Fibromatosis or desmoid tumor covers a broad spectrum of benign fibrous tissue proliferations. It is characterized by infiltrative growth and a tendency towards recurrence; however, unlike sarcoma, it never metastasizes.We report on a case of extraabdominal fibromatosis originating from the retroperitoneal space in a 43-year-old woman. Seven years earlier she had undergone ureterolysis and ureteroureterostomy for ureteral obstruction. Computed tomography revealed a tumor between the iliocostalis and the psoas muscle. Histopathological evaluation revealed uniform proliferation of spindle cells, with a moderate amount of collagen fibers, suggesting extraabdominal fibromatosis (desmoid tumor). The tumor was surgically resected, and since then, the patient has remained asymptomatic without any restrictions of daily living activities and without any signs of tumor recurrence during the two-year follow-up.Complete resection is the treatment of choice. Adjuvant therapy using non steroidal anti-inflammatory agents, tamoxifen, interferon, anti-neoplastic agents, and radiotherapy, either alone or in combination finds application for unresectable or recurrent cases. The term "fibromatosis" covers a broad spectrum of benign fibrous tissue proliferations, the biological behavior of which is similar to both benign fibrous lesions and fibrosarcoma. Like fibrosarcoma, fibromatosis is characterized by infiltrative growth and a tendency towards recurrence; however, unlike sarcoma, it never develops metastasis . TherefoA 43-year-old woman with a history of schizophrenia since 1982, and a history of hospitalization to help the patient to acquire social communication abilities, at the age of 23 presented with slight pain on her left flank and back. In 1995, she was treated with ureterolysis and ureteroureterostomy because of left-sided ureteral obstruction. Histological evaluation of the biopsy revealed benign fibrous tissue proliferations; however, no further evaluation and surgical excision was planned as her mental state was deteriorating. She was put on regular follow-up with computed tomography (CT) scans. In May 2002, she was referred from the psychiatric hospital to our Department of Urology, as the tumor tended to grow. CT scan with contrast enhancement revealed a tumor located between iliocostalis and psoas muscles in retroperitoneal space. The peripheral part of the tumor was enhanced, while the central part did not. The left paravertebral muscles around the tumor showed atrophy. The medial margin of the tumor was deformed by a left transverse process of the second lumber spine, suggesting invasive behavior (Figure Extraabdominal fibromatosis may occur in a variety of anatomic locations; the principle sites of the involvement are the shoulder, chest wall and back, thigh and head and neck. Origin of extraabdominal fibromatosis from any mesenchymal tissue is now well recognized ,2. SeverOur patient did not have a family history and upper gastrointestinal endoscopy, colonoscopy, or opthalmoscopy were normal suggesting that our patient may be negative for the syndrome. The exact histological origin of the tumor remains to be verified. The findings of CT suggested an origin from paravertebral muscles. Interestingly, this assumption was corroborated by a computed tomography performed in April 2000, which revealed that the previous tumor was located intramuscularlyPrincipally, complete resection is the therapy of choice for this type of tumors . AdjuvanIn our case the tumor detection was delayed because the psychiatric status of our patient which has been unstable for several years. As wide resection of the tumor reduces the risk of recurrence, an early diagnosis is required for this type of tumor, which is difficult as most of these patients are asymptomatic. While the silent area contains several vital organs, extraabdominal fibromatosis should be considered for the differential diagnosis for such a lesion.The authors declare that they have no competing interests.AKik and AKid performed the operation, are responsible for the clinical work and helped with the preparation of the manuscript. TK is the orthopedic consultant and helped with the preparation and editing of the manuscript. TH coordinated and drafted the manuscript. All authors read and approved the final manuscript.


Innumerable animal species produce noises of different kind and many of them sound musical to us – human beings – eliciting a variety of emotional feelings, as the frogs' chants in a rainy night, or the wild birds' songs in a sunny morning perhaps mixed with our finch's joyful trills from its small cage, or the deep thrilling whales' hissing who very few have had the chance to listen (as I once did in Colombia). Most likely, they all are just communication ways, perhaps to let the other guy know that the male is there, waiting for the female to come and meet it, because usually only males sing. Is all that really music? I do not think so, for music is unique to man and woman and only we, human beings, get together either in small or large groups just to listen to music or to make music. Music conveys a message, which only the human being can decipher in his/her own fashion; as in animals, it is no doubt a communication means. The isolated man or woman, the Robinson Crusoe, is essentially non-existent. Music is a natural human need, almost at the level of the basic biological ones (self and species preservation).Autism: An Inside-Out Approach, 1996, Jessica Kingsley Publishers), its sentences must be read over and over until one really apprehends its profound meaning, as her initial paragraph, where she states: "Mind and consciousness are like a gradual sunrise that takes time to come up. In the meantime, we are not stagnant, waiting for life to happen." She refers to "the music of life, felt with our bodies, long before we identify mind with self ... ... some of us stay here longer than others." And a little further down, "music in its broader sense is everywhere, and it is our first language ... it has the most important of all places in the lives of those who find the realm of the mind a place of rusty cogs and heavy effort." Donna declares that music was an exceptionally important part of her life and almost naïvely and charmingly confesses: "I could not understand three sentences in a row until I was nine". These deep thoughts and experiences remind of James Joyce's agenbite of inwit, or the wound of in-looking, the hurt of self-analysis, the painful knowing of oneself, introduced in his famous, conflicting and monumental Ulysses. Man at large is the prey of inner suffering.The current literature on music and the human being is enormous, from artistic to technical to psychological to physiological aspects, or what have you. Music is so much embedded in us that never many studies are or will be enough. This little book, little in size but not in scope, authored by Dorita S. Berger (an accomplished concert pianist and certified music therapist, with superb academic background and solid experience), seems to cover a paucity because it falls within the reach of those who, without the requisite of being specialists are not fully outsiders; it also serves as an introduction to those who may like to proceed further in any of the several paths that converge and diverge to and from this fascinating area of human adaptation. The book consists of a foreword, a preface, 11 chapters and 2 appendices. Its foreword is unique and deep in content, indeed. Written by Donna Williams, herself a diagnosed autistic, captivating and exemplary woman, author of several publications  can be a major factor in bringing about a feeling of well-being". Dorita aims the text at music therapists, parents, teachers and health clinicians. However, in my opinion and as anticipated above, its audience should not be restricted to such relatively small group but rather can be much broader, as there are, for example, students or even researchers developing specific projects in the area. Already ending the preface, the author underlines quite sensibly that the book is not a recipe since music therapy is an approach to solving a physiologic or psychological problem.Chapter 1 (Introduction: Who Defines "Appropriate"?, pp17–25) is a dareful good beginning that encourages the reader to proceed. For the human animal, the expectation is to "follow the rules" of the pack and behave accordingly, and Dorita very wisely asks who defines "appropriateness" and for whose benefit the rules are designed. What is normal and typical? Are the two words interchangeable? What determines "right" and "wrong" responses? Are these not "labels" somehow imposed by society? The concepts of "right" and "wrong" are basically determined by socio-cultural standards rather than scientific givens. All this set of questions go far beyond the intended objective of the book and scrape deep in the human self, both as an individual and as a member of society. Allow me to bring about the painful, senseless, dire and cruel Irak War (April 2003): Is the Bush administration not imposing its own pack rules, denying rights as illegal for other countries (other societies or packs) while retaining those very same rights as legal for itself? Is it bad behavior for the others to have weapons while it is good behavior for the USA to have them? No doubt, Dorita touches, perhaps without realizing, a huge and essentially unsolvable problem that only true generosity and unabashed love, mostly and so far unsuccessfully called for by the core of our unfulfilled religions, might one distant and dreamt of day bring forth. Yes, excellent and well-posed question: Who defines "appropriate"?neurologically atypical manner of function, with genetic and sensory-motor implications; what appears in childhood, remains throughout life. She introduces the concept of a different world the child is immersed in and, as such, cannot possibly get connected to this "real" one, with other channels and incomprehensible rules. His/her desire for sameness is broken at worst or disturbed at best. Another good point: By and large, most of the people avoid anything bringing change, anxiety, confusion, insecurity and the like. Sameness, conservation of what we know, appears as safer. A trip to a foreign country or place carries with its sole organization an element of tension and we often think "oh, we had better call it all off". And children are particularly susceptible and sensitive to these changes (such as a new school or neighborhood).In Chapter 2 (Aspects of Autism, pp26–34) the author says that autism is a Chapters 3 (Aspects of Sensory Integration, pp35–48), 4 , 5 (Understanding Basic Sensory Systems, pp 61–77) and 6 (Are You Listening? Part One: About Hearing and Listening, pp78–90) deal mainly with physiological aspects, perhaps a little in excess because it tends to overload the reader removing him/her from the central subject, which is music, as stimulus or intervention, akin in a sense to electrical or mechanical or chemical or thermic or magnetic stimulation. However, it is fine and useful. As an interested reader and somewhat also as an actor within the discipline, the comment may be taken simply as an expression of desire. One paragraph called my attention almost at the end of chapter 3: "Music does not require semantic interpretation. It simply provides an environment – a sound blanket – wrapping itself around the body and providing a sense of safety and security." Good attractive concept, but I would emphasize what I say previously: Music carries a message, it may not be semantic or absolute, but the listener somehow decodes it to suit his/her own cenesthetic state.self-determination or freedom of choice and spiritual fulfillment. Let me add that one essential tool for their satisfaction is communication, which is a need, and music appears as a phenomenal way to accomplish it. The messages left by Johann Sebastian Bach, Wolfgang Amadeus Mozart or Ludwig van Beethoven are there and will be there forever, hence demonstrating unparalleled self-determination and spiritual fulfillment, even after death. Finally, accommodation, as discussed here, is a good classical physiology concept that fits very well this new frame of music and human adaptation. An appealing idea