Chronic wasting disease in deer is the only prion disease that infects both free-ranging and captive animals -- a situation that greatly complicates efforts to control it In 1967, mule deer in a research facility near Fort Collins, Colorado, in the United States apparently began to react badly to their captivity. At least, that was the guess of researchers working on the natural history and nutrition of the deer, which became listless and showed signs of depressed mood, hanging their heads and lowering their ears. They lost appetite and weight. Then they died—of emaciation, pneumonia, and other complications—or were euthanized. The scientists dubbed it chronic wasting disease (CWD), and for years they thought it might be caused by stress, nutritional deficiencies, or poisoning. A decade later, CWD was identified as one of the neurodegenerative diseases called spongiform encephalopathies, the most notorious example of which is bovine spongiform encephalopathy (BSE), more commonly known as mad cow disease. Nowadays, CWD is epidemic in the United States. Although no proof has yet emerged that it's transmissible to humans, scientific authorities haven't ruled out the possibility of a public health threat. The media have concentrated on this concern, and politicians have responded with escalated funding over the past two years for fundamental research into the many questions surrounding this mysterious disease.Quite apart from how little is yet known about CWD, media interest is reason enough to step up investigation of it, says Mo Salman, a veterinary epidemiologist at Colorado State University in Fort Collins. He's been scientifically involved with BSE, since it was first discovered among cattle in the United Kingdom in 1986. He recalls predicting that lay interest in BSE would wane after five years. Instead, the disease was found in the mid-1990s to be capable of killing humans who ate tainted beef. “I was wrong, and it really changed my way of thinking, to differentiate between scientific evidence and the public perception,” Salman admits. “Because CWD is similar to BSE, the public perception is that we need to address this disease, to see if it has any link to human health.”CWD is the only spongiform encephalopathy known to naturally infect both free-ranging and captive animals, a situation that greatly complicates efforts to monitor, control, or eradicate it.In 2001, the United States' Department of Agriculture (USDA) declared an emergency after CWD was first diagnosed in deer east of the Mississippi River, indicating a potential nationwide problem. This year, the USDA is developing a herd certification program to help prevent the movement of infected animals in the game farming industry. This will bolster monitoring already underway in virtually every state, including postmortem examinations of game killed by hunters and by sharpshooters in mass culling operations.By June 2003, brain tissue from more than 111,000 animals had been sampled in North America, and 629 were found to have tested positive for CWD. That's a small epidemic compared to the thousands of BSE cases detected in cattle in the United Kingdom, but CWD is thought to be slow-spreading and perhaps lurking undiscovered elsewhere. So far, the United States and Canada are the only countries in which it has been identified, apart from a few imported cases in the Republic of Korea, but surveillance has not been thorough in North America and is virtually nonexistent in the rest of the world.Considered 100% fatal once clinical signs develop, CWD has struck three species of the cervid family—mule deer, white-tailed deer, and Rocky Mountain elk—which roam wild and are raised on farms for meat and hunting. It's the only spongiform encephalopathy known to naturally infect both free-ranging and captive animals, a situation that greatly complicates efforts to monitor, control, or eradicate it.The economic costs are hard to quantify, but a 2001 survey by the United States Department of Commerce's Bureau of Census shows that big-game hunters nationwide spend more than US$10 billion annually for trips and equipment. By far, their main target is deer. Wildlife watching of large land mammals, principally deer, drew 12.2 million participants in 2001. The North American Deer Farmers Association represents owners of 75,000 cervid livestock raised for their meat and for velvet antler, a health-food supplement made from antlers. These animals are valued at more than US$111 million.Over the past two years, the federal government's emphasis on CWD has been “quite high” compared to other wildlife diseases, says USDA staff veterinarian Dan Goeldner. “In no small part, that's because the disease has cropped up in new places, and those are states that have political clout.” It has now been found in ten more states beyond what became known as the endemic region of Colorado and neighboring Wyoming . Last yeThose figures don't include scientific research funded by other organizations, such as the US$42.5 million received by the United States' Department of Defense in 2002 to start up a National Prion Research Program. The prion is the protein-like agent that causes transmissible spongiform encephalopathies (TSEs). Its normal function is uncertain, but when it misfolds into an abnormal or “infectious” form, it causes the microscopic holes and globs of toxic, misshapen protein found in the brains of TSE victims. Unlike viruses, prions don't contain nucleic acids—only protein. Without DNA or RNA to issue biochemical commands, abnormal prions shouldn't be able to convert normal prions to the infectious state, but that's exactly what they do .Prion diseases occur in many species. In domestic sheep and goats, prion diseases occur as scrapie, which has a virtually worldwide distribution. North America and Europe have also reported rare cases of TSE in ranched mink. Humans get kuru, Creutzfeldt-Jacob disease (CJD), and Gerstmann-Sträussler-Scheinker syndrome—all rare—and BSE itself manifests in people as a variant form of CJD. Since the United Kingdom outbreak, BSE has been discovered in more than 20 countries, most recently in North America. As public fear rose of possible CWD transmission to humans who eat infected venison, the United States' Centers for Disease Control and Prevention (CDC) released a report last year of its investigation into several deaths among venison eaters who might have had a TSE. The report concluded that none of the deaths could be attributed to venison, but it nevertheless cautioned that animals showing evidence of CWD should be excluded from the human and animal feed chains .CWD is the least understood of all the prion diseases. Its origins are unknown and may well never be discovered. The question is largely academic, unless one hypothesis is proven true, that it derives from scrapie. In that case, the knowledge might help in efforts to control the two diseases through herd and flock management.Researchers are working to determine the minimum incubation time of CWD before clinical signs appear, now roughly estimated at 15 months in deer and 12—34 months in elk. They're trying to discover whether CWD strains exist that can affect the length of the disease process and different regions of the brain or that can infect different species, including humans. They are also investigating the period during which the prion is passed on, as well as its modes of transmission. They want to know whether disease reservoirs exist in the bodily fluids of hosts, in the environment, or both. They're racing to develop a diagnostic test that can be performed on live animals, enabling identification of the disease before clinical signs appear, which would eliminate the need to kill thousands of apparently healthy animals in areas where CWD is detected. But among the first things they need to clarify are CWD's distribution across North America and its prevalence.“…the disease has cropped up in new places, and those are states that have political clout.”“Before you can start to control CWD, you need to understand where it is and how much of it you have,” says veterinary pathologist Beth Williams of the University of Wyoming in Laramie. “So I think you really need surveillance.” Research on its pathogenesis and transmission will help to develop better diagnostic tools, which will improve surveillance, adds Williams, who first identified the disease as a TSE more than a quarter-century ago.Colorado State's Salman argues that current surveillance is primarily a series of reactions to reported cases, rather than a systematic strategy designed to determine where and at what prevalence the disease exists and where it's absent. The estimated prevalence is about 1% in elk and 2.5% in deer. But Salman says, “We don't have a good idea of areas in which we are saying we haven't found the disease because these areas are not yet, in my estimation, negative for the disease. Scrapie is a wonderful example of systematic surveillance but, to be fair to the decision-makers and technical people involved with CWD, surveillance on wildlife species is very difficult.”The USDA's Goeldner declares, “We have the goal and the hope to eradicate the disease from the farm population.” But Colorado Department of Wildlife veterinarian and CWD expert Mike Miller warns, “Given existing tools, it seems unlikely that CWD can be eradicated from free-ranging populations once established.”The gold standard of diagnosis is based on examination of the brain for spongiform lesions and abnormal prion aggregation. Suspect animals are decapitated and their bodies incinerated. “This is an approach that nobody wants, including the people who have to implement it,” says wildlife ecologist Michael Samuel, principal investigator in the United States Geological Survey–Wisconsin Cooperative Wildlife Research Unit at the University of Wisconsin in Madison.Nevertheless, when three white-tailed deer shot by hunters in the south-central part of that state during the fall of 2001 were diagnosed with CWD, the state government took swift action. By the spring of 2003, almost 40,000 deer had been sacrificed and sampled for the disease, both within and without a 411 square-mile (1065 square-kilometer) region dubbed the eradication zone. There the goal was to remove as many deer as possible, whereas the plan in contiguous outlying areas was to reduce density to about ten deer per square mile. CWD is thought to spread more efficiently in high-density populations, and normal densities in Wisconsin are 50–100 deer per square mile, about five times that of Colorado and Wyoming. The main objectives of the Wisconsin culling were to discover where the disease existed and its prevalence in affected areas. In the eradication zone, it was 6%–7%, although in the outlying region it was only 1%–2%. Samples elsewhere in the state tested negative.A key to combating the spread of CWD is to put into widespread use a preclinical diagnostic test on live animals. Miller and