by using the standard actuarial life table/Kaplan-Meier method of calculation .The idea that long-term survival rates can be estimated from short-term follow-up data is attractive because this method shortens the delay in further research to improve cancer treatment. The validation of the lognormal model has two phases. Phase 1 tests the goodness of fit to a lognormal distribution of the survival times of those cancer patients who died with disease.Phase 2 attempts to verify the lognormal model, which uses short-term follow-up data to predict long-term survival rates. These survival rates are then compared with values calculated by the Kaplan-Meier life table method from available long-term data. The second phase has been difficult to implement because of the general lack of large number of patients with sufficiently long follow-up information. With the SEER database , the valWe analyzed a total of 907 cases of laryngeal cancer treated by three treatment methods: radiation and surgery (248 patients), radiation alone (345 patients), and surgery alone (314 patients), registered in two registries, Connecticut and Metropolitan Detroit, from 1973–1977 with known survival status up to 1999 extracted from the SEER database. Fourty-seven patients with unknown survival time and 165 patients with missing treatment methods were excluded. A table of the patient characteristics was listed in Table The cause-specific survival time was defined as the interval from the date of diagnosis to the date of death from laryngeal cancer or the date of last follow-up for censoring purposes, if the patient was alive and still being followed at the time of analysis. Patients who died of other causes were also censored at date of death.10  of the distribution of patients who died of the cancer. The minimum chi-square test was run by a Microsoft Excel program. A range of S-values and M-values were tested to reduce the chi-square values to a minimum. In order to determine if the observed survival times for a given cohort are lognormally distributed, the results are given in terms of probability levels of significance P for the chi-square estimates which correspond to a minimization of chi-square and hence a maximization of P. The test statistic of the minimum chi-square test was minimized by varying the parameters and the P-value gave the significance of the test. The class intervals were in the powers of 2 in months of the survival time, such as 0–2, >2–4, >4–8, >8–16, and so on. The number of cases in each interval should not be less than 5. The null hypothesis being tested is H0: that there is no difference between the observed survival times and the expected survival times calculated from a lognormal distribution with a specified S and M. If P < 0.05 the null hypothesis is rejected.Testing for lognormality was done separately for laryngeal cancer patients who died with disease (as distinct from those who died of an intercurrent disease) treated by: radiation and surgery, radiation alone, and surgery alone. For Phase 1, a minimum chi-square method was used to estimate the standard deviation S and mean M of the logA second computer program for the Phase 2 of the study was also run using Microsoft Excel to estimate the cured fraction C by using a maximum likelihood method described by Boag . Using tThe five-year cohort extended from 1973 to the end of 1977. Prediction of the long-term CSSR were made after one year follow-up, i.e. at the end of 1978, for the laryngeal cancer patients with three different treatments: radiation and surgery, radiation alone, and surgery alone. The predicted CSSR were then validated by comparing with the results calculated by the Kaplan-Meier method using the actual follow-up data available up to 1999.Log-rank tests were performed for the three different treatment groups over the whole time period in order to see if there was a difference in CSSR between treatments.Using data from 1973–1977, the minimum chi-square tests verified that the survival times of the patients who died of laryngeal cancer and who were treated by three treatments followed three different lognormal distributions. At minimum chi-square, the S and M values, the numbers of patients N and the P values of the minimum chi-square tests for the three different treatments are listed in Table at one year after the five-year cohort period. Hence at the time of prediction by the lognormal model, the long-term data were not known yet. Table As in a prospective trial at interim analysis, Phase 2 was performed for each of the five-year cohort periods after one year of follow-up. Phase 2 predicted, using the maximum likelihood method, the long-term 10-, 15-, 20-, and 25-year CSSR. An S value was selected for the maximum likelihood method, so that the prediction curve obtained by the lognormal model would best fit the Kaplan-Meier graph The 25-year CSSR were predicted by the lognormal model after only short term follow-up to be 72%, 68% and 65% for treatments by radiation and surgery, radiation alone, and surgery alone respectively. The 25-year CSSR were found to be 72+/-3% (one standard error), 68+/-3% and 66+/-4% respectively by Kaplan-Meier method. Long-term survival rates at other years, e.g. 10-, 15-, and 20-year CSSR, were all within one standard error compared with the Kaplan-Meier calculations.There were no statistically significant differences between the CSSR of the three different treatment groups for all stages combined (p = 0.35 by log-rank test for the three treatments).Figures The SEER database provides localized and regional disease stages, instead of T1N0 or T2N0 stages, etc. The lognormal model prediction of the 25-year CSSR for 454 patients with localized stage disease were 84%, 75%, and 80% for treatments by radiation and surgery, radiation alone, and surgery alone respectively. The 25-year CSSR calculated by the Kaplan-Meier method were 83+/-4%, 75+/-4%, and 77+/-6% respectively (p = 0.08, log-rank test for the three treatments). For 286 patients with regional stage disease, the 25-year CSSR were 62%, 58%, and 52% respectively, and compared with Kaplan-Meier method were 63+/-6%, 58+/-7%, and 46+/-6% respectively (p = 0.76, log-rank test for the three treatments).The current study demonstrates the application of the lognormal model to a population based study. The lognormal model is being applied in a manner that can be applied to prospective trials in practice. Our previous publication about the application of the lognormal model was for different stages of laryngeal cancer patients treated by one radiation oncologist, Dr. M. Lederman in the Royal Marsden Hospital, United Kingdom . The curet al.