advanced in Chapter 5 refers to a possible release of chemical neurotransmitters  elicited by music stimulation. The whole thing may mark a difficult but attractive research avenue.The basic driving forces of man and woman are clearly stated in Chapter 4, two are purely biological (as anticipated above); other two pertain only to the human being, Chapter 6 is in my modest opinion and with due respects the weakest of the book: auditory scanning is definitely obscure, the section titled "sound coding tango" (what does the word "tango" do here?) does not show a relationship with the text that follows and the remaining sections are at best confusing. The last paragraph in page 89 sounds very appealing, at least to me, and I tend to agree with it ... but it lacks so far solid scientific support.auditory dyslexia? There seems to be no term for a phenomenon in which sounds are retrieved in incorrect order (as in reading or writing dyslexia). Researchers may have in this another subject to investigate. After finishing this chapter and reviewing the variety of concepts and subjects touched in it, I could not but wondering that the human being enjoys with the eyes the landscape he or she moves about, simultaneously the complex auditory tract perceives the soundscape that surely accompanies the former, probably also seasoned by an odorscape, tastescape and even a touchscape; but everything is slowly evolving in the timescape, as a multimensional function of time. The whole configures the complex scenery we live in creating what Donna calls the music of life.In Chapter 7  Dorita starts with the case of a four year old boy, Jason. No musical instrument really moved him, until one day he spotted a gong. It captured his love and reacted as fully unfazed by its intense volume. Quite an amazing response considering that most people (the pack) get annoyed by a gong sound, especially if it is played within a small room. Thereafter, she briefly discusses some common erroneous assumptions, as for example, "music is always fun" and "the content of a recognizable tune is being perceived by another in the same format in which it is being presented by the therapist". The latter agrees with the previous contention: each listener to suit his/her cenesthetic needs decodes the musical message. Such assumptions deserve to be taken into consideration in other environments, too. Example: A person complains that his neighbor plays piano every day after midnight and, thus, disturbs his sleep. The player argues back saying that he plays beautiful classic music loved by everybody. Who is right? The author brings also forward an interesting and novel possibility: Is there such a thing as music stimulation, characterized by six properties, as Dorita explains: rhythm, melody, harmony, dynamics, timbre, and form. This is not the place to give details about these elements for the author clearly fathoms in them solidly and without a single doubt. My only comment, and just as a curiosity recalling my days as cardiovascular physiologist, refers to one teacher actually using pulsed hand-clapping (a pacemaker) to call her entire class of children to order, to subdue chaotic impulses (page 114). A fibrillating heart has its fibers in a dynamic state of dyssynchrony (as the children shouting in the classroom). No effective contraction to eject blood takes place. One or may be two electric shocks usually stop the disorder and the myocardial mass resumes its rhythmic synchronic activity. This is called a defibrillating maneuver. Are the similarities of nature not nice? As Albert Einstein used to say, the most incomprehensible thing of the world is that the world is comprehensible.Chapter 8 (Elements of Music for Sensory Adaptation, pp 112–129) goes, with some tardiness in the development of the book (at least to my particular taste), into music itself, and I would like to use the term caveat emptor or let the buyer beware: "Music therapy does not lend itself readily to rigorous scientific explanation. Findings are anecdotal at best, and based on observations, insights and informed assumptions. Music therapy does not replace other interventions, nor does it need to copy the goals of other therapies in order to be effective". This is why the field is fully open for serious research.Chapter 9  is more practical as it discusses the different types of musical instruments from the viewpoint of their suitability to specific therapeutic objectives. In Chapter 10 , instead, several aspects are discussed, some of them somewhat superficially and not meeting the expectations developed by the subtitles, as for example "adaptive responses to environment of auditory and visual stimuli" or "auditory integration and differentiation". The last Chapter 11 (Conclusions, pp 166–175) is some kind of summary. Let me quote a wise paragraph, a I think the book meets the intent of its author (page 173): [It] "is an introduction to physiologic information and perspectives that can help the music therapist assess more astutely the behaviors and presenting problems of an atypically functioning patient."The Autistic Child, Sensory Integration and Music Therapy, for this is really the order followed in it. The physiology section could be reduced. There are also some unnecessary repetitions. The bibliography is given in three groups: specific references to each chapter, recommended references, and a general list at the end of the book. It is not practical. I would rather have a single list at the end properly referred to in the course of the text. Appendix A is the reproduction of an article by Schneck and Berger. It adds something to the book but not to its core material. Thus, it might be deleted in the future. Appendix B is a collection of four case histories. By far is too long containing unnecessary information. It should be greatly reduced and limited to the pertinent information. The music portion could be enhanced.Now, and to finish this review by being a little prickly but honestly (and perhaps naïvely) constructive, let me point out a few minor aspects that might improve another edition of the book: The title does not properly reflect the content of the book. It should be named Having said more than enough, I recommend the book and congratulate the author for her dedication, effort and beautiful activity by combining art with benefit to the many time forgotten children.


Seasonality of ovulatory activity is observed in European sheep and goat breeds, whereas tropical breeds show almost continuous ovulatory activity. It is not known if these tropical breeds are sensitive or not to temperate photoperiod. This study was therefore designed to determine whether tropical Creole goats and Black-Belly ewes are sensitive to temperate photoperiod. Two groups of adult females in each species, either progeny or directly born from imported embryos, were used and maintained in light-proof rooms under simulated temperate (8 to 16 h of light per day) or tropical (11 – 13 h) photoperiods. Ovulatory activity was determined by blood progesterone assays for more than two years. The experiment lasted 33 months in goats and 25 months in ewes.Marked seasonality of ovulatory activity appeared in the temperate group of Creole female goats. The percentage of female goats experiencing at least one ovulation per month dramatically decreased from May to September for the three years (0%, 27% and 0%, respectively). Tropical female goats demonstrated much less seasonality, as the percentage of goats experiencing at least one ovulation per month never went below 56%. These differences were significant.Both groups of temperate and tropical Black-Belly ewes experienced a marked seasonality in their ovulatory activity, with only a slightly significant difference between groups. The percentage of ewes experiencing at least one ovulation per month dropped dramatically in April and rose again in August  or September (temperate ewes). The percentage of ewes experiencing at least one ovulation per month never went below 8% and 17%  during the spring and summer months.An important seasonality in ovulatory activity of tropical Creole goats was observed when females were exposed to a simulated temperate photoperiod. An unexpected finding was that Black-Belly ewes and, to a lesser extent, Creole goats exposed to a simulated tropical photoperiod also showed seasonality in their ovulatory activity. Such results indicate that both species are capable of showing seasonality under the photoperiodic changes of the temperate zone even though they do not originate from these regions. Seasonality of reproduction is a common feature in sheep and goat breeds of temperate latitudes ,2 and seWhen transferred to equatorial conditions (12 h of light per day, with a limited control of temperature change amplitudes), Suffolk ewes (a European breed) cycled at irregular intervals with no clear anovulatory season . In contLocal breeds of sheep -15 and gIn the present experiment, seasonal ovulatory activities were assessed in tropical Creole goats and Black-Belly ewes. These two breeds originate from the Carribean Islands, where they have been bred for 3–4 centuries, and constitute the progeny of African tropical breeds (see Methods). The animals of the present experiment were imported into Europe and experimentally subjected for more than two years in light-proof rooms to an annual photoperiodic regimen simulating that of temperate regions (TE group), and compared to females under tropical cycle simulating that of a tropical region (TR group).Ovulatory activity demonstrated marked differences between experimental groups over the course of the experiment. Individual ovulatory activity is presented in Figure Marked seasonality of ovulatory activity appeared in female goats of the TE group; the seasonal inactivity occurred from May to September for the three years of the study Figures  &2. The In contrast, female goats exposed to the TR photoperiodic cycle demonstrated much less seasonality as the percentage of goats experiencing at least one ovulation per month never went below 56% (minima for the three years of study: 56%, 56%, 57%). Two female goats cycled continuously during the course of the experiment, one female goat in mid-1990 and three in mid-1991 continued their ovulatory activity during spring and summer, and four females were still cycling at the end of the experiment (June 1992).nd and 3rd breeding seasons were significantly higher in TR goats  Experimental ewes were artificially raised in TE vs TR photoperiod from birth to 6 months old from the start of the experiment, whereas female goats were raised under simulated tropical photoperiod until the start of the experiment at one or two years old. (c) Black-Belly ewes were included in the experiment at 6 months of age, whereas Creole goats were 12 and 24 months old at the start of the experiment. These three main differences between the experiments in female goats and ewes could possibly explain this photoperiod x species interaction. However, it may also come from a real difference of sensitivity to non-photoperiodic factors (such as temperature changes or activity, see later) between the two species.In contrast, Black-belly ewes maintained under simulated tropical photoperiodic variations did not differ greatly from those maintained under simulated temperate photoperiod. The two groups of ewes and goats used here differed in various parameters, some of which could explain the photoperiod x species interaction observed here: (a) Recipient ewes in which embryos were implanted in autumn were maintained under natural photoperiod. It is known that light changes during pregnancy may affect the progeny's photoperiod sensitivity, especially regarding the onset of puberty in sheep -25 and iThe spontaneous ovulatory activity demonstrated in the present experiment by the Black-Belly ewes from the TR group were very different from those registered earlier in their natural breeding conditions on the island of Martinique in the tropics, where they cycled all year round . The CreIn Syrian hamsters, exercise by access to a running wheel can completely inhibit the short-day induced regression of the testis ,32. ExpeThe sheep and goat breeds used here are local breeds of the Carribean islands. Even though their presence in these islands is associated with human history, they are considered as the progeny of tropical but not European ancestors, because they originate from the West coast of tropical Africa (see Methods). In these areas all sheep and goat breeds are considered as non or low seasonal breeders. Thus, the sensitivity of the Creole goats and Black-Belly ewes observed here under temperate photoperiod could be hypothetized as a true sensitivity of these breeds, not a simple inheritance of a trait coming from European ancestors.A marked seasonality in the ovulatory activity of tropical Creole goats and Black-Belly ewes was induced when females were exposed to a simulated temperate photoperiod. Unexpectedly, and differing from the results obtained in their original breeding location, Black-Belly ewes and, to a lesser extent, Creole goats exposed to a simulated tropical photoperiod also showed significant seasonality in their ovulatory activity. Such results indicate that both species are capable of showing seasonality under the the photoperiodic changes of the temperate zone even though they do not originate from these regions.Experimental animals from both species were produced after importation of deep-frozen embryos. The embryos were thawed and re-implanted into recipient females of Saanen goats for Creole embryos (1983) and of Ile-de-France sheep for Black-Belly embryos (1997).th-18th centuries [rd and 4th generations, constituting a sufficient number of animals, made up the two experimental groups.Embryos from donor Creole goats were collected as previously described  from 4 genturies -37. Creoenturies ,37. Commenturies , which rEmbryos from donor Black-Belly ewes were collected using the technique described by Heyman et al. . The donBoth experiments were performed at the INRA Station near Tours (latitude 47°25 North).