colleagues recently developed and validated the first such assay, based on a biopsy of lymphoid tissue, where the infectious agent is known to incubate. They showed that tonsillar biopsies taken from live animals can confirm disease at least 20 months prior to death and up to 14 months before the onset of clinical signs. Although the method is a useful screening tool, it requires much time and training. Each deer must be anaesthetized and blindfolded, placed in a restraint, its mouth held open with a gag, the tonsil visualized with a laryngoscope, and the biopsy taken with endoscopic forceps. Lymphoid tissue sampling was first used as a preclinical test in sheep scrapie. “Many attempts have been made to develop and evaluate tests for live animals, but it is fraught with difficulties,” declares TSE specialist Danny Matthews of the United Kingdom Government's Veterinary Laboratories Agency in Weybridge. He says that a live test for BSE in cattle is likely to be evaluated shortly by the European Food Safety Authority, but warns of a major problem: test samples are collected early in the incubation, whereas brain pathology only arises two to three years later. This creates long delays in determining whether a positive preclinical test result is, in fact, accurate: “How can one do an appropriate evaluation?”Matthews notes that blood appears to be a useful medium for testing scrapie in sheep, but current technology cannot deliver a tool applicable across a range of different scrapie genotypes. “Like sheep, elk and mule deer do have a peripheral pathogenesis, which suggests that the blood test route may have some potential, especially if the genotype variability is more restricted than in sheep.”Scrapie can be vertically transmitted from mother to offspring, either in the womb or from the transfer of infected germ plasm. It also can be transmitted horizontally, from any one animal to another. CWD, the only other known contagious TSE, is thought to be transmitted solely by as-yet-undetermined direct or indirect horizontal contact. It probably is not transmitted through infected feed, as is the case for BSE.A number of scientists are currently on the trail of suspected CWD disease reservoirs. Saliva is a leading candidate, because clinical signs of CWD include excessive thirst, drinking, and drooling. Work with lab animals suggests that the infectious agent might be produced in salivary glands and, if so, it could be transmitted through social interactions. Feces is also a possible reservoir because animals nose in the ground for feed, and urine is yet another candidate, because it is involved in the scenting activities of cervids.Soil could be an environmental reservoir, because cervids ingest dirt to supplement their diets with minerals. Bucks also lick soil on which does have urinated to ascertain their mating status. University of Wisconsin soil science professor Joel Pedersen has discovered that abnormally folded prions stick to the surface of some soil types, such as clay, resisting environmental and chemical damage. “Captive elk contracted CWD when introduced into paddocks occupied by infected elk more than 12 months earlier, despite fairly extensive efforts to disinfect the enclosures,” Pedersen notes. He has begun a five-year project to characterize interactions between infectious prions and soil particles and determine the extent to which infectivity is retained.No matter how CWD is transmitted between cervids, the likelihood of human susceptibility seems low. Laboratory evidence has demonstrated a molecular barrier against such cross-species infection, based on the failure of abnormal cervid prions to efficiently convert normal human prions to the infectious state. Likewise, abnormal cervid prions don't easily convert normal cattle prions, suggesting that cattle won't get CWD and pass it on to humans who eat tainted beef. While cattle can contract CWD if inoculated with the infectious agent, long-term studies placing cattle in close proximity to diseased cervids have resulted in no cases of natural transmission. Williams summarizes what all this suggests: “Never say never, but based on the [molecular] work, the CDC's findings, and the epidemiology, we certainly don't have evidence that humans have gotten CWD.”The relative newness to science of CWD and mad cow disease is one reason they aren't well understood, but sheep scrapie was first identified in Great Britain in 1732—and it still isn't well-characterized. The main problem is the numerous roadblocks to researchers posed by prions, the disease agents of such TSEs.Because normal and abnormal prions have identical amino acid sequences, the immune system neither recognizes an infection nor mounts a prion-specific response. Accordingly, an antibody specific to prions has not yet been identified. Without nucleic acid, prions can't be detected or analyzed using conventional techniques such as polymerase chain reaction. They also are extraordinarily resistant to a range of treatments that typically kill or inactivate infectious agents, such as ultraviolet and ionizing radiation, heating, and most chemical disinfectants. The infectious form is largely resistant to degradation by protease enzymes, and in laboratory animals it can incubate for months to years before clinical disease signs appear. Finally, prion diseases must compete for space in expensive, biohazard-safe labs. It's therefore unsurprising that knowledge of these diseases has not sped forward. Still, scientists hope that the recent upsurge of research into BSE, CWD, and scrapie in the United States and Europe will produce synergistic results for preventing and controlling all TSEs.When mad cow disease broke out in the United Kingdom in the 1980s, cattle and humans were far from the only species found to be affected. Among other bovids in zoo and research colonies that contracted spongiform encephalopathy from tainted beef were nyala, gemsbok, eland, Arabian and scimitar-horned oryx, greater kudu, and North American bison. A feline version of the disease was found in domestic cats, cougars, cheetahs, ocelots, and tigers. Among primates, rhesus macaques and lemurs were also infected.Unlike BSE, CWD is not thought to be transmitted through feed. But three species of cervids are naturally susceptible, and the question arises of how many other species might be in danger. To help answer that question, Michael Samuel and colleagues at the University of Wisconsin are staking out deer carcasses to see which scavengers come to feed. With flashlit photography, they've discovered “an amazing cast of characters,” including hawks, owls, crows, dogs, cats, coyotes, raccoons, skunks, mink, foxes, and opossums . Mammali


Announcing the next top-tier open-access journal from the Public Library of Science Open access is gaining momentum. Authors are submitting papers in ever-increasing numbers to open-access journals. Several prominent research sponsors, including the Wellcome Trust, the Max Planck Society, the Centre National de la Recherche Scientifique (CNRS), and the Institut National de la Santé et de la Recherche (INSERM), have recently pronounced that open access is the best way for the researchers they support to publish their work. Several established commercial and not-for-profit publishers have announced plans to experiment with open-access models for some or all of their journals.PLoS Medicine this autumn—the next step in our efforts to bring the benefits of open access to the entire scientific and medical community. 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Uncertainty regarding comorbid illness, and ability to tolerate aggressive therapy has led to minimal enrollment of elderly cancer patients into clinical trials and often substandard treatment. Increasingly, comorbid illness scales have proven useful in identifying subgroups of elderly patients who are more likely to tolerate and benefit from aggressive therapy. Unfortunately, the use of such scales has yet to be widely integrated into either clinical practice or clinical trials research.This article reviews evidence for the validity of the Charlson Comorbidity Index (CCI) in oncology and provides a Microsoft Excel (MS Excel) Macro for the rapid and accurate calculation of CCI score. The interaction of comorbidity and malignant disease and the validation of the Charlson Index in oncology are discussed.The CCI score is based on one year mortality data from internal medicine patients admitted to an inpatient setting and is the most widely used comorbidity index in oncology. An MS Excel Macro file was constructed for calculating the CCI score using Microsoft Visual Basic. The Macro is provided for download and dissemination.The CCI has been widely used and validated throughout the oncology literature and has demonstrated utility for most major cancers. The MS Excel CCI Macro provides a rapid method for calculating CCI score with or without age adjustments. The calculator removes difficulty in score calculation as a limitation for integration of the CCI into clinical research. The simple nature of the MS Excel CCI Macro and the CCI itself makes it ideal for integration into emerging electronic medical records systems.The increasing elderly population and concurrent increase in oncologic disease has made understanding the interaction between age and comorbid illness on life expectancy increasingly important. The MS Excel CCI Macro provides a means of increasing the use of the CCI scale in clinical research with the ultimate goal of improving determination of optimal treatments for elderly cancer patients. Comorbid illness plays an essential, but poorly defined, role in the diagnosis and management of malignant disease. Increasingly, the importance of measuring comorbidity in consistent and quantifiable ways is being recognized. This movement has stemmed in part from a growing consensus that comorbidity confounds the results of clinical trials and limits the generalization of results to older and sicker patients ,2. For vWhile multiple comorbidity indices are available, each with unique advantages and disadvantages, no single index has emerged as clearly superior to the others. In fact, we have noted that a distinct trade-off between prognostic utility and ease of use exists. We believe that a scoring system that maximizes ease of use while maintaining prognostic validity represents the optimal balance required for use in clinical research. In addition, a scoring system that can be easily integrated into an electronic medical record will further promote the widespread use of comorbidity data. We have, therefore, chosen to explore the use of the Charlson Comorbidity Index (CCI) as the prototypical comorbidity index in our department. The primary aim of this article, therefore, is to provide an electronic Charlson Comorbidity Index Scoring program and explain its development and use. In an effort to provide the reader with the context in which the electronic application