[Detroit and Connecticut registries were chosen because they have the earliest data starting from 1973 and they include a large population of both white and black patients. Generally cause-specific death rates underestimate the mortality associated with a diagnosis of the specific cancer, because some patients died of other causes. Gamel eet al. found thIn this study, for localized stage disease 5-year CSSR were 91%, 83%, 95% for treatments by radiation and surgery, radiation alone, and surgery alone respectively with Kaplan-Meier method.et al.[Jones et al. found thet al.[Jorgensen et al. found thet al.[Franchin et al. studied In this study, the treatment results were marginally different for localized stage (p = 0.08, log-rank test for the three treatments) and the treatment results were similar for regional stage (p = 0.76, log-rank test for the three treatments). For localized stage combination radiation and surgery may have more certainty of disease control and hence long-term survival benefit. The treatment results were similar for regional stage because the patients were diagnosed late and disease control may be more difficult. The predicted survivals were within one standard error of the Kaplan-Meier estimations for both localized and regional stages. It shows that the prediction method can work for both good and poor prognosis cases.The practical value of this study is that this lognormal model may be used for prediction of the results of prospective trials earlier than the Kaplan Meier method. This lognormal model may become a useful tool in research about outcomes. Use of this lognormal model could result in more rapid advances in cancer treatment and have the potential benefit of a reduction of cost in cancer research.The author(s) declare that they have no competing interests.PT: Data analysis and writing of the manuscript.EY, RS: Critical appraisal of the manuscript.JT: Data analysis and critical appraisal of the manuscript.The pre-publication history for this paper can be accessed here:


Diabetes requires significant alterations to lifestyle and completion of self management tasks to obtain good control of disease. The objective of this study was to determine if patient trust is associated with reduced difficulty and hassles in altering lifestyle and completing self care tasks.A cross-sectional telephone survey and medical record review was performed to measure patient trust and difficulty in completing diabetes tasks among 320 medically underserved patients attending diabetes programs in rural North Carolina, USA. Diabetes tasks were measured three ways: perceived hassles of diabetic care activities, difficulty in completing diabetes-related care activities, and a global assessment of overall ability to complete diabetes care activities. The association of patient trust with self-management was examined after controlling for patient demographics, physical functioning, mental health and co-morbidities.Level of patient trust was high (median 22, possible max 25). Higher trust levels were associated with lower levels of hassles (p = 0.006) and lower difficulty in completing care activities (p = 0.001). Patients with higher trust had better global assessments of overall ability to complete diabetes care activities (p < 0.0001).Higher patient trust in physicians is associated with reduced difficulty in completing disease specific tasks by patients. Further studies are needed to determine the causal relationship of this association, the effect of trust on other outcomes, and the potential modifiability of trust Diabetes mellitus is a disease associated with significant morbidity and mortality ,2. PatieAspects of the patient-physician relationship such as communication and empathy have been shown to be important to patient's adherence -18 and aGiven the underlying importance of trust in the doctor-patient relationship and the effect of the doctor-patient relationship on adherence and self-care, we hypothesized that higher levels of patient trust in physicians may be associated with reduced difficulty of self-care tasks. To explore this hypothesis, we conducted a survey of patients with diabetes to determine if level of trust is associated with the outcomes of difficulty and hassles in completing self-care tasks.Project IDEAL (Improving Diabetes Education, Access to Care and Living) was an initiative to increase the quality of care and quality of life for underserved patients with diabetes in North Carolina. Full details of the study have been published elsewhere . BrieflyTo measure patient trust, we used the Wake Forest University Trust Scale. This scale has been tested in multiple populations and found to be reliable with good construct validity ,39. We uPatient self-care measures were taken from the telephone survey. The methods for this survey have been described elsewhere . We examOur second outcome, difficulty in completing care activities, was measured in a 5-item scale also taken from the DQIP measures . This scThe final adherence measure we examined was a global measure of care. This single item asked patients to rate how they "...are at taking care of their diabetes". Possible responses on a 5-point scale ranged from "I stay right on top of it at all times" (1) to "I let it slip way too much" (5).We considered several modifying factors that might influence the relationship between trust and self-care measures. These factors were selected either because they have been shown to influence patient self-care or because they have been used in previous studies on patient trust and outcomes. Modifying factors were obtained from either the survey or through the chart review. Patient's age, gender, race (white, non-white) and insurance (any, none) were obtained from chart review. A co-morbidity score (none, 1–2, greater than 2) was generated based on the number of additional diabetes-related diseases  identified during chart review. The Medical Outcomes Study Short Form 36 (MOS SF-36) [To determine the association of patient trust and our outcomes of patient hassles, difficulty in completing care activities and global assessment, we used Generalized Estimating Equation methods Three hundred and twenty-six individuals with diabetes had information from both the telephone survey and chart review portions of the study. The response rate for the telephone survey was 67%.The mean age of the respondents was 60, over two-thirds were female and forty percent were non-white  , non-white race (p = 