- Thirty three Creole female goats were used from October 1989 when the animals were one  and two  years old, for 33 months to June 1992 . They were divided into two groups (n = 17 TR and 16 TE) in visual and tactile contact, with entire and vasectomized Creole bucks, but separated by a fence. Each group was maintained in a separate light-proof room throughout the experiment.Feeding conditions were constant throughout the experiment. The animals were fed once daily with a diet of 240 g of barley, 60 g of wheat, 700 g of meadow hay and 300 g of barley straw. No flushing was performed. They had free access to water and to mineral blocks containing oligoelements and vitamins.- Twenty four Black Belly ewes were used from September 1998 when the animals were 6 months old, for 25 months, to October 2000. They were divided into two groups (n= 12 TR and 12 TE) in visual and tactile contact, with entire Black Belly rams, but separated by a fence. Each group was maintained in a separate light-proof room throughout the experiment.Feeding conditions were constant throughout the experiment. The animals were fed once daily with a diet of 150 g of corn, 110 g of barley, 45 g of dehydrated protein complement and 400 g of hay. No flushing was performed. They had free access to water and to mineral blocks containing oligoelements and vitamins.Within each species, one group was subjected to the large photoperiodic changes prevailing at the 45° North latitude (8 to 16 h of light per day from winter to summer solstices); this group was called the temperate group (TE). The other group was subjected to the limited photoperiodic changes prevailing at the 16° North latitude (11 to 13 h of light per day from winter to summer solstices); this group was called the tropical group (TR). In all rooms, photoperiod was regulated by an electric clock that operated bulbs providing an intensity of 300 lux, lateral to the animals' eyes. The photoperiod was adjusted by 15 min shifts  to produce a complete photoperiodic cycle every 365 days.2). Temperature was not controlled but variations were parallel to those monitored outside but with a lower amplitude (minimum +1°C in January, maximum +29°C in August).The four rooms were adjacent and of the same size (30 mLiveweight of Creole goats at the beginning of the experiment was 24.6 (± 3.4, sd) kg in group TE and 25.5 (± 3.0) kg in group TR. Liveweight was measured monthly and showed a regular increase until the end of the experiment (55.7 ± 7.5 and 56.2 ± 5.2 kg for TE and TR respectively). Liveweight of Black-Belly at the beginning of the experiment was 33.2 (± 2.5 sd) kg in group TE and 31.9 (± 2.7) kg in group TR. Liveweight was measured monthly and showed a regular increase until the end of the experiment (49.5 ± 5.9 and 47.0 ± 5.8 kg for TE and TR respectively).Ovulatory activity was assessed twice weekly in goats up to end October 1991 and once weekly thereafter; and once weekly in ewes, using blood samples for the progesterone radioimmunoassay. A rapid assay was performed using the technique described by Terqui and Thimonier . When prThe first occurrence of a positive Progesterone sample was considered as the date of the first ovulation of the season, and the last occurrence of a positive Progesterone sample was considered as the date of the last ovulation of the season. Mean duration of ovulatory activity is the number of days between first and last ovulation in the same breeding season. Mean duration of anovulation is the number of days between last ovulation in a breeding season and first ovulation of the next season. Females which did not present cessations of their ovulatory activity were not included in the calculations of duration of the breeding seasons or duration of the anovulatory periods. In September and October 2000, individual blood samplings were stopped in ewes that had resumed their ovulatory activity.2 method. (Statview®, Abacus Concept, Berkeley, Ca, USA).Mean dates of onset and end of the breeding season, durations of the breeding season and of anovulatory activity were compared between groups using an unpaired t-test. Variances were compared with F-Tests. Percentages of females showing at least one ovulation per month were analyzed using the ChiAll procedures were performed in accordance with French legal requirements and with the Ministry of Agriculture authorization for animal experimentation nb A37801 .The authors contributed equally to this work. PC conceived the study, and was responsible for its design and coordination. AD followed the experiment in goats and DC the experiment in sheep. YC and GA performed all the embryo transfer procedures, and were in charge of pathological analyses. AD, DC and PC analysed the data. PC drafted the manuscript. All authors read, corrected and approved the final manuscript.


Healthy life expectancy – sometimes called health-adjusted life expectancy (HALE) – is a form of health expectancy indicator that extends measures of life expectancy to account for the distribution of health states in the population. The World Health Organization reports on healthy life expectancy for 192 WHO Member States. This paper describes variation in average levels of population health across these countries and by sex for the year 2002.Mortality was analysed for 192 countries and disability from 135 causes assessed for 17 regions of the world. Health surveys in 61 countries were analyzed using new methods to improve the comparability of self-report data.Healthy life expectancy at birth ranged from 40 years for males in Africa to over 70 years for females in developed countries in 2002. The equivalent "lost" healthy years ranged from 15% of total life expectancy at birth in Africa to 8–9% in developed countries.People living in poor countries not only face lower life expectancies than those in richer countries but also live a higher proportion of their lives in poor health. World Health Report 2000, the World Health Organization (WHO) reported for the first time on the average levels of population health for its 191 member countries using a summary measure that combines information on mortality and morbidity [In the orbidity .HALE has been calculated previously for Canada and Australia using population survey data on disability -6. The UIt has long been known that health expectancy estimates based on self-reported health status information are not comparable across countries due to differences in survey instruments and cultural differences in reporting of health ,10. The World Health Report 2004 [Given these problems, WHO undertook a Multi-Country Survey Study on Health and Responsiveness (MCSS) in 2000 and 2001 in collaboration with Member States using a standardized health status survey instrument together with new statistical methods for adjusting biases in self-reported health -19. Thesort 2004 . This paCalculation of HALE requires three inputs: life tables, prevalences of various health states, and valuations of time spent in these health states compared to full health. The WHO methods used to calculate HALE have been developed to maximise its comparability across populations. These methods are described in more detail elsewhere ,23 and hProcedures used to estimate the 2002 life tables differed for Member States depending on the data availability to assess child and adult mortality. Complete or incomplete vital registration data together with sample registration systems cover 72% of global mortality. Survey data and indirect demographic techniques provide information on levels of child and adult mortality for the remaining 28% of estimated global mortality. Separate estimates were used for the numbers and distributions of deaths due to HIV/AIDS in countries with a substantial HIV epidemic . A full Following an initial scientific review , signifiBecause comparable health state prevalence data are not yet available for all countries, two sources of information were used: the Global Burden of Disease (GBD) study and the MCSS. Data from the GBD study were used to estimate severity-adjusted prevalences by age and sex for all 192 countries . SecondlThe GBD revisions draw on a wide range of data sources to develop internally consistent estimates of incidence, prevalence, duration and years lived with disability (YLD), for 135 major causes, for 14 sub-regions of the world . PrevaleWorld Health Report 2004 [.Tables Summation of prevalence YLD across all causes would result in overestimation of the total average severity-weighted health state prevalence because of comorbidity between conditions. In earlier calculations of HALE, adjustments were made for independent comorbidity assuming that the probability of having two (comorbid) conditions would equal the product of the probabilities for having each of the diseases. For the World Health Report 2003, further work was undertaken to take dependent comorbidity into account more rigorously . For manData from five large national health surveys were analysed by age and sex to estimate "dependent comorbidity factors" for pairs of conditions. There was surprising consistency in these factors across the five surveys and the results were used for all Member States to adjust for dependent comorbidity in summation of prevalence YLD across all causes .The MCSS was carried out in 2000–2001. A total of 71 surveys were completed in 61 countries using face-to-face, postal and telephone interviewing modes . Thirty-We included in the analysis only those surveys that have met certain explicit criteria that reflect the quality of survey implementation with specific reference to the health vignettes. The USA postal survey was also excluded because respondents were presented the vignettes in order of severity rather than randomized as in the case of all other surveys. Sixty-two surveys met these criteria and were included in the model. Health state prevalences from the WHO Multi-country Household Survey Study were assumed to relate to calendar year 2000. Trends in prevalence YLD between 2000 and 2002 were calculated for each Member State using the GBD estimates. Aggregated across all causes, these trends were generally small. In calculating HALE for 2002, the 2000 survey results were adjusted for likely change over two years using these estimated trends.The health state valuations used in HALE calculations represent average population assessments of the overall health levels associated with different states. They range from 0 