was developed and should be used, the interaction of comorbidity and malignant disease and the validation of the Charlson Index in oncology are discussed. For more detailed reviews of the comorbidity indices outlined in this article, the authors refer readers to three systematic reviews of comorbid illness scoring systems by Extermann and de Groot -4.In the 1960's, Feinstein initially reported the prognostic importance of patient-related characteristics, such as symptomatology and concurrent illness, in his analyses of differences between actual survival outcomes and those predicted by TNM-based staging among lung cancer patients . In receHall, et al, for example, evaluated the effect of comorbidity on survival among head and neck cancer patients, concluding that 16% of mortality at 3 years and 18% at 5 years was attributable to comorbid illness alone, with non-cancer causes of death exceeding cancer-related causes of death after 7.5 years [Comorbidity has also demonstrated marked predictive power for survival and treatment allocation among prostate cancer patients. A Netherlands cancer registry study, for example, identified comorbidity as the single most important prognostic factor for 3-year survival, with hazard ratios of 2.0 (95% CI = 1.0–4.3) for a single comorbid illness and 7.2 (95% CI = 3.1–16.6) for 2 or more comorbid conditions, and trends toward fewer radical prostatectomies among men with higher degrees of comorbidity . Total cAlthough the preceding examples are not intended to provide a comprehensive review of the influence of comorbidity on survival and treatment-related complications in oncology, they provide a clear demonstration of the effect. In addition, the themes of increasing comorbidity with age and the influence of comorbidity on outcomes and treatment decision-making are illustrated. With these interactions in mind, the investigation of comorbidity has become an area of increasing interest in our department. In particular, we have begun focusing on the use of comorbidity indices and their application in clinical research. For a variety of reasons, which will be explained in forthcoming sections of this work, we have focused on the Charlson Comorbidity Index as the prototypical index on which to base this research.The Charlson Index was developed in 1987 based on 1-year mortality data from internal medicine patients admitted to a single New York Hospital and was initially validated within a cohort of breast cancer patients. The index encompasses 19 medical conditions weighted 1–6 with total scores ranging from 0–37. In the development phase of the index, mortality for each disease was converted to a relative risk of death within 12 months. A weight was then assigned to each condition based on the relative risk (RR); for example, RR <1.2 = weight 0, RR ≥ 1.2<1.5 = weight 1, RR ≥ 1.5<2.5 = weight 2, RR ≥ 2.5<3.5 = weight 3, and for 2 conditions (metastatic solid tumor and AIDS) = weight 6.From the weighted conditions, a sum score can be tallied to yield the total comorbidity score. The CCI can be further adapted to account for increasing age. In the validation phase of the CCI, age was also found to be an independent risk factor for death from a comorbid condition. As a result, relative risk was calculated to increase by 2.4 for each additional decade of life. In the same cohort, the relative risk of death for each 1-point increase in CCI score was 2.3. To account for the effects of increasing age, one point can be added to the CCI score for each decade of life over the age of 50 .Reviews of the CCI suggests it has good reliability, excellent correlation with mortality and progression-free survival outcomes, and is easily modifiable, particularly to account for the effect of age. The CCI's basic limitations include preservation of data only for the 19 conditions listed in the index, the exclusion of non-malignant hematologic disease, such as anemia, and reduced predictive ability for outcomes < 6-months. The CCI is praised for its ease of use, short rating time, extractability from other indices, and widespread use ,3.Statistical criteria for the assessment of the validity of a test include content validity, criterion validity, construct validity, and reliability . AlthougIn a review of validity among comorbidity indices, de Groot, et al, systemically identified articles referring to comorbidity between 1966 and 2000. They compared the Charlson Index with the Cumulative Illness Rating Scale (CIRS), Kaplan-Feinstein Index (KFI), and Index of Coexistent Disease (ICED) and identified correlation coefficients of > 0.40, "good" test-retest reliability and "moderate to good" inter-rater reliability for the CCI [A similar review by Extermann suggests the Charlson Index possesses excellent validity and reliability for use in clinical research in oncology. Extermann also reported exceptional predictive validity, correlating the CCI with outcomes involving mortality risk from weeks to years, postoperative complications, length of hospital stay, discharge to nursing home, and progression-free survival among cancer patients. Additionally, inter-rater reliability, by various measures, was reported at 0.74 among a cohort of older general oncology patients and 0.945 within a group of elderly breast cancer patients. Test-retest reliability was also good, ranging from 0.92 among surgical patients and 0.86 among the previously mentioned group of elderly oncology patients. Although Extermann urges some caution based on the tendency of the CCI to result in comorbidity scores that are sometimes lower than those observed with other indices, she concludes that the CCI is easy to use and "highly suitable for vast cohort studies but may under-detect significant problems resulting in non-lethal endpoints" [2 = 163, p < 0.0001), with CCI scores of 0, 1, 2, and 3 predicting 10-year survival rates of 93%, 73%, 52%, and 45%, respectively. In the original manuscript, Charlson, et al, cautioned that their index should be considered preliminary and that it required validation in larger populations [The Charlson Index has demonstrated excellent predictive validity for a variety of clinical outcomes as well as numerous malignancies. As discussed previously, the CCI was developed using a prospective analysis of 1-year mortality rates among internal medicine patients and then validated within a population of 588 breast cancer patients. In the validation phase of Charlson's original study, increasing CCI scores were significantly correlated with increased 10-year mortality within a breast cancer cohort , and increased risk of cancer death (RR = 2.35) for patients with advanced (≥ 2) CCI scores. The CCI compared similarly to the KFI with respect to frequency of advanced comorbidity (30% for CCI and 32% for KFI) and prognostic power (Spearman correlation coefficient, p <0.001, r = 0.73). However, the CCI was more applicable to the study population than the KFI, with the KFI successfully applied to only 80% of the study population compared with 100% application of the CCI .Fowler, et al, also examined the validity of the Charlson index in a cohort of men with prostate cancer treated with EBRT or RP. After adjusting for age, a direct relationship between actuarial survival and CCI score (p = 0.00001) was found for all patients. Among individuals with CCI scores of 0, 5 and 10-year survival rates were 86% and 66% compared with 40% and 9% for patients with CCI scores of 3 to 5. Relative mortality risk, based on CCI scores of 0, 1, 2, and 3–5, increased from 1 to 1.7, 2.6, and 5.7, respectively .Additional studies among prostate cancer patients have compared the CCI, KFI, and ICED. Albertsen, et al, for example, found each of the three comorbidity indices had similar power to predict survival (p < 0.001 for each), with the addition of any of the three indices to Gleason score improving predictive power for survival over Gleason score alone . We alsoThe Charlson Index has also been validated as a prognostic indicator for survival in lung cancer cohorts. Firat, et al, recently explored the prognostic importance of comorbidity among patients undergoing surgical resection or definitive EBRT for clinical NSCLC. Within the combined group, both CIRS-G scores ≥ 4 (p < 0.001) and Charlson score ≥ 2 (p = 0.004) emerged as significant prognostic indicators of reduced overall survival. Examination of the surgical and EBRT groups separately also demonstrated higher CIRS-G and Charlson scores within the EBRT group as compared with the surgical group .The effect of comorbidity on complication rates among lung cancer patients has also been investigated. Brim, et al, for example, identified gender, CCI score 3–4, COPD, and prior tumor within the last 5 years as predictors for major complications . Charlson scores of 3–4 maintained statistical significance after multivariate regression (OR 9.8, 95% CI 2.1–45.9) .CCI scores have also demonstrated prognostic value, both in terms of postoperative complications and survival among colon cancer patients. Rieker, et al, found raw CCI scores reached 0–2, 3–4, and ≥ 5 in 66%, 25%, and 8% of patients, respectively. With respect to survival, CCI score >2 emerged as a poor prognostic indicator for overall survival for all stages (p < 0.001, OR 2.91, 95% CI = 2.00–4.94). Subgroup analysis of stage III and IV patients revealed reduced cancer-specific survival among patients with CCI score >2 (log rank p <0.005). CCI scores > 2 were also correlated with receipt of blood transfusion (p < 0.021, OR 1.56, 95% CI = 1.07–2.28), postoperative complications (p < 0.001, OR 2.18, 95% CI = 1.50–3.16), and ICU stay > 2 days (p < 0.001, OR 3.28, 95% CI = 1.91–5.64) .Taken together, this series of papers represents a diverse and relatively large experience with the Charlson Index. In each report, CCI scores consistently correlate with disease specific survival, overall survival, or treatment-related complications, confirming its predictive validity.The CCI Calculator provided with this manuscript is based on the original index proposed by Charlson, et al, and is available in the section: supplementary material/table 1/appendix 1 [see Presented as a simple Microsoft Excel tool, it can be easily extended or integrated with other systems that can import Microsoft Excel data, or imported as a flat file. The Calculator functions well with both MS Windows and Macintosh operating systems running any Microsoft Excel version with Macro capabilities and is free to all users of Biomed Central Cancer. There are no restrictions concerning the use of the calculator software. A running CCI score can be calculated by selecting the conditions and age groups within the file. The calculator can be used with or without age modification as proposed by Charlson, et al . It is iTo use the calculator, the user must select "enable macros" when prompted to do so as the file opens. To calculate a CCI score, any of the applicable conditions can be selected. All selected