0.03), and lower score for mental health. There was no association with gender, insurance status, co-morbidities, use of insulin, physical health, length of the relationship with the provider, or the number of visits for diabetes in the past year. A higher difficulty in completing care activities was associated with younger age (p = 0.002), female gender (0.003), non-white race (p = 0.03), worse physical health (p < 0.001) and worse mental health (p = 0.001). There was no association with insulin use, co-morbidities, length of relationship, or number of visits in the past year. Better self rated ability to care for diabetes was also associated with older age (p = 0.004), better physical health (p = 0.02), and better mental health (p < 0.0001). There was no association with gender, race, co-morbidities, use of insulin, length of relationship, or number of visits in the past year.In multivariate regression analysis, level of patient trust was significantly associated with each of the outcomes we examined. Patients with higher levels of trust in their physician reported lower levels of hassles with disease (GEE parameter -0.03, 95% CI -0.05 to -0.008, p = 0.006). Similar finding were seen when self-reported difficulty was examined. Higher level of patient trust was again associated with less reported difficulty in caring for diabetes (GEE parameter -0.02, 95% CI -0.03 to -0.01, p = 0.001). Our final patient outcome, global assessment of ability to care for diabetes, also showed a significant association with higher levels of patient trust associated with higher self-reported ability to care for diabetes (GEE parameter -0.05, 95% CI -0.08 to -0.02, p < 0.0001). Thus, if a patient responded "strongly agree" to all the trust questions rather than "agree" (representing a 5-point increase in level of trust), self-reported hassles would decrease by approximately 0.2 points (about 30% of a standard deviation in hassles). Similarly, for a 5-point increase in trust, self-reported difficulty would decrease by 0.1 points (about 20% of a standard deviation in difficulty) and global ability to care for diabetes would decrease by 0.3 .  would result in an improvement of 0.1–0.3 in our outcome scores. This improvement is equivalent to the difference in self care scores seen between a 60 year old patient and a 30 year old patient. Additionally, trust was significantly associated with all self care measures while insulin use was not.Few studies have examined the association of completion of self-care tasks with patient trust. Safran et al surveyed adults employed by the state of Massachusetts using the Primary Care Assessment Survey which includes a section on patient trust . They foThese results add to growing evidence that patient trust is important to patient outcomes, but are limited by the cross-sectional design of the study. Although the results support the contention that higher levels of trust result in decreased hassles and difficulty in completing self-management task, it is possible that the reverse is true. Longitudinal studies of individuals with newly diagnosed chronic diseases such as diabetes are needed to define the temporal nature of this association. Additionally, our outcome measures did not assess whether patients were actually performing the activities, rather, the instruments were designed to determine the level of difficulty and hassles. It is possible that individuals viewed particular activities as very difficult and having a high degree of hassle and still completed the task. Future studies with measurements of both patient perception and actual completion rates are needed. The shortened trust instrument we used lacked the important dimension of patient-centered care. Patients who feel their concerns are listened to and work in partnership with their health care provider may be more likely to attempt new self care activities. It is likely that the inclusion of this dimension through questions such as the providers' ability to listen to or advocate for the patient would strengthen the association of trust with reduced difficulty in completing self care tasks. We also did not collect information on several important mediators of patient trust and self-care such as the empathy level of the health care provider, educational level of the patient, and patients' overall perceived self-efficacy. These additional factors may provide further elucidation into the relationship of patient trust and ability to complete self care task. Despite these limitations, this study adds to our understanding of the predictors of patient self-management of disease. Further studies comparing strategies for measuring trust, measurement of trust at multiple points in time and the linkage of patient trust with clinical outcomes are needed.Trust is an integral component of the doctor-patient relationship. Increasingly, external forces such as changes in reimbursement for medical services and increases in the cost of malpractice insurance place pressure on this relationship . These pThe author(s) declare that they have no competing interests.DEB wrote the text and conducted with the statistical analysis.FB assisted with the statistical analysis and the writing of the paper.RAB was responsible for selection of the quality of care markers, oversaw data abstraction and assisted with writing the article.VTD was responsible for data collection and clinic interventions and assisted with editing the article.RTA was responsible for selection of the quality of life markers and assisted with editing the article.DCG was responsible for the scientific direction of the study, design, and assisted with editing the articleAll authors read and approved the final manuscriptThe pre-publication history for this paper can be accessed here:


NCEAS -- an ecological synthesis center -- is changing the way ecological research is conducted by fostering new forms of collaboration and interdisciplinary research A substantial portion of research occurs in places where scholars congregate—in campus laboratories, in libraries, or in large specialized facilities, such as oceanographic ships, astronomical observatories, or accelerators. Under any of these circumstances, researchers can interact easily, exchanging ideas and information.Ecological research, especially the large component occurring in the field, takes place in disparate locations all over the world—in the air, on the surface, and below the oceans, lakes, and crust of the planet. Although there are many biological field stations where scientists and students gather, much of the research in ecology takes place in isolation. In addition to being highly dispersed geographically, ecology encompasses a disparate range of disciplines at scales from molecules to the globe, making the exchange of ideas and information even more difficult.Recognizing the benefits of interaction and collaboration, the ecological community began considering a synthesis center where researchers from many fields could meet to address important ecological questions. Several organizations held discussions about the nature of such a center, which culminated in two workshops hosted by the National Science Foundation (NSF) in the early 1990s, to set the scope. In 1994, NSF conducted an open competition for a synthesis center, eventually granting the University of California, Santa Barbara, the award for the National Center for Ecological Analysis and Synthesis (NCEAS). In addition to funding from NSF, the center is supported by the University of California system and its Santa Barbara campus and by several foundations.The center employs various types of research approaches. A primary approach is through Working Groups  where scNCEAS also supports up to six visiting Center Fellows  each year. These scientists often integrate their own research into a broader context or synthesize what is known about certain areas in ecology. Concurrently, the Center houses 15–18 Postdoctoral Associates for one to three years each. These postdoctoral positions are distinctive in that there are no permanent mentors for the larval scientists—rather, they interact with the other Associates, the resident Fellows, and the hundreds of individuals who annually visit the Center as part of Working Groups.The Center also conducts training activities, including a distributed graduate seminar program. In this approach, graduate students around the world become involved in seminars on specific topics using data from their region (e.g., the relationship between productivity and diversity) and then representatives from each of the seminars are brought to NCEAS for a grand synthesis.As would be expected for a discipline as broad as ecology, the participants at NCEAS are extremely diverse. Over 3,000 individuals have visited NCEAS in just over eight years, representing 43 countries and 49 states in the United States. They come from over 800 institutions, many non-biology departments, and 397 non-academic organizations (e.g., agencies and companies). An interesting measure of their breadth is that participants belong to more than 180 professional societies.Proposals are solicited twice a year and reviewed by a Science Advisory Board. The Board looks for topics that would benefit from synthesis and analysis and that would make significant contributions to our understanding of ecological relationships. While many proposals pertain to core ecological questions, others deal with economics or sociology (e.g., how metaphors affect the way we conduct research). Approximately 40% of the projects have some applied component, many influencing resource management practices and conservation policies.http://www.ecoinformatics.org) have embarked on a major research program in developing tools to characterize data and make them available in standardized formats. The initial research effort, called the Knowledge Network for BioComplexity (KNB) is yielding tools to generate metadata (precise information about the data) and to make all the data available. The current research thrust, called Science Environment for Ecological Knowledge, will expand the capabilities of KNB by employing grid technology (in particular, EcoGrid, a network of networks), semantic mediation, knowledge representation, and workflow models for analysis and synthesis.Because the Center is based on the use of existing data, access to highly dispersed and profoundly heterogeneous ecological information is essential, but also very difficult. Recognizing the need for open access to a wide variety of data—versus project-specific data solutions—NCEAS and several collaborators (see http://www.nceas.ucsb.edu). Furthermore, some of the projects have had direct influence on conservation and resource management. For example, scientists at NCEAS developed theories for the design of marine reserves that were soon thereafter applied to the placement of reserves directly off the coast of Santa Barbara.The Center has supported almost 200 projects, the results of which are published in top scientific journals (see project results at In addition to scientific results, NCEAS is changing the way we conduct ecological research through novel means of encouraging productive collaborations. Sociologists studying the NCEAS model of collaboration have identified several important factors in its success. These include a distant, neutral location facilitating periodic, highly focused opportunities to concentrate on the issues under consideration; logistic support that lowers the activation energy required to develop collaborations; and the proximity of scientists from many disciplines having the opportunity to interact in ways otherwise not possible.Many significant contributions to our understanding of the patterns and processes of the natural world have emerged from NCEAS research activities. In addition, the Center is fostering new forms of collaboration and interdisciplinary research by providing a place where scientists from many disciplines can productively interact and by working to make eclectic ecological data available to many users. This is an extremely simple model for the scientific enterprise—but one not captured in most existing institutional and organizational structures. As recognition of the success of NCEAS spreads, other institutions are attempting to incorporate some of the traits of the Center into their operations, and new centers are being proposed. For example, the NSF is in the midst of a review of proposals for an evolution synthesis center.It is clear that the complexity of ecological systems, as well as the importance of understanding and maintaining them, requires information and knowledge from many disciplines. This is true even at a time when disciplines are becoming more specialized and scientists have less time to concentrate on broader issues. By facilitating interactions among many scholars and practitioners, NCEAS provides both time when and a place where far-reaching topics can be addressed.