representing a state of good or ideal health to 1 representing states equivalent to being dead. These weights do not measure average levels of well-being or quality of life associated with health states, or imply any societal value of a person in a disability or health state. Rather they characterize health decrements on a continuum starting from the societal ideal of good health.Household surveys including a valuation module were conducted in fourteen countries: China, Colombia, Egypt, Georgia, India, Iran, Lebanon, Indonesia, Mexico, Nigeria, Singapore, Slovakia, Syria and Turkey. Data on nearly 500,000 health state valuations from over 46,000 respondents were used to develop a mapping function that captured the average relationships between levels on the six core health domains and overall health state valuations. This average global valuation function was then applied to the vignette-adjusted health domain levels for each survey respondent in order to estimate health state valuations for the calculation of HALE ,31.The MCSS survey samples did not include older people resident in nursing homes or other health institutions. Because these people will generally have worse health than those resident in households, adjustments were made to account for the older population who were resident in health institutions. Fifty-four national estimates of the proportion of the population aged 65 years and over who are resident in nursing homes were collected for 36 countries from national statistical publications and international statistical databases of OECD and the World Bank. These were used to estimate the percentage of the population aged 60+ years institutionalized in MCSS countries. This ranged from 3 to 5% in most OECD countries, was highest at around 7% in the Netherlands and Sweden, was substantially lower at around 0.3 to 1% in Eastern European countries, and was close to zero for developing countries. As data on the severity distribution of health states in institutionalized populations were not available, an average disability weight of 0.5  was assumed for the institutionalized population. Sensitivity analyses showed that the resulting HALE estimates were not sensitive to the choice of this disability weight within a plausible range of variation.Because there is potential measurement error in severity-weighted health state prevalences derived from both household surveys and epidemiological estimates, posterior estimates of prevalence for the survey countries were calculated as weighted averages of the GBD-based prevalences and the survey prevalences . The relHALE was calculated using Sullivan's method  based onApart from ongoing revisions to the GBD analyses of epidemiological information on diseases and injuries, the implementation of improved methods for dealing with comorbidity has resulted in a reduction in estimated proportion of healthy years of life lost at older ages compared to previous years.Improvements in methods used for the analysis of the MCSS survey data and in the adjustment of total YLD rates for dependent comorbidity have resulted in improved estimates of the severity-adjusted prevalence of health states and a reduction in the uncertainty associated with these estimates. For these reasons, HALE estimates for 2002 are not directly comparable with those for 2000 and 2001 published in the World Health Report 2002 .The survey data identified considerable variability in the use of question response categories to describe the same level on a particular health domain and a systematic tendency for people in countries with higher income per capita to use more severe response categories in rating a given anchoring vignette. Thus the self-reported prevalence of problems for a health domain in a country may be quite different from the prevalence of problems after adjustment for these response category cut-point shifts. In France, for example, 70% of survey respondents gave self-report responses of mild or greater problems on the question for the affect domain (anxiety and depression), whereas the standardized (vignette-adjusted) prevalence at all levels higher than "none" was only 33% for France. In contrast, for some countries such as Egypt, the self-report and standardized prevalences were almost the same at around 38%.World Health Report 2004 [Figure Japanese women led the world with an estimated average HALE at birth of 77.7 years in the year 2002, 7.5 years lower than total life expectancy at birth. HALE at birth for Japanese males was 72.3 years, 5.4 years lower than for females. This male-female gap in HALE was narrower than that for total life expectancy at birth (6.9 years). After Japan, in second to seventh places, were San Marino, Sweden, Switzerland, Monaco, Iceland and Italy, with HALE at birth  in the range 72.7 to 73.4 years, followed by Australia and a number of other industrialized countries of Western Europe. There was a considerable range of uncertainty in the ranks for countries other than Japan, with typical 95% uncertainty ranges for HALE of around 0.5 to 2 years for developed countries. Keeping these uncertainty intervals in mind, Canada was in 11th place (72.0 years) and the USA in 29th place (69.3 years).Other countries with reasonably high HALE in the Americas included Argentina (65.3 years), Chile (67.3 years), Costa Rica (67.2 years), Cuba (68.3 years), Mexico (65.4 years), Panama (66.2 years) and Uruguay (66.2 years). Brazil was split, with a high HALE in its southern half, and a lower one in the north. The total average was a relatively low 59.8 years, at 57.2 for males and 62.4 for females.Overall, global HALE at birth in 2002 for males and females combined was 57.7 years, 7.5 years lower than total life expectancy at birth Figure . In otheHALE at birth ranged from a low of 40 years for African males to over 70 years for females in the low mortality regions of Western Europe, North America and the Pacific . This reflects an almost 2-fold difference in HALE between major regional populations of the world Figure . The equThere was a similar almost two-fold variation in HALE at age 60 across the regions of the world, ranging from 19 years for women in low-mortality countries to around 10 years for men and women in sub-Saharan Africa. Males lost more healthy years of life at age 60 than females only in China and South East Asia, where life expectancy gaps at age 60 were also low compared with the more than 5-year gap in Japan  and in Eastern Europe .There was an enormous difference between the world's highest HALE at birth of 77.7 years  and the lowest of 27.2 years  in 2002. In Sierra Leone, people both lived shorter lives , and had higher levels of disease and disability at all ages. The probability of a male child dying before his 5th birthday was 33% in Sierra Leone, compared with less than 0.5% in Japan.The low levels of HALE in sub-Saharan Africa reflect the additional impact of the HIV-AIDS epidemic, as well as war and conflict in some countries such as Sierra Leone. AIDS is now the leading cause of death in Sub-Saharan Africa, far surpassing the traditional deadly diseases of malaria, tuberculosis, pneumonia and diarrhoeal disease. AIDS killed 2.1 million Africans in 2002, versus 300,000 AIDS deaths in 1990 .In Russia, HALE at birth was 64.1 for females, 4 years below the European average, but just 52.8 years for males, 9.4 years below the European average. This was one of the widest sex gaps in the world and reflects the sharp increase in adult male mortality in the 1990s. The most common explanation is the high incidence of male alcohol abuse, which led to high rates of accidents, violence and cardiovascular disease. From 1991 to 1994, the risk of premature death increased by 50% for Russian males . BetweenAt the other extreme there were 12 countries where female HALE at birth was lower than male, and an additional 20 countries where it was less than 1 year higher. These included African countries greatly affected by HIV/AIDS such as Botswana, Kenya, Tanzania and Zimbabwe, but also Eastern Mediterranean countries such as Bahrain, Kuwait, Qatar and the United Arab Emirates, and Asian countries such as Afghanistan, India, Pakistan and Bangladesh. Also included were Nigeria and Haiti. In most of these countries, female life expectancy was slightly higher than male; only in Qatar, Maldives and Bangladesh was female life expectancy at birth lower than that for males. However, higher levels of disability and poor health reduced HALE for females to a greater extent than for males in these countries. At a broader regional level, sub-Saharan Africa, the Eastern Mediterranean region, and the South East Asian region all had female HALE at birth less than three years higher than male, compared with a female-male gap of 6 to 7 years in developed countries.HALE at birth in Afghanistan was estimated at 35.5 years, the 11th lowest in the world in 2002. There was a large 95% uncertainty range around this estimate, of 27 to 44 years, reflecting the lack of population health information for that country. More health information was available for Iraq, where HALE at birth in 2002 was estimated at 50.1 years, with an uncertainty range of 47 to 54 years.China had a healthy life expectancy well above the global average, at 64.1 years, 65.2 years for women and 63.1 for men. Other countries in the Asian region generally had lower HALE. Improving health in Viet Nam has resulted in a HALE of 61.3 years, while Thailand has not improved significantly over the past decade, with a HALE of 60.1 years in 2002. HALE in Myanmar was just 51.7 years at birth, substantially behind its South East Asian neighbors.Figure Correspondingly, LHE varied from 7.3 to 11 years, or by up to 50%. If male and female HALE are considered separately, the range of variation increases to 59–66 at total life expectancy of 72 years. While LHE increases somewhat with increasing life expectancy up to around 70 years life expectancy, there is a flattening for males and a trend to decreasing LHE for females in the countries with longest life expectancies. Although there are higher prevalences of disabling conditions such as dementia and musculoskeletal disorders in countries with longest life expectancies, this is offset by lower levels of disability for diseases such as cardiovascular disease and chronic respiratory diseases where incidence and mortality rates are also lower.As discussed elsewhere, the new methods used in the WHO Multi-Country Survey Study offer clear evidence that self-report data on health status are not comparable, and allow adjustments that improve the comparability of the resulting health status measures . BuildinDespite the fact that people live longer in the richer, more developed countries, and have greater opportunity to acquire non-fatal disabilities in older age, disability has a greater absolute (and relative) impact on healthy life expectancy in poorer countries. Separating life expectancy into equivalent years of good health and years lost to sub-optimal health thus widens rather than narrows the difference in health status between the rich and the poor countries.Richer countries should be much more active in seeking ways to improve the health of the world's poor. WHO has been a strong advocate for efforts to increase the resources available for this purpose, and the recent report of its Commission of Macro-economics and Health concluded that the bulk of the global disease burden is the result of a relatively small set of conditions, each with an existing set of effective interventions . The maiThe World Health Report 2002 included an analysis of mortality and morbidity attributable to the combined effects of 20 selected leading risk factors for 14 subregions of the world ,40. GlobThe regular assessment of levels of population health is a key input to the public policy process, and comparable measurement of population health levels creates possibilities of investigating broad determinants at national and cross-national level. Mortality indicators are not adequate for this purpose, given the considerable policy interest for many populations as to whether – and to what extent – gains in life expectancy have been accompanied by improvements in non-fatal health status ,42-45. TComparability is fundamental to the use of survey results for development of evidence for health policy but has been under-emphasized to date in instrument development. We believe that the new methods used in the WHO Multi-country Household Survey Study and the World Health Survey have increased the comparability of self-report data across countries and provide the first steps towards the consistent and comparable measurement of population health across the world. Final confirmation that compression of morbidity is occuring in low mortality populations awaits longitudinal cross-population comparable data for specific populations: this is now achievable.The author(s) declare that they have no competing interests.CDM, CJLM and JAS developed the methods for calculation of HALE. CJLM, JAS and AT developed the methods and carried out the calculations for the measurement of health states and health state valuations in the MCSS, with contributions from the other authors. CJLM, JAS, SC and BU developed the MCSS survey instrument, and SC and BU coordinated the implementation and analysis of the surveys. KMI, CDM and JAS carried out analyses and calculations for the computation of HALE for the year 2002 for 192 WHO Member States, with contributions from CJLM and the other authors. CDM drafted the paper, with substantial contributions from other authors.The pre-publication history for this paper can be accessed here:


A major goal of cancer research is to identify discrete biomarkers that specifically characterize a given malignancy. These markers are useful in diagnosis, may identify potential targets for drug development, and can aid in evaluating treatment efficacy and predicting patient outcome. Microarray technology has enabled marker discovery from human cells by permitting measurement of steady-state mRNA levels derived from thousands of genes. However many challenging and unresolved issues regarding the acquisition and analysis of microarray data remain, such as accounting for both experimental and biological noise, transcripts whose expression profiles are not normally distributed, guidelines for statistical assessment of false positive/negative rates and comparing data derived from different research groups. This study addresses these issues using Affymetrix HG-U95A and HG-U133 GeneChip data derived from different research groups.We present here a simple non parametric approach coupled with noise filtering to identify sets of genes differentially expressed between the normal and cancer states in oral, breast, lung, prostate and ovarian tumors. An important feature of this study is the ability to integrate data from different laboratories, improving the analytical power of the individual results. One of the most interesting findings is the down regulation of genes involved in tissue differentiation.This study presents the development and application of a noise model that suppresses noise, limits false positives in the results, and allows integration of results from individual studies derived from different research groups. DNA microarrays have become a useful tool in biomedical research as they can be used to determine the relative expression of thousands of genes in a given sample. Such expression profiles could predict genetic predisposition to disease, serve as a set of diagnostic markers, define better drug treatments options for existing diseases (pharmacogenomics), or mark the precise nature of disease progression. A major limitation of this technology is the lack of uniform data mining strategies. This study integrates complementary approaches to more effectively analyze Affymetrix GeneChip microarray data derived from several different types of solid tumors. If the noise is consistent and reproducible it can be filtered from the data and some false positives can be eliminated. There are two principal sources of noise in microarray experiments: biological noise and technical noise. Biological noise consists of variation among patients and tumor locations, variation in the cellular composition of tumors, heterogeneity of the genetic material within tumor due to genomic instability. Technical noise consists of differences in sample preparation and experiment variables which include nonspecific cross hybridization, differences in the efficiency of labeling reactions and production differences between microarrays. Biological noise cannot be corrected but it can be accounted for with statistics using replicates of the treatments or conditions. However, the noise derived from experimental techniques is reproducible and its boundaries can be modeled. It has been observed that in differential gene expression comparisons of any given gene, there is a greater variance in the fold-change calculation at lower signal intensities ,2, and wThe principal concerns when using microarray data derived from different labs to identify cancer markers is that chip-to-chip normalization cannot eliminate differences in cRNA synthesis and labeling, hybridization protocols, scanner settings and image processing software. Variable RNA quality can influence the amount of individual cRNAs generated. The laser power on scanners can differ causing saturation of high intensity probe sets and may have a more variable estimation of the very low expressed transcripts.Two studies ,8 have sThe commonly used t-test tests to see if two populations have a different mean but does not test the overlap of the populations. Selecting markers with minimal overlap in their expression between the normal and tumor states would improve their predictive value. We developed a method to find such markers using an un-weighted voting scheme. This non-parametric method for marker selection was chosen so that no assumptions on the shape of the data distribution were required. The computed noise boundary makes the selection criteria more stringent, eliminating many false positives signals and highlighting genes that are differentially expressed most consistently in comparisons between a cancer and its corresponding normal tissue. This integrative approach can yield a signature of distinct transcripts distinguishing a variety of solid tumors.The objectives of this work were three fold: 1). develop a noise boundary for GeneChip data, 2). develop an algorithm for selecting markers with minimal overlap in their expression between the normal and tumor states, 3). integrate the analysis of previously published data from different sources.The noise boundary model was created to evaluate the reliability of calculated fold changes. Data from normal tissue biopsies obtained from public data sets were used to infer the noise boundary to be used when comparing the normal tissue to their corresponding cancer biopsies. The cancer biopsies were not used in designing the noise model as they are likely to be more variable than normal tissue. Three different signal extraction methods, MAS5 ,10, dChith percentile of the fold-change, chosen as the noise boundary, was calculated for each bin. Figure th percentile error boundaries for the five different tissues as a function of the inverse of the average bin intensity. To decrease the effect of saturation on the regression, the gene expression values in the top 8% were eliminated  of each cancer biopsy to each normal biopsy was determined. Those ratios were recorded and evaluated against the noise boundary model. If a ratio was above the ratio given by the noise boundary, the direction of the fold-change as increased (+) or decreased (-) expression was recorded. If the ratio was below the value given by the noise boundary for the average of the intensities, then the fold-change was considered insignificant and assigned a no change (0) direction.For each probe-seti in the cancer classFor each sample cj in the normal classFor each sample ni>nj then r = ci/nj else r = nj/ciIf ci+nj)/2) And If ci>njIf r>noise_boundary ((cPos_score = Pos_score + 1i+nj)/2) And If ci ≤ njIf r>noise_boundary  and the Er computation was repeated. Each time the data was shuffled, the probe sets were sorted by descending Er score and the probe set information was discarded and replaced by its rank. The average and standard deviation of the ranks was then computed and compared to the results obtained for the cancer versus normal biopsies. For all the comparisons performed, higher Er scores were obtained in the case of cancer versus normal classifications than with randomly shuffled sets. An illustration of the results obtained with the breast cancer versus normal biopsies can be seen in figure To compare the Er algorithm including the noise model to other commonly used analysis methods, the replicate set from the Latin square dataset was used . In thisThe Er model was used to compare each cancer biopsy to its corresponding normal tissue. In the absence of error modeling, the directional change algorithm identified 1,910 probe-sets that had an Er score above 0.9 in ovarian cancer, 1,355 in breast cancer, 1,730 in oral cancer and 322 in prostate cancer. Incorporation of error modeling dramatically reduced the number of probe-sets with Er scores above 0.9 to 272 for ovarian, 177 for breast, 129 for oral cancer and 2 for prostate cancer see . For lunThe advantage of determining Er scores for differentially expressed cancer transcripts is that it provides a statistical metric that can be used to underscore markers that are unique to a particular cancer. Although the Er is not a statistical test and an Er score can vary in its significance depending on the number of samples studied, we selected genes with a high Er index in one cancer type (Er> = 0.9) and low in the others (Er<0.6). As Affymetrix HG-U95A and Hu133A contain different probe-set numbers for the same gene, the SOURCE software  from StaSIM2-s expression in a colon cancer cell line restored growth inhibition and apoptotic cell death [The number of genes found to be reliable markers varied greatly between cancer types [see Additional File ll death .Two genes, AGER and MARCO, were found to be under expressed in all the lung cancer types compared to other cancer types. The advanced glycosylation end product-specific receptor (AGER or RAGE) has been previously reported down-regulated in non small cell lung carcinoma . AGER isThirty nine probe sets were found to have an Er score above 0.9 in ovarian cancer and lower than 0.6 for the other cancers. Two of these genes, Janus kinase 1 (JAK1) and a zinc finger homeobox (ZFHX1B), which are involved in the TGF β signaling pathway regulating cell growth, were down regulated. PAX8, a gene important in development which had been identified in an earlier study , was fouBreast cancer profiles have several interesting features. First, 16 ribosomal protein genes have decreased expression: L34 is involved in translational control , S27 in In oral cancer [see Additional File The method described here provides improved non-parametric approaches to microarray data analysis. After applying the noise boundary model, markers were selected according to their consistency for up-regulation or down-regulation using a voting scheme comparing normal versus cancer biopsies. Tissue-specific expression differences were eliminated by comparing the cancer samples to the normal biopsies from the same tissue. The genes with the greatest differential expression between cancer and normal biopsies were then compared between cancer types. This differs from previous studies ,8,35 whiAll of the microarray data used in this analysis was derived from RNA isolated from biopsies and hybridized on Affymetrix GeneChips HG-U95A, HG-U95Av2 or HG-U133A. All the research groups used the same standard procedure for labeling the cRNA, hybridization and scanning the GeneChips . The datVA and PT conceived the study. VA carried out the analysis and drafted the manuscript. MC performed the programming. JC helped with the evaluation of raw image analysis methods. MR supervised the programming and analysis. PS and JD participated in the study design and management.Assessing the noise level and trust threshold for differential expression on Affymetrix GeneChips. This document compares the noise from MAS5, RMA and dChip and presents the sensitivity analysis for the noise model parameters using the Latin square replicate data set.Click here for fileGene markers for prostate, breast, ovarian, oral, and lung cancer. This file presents the Top Er scores for each cancer studied when compared to its normal tissue. There is a result table with gene information for each cancer on separate tabs.Click here for fileGene markers that distinguish between prostate, breast, ovarian, oral, and lung cancer. This file presents the Er scores of genes expression levels that are consistently up or down in a given cancer compared to its normal tissue (Er>0.9) but not in any of the other four cancers (Er<0.6).Click here for file