conditions will then be displayed in a lighter shade within the table. Corrections can be made by deselecting conditions, which then removes their weighted value from the score. The CCI score can then be totaled, or an age-modified score can be determined by selecting any one of the applicable "Age by Decade" groups. Scores totaled without age modification will appear in the "Age Unadjusted CCI Score" total and no value will appear in the "Age Adjusted Score" total. Scores totaled by selecting an age group without selecting a comorbidity will result in no value for either total and the user will be prompted to "Reset & Select Condition." To reset the program, the "Reset CCI Calculator" button can be selected. The calculator can be further modified as needed by changing entries in the "Data Sheet" area of the workbook which is hidden in the read-only version of the calculator, but can be unhidden by selecting "Format," then "Sheet," followed by "Unhide" from the Excel menu. The "Data Sheet" can then be selected and will be viewable. To modify the original Macro, users can contact the authors and the password will be provided on a case-by-case basis.The extensive validation of the CCI as a powerful predictor of clinical outcome combined with its simplicity and widespread use in oncology have led to the adoption of the Charlson Index as the prototypical comorbidity index in our department. In addition to validity, our criteria for the use of a comorbidity index focus on simplicity in design, consistency in scoring, and ease of use. It is our contention that many of the commonly used comorbidity indices, such as the ICED, CIRS, and KFI have failed to achieve widespread use because they remain complicated, cumbersome to use, and poorly accessible for use in clinical research. Given the adaptability of the CCI for the inclusion of additional variables, such as age, the CCI also demonstrates marked potential for modification into cancer specific comorbidity indices. We have, therefore, developed a Charlson Comorbidity Calculator based on a Microscoft Excel File to improve the collection of comorbidity data in our department.) also require training courses for effective use [Comorbid illness has demonstrated increasing importance as a prognostic factor for survival and treatment-related outcomes in oncology. It confounds the results of clinical trials because the lack of a standardized measurement has resulted in the failure to adjust for comorbidity in statistical analysis of outcomes data ,2. It altive use . By contThe use of comorbidity data in clinical research is at an important crossroads, with necessity of its use becoming imperative as electronic capabilities for its assessment become more feasible. As the US population gets older, the use of comorbidity data in clinical trials will only increase in relevance. Current estimates indicate that the elderly will comprise 20% of the population by the year 2030 . StudiesFurthermore, evidence to suggest that comorbidity and performance status represent independent prognostic factors is accumulating. Extermann, et al, for example, examined the relationship between comorbidity and performance status. Both Charlson and CIRS-G were found to have little or no correlation with ECOG performance status, activities of daily living (ADL), or instrumental activities of daily living (IADL). More recently, Repetto, et al, found that among 269 elderly cancer patients with a reported ECOG performance score of <2, 13% had 2 or more comorbidities, 9.3% had ADL limitations, and 37.7% had IADL limitations. Although a statistical correlation between ECOG performance status, number of comorbidities, and comprehensive geriatric assessment was identified in univariate analysis, only comorbidity, ADL limitation and IADL limitation maintained statistical significance in multivariate analysis. Firat, et al also found CIRS-G and Karnofsy performace status to be independent predictors of outcome in their analysis of prognostic factors in 112 patients enrolled on 4 RTOG trials of stage III lung cancer [Without widespread integration of comorbidity data into clinical research, an increasing number of elderly patients, and their physicians, will be left with treatment recommendations and outcomes data that lack relevance for their age and level of comorbidity.Concurrently, electronic medical records (EMR) and data collection systems are becoming increasingly common and easy to use, with EMR use among European countries approaching 60% to 90% . The EMRTo our knowledge, this is the first electronic data collection system offered for the Charlson Comorbidity Index. The simplicity of the index itself, coupled with the simplicity of MS Excel and the Visual Basic programming language, have resulted in a robust electronic CCI calculator that functions well across both Windows and Macintosh platforms. The latest version of the calculator, which is provided with this manuscript, has performed without error consistently on the first (WH), second (RR) and third (SN) authors' Windows-based PCs.The major limitations of the CCI calculator lie in the limitations known to comorbidity indices and to the index itself. These include lack of understanding as to the relative importance of various individual conditions on mortality, treatment-related complications and quality of life. Furthermore, failure to include some conditions with particular relevance to cancer patients, such as non-malignant hematopoietic disorders and thromboembolic disorders, as well as uncertainty as to whether a few specific diseases or the overall disease burden is more important for prognosis, remain important considerations limiting use of the CCI ,3. AdditDespite its limitations, the general oncology literature supports the use of CCI as a prognostic variable in clinical research. It should be emphasized that the CCI is not meant to replace clinical experience and its use in clinical decision-making should be considered investigational. With additional research, CCI methodological limitations can be addressed and the index modified to improve upon its utility. In an effort to improve our understanding of the CCI and identify areas of the index in need of improvement, we are currently investigating the effect of score thresholds on treatment decision-making among prostate cancer experts. We believe that dissemination of the MS Excel CCI Macro will lead to increased use of the CCI for clinical research purposes as well as modification of the CCI to increase its validity and clinical utility. Ultimately, we hope that the comorbidity indices, such as the CCI, will see widespread use in clinical research and eventual integration into EMRs as a result of these efforts.The Charlson Comorbidity Index has demonstrated excellent predictive validity in numerous cancer-related outcome studies. It has met the criteria for statistical validity as outlined by several authors. In our opinion, the CCI represents the optimal balance between ease of use and prognostic ability. Its simplicity in design also makes its adaptation to include additional variables extremely feasible. We have, therefore, adopted the CCI as an acceptable comorbidity measurement tool in our department and created a Microsoft Excel Macro to facilitate its correct and uniform use in clinical research.Project name: Charlson Comorbidity Calculator• Project home page: None• Operating system(s): Windows or Macintosh OS• Programming language: Visual Basic• Other requirements: Microsoft Excel (macro enabled)• License: None• Any restrictions to use by non-academics: None• CCI: Charlson Comorbidity Index• ICED: Index of Co-Existent Disease• KFI: Kaplan-Feinstein Index• CIRS: Cumulative Illness Rating Scale• RR: Relative Risk• EMR: Electronic Medical Record• CDSS: Computer-Based Decision Support Services• The author(s) declare that they have no competing interests.WH, SN, AJ, and SV carried out the literature review, assembly and editing of the manuscript. RR created the CCI calculator. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:A Microsoft Excel  is included with this manuscript and can be found in supplementary material/table 1/appedix 1. A detailed description of the creation of the file and instructions for its use are included in the implementation section of this manuscript. To Calculate a Charlson Comorbidity Index score using the calculator double click on the CCI-Calc.xls icon or open the file from MS Excel. You must select "enable macros" when prompted to do so by the MS Excel macro warning pop-up window. A CCI score can then be calculated by selecting the conditions and age groups within the file. Selected conditions will appear in the table as a lighter shade than deselected conditions. As comorbidities are selected a running total of the score will be calculated. Scores totaled without age modification will appear in the "Age Unadjusted CCI Score" total and no value will appear in the "Age Adjusted Score" total. A selected condition can be deselected by clicking on once on the button for that condition. A score may be calculated without selecting an age category, however Scores totaled by selecting an age group without selecting a comorbidity will result in no value for either total and the user will be prompted to "Reset & Select Condition." Once finished with a calculation, the calculator can be reset by selecting the green "Reset CCI Calculator" button. The file is presented in a password protected format so that no changes can be made to the categories and weighting as proposed in the original Charlson Comorbidity Index.Click here for file