The pathology of Alzheimer's disease (AD) is comprised of extracellular amyloid plaques, intracellular tau tangles, dystrophic neurites and neurodegeneration. The mechanisms by which these various pathological features arise are under intense investigation. Here, expanding upon pilot gene expression studies, we have further analyzed the relationship between Na+/K+ ATPase and amyloid using APP+PS1 transgenic mice, a model that develops amyloid plaques and memory deficits in the absence of tangle formation and neuronal or synaptic loss.We report that in addition to decreased mRNA expression, there was decreased overall Na+/K+ ATPase enzyme activity in the amyloid-containing hippocampi of the APP+PS1 mice . In addition, dual immunolabeling revealed an absence of Na+/K+ ATPase staining in a zone surrounding congophilic plaques that was occupied by dystrophic neurites. We also demonstrate that cerebral Na+/K+ ATPase activity can be directly inhibited by high concentrations of soluble Aβ.The data suggest that the reductions in Na+/K+ ATPase activity in Alzheimer tissue may not be purely secondary to neuronal loss, but may results from direct effects of amyloid on this enzyme. This disruption of ion homeostasis and osmotic balance may interfere with normal electrotonic properties of dendrites, blocking intraneuronal signal processing, and contribute to neuritic dystrophia. These results suggest that therapies aimed at enhancing Na+/K+ ATPase activity in AD may improve symptoms and/or delay disease progression. Alzheimer's disease (AD) has several well-characterized post-mortem pathological markers that include both gliosis and dystrophic neurites surrounding extracellular amyloid plaques. In addition, intracellular tangles of hyper-phosphorylated tau and massive neurodegeneration are seen later in the disease process. Mutated forms of both amyloid precursor protein (APP) and presenilin 1 (PS1) lead to an increased rate of amyloid deposition and therefore an earlier onset of the dementia associated with AD  and PS1 Previously we have described decreased expression of genes critical for learning and memory and impaired induction of several immediate early genes (IEGs) in aged, memory deficient APP+PS1 mice ,7. IncreWe used the APP+PS1 transgenic mouse model to better understand how the deposition of amyloid contributes to the consistent memory loss seen in these animals -14. SpecIn order to determine if our early observation regarding reduced mRNA for Na+/K+ ATPase was functionally meaningful, we measured total and ouabain-sensitive ATPase activity in APP+PS1 brain homogenates compared to those from non-transgenic littermates using a standard colorimetric assay. Using ouabain as a selective inhibitor of Na+/K+ ATPase, we demonstrated that the specific enzymatic activity was significantly reduced by ~25% in the hippocampi of aged, memory-deficient APP+PS1 mice compared with non-transgenic littermates Figure . The perImmunohistochemical staining for the Na+/K+ ATPase αIII subunit was performed using saggital sections from non-transgenic and APP+PS1 mice. Specific staining was observed throughout the forebrain. The specificity of the Na+/K+ ATPase α subunit antibody used for immunochemistry was determined by pre-incubation of the antibody with purified Na+/K+ ATPase protein, which dramatically reduced apparent immunostaining Figure  comparedCortical staining Figure  revealedThese findings led us to postulate that the osmotic imbalance brought on by an absence or inhibition of Na+/K+ ATPase may contribute to the swelling associated with dystrophic neurites found in the vicinity of congophilic plaques in APP+PS1 mice and AD patients. We designed a dual immunostain utilizing immunohistochemical methods for Na+/K+ ATPase and immunofluorescence methods for phosphorylated neurofilament, a dystrophic neurite marker we evaluated earlier . Using tFinally, to determine whether amyloid could inactivate Na+/K+ ATPase activity, we measured the activity of purified cerebral Na+/K+ ATPase after exposure to various concentrations of Aβ 1–42 peptide in a DMSO+water suspension or a DMSO+neutralized HCl suspension. Figure Over the past 6 years, our group has characterized various aspects of the APP+PS1 transgenic mice including their pathology, behavior, and gene expression. With age, these mice progressively develop more amyloid plaques surrounded by dystrophic neurites, activated microglia and astrocytes . With inHere, we show that Na+/K+ ATPase has decreased enzyme activity in the amyloid-containing hippocampus of APP+PS1 transgenic mice. We have also demonstrated by immunohistology that Na+/K+ ATPase protein expression is reduced in the immediate vicinity of congophilic plaques, a zone where dystrophic neurites are most prevalent, suggesting that disrupted ionic homeostasis may contribute to their formation. Additionally, high concentrations of Aβ 1–42 directly inhibit the activity of Na+/K+ ATPase. This suggests that in the area surrounding amyloid plaques, where the local Aβ concentration is likely high, Na+/K+ ATPase activity may be locally inhibited.From previous gene expression studies, we found that the mRNA for the Na+/K+ ATPase αIII subunit was consistently down-regulated ~30% in the hippocampi of APP+PS1 mice compared to non-transgenic littermates and to the amyloid-free cerebella . These rPrevious investigations have shown that Na+/K+ ATPase protein levels are decreased in AD tissue but not in normal aged tissue ,25, but When we immunostained transgenic mouse tissue to visualize the distribution of Na+/K+ ATPase alpha III subunits we found that in areas where congophilic plaque staining was apparent, Na+/K+ ATPase staining was absent, and more specifically, there appeared to be no or little Na+/K+ ATPase staining in a penumbral zone surrounding the plaques stained with Congo red Figures  and 4A–BWe knew from previous studies that dystrophic neurites could be visualized surrounding amyloid plaques in the APP+PS1 mice. And we have demonstrated previously that proteins such as synaptophysin and APP are in fact increased in dystrophic neurites . TherefoOne possible explanation for this putative relationship would be that Aβ associated inhibition of Na+/K+ ATPase activity would result in osmotic imbalance and cause the neurites to begin swelling. In addition to the loss of electronic properties and accompanying dysregulation of neuronal signaling, these changes might even feedback to influence gene expression. Indeed, Huang et al. demonstrated that cells exposed to ouabain have reduced Na+/K+ ATPase αIII subunit mRNA expression . An altein vitro [Aβ has been shown to bind various cell surface proteins ,33,34. ain vitro -37. To din vitro , and theThese data indicate that Aβ deposition in transgenic mice is associated with reduced activity of Na+/K+ ATPase. In vitro studies suggest that high concentrations of Aβ can quickly inactivate the enzyme activity. One area in the brain that might harbor Aβ concentrations sufficient to suppress the activity of Na+/K+ ATPase would be the micro-domain near and immediately around the plaques. This is the area demonstrated to have reduced immunostaining for Na+/K+ ATPase, while exhibiting increased phosphorylated neurofilament staining consistent with dystrophic neurites. These results lead to the possibility that one factor contributing to the formation of dystrophic neurites is loss of ionic homeostasis. Such changes might explain the "swollen" nature of these neuronal processes in the vicinity of plaques. It might also lead to sufficient disruption of electro-chemical properties as to disrupt normal information processing and lead to memory dysfunction. If these suggestions are correct, drugs targeted at activating Na+/K+ ATPase and maintaining ionic balance in these neurons may benefit Alzheimer's patients by delaying the onset of neuritic dystrophia and memory dysfunction.Mice were bred in our facility and genotyped using previously described methods  The workAn assay to detect specific activity of Na+/K+ ATPase by measuring the release of phosphate was developed using a variation of the method described by Ellis et al. . FreshlyIn a 96-well plate, 60 μl of ATP buffer containing 140 mM NaCl, 20 mM KCl, 3 mM MgCl, 30 mM histidine and 3 mM ATP were added to wells. Two sets of samples were included, one with ATP buffer only and the other with 100 μM of the Na+/K+ ATPase selective inhibitor ouabain added to the ATP buffer. Subsequently, 10 μl of protein homogenates were added to the ATP buffer ± ouabain, which were then mixed by pipetting and incubated at 37°C for 30 minutes. The reaction was stopped by adding 120 μl of an acid molybdate solution consisting of 0.5 g ammonium molybdate (Sigma, St. Louis, MO) in 0.5 M sulfuric acid. After mixing, 10 μl of Fiske Subbarow Reducer (Sigma, St. Louis, MO) was added and wells were mixed again. The plate was allowed to incubate covered at room temperature for 10 minutes and then measured spectrophotometrically at 660 nm. A standard curve of phosphoric acid dilutions was used to calculate the specific activity of the ouabain sensitive ATP hydrolysis and converted to μmols of inorganic phosphate (Pi) liberated/mg protein/ hour. All reactions were performed in triplicate, which were then averaged to produce the single value for the sample. Differences between APP+PS1 and non-transgenic mice were analyzed for significance using one-way ANOVA. Aβ used for these studies was generated by resuspending 1 mg of commercially available recombinant Aβ 1–42 peptide (rPeptide, Athens, GA) in 221 μl of 1,1,1,3,3,3-Hexafluoro-2-propanol (HFIP, Sigma, St. Louis, MO) to generate 45 μg Aβ 1–42 films. These films were resuspended in 2 μl of anhydrous DMSO, followed by agitation and subsequent addition of either 48 μl of cold water followed by overnight incubation at 4°C (for soluble Aβ preparation) or 10 mM HCl followed by overnight incubation at 37°C (for fibrillar Aβ preparation). The acid was neutralized the following day by the addition of NaOH. These preparations yielded approximately 900 μg/ml suspensions of Aβ.For analysis of activity inhibition by both preparations of Aβ, purified Na+/K+ ATPase  was pre-incubated for 2 hours in a 37°C orbital shaker separately with 112.5, 225 and 450 μg/ml of either a DMSO+water Aβ suspension or a DMSO+neutralized HCl Aβ suspension. Vehicle alone was also used for each preparation and sample values are indicated as a percentage of the "vehicle only" values. Activity was then measured using the same activity assay as above and significance was measured using one-way ANOVA comparing activity between vehicle treated and Aβ treated.Brain homogenate from cortical tissue was equilibrated to 10 μg of total protein. This homogenate, along with 1 μg of purified cerebral Na+/K+ ATPase, was diluted 1:1 with loading buffer containing 4% SDS and 5% β-mercaptoethanol, heated to 95°C for 5 minutes and loaded onto a 7.5% Tris-glycine gel which was electrophoresed at 100 mV for one hour in the presence of SDS. The protein was subsequently transferred onto an Immobilon membrane (Millipore, Billerica, MA) for one hour at 100 mV. The blot was rinsed with borate saline + 0.05% Tween-20 (BST) and blocked overnight at 4°C in 5% non-fat dry milk (NFDM). The following day, a 1:2000 dilution of rabbit anti-rat Na+/K+ ATPase αIII antibody (Upstate Biotech, Lake Placid, NY) in 0.5% NFDM+BST was applied to the blot for 1 hour, followed by washing and a subsequent 1 hour incubation with a 1:5000 dilution of hrp-labeled anti-rabbit IgG (Sigma, St. Louis, MO) in 0.5% NFDM+BST. After washing, the blot was developed for chemiluminescence using a luminol substrate kit (Santa Cruz Biotech, Santa Cruz, CA). Band density was quantified using the SoftMax Pro program and one-way ANOVA was used to determine significance.® Elite® ABC kit (Vector Labs, Burlingame, CA). The tissue was then washed and stained with a diaminobenzidine: peroxide system plus nickel enhancement (DAB/Ni2+), followed by final washes. Compact amyloid plaques were visualized using Congo red staining after sections were slide mounted and dried [Immunohistochemical and immunofluorescence analyses for Na+/K+ ATPase αIII and phosphorylated neurofilament, respectively, were performed on the same 25 μm free-floating hippocampal sections. Sections were treated 15 minutes with 10% methanol, 3% hydrogen peroxide and 80% phosphate buffered saline (PBS) to block endogenous peroxidase activity, and then washed 3 times with PBS. Sections were subsequently treated with sodium borohydride for 15 minutes to reduce background auto-fluorescence  followednd dried . BrieflyC D contributed to the design the study, developed the activity assay, generated the Aβ preparations, performed the histology and western blotting, and drafted the article. M G was responsible for maintenance of the animals used in the study, prepared the tissue for subsequent analysis, and assisted in the design. Both D W and D H participated in the histology and contributed to the coordination of the study. M B facilitated the investigations and assisted with histology. M F performed the genotyping of the mice. D M conceived of the study, and contributed to its design and coordination, along with helping to draft the manuscript. All authors read and approved the final manuscript.