Protease inhibitors are known to alter the lipid profiles in subjects treated for HIV/AIDS. However, the magnitude of this effect on plasma lipoproteins and lipids has not been adequately quantified.To estimate the changes in plasma lipoproteins and triglycerides occurring within 12 months of initiating PI-based antiretroviral therapy among HIV/AIDS afflicted subjects.We included all antiretroviral naïve HIV-infected persons treated at St-Paul's Hospital, British Columbia, Canada, who initiated therapy with protease inhibitor antiretroviral (ARV) drugs between August 1996 and January 2002 and who had at least one plasma lipid measurement. Longitudinal associations between medication use and plasma lipids were estimated using mixed effects models that accounted for repeated measures on the same subjects and were adjusted for age, sex, time dependent CD4+ T-cell count, and time dependent cumulative use of non-nucleoside reverse transcriptase inhibitors and adherence. The cumulative number of prescriptions filled for PIs was considered time dependent. We estimated the changes in the 12 months following any initiation of a PI based regimen.A total of 679 eligible subjects were dispensed nucleoside analogues and PI at the initiation of therapy. Over a median 47 months of follow-up (interquartile range (IQR): 29–62), subjects had a median of 3 (IQR: 1–6) blood lipid measurements. Twelve months after treatment initiation of PI use, there was an estimated 20%  increase in total cholesterol and 22% (12% – 33%) increase in triglycerides.Twelve months after treatment initiation with PIs, statistically significant increases in total cholesterol and triglycerides levels were observed in HIV-infected patients under conditions of standard treatment. Our results contribute to the growing body of evidence implicating PIs in the development of blood lipid abnormalities. In conjunction with the predominance or men, high rates of smoking, and aging of the treated HIV-positive population, elevated lipoproteins and triglycerides may mean that patients such as these are at elevated risk for cardiovascular events in the future. Abnormalities in the lipid metabolism of persons infected with human immunodeficiency virus (HIV), potentially induced by the disease itself and the medications used for treatment, were first reported in the early 1990s-5, elevaUp to one-half of subjects treated with PIs have shown elevated levels of triglycerides, total cholesterol (TChol), LDL, insulin, and fasting glucose -10. The We included all antiretroviral naïve HIV-infected persons treated at St-Paul's Hospital, British Columbia (BC), Canada, who initiated use of PIs between August 1996 and January 2002. Plasma lipoprotein and triglyceride levels were obtained from measurements taken over the course of regular monitoring. Longitudinal effects of the impact of PIs on lipoproteins and triglycerides were estimated using statistical models that accounted for correlation due to repeated measurements on the same individuals.In BC, antiretroviral drugs have been centrally distributed at no cost to eligible HIV-infected individuals since 1986,13. In OAt the BC Centre for Excellence in HIV/AIDS, records of CD4+ T-cell counts and a profile of dispensed antiretroviral therapy are routinely maintained, including the: prescription fill dates, medications prescribed, and amount dispensed. Records of dispensed antiretroviral medications,  were used to determine the drugs dispensed and available to each subject during each month of follow-up. Subjects were considered unexposed until the first month that a PI was dispensed. The exposure at the time of the lipid measurement was calculated as the cumulative number of consecutive months of drug exposure up until and including the month in which a measurement was taken. As we were interested in estimating changes that occur in plasma lipoproteins and triglycerides within the first year after treatment initiation, we included measurements with a cumulative PI exposure up to a maximum of twelve months. Subjects were considered unexposed thirty days after the last PI was dispensed and, at that time, the cumulative exposure was set to zero.Approximately one-half of HIV-infected patients in BC are followed at one treatment centre located at St. Paul's Hospital, a large teaching hospital in Vancouver. For these subjects, in addition to virological testing, the hospital laboratory records the results of plasma lipoproteins and triglycerides. Subjects were routinely instructed to fast for 12 hours prior to the sample being drawn. Blood samples were collected in 10-1 EDTA-coated vacutainer tubes. Plasma was separated by centrifugation for 10 minutes at 2,000 revolutions per minute. TChol in the plasma was determined using an enzymatic method and plasFor some subjects, the first lipid measurement was taken prior to the dispensation of any antiretroviral drug ("treatment naïve" baseline lipid measurements). Other subjects had their first recorded plasma lipoproteins and triglycerides after HAART was initiated (initiation lipid levels).© function lme(.). An analysis of variance indicated that simple parallel-line models, where the exposure effect was assumed to be constant over subjects, could adequately explain variation in the data compared to more complex models with random slopes. To account for correlated responses due to repeated measurements on the same individual, the correlation structure of the model was specified to include only a random intercept for each subject.We used linear mixed effects models to estimThe following explanatory variables were included in the models: age, sex, and CD4+ T- cell count at PI initiation, concomitant use of NNRTI, and a measure of adherence to antiretroviral therapy. Exposure to NNRTI was considered time-dependent and quantified using the same algorithm that was used to calculate time dependent PI exposure. Adherence was calculated by dividing the number of months of antiretroviral medications dispensed by the number of months of follow-up in the first twelve months after treatment initiation. Incomplete adherence represents the gap between the time that the previous medication supply ran out until the next refill date, and/or until the last contact date with the program. This method is reliably associated with both clinical outcomes and un-timed drug level monitoring,21.For each outcome and associated regression coefficient β, the quantity exp(β)-1 represented the adjusted monthly percent change in that plasma lipid fraction. These values were annualized using the formula exp(12 × β)-1. Ninety five percent confidence intervals (95% CI) for the effect estimates were obtained using the standard error for each regression coefficient.Two sensitivity analyses were conducted. The first analysis involved restricting the analysis to lipid measurements which were taken on subjects prior to any change from baseline antiretroviral therapy. The second sensitivity analysis included only subjects who had lipid measurements taken prior to initiation of therapy.3. All subjects initiated therapy that included a nucleoside analog and a PI.There were 679 subjects who were eligible for analysis, 91% of whom were male  measurements per subject. The median time between lipid measurements was 3 (IQR 2–5) months for all subjects.Table The sensitivity analyses indicated that the models were robust to changes in the sub-population studied and the exposures that were included. In the analysis that included subjects who had a baseline measurement prior to start of HAART, a plasma profile prior to antiretroviral therapy initiation showed a similar pattern but with wider confidence intervals. In the analysis which was restricted to lipid measurements taken on subjects prior to switching from baseline therapy, the effect estimates were similar to those in Table In patients treated for HIV infection with HAART in a naturalistic setting, we observed that treatment with PIs was estimated to result in 20% increases in the levels of total cholesterol, HDL- and LDL-cholesterol and triglycerides twelve months after treatment initiation. Our results contribute to the growing body of evidence implicating PIs in the development of blood lipid abnormalities and are Low HDL levels and other forms of dyslipidemia, and disturbances in glucose metabolism, as well as central obesity, have been shown to be strong independent risk factors for cardiovascular morbidity and mortality in the general population,26. FurtTwo large observational cohort studies, published in 2003, showed discrepant results regarding the risks of cardiovascular disease among persons treated with HAART,30. A reThis study has a number of features that add credence to the results. First, while only based at one hospital, the study population comprised about one-half of the treated population in BC. The study sample had similar demographic composition (age and sex) and CD4+ T-cell count at initiation of therapy as other treated subjects in the province. We believe that these results are therefore generalizable to PI-regimen treated HIV-infected patients in BC, as well as to other target populations with similar demographic characteristics. Second, as all dispensed PIs and other antiretroviral medications are paid for and recorded centrally, there was complete information on all HAART medications available to all study subjects. We adjusted for adherence using each subjects' refill compliance in the first year of treatment. Third, data on the plasma lipid profile, including both lipoproteins and triglycerides, were of high quality. The measurements, while lacking the feature of being taken at uniformly spaced intervals as in closely monitored system such as randomized trial, represent the actual experience in an observational setting. Fourth, the enrollment period lasted over five years, allowing a large sample size. We employed repeated measures analyses to account for the correlated structure of the data.This study was also subject to several limitations. First, lipid measurements were not collected in a predetermined manner as is typical in a prospective research study. Consequently, the timing of measurements was irregular and not all lipid fractions were measured when blood was drawn. Second, despite instructions some subjects may not have fasted for the full 12 hour period prior to blood draws. Non-fasting triglyceride measurements are still useful for predicting cardiovascular disease and death. Third, Due to changes in the HAART regimen that occurred because of resistance, non-compliance, or other reasons, it was not possible to isolate the effect of individual PIs. Over the period under study, most subjects initiating PI-based HAART were prescribed either indinavir or nelfinavir.As PI-based HAART is very effective in increasing survival in HIV-infected patients, discontStatins have been shown to be effective drugs to prevent cardiovascular disease in non-HIV patients. While tFibrates are effective in lowering triglycerides and increasing HDL and have been shown to be effective in HIV patients. DespiteWe conclude that there was an estimated 20% increase in lipoproteins and triglycerides in the first year after initiating PI-based antiretroviral therapy in HIV-infected patients under conditions of standard treatment. Whether these increases continue beyond one year is of considerable interest because lipoproteins and triglycerides are known risk factors for cardiovascular disease. In conjunction with the predominance or men, high rates of smoking, and aging of the treated HIV-positive population, elevated lipoproteins and triglycerides may mean that patients such as these are at elevated risk for cardiovascular events in the future.