Broad-band UVA, long-wave UVA1 and PUVA treatment have been described as an alternative/adjunct therapeutic option in a number of inflammatory and malignant skin diseases. Nevertheless, controlled studies investigating the efficacy of UVA irradiation in connective tissue diseases and related disorders are rare.Searching the PubMed database the current article systematically reviews established and innovative therapeutic approaches of broad-band UVA irradiation, UVA1 phototherapy and PUVA photochemotherapy in a variety of different connective tissue disorders.Potential pathways include immunomodulation of inflammation, induction of collagenases and initiation of apoptosis. Even though holding the risk of carcinogenesis, photoaging or UV-induced exacerbation, UVA phototherapy seems to exhibit a tolerable risk/benefit ratio at least in systemic sclerosis, localized scleroderma, extragenital lichen sclerosus et atrophicus, sclerodermoid graft-versus-host disease, lupus erythematosus and a number of sclerotic rarities.Based on the data retrieved from the literature, therapeutic UVA exposure seems to be effective in connective tissue diseases and related disorders. However, more controlled investigations are needed in order to establish a clear-cut catalogue of indications. Unlike UVB radiation that can penetrate at the most into the papillary dermis, longer wavelengths in the UVA region have the capacity to reach the subcutis as well. Accordingly, as well as due to its lesser antiproliferative activity, UVB irradiation has not been established in the treatment of sclerotic disorders except for occasional cases of graft-versus-host disease (GvHD) ,2. Hence2), which is the most commonly used term in photobiology, relates to the subject (e.g., patient) struck by the irradiation. In photobiology, the time integral of the irradiance is commonly expressed as fluence (e.g., in J/cm2), or even more loosely as dose [2 single (975–1840 J/cm2 cumulative) irradiation, medium-dose UVA1 phototherapy admitting doses between 20–90 J/cm2 single (300–975 J/cm2 cumulative) UVA1 and last but not least low-dose UVA1 phototherapy administering single UVA1 doses of ≤ 20 J/cm2 or a cumulative doage ≤ 300 J/cm2, respectively [2 UVA [2 UVA [The term irradiance  in systemic sclerosis (SSc) and morphea -19, firsHowever, encouraged by the clinical success and the diversity of immunomodulatory effects achieved by the use of UVA phototherapeutic regimens in a great number of different indications, additional studies focused on investigating the efficacy of UVA phototherapy in the treatment of a widespread range of sclerotic skin diseases . FurtherToday, different forms of UVA phototherapy are widely used and have subsequently developed into a treatment modality of importance within the field of dermatology and rheumatology at least as an adjunctive treatment and, beside the 'initial indications', may also or even especially be indicated as a successful alternative in the treatment of skin manifestations of connective tissue diseases and related disorders.For this systematic review we concentrated on the therapeutic use of UVA application in humans. The computerized bibliographic database PubMed  without time limits (January 1966 to April 2004) was screened for original papers, case reports, letters, reviews and book articles on UVA/UVA1/PUVA. As main key words we used "UVA", "UV-A", "UVA phototherapy", "UVA1", "UV-A1" "UVA1 phototherapy", "PUVA", "PUVA phototherapy", "PUVA photochemotherapy", "ultraviolet A", "ultraviolet A1", "sclerosis", "scleroderma", "sclerosus", "sclerotic", "sclerodermoid", "morphea", and "lupus erythematosus". Other sources included monographs, textbooks, and the reference lists from all the articles retrieved. All abstracts were read and selected by two authors (F.B., T.G.) Inclusion or exclusion of articles were based on consensus. Relevant data including study design, number of patients, duration of treatment, clinical outcome, cumulative UVA doses, and adverse effects were retrieved from the articles, summarized and briefly discussed as follows.SSc, affecting the connective tissue of various organs including the skin, is histologically recognized by an alteration of the microvasculature with a rarefaction of the vessels within the papillary layer, perivascular skin infiltrating T lymphocytes , rapid proliferation of dermal fibroblasts exhibiting an elevated status of protein synthesis and by a resulting massive deposition of collagen in both the skin and internal organs -27.et al. reported on preliminary results about the efficacy of low-dose UVA1 phototherapy within the treatment of acrosclerosis in eight patients suffering from progressive SSc [2 UVA1 was administered four times per week for eight weeks and subsequent three times per week for six weeks resulting in a total of 50 sessions and a cumulative dose of 1500 J/cm2. In 2000, Morita et al. could confirm the UVA1-induced softening of sclerosis following partial body 60 J/cm2 medium-dose UVA1 phototherapy ranging from 510 to 1740 J/cm2 cumulative dose in three patients with diffuse and one with limited SSc, later further underlined by decreased dermal decorin levels as published in 2003 [et al. [So far UVA1 phototherapy has only been reported to be effective in the clearance of acral sclerotic skin lesions of SSc patients by administering local UVA1 irradiation of the hands or forearms, respectively. First, Kobyletzki sive SSc . Exposur in 2003 ,30. A re [et al. . However2 to 0.4 J/cm2 (cumulative dosage: 3.5 J/cm2 to 9.6 J/cm2) resulting in remarkable clinical improvement of skin sclerosis index as well as stiffed fingers, hands and knees. Another small uncontrolled study investigated oral PUVA therapy for SSc. The study included four women suffering from SSc receiving a PUVA protocol consisting of 0.5 to 4 J/cm2 single dose UVA given three times a week for ten weeks and a mean cumulative dose of 70.5 J/cm2 UVA. Even though posttherapeutic skin severity scores did not alter significantly, at least microscopic analysis of the histological skin scores of all patients revealed visible improvements [Based on first studies reporting the efficacy of topical PUVA in one patient with SSc , Kanekurovements . The lasovements .LS is characterized by circumscribed fibrotic plaques generally affecting the whole dermis. Thus LS, particularly when occurring in childhood, may contribute to progressive and long-lasting induration of the skin and subcutaneous tissue, growth retardation, muscle atrophy and, in severe cases, even to flexion deformities and poorly healing ulcerations .2 broad-band UVA three times a week for a total of 20 sessions (400 J/cm2 cumulative dose). Following treatment, all patients experienced marked softening of former skin lesions accompanied by significant reduction of the mean concentration of collagen. Additionally, nine patients received 10 J/cm2 UVA single and 200 J/cm2 UVA cumulative dose. Even though different study parameters varied between both groups, no statistically significant differences could be detected in the clinical response to those doses.As to our knowledge, there has been conducted only two large study investigating low-dose broad-band UVA exposure in morphea ,37. Twelet al. in 1997 [2 high-dose UVA1 therapy (30 sessions, 3900 J/cm2 UVA1 cumulative dose) were compared with seven patients treated by low-dose UVA1 phototherapy (30 sessions, 600 J/cm2 cumulative dosage) and internal controls. The authors state that high-dose UVA1 significantly reduced skin thickness and stiffness and increased elasticity of plaques. High-dose UVA1 was superior to low-dose UVA1. By contrast, a number of different studies and case series could also confirm the effectiveness of low-dose UVA1 phototherapy. In 1995, Kerscher et al. were able to discuss the first successful phototherapeutic approach of low-dose UVA1 phototherapy of LS [2 single dose, 600 J/cm2 cumulative dose) resulting in significant clinical improvement in about 80% of the patients [et al. analyzed and compared the effect of their low-dose UVA1 irradiation protocol on late-stage lesions, inflammatory lesions and late-stage lesions with overlying lichen sclerosus et atrophicus (LSA) [2 medium-dose UVA1 phototherapy three times weekly during a ten week period [2 UVA1 [2 UVA1. Furthermore, combined therapy with calcipotriol ointment and low-dose UVA1 phototherapy seems to be highly effective at least in childhood morphea. Following a first case report, Kreuter et al. conducted a large open prospective study including 19 children suffering from LS [2 single dose UVA1, cumulative dose: 800 J/cm2) as an adjunct to twice daily topical calcipotriol application. Combined therapy resulted in a relative reduction of clinical scores of about 67%. Its successful use has also been reported regarding the variant of LS en coup de sabre (30 J/cm2 UVA1, 30 sessions) [High-dose UVA1 phototherapy of LS has been introduced by Stege  in 1997 . Ten patpatients . Two patus (LSA) . All thrk period . All pat [2 UVA1 . Irradia from LS ,44. UVA1essions) .et al. UVA irradiation was administered once daily four times a week for five consecutive weeks followed by twice per week for additional five weeks (30 treatments, maximum single dose of 20 J/cm2), leading to an almost clearance of lesional skin [2 to 0.5 J/cm2 initial dosage, 1.2 J/cm2 to 3.5 J/cm2 UVA maximum dose) revealed marked clinical improvement in 13 of 17 persons even after 15 treatment sessions [et al. could also verify the effectiveness of PUVA therapy, beside three patients with SSc, in one patient exhibiting generalized morphea [et al. demonstrated that local PUVA bath may also be of certain benefit for LS in childhood [et al. in four LS patients (cumulative dose ranging from 67.5 J/cm2 to 121 J/cm2, maximum single dose: 3.5 J/cm2) and, analogous to UVA1 phototherapy, improvement of linear scleroderma en coup de sabre treated with topical calcipotriol ointment and PUVA cream could be observed by Gambichler et al. [First application of PUVA bath photochemotherapy in two cases of LS was published in 1994 by Kerscher sessions . As alre morphea . Within  morphea -49. Recehildhood . Moreover et al. ,51.Extragenital LSA is an uncommon skin disease characterized by white porcelain-like sclerotic skin lesions predominantly affecting the flexor surface of the wrists, the upper part of the trunk, and the axillae. In the common form of LSA, genital involvement with atrophy of the vulval, penile, and perianal skin is usually observed . Althouget al. in 2001 [2 low-dose UVA1 per session, 800 J/cm2 cumulative dose). In the same year, a subsequent double casuistic was presented, both receiving the same low-dose UVA1 phototherapy and both responding to therapy with an almost complete clearance of formerly sclerosing lesions [et al. were able to present the improvement of extragenital LSA in ten patients, all being treated by the established standard irradiation protocol [The efficiency of UVA1 phototherapy in extragenital LSA was first established by Kreuter  in 2001 . The aut lesions . Only onprotocol . In contprotocol .2 resulting in a cumulative dose of 31.7 J/cm2 during a six week period. In addition to the extragenital manifestation, PUVA cream photochemotherapy has also been proven to be even effective in genitoanal lesions of LSA [As far as PUVA therapy in extragenital LSA is concerned, one case report could demonstrate a promising therapeutic attempt . Interess of LSA . NeverthChronic graft-versus-host disease (GvHD) is an immunological condition frequently occurring as a late consequence of allogenic bone marrow transplantation. Two subtypes, cutaneous lichenoid and sclerodermoid, have been described, based on clinical and histopathological examinations. Sclerodermoid GvHD is a severe adverse immunologic reaction with deposition of collagen in the skin and possibly other soft tissues, resulting in loss of range of motion and functional capabilities .et al. presented a patient with chronic sclerodermic GvHD, who did not respond to conventional chemotherapeutic agents [2 single dose, 480 J/cm2 cumulative dose) combined with mycophenolate mofetil therapy. Based on the potentially beneficial effect of UVA1 phototherapy in scleroderma, Staender et al. investigated the efficacy of low- or medium-dose UVA1 phototherapy, respectively [2 single-dose UVA1 irradiation five times per week for two months followed by a subsequent reduction towards three times weekly. One patient was treated by a stable dosage of 20 J/cm2 in combination with immunosuppressives and extracorporeal phototherapy. In all cases, therapy led to softening of formerly stiffed sclerotic lesions. Most recently, the positive effect of UVA1 irradiation was underlined by Calzavara Pinton et al. [2 single dose, 750 J/cm2 to 1650 J/cm2 UVA1 cumulative dose) resulting in a complete remission in three and a partial improvement in two patients.In 2000, Grundmann-Kollmann c agents . Low-dosectively . Five pan et al. . Five paet al. performed a successful PUVA treatment in two patients suffering from sclerodermoid GvHD [2 cumulative UVA1, respectively). One of both received additional 667 J/cm2 UVA1 irradiation. Nevertheless, most authors state that UVA irradiation should only be performed as an adjunct treatment in addition to conventional chemotherapeutic regimens.Already years ago it has been shown that systemic PUVA therapy might be of certain benefit to chronic lichenoid and recalcitrant stages of GvHD, but remains insufficient in sclerotic forms -67. In 1oid GvHD . InasmucLE is an autoimmune disease including a wide spectrum of manifestations in various organ systems. LE specific skin lesions can be found in over 80% of the patients. Currently, three epidemiological forms are distinguished: discoid LE, subacute cutaneous LE and systemic LE beside the presence of a variety of specific subtypes .2 had been administered. Thereafter, an impressive improvement of LE lesions was noted. In another uncontrolled study conducted in 1994, ten patients with systemic LE were treated with 6 J/cm2 for 15 sessions during a period of three weeks [et al. reported in a two-phase study two groups of patients, one receiving 6 J/cm2 UVA1 five times a week for three weeks followed by a three week exposure of placebo visible light, the other vice versa [et al. tried to compare exactly the two different groups in a total of eleven patients [2 cold-light UVA1 five times weekly, significant clinical improvement was restricted to the UVA1 group. Apart from the short term benefit following UVA1 phototherapy, Molina et al. were also able to describe a long term benefit following low-dose UVA1 treatment (once/twice per week, 6–15 J/cm2) for a mean impressive period of 3.4 years in six patients of their former study [The first study on UVA1 phototherapy in subacute cutaneous LE appeared in 1993 . A nine ee weeks . Four ofce versa . Twenty-patients . Althouger study . Additioer study . As to oEosinophilic fasciitis is a rare disorder disabling joint motility closely related to profound morphea with a variable response to treatment .2 UVA1 were applied, resulting in a cumulative dose of 800 J/cm2. Afterwards the induration had softened markedly and the patient was able to close the fist again [A case report could verify a significant clinical improvement of eosinophilic fasciitis with low dose UVA1 therapy four times a week for ten weeks, resulting in a total of 40 treatment sessions, additional to azathioprine treatment. At each treatment session 20 J/cmet al. in 2000 [2 PUVA four times a week for period of 35 treatments including a progression of 0.3 J/cm2 every third session. Subsequently, irradiation frequency was reduced to three times a week for three weeks or two times a week for another two weeks resulting in a total of 50 treatment sessions and a cumulative dose of 102.1 J/cm2.Eosinophilic fasciitis successfully treated with PUVA bath photochemotherapy was described by Schiener  in 2000 . In theiPansclerotic morphea of childhood represents a severe variant of LS, often lethal even in young patients .et al. reported the successful administration of low-dose UVA1 phototherapy in disabling pansclerotic morphea of childhood by the usage of 20 J/cm2 four times a week for eight weeks resulting in a total of 32 treatment sessions, a cumulative dose of 640 J/cm2 UVA1 and a remarkable softening of the skin [In 1997, Gruss the skin . Anotherthe skin .et al. presented a successful approach of PUVA therapy in disabling pansclerotic morphea of a young girl [2 four times weekly for the first two months followed by maintenance on two treatments per week for another six months. In contrast, an additional case report demonstrated one patient failing to respond to PUVA therapy as an adjunct to penicillamine treatment [In 1995, Scharffetter-Kochanek ung girl . UVA wasreatment .Scleromyxedema is a variant of lichen myxedematosus exhibiting erythematous, sclerotic and stiffed lesions beside lichenoid papules caused by an extensive dermal deposition of glycosaminoglycans with only little tendency of spontaneous remission -89.et al. tried systemic PUVA photochemotherapy in lichen myxedematosus administering 35 treatment session at a cumulative dose of 202 J/cm2 [et al. achieved only limited beneficial effect after combined chlorambucil and PUVA therapy [Following a first promising attempt of PUVA treatment as early as 1984 , Adachi 02 J/cm2 . In this therapy .Scleredema adultorum Buschke, occurring secondarily to diabetes or independently, is an uncommon party sclerodermoid disease characterized by erythematous indurated skin and a mucinous dermal infiltration exhibiting increased collagen deposition ,94.et al. in case of three patients exhibiting resistant scleredema adultorum [2 UVA was applied resulting in a substantial clinical improvement in all three patients. Later, Grundmann-Kollmann and co-workers introduced cream PUVA in a patient responding excellently to UVA irradiation  [Both PUVA bath and PUVA cream have been reported to be of benefit in patients suffering from Buschke's disease. First, bath PUVA therapy was tested in 1998 by Hager dultorum . A mediave dose) . As to oPOEMS syndrome, characterized by polyneuropathy, organomegaly, endocrinopathy and elevated levels of a monoclonal protein, often exhibit scleroderma-like skin changes .Severe therapy-resistant cutaneous sclerodermatous lesions of one patient suffering from POEMS syndrome showed a remarkable improvement following low-dose UVA1 phototherapy given for 35 treatment sessions .Bleomycin-induced SSc-like scleroderma may occur following application of the antitumor agent bleomycin .2 UVA1, three to four times a week) caused an initial improvement of skin condition, but could not stop the overall progress [The authors report a case of drug induced scleroderma after bleomycin administration given due to a malignant testicular seminoma. Low-dose UVA1 phototherapy (20 J/cmprogress .Pansclerotic porphyria cutanea tarda is an uncommon subtype of cutaneous porphyria . Simultaet al. could stop progression of skin affection by the use of medium-dose UVA1 phototherapy combined with intensive physiotherapy and oral glucocorticoids in a patient with pansclerotic porphyria cutanea tarda after chronic exposure to organic solvents [2 and a corresponding cumulative dose of 1200 J/cm2.In 2003, Karamfilov solvents . UVA1 irBeside a high number of different side indications, systemic and especially topical PUVA treatment have been shown to provoke a remarkable clearance of psoriatic plaques and infiltrated lesions of cutaneous T cell lymphoma. On the other hand, UVA1 phototherapy achieved practical value in the treatment of inflammatory and malignant T cell related skin diseases. Typical indications regularly include exacerbated atopic dermatitis, cutaneous T cell lymphoma, parapsoriasis or mucinosis follicularis due to the induction of T cell apoptosis and dermal immunoregulation. By reason of notable collateral induction of dermal collagenase activity, UVA irradiation was subsequently introduced as a treatment alternative in LS and other sclerotic collagenoses in both dermatology and rheumatology.As far as the extensive accumulation of collagen is concerned several investigations demonstrated the long-wave UVA-induced stimulation of the synthesis of specific mRNA-levels of various matrix-metalloproteinases in cultured human fibroblasts, probably due to their lower antioxidant capacity and involvement of the protein kinase C pathway ,102-110.On the other hand, UVA1 irradiation has been shown to initiate apoptotic cell death in dermal T lymphocytes ,115. A sIf and to what extent additional modulations of impaired endothelial cells might also contribute to the posttherapeutic clinical and histological improvement still has to be investigated . NeverthInasmuch as LE and other autoimmune disorders are concerned, a transparent mechanism of action remains obscure. Immunohistologically, LE is at least characterized by an inflammatory T cell derived infiltration mainly of the T helper subtype combined with an impairment of T and B lymphocyte regulation, dysregulated dendritic cell abnormalities and defective clearance of immune complexes and autoantigens -126. Ana2 UVA1 [2 single dose UVA1 [Despite an extensive therapeutic administration of UVA irradiation, relatively little data are available concerning possible acute and long-term side effects. Usually, patients exhibit a dose-dependent tanning of the skin, which has been described to appear following a single minimal pigmenting dose of 50 J/cm2 UVA1 ,133, wheose UVA1 . After Uose UVA1 ,136. Add2 UVA1 seems to be imminent [2 for a period of 265 days [As far as long-term side effects are concerned no definite prediction has yet been taken. Controlled studies dealing with the carcinogenesis induced by broad-band UVA sources are still rare. Nevertheless, the induction of dermal hyperplastic elastic fibers resulting in early skin ageing following a cumulative dose of 4000–8000 J/cmimminent . Additioimminent ,137. On imminent . Indeed,imminent ,140. Sim265 days ,141-143.2 UVA1 radiation. Due to the penetration of up to 20% of UVA to the level of dermal vasculature, the induction of the programmed cell death cascades may develop to one of the main side effects of UVA phototherapeutic strategies [Moreover, recent investigations concerning the effects of UVA1 irradiation on human dermal endothelium revealed the initiation of apoptotic cascades even after a comparably low dose of single 80 J/cmrategies .Even though especially in case of LE sunlight exposure has been postulated to induce exacerbation in as much as half of the patients, courses of UVA irradiation can also be used in such disease. In this respect, UVA2 and UVB seem to be responsible for the induction of LE eruptions . NeverthAs the peak of dermatological therapeutic usage of UVA irradiation still seems to rise, scientific research engagement is needed in order to rate its potential long-lasting negative impact. Therefore, until the evaluation of firm data UVA phototherapy should most likely be restricted in the number of cycles per year, treatment should be supervised by an experienced dermatologist and a UV pass book should be issued.Today, by considering this widespread range of