Children with congenital hearing impairment benefit from early detection and treatment. At present, no model exists which explicitly quantifies the effectiveness of universal newborn hearing screening (UNHS) versus other programme alternatives in terms of early diagnosis. It has yet to be considered whether early diagnosis (within the first few months) of hearing impairment is of importance with regard to the further development of the child compared with effects resulting from a later diagnosis. The objective was to systematically compare two screening strategies for the early detection of new-born hearing disorders, UNHS and risk factor screening, with no systematic screening regarding their influence on early diagnosis.Design: Clinical effectiveness analysis using a Markov Model.Data Sources: Systematic literature review, empirical data survey, and expert opinion. Target Population: All newborn babies.Time scale: 6, 12 and 120 months.Perspective: Health care system.Compared Strategies: UNHS, Risk factor screening (RS), no systematic screening (NS). Outcome Measures: Quality weighted detected child months (QCM).UNHS detected 644 QCM up until the age of 6 months (72,2%). RS detected 393 child months (44,1%) and no systematic screening 152 child months (17,0%). UNHS detected 74,3% and 86,7% weighted child months at 12 and 120 months, RS 48,4% and 73,3%, NS 23,7% and 60,6%. At the age of 6 months UNHS identified approximately 75% of all children born with hearing impairment, RS 50% and NS 25%. At the time of screening UNHS marked 10% of screened healthy children for further testing , RS 2%. UNHS demonstrated higher effectiveness even under a wide range of relevant parameters. The model was insensitive to test parameters within the assumed range but results varied along the prevalence of hearing impairment.We have shown that UNHS is able to detect hearing impairment at an earlier age and more accurately than selective RS. Further research should be carried out to establish the effects of hearing loss on the quality of life of an individual, its influence on school performance and career achievement and the differences made by early fitting of a hearing aid on these factors. Approximately one to three per 1000 children are born with at least moderate, bilateral hearing disorders . ChildreVarious tests and test combinations with acceptable sensitivity and specificity are available. Transient evoked oto-acoustic emissions (TEOAE) or brainstem evoked responses (BERA) can be measured. One common strategy consists of a two-step TEOAE with the first measurement within the first days of life and a second test a few days later   . The TasHowever, there is presently no model explicitly quantifying the effectiveness of UNHS versus other programme alternatives in terms of early diagnosis, nor has it been taken into account that diagnosis of hearing impairment within the first few months of life is more "valuable" for the child's further development than diagnosis later in life. Children identified within the developmentally sensitive time frame should therefore be given more weight compared to children with delayed diagnosis.The objective of this clinical decision analysis was to systematically compare two screening strategies for the early detection of new-born hearing disorders: UNHS and risk factor screening; with the option of no systematic screening regarding their influence on early diagnosis.Our specific objectives were to show differences between strategies expressed as the number of quality weighed detected child months (QCM), the number of true positive cases at the age of 6 and 12 months, and the number of false positive cases. We also wanted to investigate which parameters had the most influence on the reported differences and how likely these differences were.We developed a clinical decision model to compare two different screening strategies with the option of no systematic screening. Parameters were extracted from the literature, empirically derived from a representative patient survey, and estimated by experts. Univariate and multivariate sensitivity analyses were performed on all relevant parameters.The decision model was used to predict absolute and incremental effectiveness of two new-born hearing strategies compared with the option of no screening in new-born infants. For the modelling of effectiveness the recommendations of the Panel on Cost-Effectiveness in Health and Medicine were followed .Three possible strategies for neonatal hearing screening (NHS) were evaluated:- Universal neonatal hearing screening (UNHS): Every hospital-born baby is screened during the first days of life.- Risk factor screening (RS): The prevalence of hearing disorders is estimated to be higher at risk groups such as children with a positive family history, with congenital infections, cranofacial abnormalities, low APGAR-Score or low birth weight. This strategy screens all children with one or more risk factors for hearing disorders.- No systematic screening (NS): Children undergo the usual distraction test when presented to the paediatric service during the routine visit at the age of 12 weeks. Some neonates are screened in the hospital, but not in a systematic way. This reflects the present situation in Germany. UNHS is performed in some maternity hospitals and outpatient paediatric services with pilot screening projects in several regions.The target population of this analysis was all newborn infants. Health effects are expressed as quality weighed number of detected child months (QCM), and as true positive and false positive cases at certain developmentally important ages 6 and 12 months); for example, if a hearing impairment was diagnosed briefly after birth, the infant contributed six QCM at the age of six months. If the infant's hearing loss was diagnosed at the age of five months, the infant added only one detected child month at the age of six months. The term 'quality' is to reflect the idea that the early detection of impairment is a better and desired outcome, although there is no data on quality of life gained by this early detection. QCM, true positives and false positives are reported at the age of 6 and 12 months and with a time horizon of 120 months. Child months which were added up until the age of 6 months were multiplied with a weight of 1, child months added after the age of 6 months were multiplied with decreasing weighting. The derivation of this weight index is described in the section 'data and assumptions' below. We assumed that all children with hearing impairment would be detected before the age of 72 months, the age of school entry, regardless of the kind of screening strategy. In order to give outcomes in the present more weighting, compared to outcomes in the future, future effects have been discounted at an annual rate of 3%. Discounting reflects the higher value of money spent now as opposed to in the future. Similarly, discounting also weights outcomes experienced now (e.g., being diagnosed as true positive) more heavily than those experienced in the future. Table 2 months;We developed a state-transition (Markov) model  with mon- Unknown status- Healthy (hearing) confirmed by diagnostic test and/or screening – true negative- Healthy (hearing) not confirmed by diagnostic test- Hearing impaired confirmed by diagnostic test and/or screening – true positive- Thought to be healthy (hearing) but hearing impaired – false negative- Thought to be hearing