In type 2 diabetes, free fatty acids (FFA) accumulate in microvascular cells, but the phenotypic consequences of FFA accumulation in the microvasculature are incompletely understood. Here we investigated whether saturated FFA induce apoptosis in human microvascular mesangial cells and analyzed the signaling pathways involved.Saturated and unsaturated FFA-albumin complexes were added to cultured human mesangial cells, after which the number of apoptotic cells were quantified and the signal transduction pathways involved were delineated.The saturated FFA palmitate and stearate were apoptotic unlike equivalent concentrations of the unsaturated FFA oleate and linoleate. Palmitate-induced apoptosis was potentiated by etomoxir, an inhibitor of mitochondrial β-oxidation, but was prevented by an activator of AMP-kinase, which increases fatty acid β-oxidation. Palmitate stimulated an intrinsic pathway of pro-apoptotic signaling as evidenced by increased mitochondrial release of cytochrome-c and activation of caspase 9. A caspase 9-selective inhibitor blocked caspase 3 activation but incompletely blocked apoptosis in response to palmitate, suggesting an additional caspase 9-independent pathway. Palmitate stimulated mitochondrial release of endonuclease G by a caspase 9-independent mechanism, thereby implicating endonuclease G in caspase 9-indpendent regulation of apoptosis by saturated FFA. We also observed that the unsaturated FFA oleate and linoleate prevented palmitate-induced mitochondrial release of both cytochrome-c and endonuclease G, which resulted in complete protection from palmitate-induced apoptosis.Taken together, these results demonstrate that palmitate stimulates apoptosis by evoking an intrinsic pathway of proapoptotic signaling and identify mitochondrial release of endonuclease G as a key step in proapoptotic signaling by saturated FFA and in the anti-apoptotic actions of unsaturated FFA. Recent evidence suggests that intracellular accumulation of saturated free fatty acids (FFA) in vascular cells contributes to lipid-mediated cellular damage , human active fragment caspase-8 and caspase-2 (BD Biosciences), endonuclease G (Chemicon, Temecula, CA), and β-Actin (Sigma, #A5316). Cell-permeable inhibitors of caspase 9 (Z-LEHD-FMK) and caspase-8 (Z-IETD-FMK) were from R&D systems (Minneapolis, MN). Etomoxir and 5-aminoimidazole-4-carboxamide-1-β-D-ribonucleoside (AICAR) were from Sigma and Toronto Research Chemicals (Ontario, Canada), respectively.Fatty acid-albumin solutions were prepared by the protocol of Spector . BrieflyHuman mesangial cells (HMC), purchased from Cambrex Bioscience Inc. , were maintained in Dulbecco's modified essential medium (Gibco-BRL) supplemented with 17% fetal bovine serum (FBS), 100 U/ml penicillin, 100 μg/ml streptomycin, 5 ng/ml selenite, and 5 μg/ml each of insulin and transferrin. Characterization was performed by phase contrast microscopy and by immunostaining for intermediate filaments and surface antigens as described previously . Briefly3VO4, and 1 μg/ml luepeptin. After adjusting for cell protein (DC Assay, BioRad, Hercules, CA), the amount of cleaved human caspase-3 (Asp 175) was measured by ELISA . For Western blotting of cleaved caspase proteins, the cells were washed with ice cold PBS and scraped in CHAPS extraction buffer(50 mM Pipes/HCI, pH 6.5, 2 mM EDTA, 0.1% Chaps, 20 μg/ml leupeptin, 10 μg/ml pepstatin A, 10 μg/ml aprotinin, 5 mM DTT, 2 mM Na pyrophosphate, 1 mM Na3VO4, and 1 mM NaF) and centrifuged at 2,000 × g for 10 min at 4°C. Protein content in the supernatant was assayed with the DC protein assay. An aliquot of the lysate (25 μg protein) was boiled in SDS sample buffer, resolved on a 4–12% SDS-PAGE gradient gel, and transferred to a 0.2 μm nitrocellulose membrane. After blocking in 5% non-fat dried milk in TBS-T (20 mM Tris-Cl, pH 7.5, 150 mM NaCl, 0.05% Tween 20) for 1 h, the membrane was washed 3 times with TBS-T for 5 min each and incubated overnight at 4°C with primary antibody in 3% BSA in TBS-T. After incubating with suitable HRP-labeled secondary Ab (1:2,000) and extensive washing, the proteins were detected by chemiluminescence with an average exposure ranging from 10–30 sec. As previously described [To measure endogenous levels of cleaved caspase-3, cells were lysed in a buffer containing 20 mM Tris, pH 7.5, 150 mM NaCl, 1 mM EDTA, 1 mM EGTA, 1 % Triton X-100, 2.5 mM Na pyrophosphate, 1 mM β-glycerophosphate, 1 mM Naescribed , the WesTo quantify the number of pyknotic nuclei, HMC on coverslips were washed once with PBS and fixed for 20 min with freshly-prepared 3.7% formaldehyde/20% sucrose in PBS. After washing twice with PBS the HMC were stained with 5 μg/ml Hoechst 33342 (Molecular Probes, Eugene OR) and mounted in Slow Fade Light (Molecular Probes). Using a Nikon Diaphot microscope, the number of pyknotic nuclei were counted and expressed as a percentage of the total number of nuclei counted (n = >300 nuclei per condition).in situ for 10 min at 200 × g and the supernatant gently removed. The monolayer was incubated in lysis buffer for 30 min at room temperature and centrifuged again at 200 × g. The supernatant (i.e., cytosolic fraction) was assayed immediately for nucleosomal fragments.DNA fragmentation was assessed by measuring release of nucleosomal fragments into the cytosol (Cell Death Detection ELISA Plus, Roche). Briefly, HMC in 24-well plates were centrifuged HMC treated with FFA were lysed (20 mM Tris, pH 7.5, 150 mM NaCl, 1.0% Triton X-100) and frozen at -40°C. Equivalent amounts of total HMC protein were added to buffer containing the LEHD caspase 9 peptide substrate linked to a cleavable luciferase substrate, aminoluciferin (Promega). The amount of light produced in a coupled reaction with luciferase was measured once every hour for 3 hours in a Berthold Luminometer. Experiments with increasing amounts of cell protein confirmed that the assay was in the linear range under the conditions described.To analyze cytochrome-c redistribution in HMC treated with FFA, cells were fractionated into cytosol and membrane fractions using 0.05% digitonin in an isotonic sucrose buffer exactly as described by Dong and coworkers . BecauseIntracellular accumulation of long-chain saturated FFA  has been shown to induce apoptosis in several cell types including cardiac myocytes and pancreatic β-cells ,11,13. TWe next investigated the signaling pathways by which palmitate induces apoptosis in HMC. To begin answering this question, we examined activation of initiator caspases associated with different pathways of apoptotic signaling. Cleavage of procaspase zymogens is required to form active heterotetrameric caspase complexes, so we analyzed the time course of caspase cleavage by Western blotting in 3 independent experiments. The p35 cleaved fragment of caspase 9 was elevated in cells treated with palmitate Fig. . After 4To confirm that palmitate activated caspase 9, we used a luminometric caspase 9 substrate to directly measure caspase 9 enzyme activity in cytosolic extracts of HMC. Palmitate at 0.4 mM increased caspase 9 activity 2.2- and 4.8-fold at 24 and 48 h, respectively  declare that they have no competing interests.RM carried out most of the technical studies and helped draft the manuscript. MSS conceived of the study, participated in its design and execution, and helped to draft the manuscript.


In neuropathological processes associated with neutrophilic infiltrates, such as experimental allergic encephalitis and traumatic injury of the brain, the CXC chemokine, macrophage inflammatory protein-2 (MIP-2) is thought to play a pivotal role in the induction and perpetuation of inflammation in the central nervous system (CNS). The origin of MIP-2 in inflammatory disorders of the brain has not been fully defined but astrocytes appear to be a dominant source of this chemokine.Curcumin is a spice principle in, and constitutes approximately 4 percent of, turmeric. Curcumin's immunomodulating and antioxidant activities suggest that it might be a useful adjunct in the treatment of neurodegenerative illnesses characterized by inflammation. Relatively unexplored, but relevant to its potential therapeutic efficacy in neuroinflammatory syndromes is the effect of curcumin on chemokine production. To examine the possibility that curcumin may influence CNS inflammation by mechanisms distinct from its known anti-oxidant activities, we studied the effect of this spice principle on the synthesis of MIP-2 by astrocytes.Primary astrocytes were prepared from neonatal brains of CBA/CaJ mice. The cells were stimulated with lipopolysaccharide in the presence or absence of various amount of curcumin or epigallocatechin gallate. MIP-2 mRNA was analyzed using semi-quantitative PCR and MIP-2 protein production in the culture supernatants was quantified by ELISA. Astrocytes were transfected with a MIP-2 promoter construct, pGL3-MIP-2, and stimulated with lipopolysaccharide in the presence or absence of curcumin.The induction of MIP-2 gene expression and the production of MIP-2 protein were inhibited by curcumin. Curcumin also inhibited lipopolysaccharide-induced transcription of the MIP-2 promoter reporter gene construct in primary astrocytes. However MIP-2 gene induction by lipopolysaccharide was not inhibited by another anti-oxidant, epigallocatechin gallate.Our results indicate that curcumin potently inhibits MIP-2 production at the level of gene transcription and offer further support for its potential use in the treatment of inflammatory conditions of the CNS. As is true of other naturally occurring polyphenolic compounds, such as caffeic acid phenyl ester, rosmaric acid and resveratrol, curcumin possesses antioxidant properties which may reduce the production of free radicals and improve cell viability under conditions of enhanced oxidative stress. CurcumiCurcumin's immunomodulating and antioxidant activities suggest that it might be a useful adjunct in the treatment of neurodegenerative illnesses characterized by inflammation such as Alzheimer's disease. RelativTo explore the possibility that curcumin may influence CNS inflammation by mechanisms distinct from its antioxidant and known anti-inflammatory activities, we examined the effect of this spice principle on the synthesis of MIP-2 by astrocytes. Our results indicate that curcumin potently inhibits MIP-2 production at the level of gene transcription and offer further support for its potential use in the treatment of inflammatory conditions of the CNS.Six to eight-week-old CBA/CaJ mice were purchased from Jackson Laboratories (Bar Harbor, ME) and bred in our animal facility.E. coli lipopolysaccharide  were purchased from Sigma, (St Louis, MO). Rabbit anti-cow glial fibrillary acidic protein polyclonal antibody was obtained from Dako Corp. (Carpinteria, CA).Curcumin, epigallocatechin (EGCG) and g. The pellet was suspended in Hank's Buffered Salt Solution (HBSS) and debris was removed by gravity sedimentation on ice for 3 min. The supernatant was collected, centrifuged and the pellet was washed twice with culture medium consisting of DMEM containing 10% heat-inactivated fetal bovine serum (Hyclone, Logan, UT), 1 mM L-glutamate and penicillin/streptomycin (Gibco BRL, Grand Island, NY). The cells were plated on 35 mm dishes and cultured at 37°C in a humidified atmosphere contain 5% C02. After 16 hours, plates were washed to remove non-adherent cells and debris. For experiments in which mRNA or MIP-2 protein were quantified, adherent cells were cultured until they reached confluence. For transfection experiments, adherent cells were cultured until they were nearly confluent. Medium was refreshed in all astrocyte cultures every 2–3 days. The preparations were >98% glial fibrillary acidic protein positive, as measured by flow cytometric analyses using a EPICS XL flow cytometer[Preparation and culture of astrocytes: Astrocytes were prepared from the brains of neonatal (3 to 7-day-old) CBA/CaJ mice by a modification of the method of Pousset et al. Brieflycytometer.4 M to 10-6 M) for up to 48 hours, the supernatants were then harvested and LDH was measured by colorimetric assay using a kit from Sigma diagnostics.Cell viability determination: The effect of curcumin on the viability of astrocytes was assessed by measuring cytosolic lactate dehydrogenase (LDH) leakage into the media as detailed earlier. Briefly4 M to10-7 M). After 4 hours of culture, cells were harvested and mRNA was isolated as previously reported[3M to 10-4M). To assess the effect of curcumin on MIP-2 protein production, astrocytes were cultured with LPS in the presence or absence of curcumin (10-5M) for 16 hours. Supernatants were then harvested and MIP-2 levels were determined by enzyme linked immunosorbant assay .mRNA and protein analyses: Confluent cultures of astrocytes were incubated with LPS (10 ηg to 5 μg/ml) for varying periods of time in the presence or absence of curcumin (10- reported. MIP-2 m reported using thPreparation of the reporter gene, pGL3-MIP-2: A 537 base pair MIP-2 fragment was prepared by amplifying rat genomic (kidney) DNA using the primers: 5'GCCCACCGAGTCTCTGTTTC3' (forward) and 5'GTTGGTGGCCAGCAGGAGGA3' (backward), then digesting with Rsa I/Nco I. The fragment, which corresponded to base pairs -539 to -2, relative to adenine (assigned +1) in the translation initiation codon of the MIP-2 gene (accession number AJ49888), was ligated to a Sma I/Nco I digested, promoterless luciferase reporter vector, pGL3-Basic (Promega, Madison, WI). The direction of the insert was confirmed by restriction endonuclease digestion and its fidelity determined by sequence analyses as previously described. The MIP4M to 10-7M) was then added and transfected cells were further cultured for 24 hours. At the conclusion of culture, cells were harvested, cell lysates were prepared, and lysates were analyzed using a luciferase assay system (Promega, Madison, WI) in accordance with the manufacturer's instructions.Transfection experiments: Astrocytes were transfected cells using a modification of the method of Franzoso et al. Briefly5M) that had no effect on viability as measured by LDH release (data not shown), abrogated LPS-stimulated MIP-2 production . Culturing such astrocytes with a dose of curcumin (10-5M) markedly inhibited chemokine gene expression in response to LPS . As was true for MIP-2 protein, culture of astrocytes with curcumin , were fused to a promoter-less luciferase reporter gene , induces the release of MIP-2 within 4 to 8 hours of o culture. Since T2 production in blood samples taken 1 hour after dose on days 1 and 29 of treatment by approximately 60%[Apart from its ability to inhibit MIP-2 production, curcumin's pleotropic antiinflammatory and anti-oxidative properties suggest its possible use in diseases of the brain accompanied by inflammation. Thus, LPS stimulation transcriptionally upregulates inducible nitric oxide synthase and cyclooxygenase-2 genes in microglia. This leads to the synthesis of nitric oxide (NO) and prostaglandins (PGs), respectively, and the possible formation of neuron-damaging free radicals, such as peroxynitrite. Curcumin abrogates the production of both NO and PGs in LPS activated microglial cells. In a reately 60%. Consistately 60%, and to ately 60%.In summary, the capacity of curcumin to inhibit astrocyte production of MIP-2, together with its broad immunosuppressive activities, strongly support the potential use of this spice principle in the treatment of inflammatory diseases of the CNS.EAE, experimental allergic encephalitis; EGCG, epigallocatechin gallate; LDH, lactate dehydrogenase; LPS, lipopolysaccharide; MIP-2, macrophage inflammatory protein-2; NFκB, nuclear factor kappa B; NO, nitric oxide; PG, prostaglandin;pGL3-MIP-2, a reporter gene construct containing the MIP-2 promoter; PMN, polymorphonuclear leukocyte; TBI, traumatic brain injury; TNFα, tumor necrosis factor alpha.The author(s) declare that they have no competing interests.MT participated in experimental design, acquisition of data, supervised all experiments, and carried out isolation of astrocytes, ELISA and transfection assays.BH isolated and amplified the MIP-2 gene promoter, and generated the MIP-2 promoter construct, pGL3-MIP-2.CS participated in culture of astrocytes and PCR analysis of MIP-2 gene.TS conceived of the study, participated in its design, and helped to draft the manuscript.All authors read and approved the final manuscript.