clinical and experimental studies, one might clearly conclude that different regimens of UVA phototherapy have simultaneously been developed to effective, often well-tolerated and beneficial therapeutic strategies in the treatment of a variety of sclerotic skin diseases such as SSc, LS, chronic GvHD, extragenital LSA or sclerodermoid rarities and other disorders affecting the connective tissue. In this respect, the controlled application of UVA irradiation seems to exhibit a comparably tolerable risk/benefit ratio as a minimum in case of these precise indications. Furthermore, UVA phototherapy might also be considered as an optional treatment in both the cutaneous and systemic forms of LE, although the mechanism of action remains difficult to understand.Nevertheless, therapeutic application of UVA phototherapy, especially of long-wave UVA1 phototherapy, is still 'under construction' as to its limited availability apart from selective centers of excellence and mostly uncontrolled pilot investigations or case reports especially as far as PUVA or conventional UVA1 phototherapy in sclerodermic skin affections or autoimmune disorders are concerned. From our point of view there is no doubt that UVA phototherapy could by far be much more frequently used in the treatment of connective tissue lesions of the skin and, due to its ability to affect dermal vascular structure, even of extracutaneous manifestations. However, additional research efforts are required to determine an exemplary clear-cut catalogue of indications responding to UVA irradiation. Therefore, oncoming controlled randomized studies evaluating the efficacy of UVA phototherapy in connective tissue diseases should not only focus on the assessment of further innovative indications, but also on the comparison between phototherapeutic agents and conventional immunosupressive/-modulating regimens as for example systemic glucocorticoids, azathioprine, methotrexate or cyclophosphamide as well as on the confirmation of former uncontrolled reports, not only because of the fact that the natural history of fibrotic disorders includes a period of inflammation/rapid induration followed by a prolonged period of regression even in untreated patients, but also in order to expand its usage to a widely available treatment option.None declared.FB conceived of this investigation including its methods and manuscript structure, performed the comprehensive literature search including data extraction and interpretation, and finished the paper. TG participated in the literature search. A.K. conceived of the study. P.A. participated in its design and coordination.All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:


Imagine three cities, A, B, and C, splayed across the landscape to form a triangle, with each connected to the other two by two-lane roads. Such an arrangement of cities and roads constitutes a structural network. On any given day traffic may flow, say, only from A to B to C, or in both directions between A and B but from C only to A, or in both directions between all three, or any one of ten other arrangements. Within this structural network, then, there are 13 possible functional networks. If these cities are embedded within a larger network of routes and destinations, their particular triangular traffic pattern represents a “motif” of connectivity, akin to a recurring musical motif within a larger symphony.Such connectivity networks are central to information processing in the brain, and understanding the recurring structural and functional motifs they contain is one way to begin to dissect how the symphony of brain function is composed. In this issue, Olaf Sporns and Rolf Kötter identify several common motifs in real brain networks, and show that brains tend to maximize the number of functional motifs while keeping the number of structural motifs relatively low.Caenorhabditis elegans. For comparison, they generated matrices that contained an equivalent number of components (nodes and connections), but whose connections were either random or lattice-like, in which all nearest neighbors were connected. They found that, compared to the artificial networks, the biological ones were relatively low in structural diversity. For instance, macaque visual cortex contained instances of 3,697 different motifs with five nodes, versus 8,887 for equivalent random networks. Functionally, however, unlike the artificial systems, the biological systems were maximally diverse, with the maximum functional motif diversity (e.g., 13 for three vertices and 9,364 for five vertices) observed in all motif sizes they investigated.The authors began with the frequency of motifs of different sizes (two, three, four, or five nodes) found in the visual cortex and whole cortex of the macaque monkey, the cat cortex, and the nervous system of the nematode The researchers also found some intriguing patterns within this maze of connectivity. For instance, not all motifs were found in equal numbers. A common functional motif for three vertices was for both A and C to communicate back and forth with B, but not with each other. This structure allows B to function as an integrator of signals from A and C, while keeping the activities of A and C distinct from one another. This kind of structure is widespread throughout the nervous system.The authors then ran an evolutionary algorithm on their artificial networks. They showed that by selecting for maximal functional motif number, the structure of the artificial systems quickly came to resemble the structure of the real ones, with dense local connections and relatively fewer long-distance ones. Such a structure, termed “small world” connectivity, promotes cooperation between functional units, and efficient information exchange. Taken together, these results suggest that one factor that may drive the evolution of neural architecture is the maximization of functional connectivity within a network of relatively few neural actors.


Procyon lotor) living around a large Chicago-area zoo, and appeared higher in year 2001 than in 1998 and 2000. We hypothesized that a more lethal variant of the local Canine distemper virus (CDV) lineage had emerged in 2001, and sought the genetic basis that led to increased virulence. However, a more complex model surfaced during preliminary analyses of CDV genomic sequences in infected tissues and of virus isolated in vitro from the raccoons.Mortality rates have differed during distemper outbreaks among free-ranging raccoons (fusion (F) -, phosphoprotein (P) -, and complete hemagglutinin (H) – gene sequences indicated that distinct American CDV lineages caused the distemper epizootics. The 1998 outbreak was caused by viruses that are likely from an old CDV lineage that includes CDV Snyder Hill and Lederle, which are CDV strains from the early 1950's. The 2000 and 2001 viruses appear to stem from the lineage of CDV A75/17, which was isolated in the mid 1970's. Only the 2001 viruses formed large syncytia in brain and/or lung tissue, and during primary isolation in-vitro in Vero cells, demonstrating at least one phenotypic property by which they differed from the other viruses.Phylogenetic analyses of subgenomic CDV Two different American CDV lineages caused the raccoon distemper outbreaks. The 1998 viruses are genetically distant to the 2000/2001 viruses. Since CDV does not cause persistent infections, the cycling of different CDV lineages within the same locale suggests multiple reintroductions of the virus to area raccoons. Our findings establish a precedent for determining whether the perceived differences in mortality rates are actual and attributable in part to inherent differences between CDV strains arising from different CDV lineages. Canine distemper virus (CDV) (family Paramyxoviridae, genus Morbillivirus) is a single-stranded (negative-sense) enveloped RNA virus that is highly contagious and transmitted predominantly by aerosols [Canidae, Mustelidae, and Procyonidae, CDV has recently been detected as a cause of morbidity and mortality in large felids [Phoca sibirica) [Phoca caspica) in year 2000 [Panthera leo) in 1994, whereas mortality due to CDV had not been previously described in large felids [Felis sylvestris catus) can be infected by CDV wherein pathogenesis is unclear [aerosols . Long kne felids , fresh-wibirica) , and varear 2000 , and decear 2000 , demonste felids . However unclear ,8.The increased importance of emerging pathogens has been most commonly attributed to changes in interactions between species or other ecological parameters , though Procyon lotor), and free-ranging raccoons were implicated as the source of CDV to the susceptible animals of the zoo, as large numbers of raccoons from adjoining forest preserves forage on the zoo grounds. The raccoons potentially transmit CDV to zoo animals indirectly through droplet infection and perhaps also through contact infection of nasal and oropharyngeal mucosa, since they are sometimes caught and consumed by zoo carnivores. Although CDV can cause high mortality in raccoons [Macaca fuscata) [Tayassu tajacu) [Serological tests of various captive carnivores in 1997 indicated seroconversion to CDV occurred among 28% of large felids after they were housed in outdoor exhibits at a large zoo located near Chicago (Illinois, USA) (T. Meehan and L. Hungerford, unpublished). The animals were CDV seronegative prior to outdoor display, and had not been vaccinated against CDV. Seroconversion did not occur among large felids kept indoors. It was thus apparent that the large felids acquired CDV infections during outdoor display. Distemper epizootics occur sporadically among area raccoons (raccoons ,17, it craccoons . This sufuscata)  and coll tajacu) , raisingLive raccoons are trapped on zoo grounds. Those with clinical neurologic signs are euthanized, necropsied, and examined for evidence of distemper or other infections. Dead raccoons found on-site are similarly evaluated whenever possible . These pappeared to be a surge in distemper mortality in 2001, and comprehensive necropsy evaluations (performed by the same pathologist) revealed that the CDV lesions of the 2001 animals differed somewhat from those seen in the 1998 and 2000 animals. Since phylogenetic analyses suggest that wild-type CDVs differ according to geographical distribution rather than to host species [Distemper was detected in raccoons on zoo grounds in years 1998, 2000, and 2001 but not in 1999, 2002, and 2003. A total of 9/25 36%) of the animals submitted for necropsy in 1998 and 1/14 (7%) in 2000 had lesions consistent with CDV infection. The number of animals submitted in 2001 was higher (n = 49) than for years 1998 and 2000, as was the percentage positive for CDV: 26/49 (45%). Precise data about the number of animals living within the forest preserve was not available. It was also not known whether significantly different numbers of animals utilized the zoo during the time line of this study (1998–2002). Nevertheless, there % of the  species , we askephosphoprotein (P) gene, since the P-gene tends to remain conserved within clades of a given CDV lineage [fusion (F) gene sequence that encodes a protein cleavage site [subtilisin-like endoprotease motif (-R-X-K/R-R-)] and the fusion domain [F-gene sequence can be used to determine phylogenetic relationships between different morbillivirus species, such as the relationship between CDV and the closely related morbillivirus of salt-water seals called Phocine distemper virus-1 (PDV-1) [F-gene analysis would thus help establish whether the virus was authentic CDV and not a related raccoon morbillivirus. Finally, the entire CDV receptorbinding hemagglutinin (H) gene was analyzed, since the H protein is the major determinant of tropism and cytopathogenicity [We first sought to identify the local lineage of CDV through direct sequence analysis of viral RNA (vRNA) in infected raccoon tissues and also attempted virus isolation from the specimens. Virus isolation was important not only to confirm direct sequence analyses but also: (a) because it was possible that direct sequence analyses might not work for various technical reasons, and (b) for future vaccine development in the event that unusual viral variants were detected for which current vaccines were ineffective. Following the example of previous investigators, we tried to obtain the identity of the circulating local CDV by determining the sequence of a subsection of the CDV  lineage , and is  lineage ,24,25. Tn domain . The F-pn domain , and the (PDV-1) . F-gene genicity , and is genicity ,23.Whereas all the viruses were related to American CDV strains, the 1998 and 2001 viruses were clearly resolved by phylogenetic analyses into two genetically distant CDV clusters (lineages). The 2000 virus apparently stems from a sublineage related to the 2001 viruses.Encephalomyocarditis virus (EMCV) in animals 01-2641 and 01-2690, however, was unexpected.In general, the results obtained from gross and histologic examinations of the animals were typical for CDV-induced distemper. Major findings included non-suppurative encephalitis and necrotizing bronchointerstitial pneumonia of variable severity Table . As expeHistologic differences in the CDV lesions were apparent. While lymphoid depletion and characteristic eosinophilic intracytoplasmic inclusions in various epithelial tissues were observed in all years, inclusion bodies were more plentiful in the brain and lung tissues of raccoons examined in year 2001 than those of years 1998 and 2000. Of note, small and large (multinucleated) syncytia were present in the central nervous system and Fig.  and lungrare formation of small stellate syncytia (consisting of 2–3 cells fused together) for viruses isolated from year 1998 and 2000 specimens or frequent larger rounded syncytia typically containing >8 nuclei in viruses from year 2001 [in vivo , only the deduced aa sequences are shown  was also the same in both cladograms. However, while parsimony joined the 01-2641 sequence from an offsite raccoon to the base, the distance based tree grouped this sequence with CDV A75/17. The 2000 virus was also not resolved by either method of analysis. Of the 390 bases, 34 were informative. Derivatives of the 1998 cluster form a distantly related lineage to that of 2001 cluster that is nevertheless rooted in the CDV group when compared to PDV-1 as an outgroup. CDV Lederle appears to be more derived than A9224/14b  raccoon [The 70% majority-rule consensus parsimony Fig.  and neigF-gene and 32 of these were parsimony informative. Both parsimony  while the 2001 isolates were most distant (D = 9% and 10% respectively). Distances within 1998 viruses were low (D ≤ 0.2%); within 2001, distances were slightly higher (D = 1%); and comparing years 1998 with 2000 and 2001, distances were highest (D = 7% to 9% respectively).Noteworthy, P-, F- and H- genes were combined into a single linear sequence and analyzed using parsimony and neighbor-joining algorithms with only PDV-1 as an outgroup, two independent clades are formed, the 1998 clade and the 2000/2001 clade (data not shown). In the later group, both methods join the 2000 sequence (00-2601) at a basal position to the 01-2641 off-site raccoon followed by the 2001 isolates.When the This report shows that different CDV sublineages stemming from at least two genetically distant CDV lineages recently circulated through the local raccoon population. Our conclusion is based on numerous observations: differences in the lesions observed in animal tissues, possible dissimilarities of virulence between the viruses, variation in one viral phenotype in tissue culture (formation of large syncytia by the 2001 viruses), and from the results of nucleotide sequence and phylogenetic analyses. CDV is not maintained in hosts that recover from distemper, and persistent CDV infections do not occur. However, CDV infects a wide range of genera, and though each individual population may be small, the number of alternative host species may be substantial [Since past studies indicated that wild-type CDVs differed according to geographical distribution ,23, we iin vivo and in vitro. Previously, an inverse relationship between the proficiency of syncytium formation and the level of CDV virulence was reported: the more attenuated a strain is, the higher its fusogenicity, and fusogenicity was attributed to the viral H-protein [in vivo and in vitro. However, past notions concerning the inverse relationship between fusogenicity and virulence may be imprecise. Indeed, virulent wild-type CDVs that formed syncytia in Vero cells were recently reported; the same study demonstrated that genetic changes within the H-gene were not required for CDV growth in Vero cells [including the F- and H- proteins [The viruses from year 2001 formed syncytia -protein -34. Therro cells , as was ro cells . Also, nro cells -38, and proteins . Thus, wproteins ,41. It iH-gene phylogenetic analyses  in urban areas. The possibility of reversion to virulence of attenuated CDV exists [s figure  suggest  figures ,5,6 indi results . Becauseequences , it is cthe past . The vacV exists , and a vV exists . We coulV exists , and theBordetella bronchiseptica, and Toxoplasma gondii. It is possible that the increased mortality in 2001 was due to secondary infections with EMCV; however, no lesions attributable to EMCV were observed in pathology exams of the animals of this study, and EMCV was not isolated from all of the 2001 specimens. The significance of isolating EMCV from the brain tissue of animal 01-2641 is thus uncertain.EMCV has been isolated or detected in raccoons before ,45. Howein vitro. The baseline genetic values established here will be helpful toward the development of a contemporary field-based model  for studies on the emergence, evolution, maintenance, and transmission of morbilliviruses, and the efficacy of vaccines against changing viruses.Our findings are especially useful for the molecular epidemiology of CDV in local wildlife, as they provide a molecular basis for CDV surveillance in area wildlife. Whereas it is considered difficult to obtain field isolates of CDV, we succeeded and can now obtain complete viral genomic sequence data . Taken together, we can now monitor viral genetic drift during a long-term study of CDV in local raccoons, and will be able to conduct animal studies with the newly isolated viruses. We can also clone relevant CDV virulence genes, and express and study the biochemical properties of their specific products The 1998 and 2001 distemper outbreaks were caused by two genetically distant American CDV lineages. Since CDV does not cause persistent infections, the cycling of different CDV lineages within the same locale suggests multiple reservoirs were responsible for the reintroduction of the virus to area raccoons. Whereas different susceptible species of the forest preserves and perhaps also some caged animals of the zoo are the most likely reservoirs, our study raises the possibility that vaccines might also be a source of CDV. The perceived differences in mortality rates that occur during intermittent distemper epizootics may be attributed in part to inherent differences between CDV strains.The raccoon tissues used in this study were described previously ; relevanin vitro in MDCK, MV1-Lu, and Vero cells, eliminating the need for virus isolation in specific pathogen-free animals or in primary macrophages or other suitable cells derived thereof [Detailed virus isolation procedures were described previously . Briefly thereof .RNA purification and RT-PCR methods were previously detailed . Brieflyprimary viral isolates [Methods used for nucleic acid sequencing were previously described . Brieflyisolates . The GenP-, F-, and H-gene sequences were constructed using the maximum-parsimony and neighbor-joining algorithms in Phylogeny Analysis Using Parsimony (PAUP) Beta Version 4.0B10 for Macintosh [Phocine distemper virus sequence (PDV-1) was included for outgroup rooting.Phylogenetic trees of the acintosh . Heuristacintosh . Phylogeacintosh ,50. The P-gene phylogenetic analyses were performed after an alignment of 25 P-gene sequences. Each P-gene sequence consisted of 390 ungapped positions (nucleotides 2154 to 2543 of CDV reference strain Onderstepoort) within the P-gene PCR amplicon. Only the internal 390 bp section of the P-gene PCR amplicon (432 bp) was analyzed because many relevant GenBank entries did not include the entire sequence amplified by the P-gene primers of this study. An additional P-gene sequence for raccoon A9224/14b was obtained from published data currently not deposited at GenBank [F-gene sequences corresponding to nt 5399–5733 (335 bp) of CDV Onderstepoort were analyzed. Unlike the P- and F-genes, the entire H-gene was analyzed since many complete H-gene sequences were available at GenBank. Phocine distemper virus 1 (PDV1) sequences were included in the analyses for outgroup rooting. GenBank . SimilarNone declared.JAL co-conceived, designed, and coordinated the study, isolated virus, participated in the molecular genetic studies and sequence alignment, interpreted data, oversaw the training of technicians, and drafted the manuscript; JD performed phylogenetic analyses, interpreted data, and helped draft the manuscript; MJK performed pathology examinations, provided tissue specimens, helped draft the manuscript, and interpreted data; TPM co-conceived the study, provided serology data, helped draft the manuscript, and interpreted data; MB performed phylogenetic analyses, interpreted data, and helped draft the manuscript; LLH provided serology data and epidemiology perspectives, and helped draft the manuscript; NAS participated in virus isolation, molecular genetic studies, sequence alignment, and proofreading of the manuscript; KEW participated in virus isolation and molecular genetic studies, and MDB, CP, and CMH performed molecular genetic studies. All authors read and approved the final manuscript