impaired but healthy (hearing) – false positive- Not compliant/not followed upThe baseline cohort consisted of infants with a certain prevalence of hearing impairment but unknown status regarding this disorder. Screened and impaired children are detected with the sensitivity of the screening test, whereas screened and healthy children are classified as healthy with the specificity of the screening test. All children with a positive screening test  undergo a second confirmatory diagnostic test, unless they did not adhere to the screening or did not present for the following tests (lost to follow-up). Impaired children who have not been screened in the first cycle can be diagnosed in the subsequent cycles according to the "natural history" of diagnosis, that is, because they don't develop speech adequately or become apparent during the routine visits to the paediatrician. In each cycle children can move to other health states according to the transition probabilities. QCM are only attributed to impaired children in whom hearing impairment is detected. Ultimately, all impaired children of the model cohort are diagnosed as impaired and all healthy children are either classified as healthy or remain unclassified.Data Professional (TreeAge Inc., Williamstown, MA) was used to construct and run the Markov model and Excel for Windows (Microsoft Corp.) was used to validate the model and to perform the Monte Carlo simulations.A pre-defined and externally reviewed literature search was performed on new-born hearing screening using all relevant electronic databases. Search strategy and methods have previously been reported in detail . In brieAll model parameters are shown in Table Screening procedures and diagnostic procedures are based on different biological and clinical testing principles. We therefore assumed conditional independence of screening procedures and subsequent diagnostic procedures.In order to investigate the influence of the parameter estimates on the outcome measures, one-way sensitivity analyses were performed on all relevant parameters. Ranges used for sensitivity analyses were derived from literature searches and are shown in table The decision model was validated on three levels:(i) Technical validation: The model was tested independently with two different software packages . Routine tests  yielded the expected results.(ii) Internal validation: All data used to derive model parameter values, were reproduced exactly by the model (e.g., number of detected children at model end point).(iii) External validation: The derived values are consistent with external projections and estimates of recently published studies which were not used in our model ,22. for Table Results of sensitivity analyses are presented in table We developed a decision-analytic Markov model for the evaluation of the effectiveness of different new-born hearing screening strategies. In our model, UNHS identified 72% of all detectable QCM at the age of 6 months, RS identified 44% QCM, the control group with no systematic screening identified 17% QCM. UNHS shows higher effectiveness even under a wide range of additional relevant parameters. QCM was introduced as a dynamic time-to-event measure which takes into account that the age of confirmation of congenital hearing impairments is important for further language development. The model results were not sensitive to test the accuracy of parameters within the assumed range but varied with the prevalence of hearing impairment. We have shown that UNHS leads to an earlier age of confirmed diagnosis compared to selective RS.The cost effectiveness of UNHS has already been modelled along secondary data ,23,24. TOur findings are consistent with study results and other projections of effectiveness. The Wessex Universal Neonatal Hearing Screening Trial Group found that 71 more babies with moderate or severe hearing loss per 100 000 target population were diagnosed before the age of 6 months during periods with neonatal screening than during periods without . We founOur study has several limitations. Firstly, it does not differentiate between bilateral and unilateral hearing loss or moderate and profound impairment. We believe, however, that even with a more refined model the differences in effectiveness would not be substantial. Variations in the degree of impairment would result in variations in sensitivity of the test, and the model was rather insensitive to changes of test parameters. Secondly, even though QCM has been weighted, it is a surrogate parameter for the actual burden of disease for the child. Preference-based utilities have not been measured and the weighting for the impact of early or late identification of hearing loss used in our analysis were estimated by experts. Sensitivity analyses, however, revealed that without weighing, the difference in effectiveness would still be substantial. Thirdly, effectiveness was measured as a function of time to diagnosis. In routine health care, adequate treatment does not necessarily start immediately after the diagnosis is made. However, as knowledge on the consequences of delayed intervention is limited, including time to intervention as another variable in the model would have resulted in decreased precision . FourthlThe value of this modelling exercise on effectiveness, lies in the facilitation and provision of information to decision makers- by quantitatively projecting available data, making explicit and transparent statements about assumptions and the degree of uncertainty involved in this area. The probability of timely intervention increases with UNHS. UNHS can reduce age of confirmation to a much greater extent than RS. In further studies, our model can be used to predict costs of real life situations to evaluate whether programme implementation costs would surpass cost-effectiveness thresholds. Policy makers can also base their decisions on the incremental effectiveness of UHNS, by introducing a screening programme. The model shows how likely an outcome is under the assumption of parameter uncertainty.In our model UNHS showed higher clinical effectiveness compared to RS and NS. The strength of our model lies in the naturalistic and generic structure, which makes it useful as a model for further evaluation. The model gives explicit, transparent and quantitative information about the effectiveness of different screening strategies for policy makers who have to decide on the potential impact of neonatal screening. The model presented here is easily adaptable to different settings. It will and should be verified and tested with longitudinal data of ongoing trials and model projects.This can be one of the first steps towards the needed transparency concerning universal new-born hearing screening.The author(s) declare that they have no competing interests.EG developed the decision model, carried out the statistical analyses and drafted the manuscript. FH designed and coordinated the study and participated in the development of the decision model and in the writing process. US participated in the statistical analyses, in the development of the decision model and in the writing process. PS-I, SK and AN performed the systematic review and data extraction. AN participated in the design of the study. JW conceived of the study and participated in its design and coordination. All authors revised the manuscript and read and approved the final version.The pre-publication history for this paper can be accessed here: