The International Network for the Availability of Scientific Publications (INASP) was established in 1992 to bridge the information divide between the developed and developing world Since 1992 INASP has worked, in response to requests, to develop its activities for capacity building in information production, access, and use, with an overarching vision that all people are able to access and contribute information, ideas, and knowledge necessary for sustainable and equitable development.To ensure that INASP activities are appropriate for the communities and cultures of the countries in which INASP works, local partners are used to build networks and to provide advice and support. Enhancing capacities is central to all activities, and local ownership and sensitivity to local conditions and opinions are of paramount importance. Here I highlight two aspects of our work: increasing access to information and supporting the visibility of regional journals within the global research community.The growth and acceptability of the internet during the 1990s opened up tremendous possibilities for the dissemination of research information, providing many nations with access to information that had previously been out of their reach. Although internet connectivity remains problematic in many countries, it still offers great potential for bridging the information gap.Arising from discussions with librarians and researchers in 1999 and 2000, the Programme for the Enhancement of Research Information was formally launched in 2002 after a two-year pilot programme. The Programme for the Enhancement of Research Information works in a two-phase manner: (1) providing and supporting access to international research information and (2) supporting and promoting access to nationally published research.To support access to international information, INASP negotiates for heavily discounted or free access to online information from publishers and information providers in developed countries. Enabling access, however, does not guarantee that resources are used; both training and promotion are needed so that researchers and downstream information providers know how to make the best use of what is available. With this in mind, INASP has set up four series of training workshops, which have trained over 1,000 people from over 200 institutions in over 17 countries during the last two years. Although some of the training is undertaken by INASP staff, most is facilitated by in-country trainers.Planning for long-term sustainability, INASP aims to hand over the tasks of negotiation, purchasing, and training to local consortia, associations, or networks.Although much needed, access to international resources can discriminate against nationally published scholarly information. This may be due to one of the following: a perception that local publications are lower quality, distribution problems and irregular publishing, or lack of online visibility. However, national publications provide vital access to potential collaborators and information about research on topics of local relevance—since 1998, INASP has provided support to indigenous research publications to enable them to survive and coexist with international information.One specific project that exemplifies these aims is known as African Journals OnLine (AJOL). AJOL launched in 1998 in response to requests from African journals. Starting with only ten titles, it now includes 189 from 21 African countries. Access to the site, which includes tables of contents, article abstracts, and a homepage for each journal with information about editorial boards, guidelines for authors, and more, is entirely free. Participating journals report increased international submissions and increasing contact with international researchers.Researchers make wide use of this service, and over 8,000 people have registered to use AJOL since it launched. Registration is optional and until March this year did not provide the user any benefit—it simply provided an indication of the number of people visiting and from which countries. However, since March 2004 anyone who registers can sign up to receive a free E-mail table of contents alert. Over 500 people have chosen to receive E-mail alerts from an average of four journals each, and the effect of these alerts is felt through the increase in document delivery requests.AJOL does not currently host full text, but can provide full-text articles through a document delivery service (there are plans to load full-text articles on AJOL in the future). This service is provided to researchers from developing countries for free and to researchers elsewhere at a minimal charge . In the first six months of 2004, over 700 articles were ordered and sent out.Most journals publishing out of Africa are not run by commercial publishers, and most of them operate at a loss, subsidised by universities, associations, funding agencies, or a mixture of all three. Paid subscriptions to print journals are frequently a vital part of their economics, and the financial viability of many journals is constantly under threat. Originally, it was hoped that AJOL would increase subscriptions, thereby providing greater financial security to the journals. This has not been achieved and is unlikely to occur in the future. However, with increasing visibility, the value of the journals increases along with, hopefully, their importance to the supporting agencies and long-term sustainability.Since AJOL is set up to provide support for the participating journals, the journals' opinions are constantly sought before any developments are undertaken, meaning AJOL is effectively “owned” by them. Although the service is not actively run by the journals themselves, all participating journals are considered to be part of a community, receiving regular E-mail contact and skills support. Many journal editors  feel isolated and unskilled, and even though AJOL does not operate as an association for the journals, it encourages communication between the editors, and a sharing of experience.The AJOL website was relaunched in March 2004 using open-source software called Open Journal System, originally developed in Canada by the Public Knowledge Project at the University of British Columbia and further developed for AJOL at Bristol University, United Kingdom. This software was written to enable a single journal to manage the entire publishing process online from submission to publishing. Being open source, the software can also easily be adapted and modified. The Public Knowledge Project set up the system with the developing world in mind: it operates efficiently at low bandwidths and is easy to use, with many guides and help functions built in.For the users, this software offers sophisticated searching, E-mail alerts, and a space for each journal within AJOL for journal-specific information. It also now provides a range of management tools, which makes the service more efficient and enables it to grow.Another important consideration for choosing this system was that individual journals can take over the responsibility for maintaining their own journal areas within AJOL via the Internet. Over 50 journals have expressed an interest in taking this on, and one publisher is already successfully maintaining its material. To support this, training workshops are currently in preparation. This development will assist the long-term sustainability of AJOL and also give the participating journals experience in managing and publishing content online.In the near future, INASP will be including full text on AJOL and hopes to move the management of AJOL to an African organisation so that it will truly become an African gateway for published research. In addition, INASP continues to work with journals to strengthen their quality and sustainability, providing advice, training workshops, study tours, and a coordinating point for discussion and collaboration.Outside Africa, INASP is working on similar developments in Nepal and the Caribbean and has received expressions of interest from Bangladesh, Sri Lanka, and Vietnam.It is vital that researchers everywhere in the world have access to reliable, relevant information. At the same time, providing access to international literature needs to be balanced with supporting local publications to ensure that indigenous knowledge is not lost, but can take its place in the research community and contribute to the continuing development of science. Worldwide access to information is central to all INASP activities, and INASP supports policies and activities that work towards this.http://www.inasp.infoINASP: http://www.ajol.infoAJOL: http://pkp.ubc.caPublic Knowledge Project:


In vitro, TRAIL-mediated apoptosis of prostate cancer cell lines can be enhanced by doxorubicin and correlates with the downregulation of the anti-apoptotic protein c-FLIP. This study evaluated the effects of doxorubicin on c-FLIP expression and tumor growth in combination with Apo2L/TRAIL in a xenograft model.Prostate cancer is a significant health problem among American men. Treatment strategies for androgen-independent cancer are currently not available. Tumor necrosis factor-related apoptosis-inducing ligand (Apo2L/TRAIL) is a death receptor ligand that can induce apoptosis in a variety of cancer cell lines, including androgen-independent PC3 prostate carcinoma cells. In vitro cytotoxic effects of TRAIL were measured using a MTS-based viability assay. For in vivo studies, PC3 prostate carcinoma cells were grown subcutaneously in athymic nude mice and tumor growth was measured following treatment with doxorubicin and/or Apo2L/TRAIL. c-FLIP expression was determined by western blot analysis. Apoptosis in xenografts was detected using TUNEL. Statistical analysis was performed using the student t-test.In vitro experiments show that PC3 cells are partially susceptible to Apo2L/TRAIL and that susceptibility is enhanced by doxorubicin. In mice, doxorubicin did not significantly affect the growth of PC3 xenografts but reduced c-FLIP expression in tumors. Expression of c-FLIP in mouse heart was decreased only at the high doxorubicin concentration (8 mg/kg). Combination of doxorubicin with Apo2L/TRAIL resulted in more apoptotic cell death and tumor growth inhibition than Apo2L/TRAIL alone.in vivo than either agent alone and could present a novel treatment strategy against hormone-refractory prostate cancer. The intracellular mechanism by which doxorubicin enhances the effect of Apo2L/TRAIL on PC3 xenografts may be by reducing expression of c-FLIP.Combination of doxorubicin and Apo2L/TRAIL is more effective in growth inhibition of PC3 xenografts  Prostate cancer is a significant health problem among American men. This year about 230,110 men will be diagnosed with the disease and about 30,000 will likely die in this country alone  reagent was added 24 hours after initiation of treatment and plates read at an absorbance of 490 nm one to two hours later using a Vmax kinetic microplate reader . All treatments were performed in triplicate. Background absorbance was determined by incubating media with substrate alone and subtracting the values from wells containing cells. Percent cytotoxicity was calculated as follows: % cytotoxicity = 1 - [ × 100]. Experiments were repeated three times with similar results. There were no discrepancies between results obtained in the MTS assay and visual assessment of the cells prior to adding the MTS reagent.Cells were seeded into 96-well plates at 1 × 106) were injected subcutaneously into the flanks of mice. Animals bearing tumors were randomly assigned to treatment groups (five or six mice per group) and treatment initated when xenografts reached volumes of about 100 mm3. Tumors were measured using digital calipers and volume calculated using the formula: Volume = Width2 × Length × 0.52, where width represents the shorter dimension of the tumor. Treatments were administered as indicated using vehicle (PBS containing 0.1% BSA), doxorubicin (2–8 mg/kg), Apo2L/TRAIL , or a combination of 4 mg/kg doxorubicin followed by 500 μg Apo2L/TRAIL. Doxorubicin was administered systemically whereas Apo2L/TRAIL was given either intra-tumorally  were purchased from Harlan, Indianapolis IN and were housed under pathogen-free conditions according to Medical University of South Carolina animal care guidelines. All animal experiments were reviewed and approved by the Institutional Animal Care and Use Committee at MUSC. PC3 cells  prior to performing protein assays on the supernatant. Protein (50 μg) was separated on 4–12% Bis/Tris NuPage gels in MES buffer and transferred to nitrocellulose for 60–90 minutes at 30 V. After transfer and blocking (5% milk), blots were probed with Dave-2 (1:500 in 0.5 % milk) or NF-6 (1:5 in TBS-Tween) overnight at room temperature. Following three washes with TBS-Tween, membranes were incubated with the anti-mouse  or anti-rat  HRP-conjugated secondary antibodies for 1 hour at room temperature in 5% milk in TBS-Tween. Membranes were washed three times in TBS-Tween followed by chemiluminescent detection of the secondary conjugates with DuraWest Supersignal. Membranes were reprobed with anti-actin (1:2000) to ensure equal loading.Tumors were excised and fixed in 10% formalin and processed by standard procedures. Sections were analysed for apoptotic cells using the DeadEND Tunel kit according to the manufacturers instructions. Stained slides were examined for TUNEL positive cells using a Zeiss Axiovert 200 microscope (20×). TUNEL positive cells from 4 fields/slide were counted by two investigators to calculate the mean ± SEM. P-values were calculated using the student's t-test.We have previously shown that the TRAIL apoptotic response in prostate cancer cells can be enhanced by doxorubicin ,15. Thesin vitro. As shown in Figure Initially we compared the susceptibility of PC3 prostate carcinoma cells to KillerTRAIL and Apo2L/TRAIL in parallel assays in vivo experiments, mice bearing PC3 xenografts were injected with 2, 4 or 8 mg/kg doxorubicin and tumor volume was measured over time  was not diminished following doxorubicin treatment, whereas the signal of the upper band (c-FLIPL) was slightly reduced following administration of 8 mg/kg doxorubicin. Since 4 mg/kg doxorubicin reduced c-FLIP in PC3 xenografts as effectively as 8 mg/kg without affecting endogenous mouse c-FLIP, this dose was chosen for combination therapy.Previously, we have examined possible targets of doxorubicin that may be responsible for increasing the susceptibility of prostate cancer cells to TRAIL d c-FLIP . In PC3 in vivo following treatments, mice bearing bilateral PC3 xenografts were injected systemically with vehicle or 4 mg/kg doxorubicin, followed by intratumoral injection of vehicle (left tumor) or Apo2L/TRAIL (right tumor). Twenty-four hours after Apo2L/TRAIL injection, tumors were harvested and analysed for apoptosis by TUNEL staining , which was not significantly different from the control group . Tumors in animals treated with Apo2L/TRAIL were reduced compared to either untreated or doxorubicin treated groups . However, tumors that had been exposed to both doxorubicin and Apo2L/TRAIL were significantly smaller  and remained smaller at day 33 (490 ± 197 mm3) when the experiment was terminated. Analysis of tumor volume over time suggests that a single round of combination treatment delays growth until day 26  declare that they have no competing interestsAZ carried out the animal experiments using doxorubicin and Apo2L/TRAIL and TUNEL staining. JM carried out the animal experiments using doxorubicin. CVJ carried out viability assays and western blot analysis, conceived of the study, participated in its design and coordination, and prepared the manuscript. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:


PK2) is a clock-controlled gene that may function as a critical SCN output molecule responsible for circadian locomotor rhythms. As light is the principal zeitgeber that entrains the circadian oscillator, and PK2 expression is responsive to nocturnal light pulses, we further investigated the effects of light on the molecular rhythm of PK2 in the SCN. In particular, we examined how PK2 responds to shifts of light/dark cycles and changes in photoperiod. We also investigated which photoreceptors are responsible for the light-induced PK2 expression in the SCN. To determine whether light requires an intact functional circadian pacemaker to regulate PK2, we examined PK2 expression in cryptochrome1,2-deficient (Cry1-/-Cry2-/-) mice that lack functional circadian clock under normal light/dark cycles and constant darkness.The suprachiasmatic nucleus (SCN) contains the master circadian clock that regulates daily rhythms of many physiological and behavioural processes in mammals. Previously we have shown that prokineticin 2 (PK2 expression exhibits transients in response to phase advances but rapidly entrains to phase delays. Photoperiod studies indicate that PK2 responds differentially to changes in light period. Although the phase of PK2 expression expands as the light period increases, decreasing light period does not further condense the phase of PK2 expression. Genetic knockout studies revealed that functional melanopsin and rod-cone photoreceptive systems are required for the light-inducibility of PK2. In Cry1-/-Cry2-/- mice that lack a functional circadian clock, a low amplitude PK2 rhythm is detected under light/dark conditions, but not in constant darkness. This suggests that light can directly regulate PK2 expression in the SCN.Upon abrupt shifts of the light/dark cycle, PK2 in the SCN is regulated by both the circadian clock and light. PK2 is predominantly controlled by the endogenous circadian clock, while light plays a modulatory role. The Cry1-/-Cry2-/- mice studies reveal a light-driven PK2 rhythm, indicating that light can induce PK2 expression independent of the circadian oscillator. The light inducibility of PK2 suggests that in addition to its role in clock-driven rhythms of locomotor behaviour, PK2 may also participate in the photic entrainment of circadian locomotor rhythms.These data demonstrate that the molecular rhythm of  Per1 and Per2, as well as immediate-early gene c-fos. Exposure to light pulses at night induces expression of these genes in the SCN, and this light induction mechanism has been suggested as a critical pathway for the resetting of circadian clock in response to changes in light/dark conditions [Light is the principal zeitgeber that entrains circadian rhythms of physiology and behaviour ,2. The mnditions -19. Intenditions .Cry1-/-Cry2-/-) mice, which are behaviourally arrhythmic under constant darkness. The contribution of masking to normal locomotor activity rhythms is unclear, as is the participation of the SCN in masking effects of light. Vitaterna et al (1999) first observed a light-driven Per2 rhythm in the SCN in Cry1-/-Cry2-/- mice, and have suggested that the light-driven molecular rhythm in the SCN may be related to the preservation of their locomotor rhythm [In addition to the effect of light on circadian entrainment, light also has a direct effect on physiology and behaviour, generally termed as "masking" ,22. For r rhythm .PK2) is a first order clock-controlled gene, whose expression in the SCN is regulated by CLOCK and BMAL1 acting on the E-boxes in the gene's promoter [PK2 expression is rapidly induced by light pulses administered at night [PK2 expression in the SCN. In particular, we investigated the photoreceptive mechanisms responsible for the light-induced PK2 expression in the SCN. Utilizing Cry1-/-Cry2-/- mice, we also determined whether light can drive PK2 expression in the SCN independent of a functional circadian clock.We previously found that prokineticin 2 , then subjected to either a 6 hour delay (6hrD) shift or 6 hour advance (6hrA) shift of light/dark cycles. We measured PK2 mRNA in the SCN of these animals to examine how quickly the PK2 mRNA rhythm re-entrains to the shifted light/dark cycles. Under LD, PK2 mRNA peaks during the day and remains low or undetectable during the night. During the first cycle of the delayed shift (6hrD), the PK2 mRNA rhythm responds quickly: the rising phase of PK2 expression adjusts rapidly to the delayed light/dark cycles, while the falling phase still resembles that of the unshifted light/dark cycles . During the first cycle of the advance shift, the PK2 oscillation pattern remains similar to that of the unshifted LD , 16 hour light: 8 hour dark (16L:8D), or 20 hour light: 4 hour dark (20L:4D). During 12L:12D, PK2 mRNA is highly expressed during the 12 hour light phase with peak level at ZT4 , as PK2 mRNA rises before lights on and persists after lights off  is very similar to that observed under 12L:12D  than in shorter days (8L:16D)   Figure , further) Figure . We alsoe Figure . Under td Figure . As it hoperiods -35, we hdies see . The PerPK2 molecular rhythm is normally entrained in melanopsin-deficient (Opn4-/-) mice. Figure PK2 in the SCN of Opn4-/- mice is essentially identical to that observed in the wild type mice under LD. This normal temporal profile of PK2 mRNA corresponds with the normal locomotor rhythm of Opn4-/- mice under light/dark conditions [Opn4-/- mice display attenuated phase resetting in response to light pulses and exhibit impaired light masking responses to bright light [PK2 is blunted in Opn4-/- mice. Figure PK2 in the SCN of Opn4-/- mice was significantly reduced by about 50% and 60%, one and two hours after the light pulse, respectively.As melanopsin has been implicated in circadian photoreception -11, we enditions ,8. As Opht light , we alsoOpn4-/- light pulse studies show that a residual PK2 expression is still present after a light pulse, suggesting that without melanopsin, other phototransduction system can still transmit light information to induce PK2 expression. Thus, we decided to examine the light inducibility of PK2 in triple knockout mice lacking melanopsin, rod and cone phototransduction systems (Opn4-/- Gnat1-/- Cnga3-/- mice), as these animals free run under light dark conditions (LD) and lack masking responses to light [PK2 in the SCN is completely eliminated in these triple knockout mice, consistent with their malfunctioning photoentrainment systems and their lack of masking responses to light [PK2 mRNA followed the free-running locomotor rhythms in these triple knockout mice  and low levels during active phase (CT15). Together, these results suggest that melanopsin contributes to the light inducibility of PK2, and intact melanopsin with functional rod/cone phototransduction systems are required for the light inducibility of PK2.The to light . Figure to light . In addie Figure , with hiPer2 rhythm is maintained in the SCN of cryptochrome-deficient (Cry1-/-Cry2-/-) mice that lack functional circadian clock [PK2, Per1, Per2 and Bmal1 expression by light requires an intact circadian pacemaker, we systematically assessed the temporal mRNA profiles of clockwork genes in Cry1-/-Cry2-/- mice under both light/dark (LD) and constant dark (DD) conditions. Figure Per2 remained largely intact in Cry1-/-Cry2-/- mice entrained under12L:12D, with levels about 4-fold higher during the light phase than the dark phase. This amplitude of the Per2 oscillation profile was similar to that observed in wild type mice [Per1 rhythm in Cry1-/-Cry2-/ mice was also apparent under LD, but not DD . As PK2 remains responsive to light in these clock mutant mice that lack functional circadian clock, it is likely that the low amplitude PK2 rhythm in Cry1-/-Cry2-/- mice under LD is directly driven by light.We also examined the molecular rhythm of hase see . Similar Figure. . No PK2 D Figure . Further4 Figure . NeverthPK2 rhythm may be related to the maintenance of behavioural rhythms observed in Cry1-/-Cry2-/- mice under LD, we studied the responses of Cry1-/-Cry2-/- mice to a 6 hour advance of lighting schedule. In contrast to the transients of entrainment of locomotor rhythms in wild type mice (which takes about 4-5 days to re-entrain to phase advance), the locomotor activity of Cry1-/-Cry2-/- mice adjusted rapidly to 6 hr advance   Figure . As the L:4D see , it is lCry1-/-Cry2-/- mice revealed the presence of a light-driven PK2 molecular rhythm in the SCN under LD, indicating that light can drive PK2 rhythm independent of functional circadian clock. Interestingly, the molecular rhythms of some clockwork genes such as Per2, Per1, and Bmal1 were also partially maintained in the SCN of Cry1-/-Cry2-/- mice under LD  in the promoter of the PK2 gene [PK2 in mutant mice that lack functional clock may indicate that CRE-dependent pathway and CLK/BMAL1 transcriptional factors may interact in the light-induced PK2 expression in the SCN. Accumulative data have implicated the photic regulation of the transcription of clock genes such as Per1 and Per2 in the entrainment of behavioural rhythms [Per1 promoter, whose activation in the SCN shifts rapidly when the LD cycle is advanced [PK2 exhibits transients during phase advance, more similar to those of Cry1 and Cry2 [Per1 or Per2. The presence of E box motifs in the PK2 promoter suggests that light-regulated Per1 (and perhaps Per2) expression can influence PK2 expression. However, the light inducibility of PK2 indicates that PK2 may have a more direct and central role in entrainment in addition to its putative role as an SCN output signal. In other words, whether PK2 functions completely outside the central circadian loops or partly within them has yet to be determined. It is well established that the activation of glutamate receptor and its downstream actions are critical for the retinohypothalamic inputs of light to the SCN [PK2 may be relevant to both the phase resetting of the core circadian loops and critical SCN output signals.The light inducibility of 2 Figure . The samPK2 gene . CRE-depPK2 gene -48. The  rhythms ,34. The advanced , PK2 exhand Cry2 ,31. This the SCN . As rece the SCN  and acti the SCN , it is p the SCN , furtherPK2 is predominantly driven by the circadian clock, as PK2 expression exhibits circadian transients in response to phase advances. Furthermore, shortening of the light period does not result in corresponding reduction of the phase of PK2 rhythm, also consistent with the dominant control from the circadian clock on PK2 expression. However, light also modulates PK2 rhythm. Nocturnal light pulses can directly induce PK2 expression in the SCN. Studies with Cry1-/-Cry2-/- mice revealed that light can drive a low amplitude PK2 molecular rhythm in the SCN in the absence of functional circadian oscillators. These studies demonstrate that PK2 molecular rhythm in the SCN is controlled by dual mechanisms: dominantly by the circadian transcriptional loops but also directly by light. The light inducibility of PK2 in the SCN suggest that in addition to PK2's role as a SCN output signal, PK2 may also participate in the photic entrainment of circadian clock and perhaps in masking.Our studies demonstrate that PK2 expression two days after the shift, animals were placed in two additional light/dark cycles and brain samples were collected. All animal procedures were approved by the Institutional Animal Care and Use Committee and consistent with Federal guidelines. In situ hybridization was used in all studies to examine PK2 mRNA expression in the SCN [PK2 (accession number AF487280 1-528 nt), mouse Per1 (accession number AF022992 340-761nt), mouse Per2 (accession number AF035830 9-489 nt) and mouse Bmal1 (accession number AB015203 864-1362 nt) were generated.Male adult C57BL/6 mice  were entrained under 12 hour light: 12 hour dark  cycle for two weeks with food and water available ad libitum. Light phase was either delayed by 6 hours (lights on at 1300 h) or advanced by 6 hours (lights on at 0100 h) and samples were taken every three hours for the 24 hour period . To examine  the SCN . AntisenAnimals were initially entrained under 12L:12D for one week, followed by placement in different photoperiods (light intensity ~400 lux) for three to four weeks: 8 hour light:16 hour dark , 16 hour light: 8 hour dark . For the 20 hour light: 4 hour dark , animals were first placed in 14L:10D for one week, transferred to 16L:8D for another week, followed by two weeks in 20L:4D. All brain samples were taken every two hours throughout the 24 hour cycle, except the first and the last two time points which were sampled every three hours.Opn4-/-) mice (on C57BL/6:129 hybrid background) [Opn4-/- mice and triple knockouts (Opn4-/- Gnat1-/- Cnga3-/- mice) that lack melanopsin, rod and cone phototransduction systems were used [Wild type and melanopsin-deficient  mice on a C57BL/6:129 hybrid background were kindly provided by Dr. Aziz Sancar (University of North Carolina at Chapel Hill). Wild type and Cry1-/-Cry2-/- mice were entrained to 12L:12D and sampled every three hours for the 24 hour period (ZT1-22). A second group of Cry1-/-Cry2-/- mice were placed into two days of constant darkness (2DD) . The mRNA levels of PK2, Per2, Per1 and Bmal1 were measured in the SCN. For light pulse experiments, Cry1-/-Cry2-/- mice received a 15 min light pulse (~400 lux) at ZT14, and sampled one or two hours after light pulse. Dark control Cry1-/-Cry2-/- mice did not receive a light pulse. For the shifting experiments, wildtype and Cry1-/-Cry2-/- mice were initially entrained under 12L:12D, then subjected to an acute 6 hour advance of lighting schedule. Running-wheel activities of these mice were monitored 10 days before and 10 days after the 6 hour advance shift. The 6 hour phase advance was then repeated and brains were collected at ZT4 and ZT16 on the day of the shift.Cryptochrome-deficient  and Per2 (b) mRNA under 8L:16D, 16L:8D, 20L:4D. Open and filled bars indicate light and dark periods, respectively. The zeitgeber time (ZT) on the x-axis reflects the timescale for each photoperiod. Each value represents the mean ± SEM of 3–4 animals.Click here for filePK2 mRNA expression in Cry1-/-Cry2-/- and wildtype mice. Representative autoradiograms of PK2 mRNA in the SCN of Cry1-/-Cry2-/- mice (Cry) and wild type mice (WT) under LD (ZT1-22) are shown . Scale bar = 1 mm.Click here for file


The Medical Library Association converts access to information into access to knowledge in a networked environment of digital resources Access to PMC is free and unrestricted. Recently, NLM, working with MLA headquarters, made the full-text archives of BMLA from 1911 onward available online through PMC. This is an excellent resource for the study of health information sciences and the management of knowledge-based information, putting into practice MLA's belief in open access. The association has supported open access to information in several other ways, including memberships in the Scholarly Publishing and Academic Resources Coalition (SPARC) and the Information Access Alliance (IAA). MLA's statement on open access, found at http://www.mlanet.org/government/info_access/openaccess_statement.html, defines the association's position on this important topic.For over 100 years, the Medical Library Association (MLA) has upheld the belief that quality information is essential for improved health and has worked to ensure that health sciences librarians have the skills, knowledge, and leadership necessary for the delivery of information in a biomedical setting. The association has also promoted the concept of unrestricted, affordable, and permanent access of health information worldwide. For example, MLA's peer-reviewed User's Guide to Finding and Evaluating Health Information on the Web for the Pew Internet and American Life Project. The guide provides access and evaluation guidelines and MLA's top ten most useful Web sites, as well as lists of top Web sites for cancer, diabetes, and heart disease.However, open access increases the need for more sophisticated information management tools and systems, such as quality filtering and customization of clinical and research information at the point of need and decision-making. MLA is pursuing a number of initiatives that address the specific information needs of clinicians, healthcare students, biomedical researchers, and institutional leaders. Our members are excited to be in a unique position to develop tools, resources, and advice on how to find relevant information on the Internet. For example, MLA members have developed a http://www.mlanet.org/resources/expert_search/) and the provision of continuing education opportunities in this area (see http://www.mlanet.org/education/telecon/ebhc/index.html). These techniques identify best practices and cutting-edge clinical and research knowledge and cull through a sometimes overwhelming amount of medical literature that continues to grow exponentially. MLA's work in the area of expert searching was prompted by the increased emphasis on evidence-based practice by the Institute of Medicine. This, along with the publicity following the unfortunate death of a healthy research volunteer at Johns Hopkins about the need for more vigilance in maintaining the quality of literature searching, has created a renewed interest in the knowledge base and skill set required for expert literature searching and expert consultation. The use of evidence- or knowledge-based information retrieved through the expert searching process can help insure the clinical, administrative, educational, and research success and positive performance of the individual healthcare provider as well as the hospital or academic health center.MLA is furthering the concept of evidence-based medicine through its exploration and definition of expert searching techniques (see http://www.mlanet.org/research/informationist/). Librarians are being recruited to join clinical and research teams as clinical medical librarians and information specialists in context and to provide expert consultation on issues ranging from informatics literacy to evidence-based medicine classes.In addition to retrieving the best evidence, it is also important to deliver knowledge and services within the specialized context to patient care, research, and learning. MLA's exploration, along with NLM, of the informationist concept, i.e., specialist librarians who blend the knowledge and skills of both the clinical and information sciences, is defining new roles for librarians for providing filtered and customized clinical/research information at the point of need and decision-making  to stress the importance of “information” in health literacy. The association defines health information literacy as the set of abilities needed to recognize a health information need; to identify likely information sources and use them to retrieve relevant information; to assess the quality of the information and its applicability to a specific situation; and to analyze, understand, and use the information to make good health decisions. MLA has also developed a resources Web site for health consumers at http://www.mlanet.org/resources/consumr_index.html and http://caphis.mlanet.org/consumer/index.html that helps them find quality health information on the Web. These tools are publicly available to anyone in the world at any time.Besides health-care providers, millions of consumers search for health information on the Web every year. Recognizing the documented difficulties and frustrations health professionals and consumers face in coping with the barrage of available information in a way that results in informed healthcare decisions, MLA has established its health information literacy program (see MLA recognizes that this is a time of rapid change in our society in which the availability of digital resources in a networked environment provides unprecedented opportunities for more open access to the scientific and medical literature. As health sciences librarians, we are excited about the potential to serve a much wider group of international consumers, ranging from medical researchers to patients and their relatives. We will continue to work to convert access to information into access to knowledge.


Exhaustive methods of sequence alignment are accurate but slow, whereas heuristic approaches run quickly, but their complexity makes them more difficult to implement. We introduce bounded sparse dynamic programming (BSDP) to allow rapid approximation to exhaustive alignment. This is used within a framework whereby the alignment algorithms are described in terms of their underlying model, to allow automated development of efficient heuristic implementations which may be applied to a general set of sequence comparison problems.The speed and accuracy of this approach compares favourably with existing methods. Examples of its use in the context of genome annotation are given.This system allows rapid implementation of heuristics approximating to many complex alignment models, and has been incorporated into the freely available sequence alignment program, exonerate. George Box  once rem"All models are wrong, but some are useful."useful in the context of large scale analyses.This statement bears much relevance to biological sequence alignment, where there is no guarantee that the alignment model will accurately represent the evolutionary (or other) processes which separated the two sequences. All that is certain is that exhaustive dynamic programming (DP) algorithms (such as Smith-Waterman ) will yiTransformation between a finite state automata describing an alignment model and the recurrence relations used in DP is a powerful technique ,5 as it The availability of vast amounts of sequence data has generated a need for faster alignment algorithms . Many ofThe alignment program FASTA , generatautomated generation of heuristics in terms of the underlying model. This allows the development of heuristics for complex models such as those used in GeneWise.The aim here is to combine the strengths of Gapped BLAST and Dynamite, in a system which allows Firstly, we describe bounded sparse dynamic programming (BSDP), a novel heuristic for sequence alignment, then we describe the system for automated implementation of the complex alignment algorithms required. We present proof of principle results, but this paper is primarily focussed on developing a framework for the general case.The basic strategy of seeding alignments used here is the same as for BLAST, in that alignments seeds are generated, and then extended to form High-scoring Segment Pairs (HSPs), which are then joined together to form the alignments. The alignments are seeded using an Aho and Corasick  type finHowever the methods for seeding HSPs are independent from those used for building the alignments, and this paper only deals with algorithms involved in the generation of gapped alignments from sets of HSPs, and not in the calculation of the HSPs themselves.The following strategies are employed to enable alignments to be built efficiently from sets of HSPs:portal describes a set of states in the model which correspond to a set of HSPs, a span refers to a looping state for large alignment features such as introns, and a SAR (Sub-Alignment Region) describes a rectangular region on an HSP to which DP is applied.• To connect the underlying alignment model to the heuristics, a upper bounds are generated for the best alignment score for each SAR, and BSDP (Bounded Sparse Dynamic Programming) exploits these bounds to yield alignments in an efficient manner.• To avoid DP in every SAR, • To perform various types of DP in these SARs, the required models are generated automati cally, including C code to produce an efficient viterbi implementation for each model.sparse dynamic programming [sub-alignments improve the quality of the overall alignments, and they allow complex alignment models, and large gaps such as introns to be integrated into a sparse DP framework. Secondly, as it would take too long to apply DP to every sub-alignment region (SAR), upper bounds are calculated for the DP scores for each of these SARs. This allows the sub-alignment DP to be avoided in cases where it joins HSPs which cannot feature in the final alignment, so that alignments can still be generated very rapidly even when large numbers of HSPs and SARs are involved.Dynamic programming  requires quadratic time, and hence is the most computationally expensive part of building an alignment. For pairs of sequences more than a few kilobases long, DP becomes prohibitively slow. The approach used here is similar to gramming , and thegramming , in thatBefore the BSDP can be performed, a single point on each HSP is selected which will feature in any alignment generated using that HSP. This point corresponds to a pair of equivalenced symbols which must feature in any alignment to include that HSP. A point is chosen where half the HSP score is generated by equivalenced symbols on either side of it, as this is likely to be in the highest quality portion of the HSP. As shown in the example in Figure The five types of region used for sub-alignments are classified in Figure Regions for the sub-alignments are selected within the area between the centre points of the two HSPs to be joined, or in the case of terminal HSPs, between the HSP and the ends of the sequences. In addition, the positions of the SARs must be constrained to limit their size, and so that the HSPs correctly intersect with the corners of the SAR. In the case of overlapping HSPs, where there is a choice of positions for placement of the SAR, the position is chosen such that the highest scoring parts of the HSPs are outside the SARs.Once the SARs have been selected, an upper bound is placed on the score for each sub-alignment. The calculation of these bounds is described in a later section describing automation of this method. The BSDP approach can then utilise these upper bounds to avoid application of DP in some SARs, as demonstrated by the example in Figure The BSDP is mediated through a set of priority queues, one of which is associated with each HSP, and will contain an entry for each partial alignment that ends at the HSP. The key for these priority queues is the highest score for any partial alignment ending in that HSP. Additionally, there is one global priority queue containing the highest scores from each of the other priority queues. The upper bound scores are confirmed by DP in the SARs in the current highest scoring putative alignment path. The highest scoring path will change as the scores are updated during this process. DP is applied to SARs in this way until the highest scoring path does not contain any bound scores, and then the alignment may be extracted. Upper bounds dictate that there can be no better alignment using these HSPs.admissibility property of A* search, such that the result of the BSDP computation is guaranteed to be the same as if DP had been performed on every candidate SAR prior to calculation of the alignment. This is because no alignment can be extracted until all the alternative sub-alignments (which have upper bounds that indicate they could contribute to a higher-score) have been eliminated.This algorithm is similar to A* search, (but differs in that many different points may be the start or end of the search), and retains the The BSDP alignment process can be iterated to generate sub-optimal alignments similar to those generated by the Waterman-Eggert algorithm , with onAfter the first alignment has been reported, the scores for any SARs which have already been confirmed by DP, but which are not yet included in a reported alignment, are then considered as an upper bound. SARs are disallowed before recalculation when the region between the centre of the HSP and its SARs overlaps with a previously reported HSP, in which case, the SARs are disallowed. Otherwise the DP is recomputed for SARs which contain part of an alignment which has been reported since the DP for the SAR was last calculated.As illustrated in the previous section, BSDP becomes quite complex and requires a large number of DP algorithms for computation of the alignment through the SARs. We have build a system to facilitate implementation of these models and the integration of the sub-alignments which they produce. To allow generalisation of the BSDP, everything must be defined in terms of the underlying alignment models. The alignment models are described as finite state machines, consisting of states and transitions, similar to those used in Dynamite .Briefly, to convert these models into DP implementations, each state must correspond to a score in each cell of the DP matrix, and the scores for each cell are calculated by taking the maximum of the score from transitions arriving at each cell. In addition, a topological sort is required to satisfy dependency ordering for silent states.However, in addition to automated generation of code from alignment models, the generation of the models required for DP in the SARs is also automated, as described below.Table To enable DP in the SARs for the BSDP, a heuristic model is generated from the original alignment model. This model is not used directly for calculation of alignments, but a derived model is generated corresponding to each transition in the heuristic model. Each of these derived models correspond to a type of SAR used in the BSDP.portal states or span states. A portal defines a group of states which can share a set of HSPs (High-scoring Segment Pairs); these are the match states. A span is a state which has sequence independent looping transitions .The model is first annotated, labelling certain states as either portal which corresponds to the match forward and match reverse states, and the intron forward and intron reverse states are span states.The heuristic model is build using states corresponding to each portal and span state, with transitions between these states in cases where there is a valid path between the corresponding states in the original model. An example model is shown in Figure Derived models are produced for the DP in SARs automatically from each transition in the heuristic model. The source and destination states from each transition in the heuristic model become the start and end states in each derived model. All reachable states and transitions from these states in the original model are recursively copied to the derived model. An example of this process is shown in Figure match forward and match reverse states, shown in Figure For some cases, such as between the portal states and two span states in this model, and therefore, a derived model is generated for each of the five cases in Figure Ten different derived models are generated from the model shown for cDNA to genomic alignment in Figure For each derived model, an additional model is created which is used for the pre-calculation of upper bounds for all possible sizes of SARs. For each transition in the model which has a position dependent score associated with it, the upper bound is also supplied. For example, in a match transition, the upper bound is the maximum value from the substitution matrix. A special model is created using these transition upper bounds, instead of the normal sequence-dependent transition weights. As this removes the sequence-dependent components of the algorithm, it allows pre-calculation of the upper bound for alignment score of any sequences up to the maximum permitted size of SARs. These bounds are then stored in a table for retrieval during the BSDP.The model used in Figure This system is used for alignment of ESTs within the Ensembl gene-building pipeline , and a pFigure Another example is the alignment of the Collagen alpha 1(IX) precursor to a region of chromosome 6 containing the corresponding gene. This is a large gene, containing 38 exons over about a 90 Kb region of the genome. Using GeneWise, the alignnment required 4260 seconds  using exonerate to perform full DP alignment required 2700 seconds (about 45 minutes), and using exonerate with the heuristic BSDP approach required only 7 seconds, with all three methods generating identical alignments.This approach represents an advance from previous methods for automatic implementation of sequence alignment algorithms -6, in thThis has allowed development of heuristics with sub-quadratic running times. This makes their application practical to a much larger set of problems, while retaining the much of the simplicity of their implementation.We recognise that this approach is limited to the subset of sequence comparison problems which can be represented by a regular grammar. For example, it is not possible to use this system to model stochastic context free grammars as used in some types of RNA secondary structure such as pseudo-knots . This apThis framework has already been used for many different alignment models ranging from simple models such as Smith-Waterman-Gotoh, to more complex models such as those for protein to genome alignment as used by GeneWise . It is aAlthough this method is useful in many cases, for some types of distantly related sequences, the method can breakdown. For example, when long regions of the correct alignment contain many gaps with intervening sequences too short to be an alignment seed, the alignment cannot be extended beyond the boundary of the SAR, and the correct alignment may be missed. These cases can be avoided by increasing the size of the SARs, but this results in higher bound scores, so DP become necessary in more of the SARs. Such gap rich alignment are the type where the gapped HSP extension used by Gapped BLAST excels, however such gapped extension necessitates DP surrounding all HSPs, which becomes time consuming when allowing both short exons and long introns during alignments of cDNAs or proteins to genomic sequences.As this system separates the development of the underlying alignment model from the heuristics which are built on top of them, we expect that this framework will prove useful for evaluation of the quality of the heuristics, as comparison between the alignments from the two techniques can be automated, and training may be performed to select optimal parameter sets., and in the exonerate module of the Ensembl CVS repository from . It is built using the glib portabilility library available from  Both exonerate and glib are available under the GNU lesser general public license. The code has been tested extensively on Linux and OSF1/alpha but has been written to be portable to many UNIX systems.The implementation of the system described here is called C4 (to reflect the aim of producing something more powerful than Dynamite ), and isCode generation for the DP is performed to exploit compile time optimisations such as loop un- rolling and and efficient handling of edge conditions in the viterbi matrix, which is particularly beneficial for the small DP calculations required by SARs. This generated code is typically about five times faster than using a generic viterbi implementation, but produces about a million lines of code for the current set of models used by exonerate, and hence compilation takes longer.


The delivery of technology-enhanced home care is growing in most industrialized countries. The objective of our study was to document, from the patient's perspective, how the level of user-friendliness of medical technology influences its integration into the private and social lives of patients. Understanding what makes a technology user-friendly should help improve the design of home care services.Four home care interventions that are frequently used and vary in their technical and clinical features were selected: Antibiotic intravenous therapy, parenteral nutrition, peritoneal dialysis and oxygen therapy. Our qualitative study relied on the triangulation of three sources of data: 1) interviews with patients (n = 16); 2) interviews with carers (n = 6); and 3) direct observation of nursing visits of a different set of patients (n = 16). Participants of varying socioeconomic status were recruited through primary care organizations and hospitals that deliver home care within 100 km of Montreal, the largest urban area in the province of Quebec, Canada.both a negative and positive effect on patients' lives. These technologies were rarely perceived as user-friendly, and user-acceptance was closely linked to user-competence. Compared with acute I.V. patients, who tended to be passive, chronic patients seemed keener to master technical aspects. While some of the technical and human barriers were managed well in the home setting, engaging in the social world was more problematic. Most patients found it difficult to maintain a regular job because of the high frequency of treatment, while some carers found their autonomy and social lives restricted. Patients also tended to withdraw from social activities because of social stigmatization and technical barriers.The four interventions have While technology contributes to improving the patients' health, it also imposes significant constraints on their lives. Policies aimed at developing home care must clearly integrate principles and resources supporting the appropriate use of technology. Close monitoring of patients should be part of all technology-enhanced home care programs. The possibility of managing patients outside of the hospital has rarely been so widely considered. Indeed, home care is often seen as less costly and more patient-friendly . HoweverSullivan  showed hdevice they are designing. Users are often expert at the task they are trying to perform with the device" .In the field of health care, this specialization often adds to the complexity of the work of designers, who, in addition to not being end users of the device, are simply unfamiliar with the complicated tasks health care providers are achieving through the use of technology. When moving health technologies away from the hospital and into the patient's home, the design characteristics of medical devices become even more salient, since patients have to learn how to operate them safely and with confidence. According to Norman , the useBecause most computer interfaces are used in a somewhat confined environment, the work of scholars who have studied technical aids for the disabled and the elderly brings another dimension to the definition of user-friendliness. Conceptualizing disability as a social phenomenon, the user-friendliness of technical aids has to be gauged with respect to their ability to assist users' move freely in their social environment . From thSocial scientific work on patients learning how to cope with chronic illnesses and life-sustaining technology has offered similar observations, highlighting that each patient tends to go through a personal trajectory, or engage in "biographical work" whose aim is to give meaning to a constellation of unfolding events . Here alTo summarize, the literature underscores the many technical  and human  variables that influence the use of technology and which are affected by the setting  where technology use takes place. The user-friendliness of a technology therefore results from a smooth fit between human and technical features, with the fit varying between and within settings and individuals. Figure We selected four interventions: Antibiotic intravenous therapy (IV), parenteral nutrition (PN), oxygen therapy (O2) and peritoneal dialysis (PD). These were chosen because they are frequently used  and varyOur study relied on the triangulation of three sources of data. We conducted semi-directed, individual interviews with patients (n = 16) and carers (n = 6), and directly observed nursing visits, involving a different set of patients (n = 16). This strategy enabled us to gather data on a broader set of patients. The carers we interviewed were not necessarily related to a patient participating to our study (to reduce pressures on interviewees) and were spouses or family members (often mother or daughter) of a person receiving high-tech home care. Our purposeful sampling strategy was to diversify viewpoints, by including participants of varying socioeconomic status, gender and age Table . These vOur approach was structured according to symbolic interactionism, which focuses on how individuals, through regular interactions, develop shared meanings and conceptualize, perceive and understand the role of technology : p.201].1.20]. InHome care technology transforms the patient's life both inside and outside the homeUser-acceptance was shaped by different types of anxiety . User-acceptance is in fact closely linked to competence. Older patients on IV did not feel comfortable with the electronic components of the programmable pump, which they associated with the "computer age" and about which they felt ignorant. Chronic patients seemed, in general, keener to master the technical aspects. "You can't live without air! So you have to be careful and do it right" . One PN patient was technically confident and had developed her own technique for preventing air bubbles from forming in the tube . A similar confidence was shown by the carer of a PD patient: "When you see all that stuff – the reservoir, the wires – you wonder if you'll be able to do it! But, once you know how, it's easy" . For all four interventions, manual dexterity was required to properly manipulate the different components. "If my eyes were okay, I'd have been able to do it. But I was frightened of not doing it properly, of not seeing the needle, which is so tiny" . We also observed patients who were not able to read messages on the digital screen due to poor eyesight (due to old age or co-morbidity), limited English linguistic skills, or illiteracy. They relied on their memory or made informed guesses when operating the device.Finally, the technology did not always fit neatly in the home setting: "Well, you wouldn't believe how hot [the room gets] when the door is closed!" . Some O2 patients liked to have an extra set of tubing so they could use a second floor or sit outside on a patio . One PD patient planned to have an evacuation system installed so he would not have to dispose of the solution exiting the tubing from his peritoneal cavity through the toilet anymore .While some of the barriers described above can be managed fairly well in the home setting, problems arise in the unpredictable "outside world": "It's great when you're at home where you're all set up. But when you're out, you're always worried about people lighting up a cigarette"  . One PN patient said it was "impossible to work because of being connected for 12 hours", and receiving lots of fluid at night compromised her sleep . On the other hand, one PD patient chose a nocturnal exchange regulator, refusing hospital-based hemodialysis, in order to work: "You can't work if you go to the hospital three times a week, and work is very important to me" . In the latter case, the comparison with an alternative makes PD more acceptable.More crucial was the "black-and-white" definition of ability to work that governs disability pension plans, which is incompatible with what patients experience: "You know, sometimes you feel okay, and sometimes you don't; sometimes you're disabled and sometimes you're not..." . Overall, due to compromised health and technical barriers, most patients agreed to apply for a disability plan (according to which they cannot accept paid work). A number of patients did volunteer work, such as helping neighbourhood kids with their homework , doing clerical work for the family business , or volunteer work for a patient association .both a negative and a positive effect on the lives of patients and carers. Indeed, our analyses sought to provide more detail on how technology simultaneously improves and constrains patients' lives. This is compatible with Pierret's observation that "Medicine gives the chronically ill reason to hope, even as it produces limitations with which these persons have to live by making adjustments to meet everyday requirements" . 4. both aterature  indicateAs observed in a recent U.K. survey on the quality of primary health care provision, crucial factors include educational training, patient education programs and improved communication and teamwork . In the In particular, two issues related to policy-making and clinical practice require prompt consideration. First, technology is often designed as though patients all possess similar abilities, and are neither ageing or incapacitated by other illnesses or physical disabilities . Since tSecond, competence of patients and their carers should be reinforced through adequate education and support from physicians and nurses. Medical specialists who manage hospital-based home care programs for O2, PN, PD patients could emphasize, when enrolling patients, the need for a smooth fit between the technical and human barriers that affect patient compliance. Training programs for nurses could also focus on skills and routines that help increase the user-friendliness of technology ,30. FinaThis study has sought to better understand how the level of user-friendliness of medical technology influences its integration into the private and social lives of patients. In this regard, qualitative methods are particularly well suited for uncovering patients' views. Nevertheless, the limitations of our study should be acknowledged ,31. The both the positive and negative impact of technology on patients' lives, not only brings medicine closer to issues that really matter to patients, but also generates "greater scientific, ethical, and social complexity" ..both thelexity" [.The author declares that she has no competing interests.The pre-publication history for this paper can be accessed here:


Laser microdissection allows precise isolation of specific cell types and compartments from complex tissues. To analyse proteins from small cell numbers, we combine laser-microdissection and manipulation (LMM) with mass spectrometry techniques.® Arrays. Initially, to establish the principle, we identified specific protein peaks from 20,000 laser-microdissected cells, combining column chromatography, SDS-PAGE, tryptic digestion, SELDI technology and Tandem MS/MS using a ProteinChip® Tandem MS Interface. Secondly, our aim was to reduce the labour requirements of microdissecting several thousand cells. Therefore, we first defined target proteins in a few microdissected cells, then recovered in whole tissue section homogenates from the same lung and applied to these analytical techniques. Both approaches resulted in a successful identification of the selected peaks.Hemalaun stained mouse lung sections were used to isolate 500–2,000 cells, enough material for complex protein profiles by SELDI-TOF MS (surface enhanced laser desorption and ionization/time of flight mass spectrometry), employing different chromatographic ProteinChipLaser-microdissection may thus be combined with SELDI-TOF MS for generation of protein marker profiles in a cell-type- or compartment-specific manner in complex tissues, linked with mass fingerprinting and peptide sequencing by Tandem MS/MS for definite characterization. Investigation of cell-type specific gene expression and regulation in complex tissues is hampered by the lack of accuracy of cell isolation and sensitivity of post-isolation analysis. Laser-microdissection techniques have proven to be a reliable tool for selectively harvesting cell clusters or single cell profiles from stained tissue sections for mRNA and protein investigation. When combined with qualitative and quantitative PCR, mRNA can be successfully analysed from a few cells -3. The cet al. combined 2D-PAGE with peptide mapping and tandem mass spectrometry to identify a protein significantly higher expressed in tumour tissue and confirmed the identity by immunodepletion assay and immunhistochemistry . Lung preparation was performed as described previously [Laser-microdissection and manipulation was performed as described previously -3,5. In ® Arrays and incubated in a humid chamber for 1 h. For profiling, SAX ProteinChip® Arrays were preincubated in SAX Binding Buffer .Needles with adherent cells were transferred to the reaction tubes containing 15 μl of the HEPES/Triton X-100 lysis buffer. After vigorous shaking for 30 min at room temperature, samples were centrifuged at 14,000 g for 10 min. 3 μl of this supernatant were directly applied to the spots of SAX and WCX ProteinChip® Arrays. These were pre-treated with 10 mM HCl for 5 min and equilibrated two times with WCX binding buffer  for 5 min. Fifteen μl of UTC supernatant were diluted 1:10 v/v in WCX binding buffer and incubated under vigorous shaking for 45 min. In order to deal with high amounts of volume (150 μl) the Bioprocessor (Ciphergen Biosystems. Inc.) was applied. After removal of the samples every spot was washed twice using binding buffer followed by a final 10 sec water rinse. After air-drying, saturated sinapinic acid (0.6 μl) dissolved in 50% acetonitrile and 0.5% trifluoracetic acid (TFA) was added twice. Subsequently, mass analysis of bound peptides/proteins was performed using the Ciphergen PBS IIc system. ProteinChip® Arrays were analyzed by averaging 100–150 laser shots collected in the positive mode. Optimization range of the time lag focusing was set between 10–30 kD. Deflector settings were used to filter out peaks with <2000 m/z. Calibration was performed externally using purified peptide and protein standards. Obtained spectra were analyzed by the ProteinChip Software version 3.01.After first extraction of the microdissected material using HEPES buffer, 15 μl of UTC buffer  were applied to needles/cells. The pellet in UTC buffer was centrifuged for 10 min at 14,000 g and the complete supernatant was used for profiling on WCX ProteinChipSDS-PAGE was performed as described previously  with min® Arrays to reveal the enrichment of selected protein peaks in a certain fraction. The fractions containing the enriched proteins were concentrated by TCA precipitation in order to apply the complete fraction to a single lane of an SDS gel. Staining was performed by colloidal Coomassie brilliant blue .For selective enrichment of marker proteins we used small sized anionic exchange spin columns resulting in 6 fractions after elution using a stepwise pH gradient from pH 9–3 and an organic fraction. The protein amount reflecting 50,000 cells was loaded onto a Q HyperD spin column and aliquots of the eluted fractions were analyzed on NP20 ProteinChip® Arrays. A 20% matrix solution of alpha-4 hydroxy-cinnamic acid (CHCA) was applied to the spots. The remaining gel pieces were extracted with a 60% acetonitrile and 0.2% TFA solution for 1 h with a 5 min sonication to extract remaining organic peptides. Supernatants from this second extraction step were also applied to H4 and NP20 ProteinChip® Arrays. All Arrays were measured in the PBS IIc system by averaging 150 laser shots. After subtraction of all peaks also present in the blank gel piece (e.g. Trypsin autolysis peaks), m/z values were submitted to Profound and Mascot for database searching.The CBB stained bands matching the expected molecular weight regions of selected proteins were excised and subjected to Trypsin digestion. Gel pieces were washed three times with 400 μl of 100 mM ammonium bicarbonate and 50% acetonitrile for 15 min followed by 15 min incubation in 100% acetonitrile. After removal, gel pieces were dried shortly in a speed-vac centrifuge. Depending on the gel volume, 10–15 μl of a Trypsin solution (20 ng Trypsin/μl in 25 mM ammonium bicarbonate) was applied and digestion was performed overnight (16 h) at 37°C. Afterwards, reaction tubes were centrifuged and 0.5–1.5 μl aliquots of each supernatant were applied to the spots of H4 (hydrophobic surface coating) and NP20 (hydrophilic surface coating) ProteinChip® Arrays and 2 × 0.6 μl of a saturated CHCA solution was added. For quality control of the peak intensities, the NP20 Arrays were analyzed in a PBS IIc instrument. Afterward, the arrays were transferred to a Tandem MS instrument. Data were acquired on a Micromass QTOF II  tandem quadrupole-time of flight (Q-TOF) mass spectrometer equipped with a PCI 1000 ProteinChip® Tandem MS Interface (Ciphergen Biosystems). Ions were created using a pulsed nitrogen laser operating with 30 pulses/sec. Nitrogen gas was used for collisional cooling of formed ions and argon gas was used for all low-energy collision-induced dissociation experiments. The system was externally calibrated in MS/MS mode using the parent ion and selected fragments of adrenocorticotropic hormone (ACTH) human fragment 18–39 .Peptides from tryptic digestion were applied to NP20 ProteinChipGK: laser-microdissection, preparation of samples, PAGE, SELDI-MSMM: SELDI-MS and optimalisation for microdissected materialRB: tandem MS measurementsRMB: instruction to laser-microdissectionWS: design of project, preparation of the manuscriptNW: animal model, preparation of the lungsLF: design of project, preparation of the manuscript


We sought to elicit preference weights from parents for health states corresponding to children with various levels of severity of atopic dermatitis. We also evaluated the hypothesis that parents with children who had been diagnosed with atopic dermatitis would assign different preferences to the health state scenarios compared with parents who did not have a child with atopic dermatitis.Subjects were parents of children aged 3 months to 18 years. The sample was derived from the General Panel, Mommies Sub-Panel, and Chronic Illness Sub-Panel of Harris Interactive. Participants rated health scenarios for atopic dermatitis, asthma, and eyeglasses on a visual analog scale, imagining a child was experiencing the described state.A total of 3539 parents completed the survey. Twenty-nine percent had a child with a history of atopic dermatitis. Mean preference scores for atopic dermatitis were as follows: mild, 91 ; mild/moderate, 84 ; moderate, 73 ; moderate/severe, 61 ; severe, 49 ; asthma, 58 ; and eyeglasses, 87.Parents perceive that atopic dermatitis has a negative effect on quality of life that increases with disease severity. Estimates of parents' preferences can provide physicians with insight into the value that parents place on their children's treatment and can be used to evaluate new medical therapies for atopic dermatitis. Atopic dermatitis is the most common of childhood skin diseases, with a lifetime prevalence in children of 10% to 20% .Atopic dermatitis can have a negative impact on quality of life by affecting psychosocial adjustment in children. Lapidus and Kerr  report tAs the need to control increasing medical expenditures continues to mount, formal economic evaluations are taking on a prominent role in assessing the value of new medical therapies. To properly evaluate the impact of new therapies for atopic dermatitis, patients' health-related quality of life (HRQOL) must be considered. Although a number of quality-of-life evaluations have been conducted for adults and children affected with atopic dermatitis ,7,9-12, Although the prevalence of atopic dermatitis is highest in children, the existing literature on patient preferences for atopic dermatitis is limited to the adult population ,14. HowePatient preferences can be elicited using standard gamble or time-tradeoff or direct rating methods such as a visual analog scale. Because both the standard gamble and the time-tradeoff exercises involve choices between two alternatives that involve a chance of death or longevity, we believed it was unethical to ask parents to participate in such exercises when children were the subjects. Therefore, our choice for eliciting preferences was the rating scale.We developed case scenarios for 5 levels of atopic dermatitis severity – mild, mild/moderate, moderate, moderate/severe, and severe. These severity levels were created by combining the characteristics of an Investigator Global Assessment (IGA) and the Eczema Area and Severity Index (EASI) score . Each scUsing cognitive interview techniques, we pilot-tested the preference assessment instrument in a convenience sample of 20 parents of children who were being evaluated at a local children's primary care clinic to assess patients' understanding of the instrument and its instructions. The instrument was further revised based on the results of the pilot test.A health state preference assessment asks subjects to make judgments regarding the value of particular health states . PrefereSubjects were invited to participate in the survey from February 12 through 14, 2002, and were asked to register at a specific survey site. After consent was obtained online, subjects completed the survey. Respondents were offered the incentive of a chance to win one of five $100 prizes. Respondents had to be adults with children aged 3 months to 18 years in order to be included in the study. The study was approved by the institutional review board of Duke University Medical Center.Clinical data were based on self-report and included information on diagnosis history and severity level. Specifically, respondents were asked if they had a child between the ages of 3 months and 18 years who had ever been diagnosed by a medical professional with atopic dermatitis. If they responded "yes," they were then asked to describe the child's atopic dermatitis at its worst point by selecting from the following response options: mild, mild/moderate, moderate, moderate/severe, severe.For the preference assessment, each respondent was given the scenarios in the same order – mild through severe atopic dermatitis, asthma, and glasses. Subjects were instructed to indicate on a scale ranging from 100  to 0 (death) how good or bad they believed it would be to be a child experiencing the scenario depicted. Respondents recorded their values using a movable pointer on the scale. Respondents whose Internet browser software did not support the movable pointer entered their numerical responses manually into a required field. All 7 values were summarized at the end of the survey to allow respondents to review and, if desired, revise their ratings.P value of ≤ .05 was used as the criterion for statistical significance.Descriptive statistics were used to describe the sample. Because subjects provided responses across severity levels, a repeated-measures analysis of variance was conducted using polynomial contrasts for the within-subjects (severity) effect. A Of the 28105 subjects contacted, 6131 (22%) responded. Of the 6131 respondents, 3539 (57.7%) met the inclusion criteria, consented to participate in the study, and completed the survey . The linear effect of severity  indicated that preference ratings significantly decreased as the severity of the health states increased . Across all health states, parents of children with atopic dermatitis gave a slightly higher mean preference  compared to parents whose children did not have atopic dermatitis  , indicating that the differences across health states were the same for both parent groups.There was no significant severity by parent group interaction . Research on adults who rate the health states of other adults has suggested that people who have experienced a particular health state are more likely to assign a higher value to it than others who are asked to imagine the health state -21. The Our study has several limitations. First, by using the Internet, respondents did not have an opportunity to ask questions if they did not understand what they were being asked to do. However, we feel that this limitation was negligible, because the instrument was pilot-tested using in-person interviews, and the very large majority of responses were ranked appropriately . Secondly, there may be a sample bias in using the Harris Interactive database. Our sample reflected a predominately white, female cohort from a high socioeconomic class and may present generalizability issues. However, we received responses from 351 (14%) nonwhite respondents and 779 (22%) responses from participants with an annual household income of less than $35000, providing a sufficient number of responses to test for differences by race/ethnicity and income level. Further research will be needed to corroborate our findings using a population-based sample. Third, since these data are self-reported, some parents may have misclassified their children as having or not having atopic dermatitis, potentially biasing our results. Fourth, it is unclear whether physician assessment of severity would correspond with the severity levels that we assigned to the health states. However, physicians could evaluate the descriptions provided to judge whether their assessments are consistent. Finally, people enrolled in the Harris Interactive database are computer users who may be more motivated to participate in a survey than the general population. It is unclear how or in what direction these sample biases might affect the results of our analyses.We had an apparent response rate of 22%. Harris Interactive generally achieves a 15% to 20% response rate when using the Chronic Illness Sub-Panel. While our response rate was higher than Harris' average response rate, possible reasons for why the response was low could be attributed to the nature of the study design. First, because subjects were contacted by e-mail, it is possible that some subjects did not open the e-mail message until after the survey deadline. Second, Harris Interactive panel members agree to be notified about survey opportunities, but do not agree to participate in each survey. Since the characteristics of responders and nonresponders did not differ, we have no reason to believe that nonresponse bias is exerting a substantial influence on our results.The results of this analysis clarify the values that parents of children with atopic dermatitis assign to different atopic dermatitis health states. These assigned values, relative to the comparison states, clearly demonstrate the perceived burden of atopic dermatitis by parents of children suffering from the disease. Understanding the preferences for atopic dermatitis can provide physicians insight into the value that parents place on treatments for their child's disease and in evaluating the cost-effectiveness of therapies for atopic dermatitis.This study was supported by a research agreement between Duke University Medical Center and the Novartis Pharmaceuticals Corporation, East Hanover, NJ, which manufactures a cytokine inhibitor for the treatment of atopic dermatitis.KPW and KAS have received monetary compensation for consultancies, and EBW and KAS have received research grants, from Novartis. KHK is an employee of Novartis.JYF conceived of and designed the study, performed the statistical analysis, interpreted the data, and drafted the manuscript. SDR conceived of and designed the study and assisted in interpretation of the data and drafting of the manuscript. KPW assisted in interpretation of the data and drafting of the manuscript. EBW and KHK conceived of and designed the study and assisted in drafting of the manuscript. KAS conceived of and designed the study, assisted in drafting of the manuscript, and obtained funding. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:


A number of approaches have been used to grade levels of evidence and the strength of recommendations. The use of many different approaches detracts from one of the main reasons for having explicit approaches: to concisely characterise and communicate this information so that it can easily be understood and thereby help people make well-informed decisions. Our objective was to critically appraise six prominent systems for grading levels of evidence and the strength of recommendations as a basis for agreeing on characteristics of a common, sensible approach to grading levels of evidence and the strength of recommendations.Six prominent systems for grading levels of evidence and strength of recommendations were selected and someone familiar with each system prepared a description of each of these. Twelve assessors independently evaluated each system based on twelve criteria to assess the sensibility of the different approaches. Systems used by 51 organisations were compared with these six approaches.There was poor agreement about the sensibility of the six systems. Only one of the systems was suitable for all four types of questions we considered . None of the systems was considered usable for all of the target groups we considered . The raters found low reproducibility of judgements made using all six systems. Systems used by 51 organisations that sponsor clinical practice guidelines included a number of minor variations of the six systems that we critically appraised.All of the currently used approaches to grading levels of evidence and the strength of recommendations have important shortcomings. In 1979 the Canadian task Force on the Periodic Health Examination published one of the first efforts to explicitly characterise the level of evidence underlying healthcare recommendations and the strength of recommendations -28.The original approach used by the Canadian Task Force was based on study design alone, with randomised controlled trials (RCTs) being classified as good (level I) evidence, cohort and case control studies being classified as fair (level II) evidence and expert opinion being classified as poor (level III) evidence. The strength of recommendation was based on the level of evidence with direct correspondence between the two; e.g. a strong recommendation (A) corresponded to there being good evidence. A strength of the original Canadian Task Force approach was that it was simple; the main weakness was that it was too simple. Because of its simplicity, it was easy to understand, apply and present. However, because it was so simple there were many implicit judgements, including judgements about the quality of RCTs, conflicting results of RCTs, and convincing results from non-experimental studies.For example:• Should a small, poorly designed RCT be considered level I evidence?• Should RCTs with conflicting results still be considered level I evidence?• Should observational studies always be considered level II evidence, regardless of how convincing they are?The original approach by the Canadian Task Force also did not include explicit judgements about the strength of recommendations, such as how trade-offs between the expected benefits, harms and costs were weighed and taken account of in going from an assessment of how good the evidence is to determining the implications of the results for practice.The GRADE Working Group is an informal collaboration of people with an interest in addressing shortcomings such as these in systems for grading evidence and recommendations. We describe here a critical appraisal of six prominent systems and the results of the critical appraisal.We selected systems for grading the level of evidence and the strength of recommendations that we considered prominent and that included features not captured by other prominent systems. These were selected based on the experience and knowledge of the authors through informal discussion. A description of the most recent version (as of summer 2000) of each of these systems (Appendix 1 to 6), was prepared by one of the authors familiar with the system, and used in this exercise. The following six systems were appraised: the American College of Chest Physicians  21], A, A21], AThese descriptions of the systems were given to the twelve people who independently appraised the six systems, all of the authors minus GEV appraised the six systems, three of the authors  appraised as a group and reported as one (see contributions). The 12 assessors all had experience with at least one system and most had helped to develop one of the six included systems. Twelve criteria described by Feinstein  provided1. To what extent is the approach applicable to different types of questions? -effectiveness, harm, diagnosis and prognosis 2. To what extent can the system be used with different audiences? -patients, professionals and policy makers 3. How clear and simple is the system? 4. How often will information not usually available be necessary? 5. To what extent are subjective decisions needed? 6. Are dimensions included that are not within the construct (level of evidence or strength of recommendation)? 7. Are there important dimensions that should have been included and are not? 8. Is the way in which the included dimensions are aggregated clear and simple? 9. Is the way in which the included dimensions are aggregated appropriate? 10. Are the categories sufficient to discriminate between different levels of evidence and strengths of recommendations? 11. How likely is the system to be successful in discriminating between high and low levels of evidence or strong and weak recommendations? 12. Are assessments reproducible? No training was provided and we did not discuss the 12 criteria prior to applying them to the six systems.Our independent appraisal of the six systems were summarised and discussed. The discussion focused on differences in the interpretation of the criteria, disagreement about the judgements that we made and sources of these disagreements, the strengths and weaknesses of the six systems, and inferences based on the appraisals and subsequent discussion.In order to identify important systems that we might have overlooked following our appraisal of these six systems we also searched the US Agency for Health Care Research and Quality (AHRQ) National Guidelines Clearing House for organisations that have graded two or more guidelines in the Clearing House using an explicit system . These sThere was poor agreement among the 12 assessors who independently assessed the six systems. A summary of the assessments of the sensibility of the six approaches to rating levels of evidence and strength of recommendation is shown in Table The poor agreement among the assessors likely reflects several factors. Some of us had practical experience using one of the systems or used additional background information related to one or more grading systems, and we may have been biased in favour of the system with which we were most familiar. Each criterion was applied to grading both evidence and recommendations. Some systems were better for one of these constructs than the other and we may have handled these discrepancies differently. In addition each criterion may have been assessed relative to different judgements about the evidence, such as an assessment of the overall quality of evidence for an important outcome (across studies) versus the quality of an individual study. Some of the criteria were not clear and were interpreted or applied inconsistently. For example, a system might be clear and not simple or visa versa. We likely differed in how stringently we applied the criteria. Finally, there was true disagreement.There was agreement that the OCEBM system works well for all four types of questions. There was disagreement about the extent to which the other systems work well for questions other than effectiveness. It was noted that some systems are not intended to address other types of questions and it is not clear that it is important that a system should address all four types of questions that we considered , although criteria for assessing individual studies must take this into account ,32.Most of us did not find that any of the systems are likely to be suitable for use by patients. Almost all agreed that the ACCP system was suitable for professionals and most considered that the USPSTF system was suitable for professionals. There was not much agreement about the suitability of any of the other systems for professionals or about the suitability of any of the systems for policy makers, although most assessed the USTFCPS system to be suitable for policy makers.There was no agreement that any of the systems are clear and simple, although USPSTF, ACCP and SIGN systems were generally assessed more favourably in this regard. It was generally agreed that the clearer a system was the less simple it was; e.g. the OCEBM system is clear but not simple for categorising the level of evidence. There was some confusion regarding whether we were assessing how clear and simple the system was to guideline developers (as some interpreted this criterion) or how clear and simple the outcome of applying the system was to guideline users (as others interpreted this criterion). Either way, the simpler a system is the less clear it is likely to be.Most of us judged that for most of the systems necessary information would not be available at least sometimes. The OCEBM system came out somewhat better than the other systems and lack of availability of necessary information was considered to be less of a problem for the USTFCPS system. However, the OCEBM and USTFCPS systems were considered by most to be missing dimensions which may, in part, explain why missing information was considered to be less of a problem. This would be the case to the extent the missing dimensions were the ones for which information would often or sometimes not be available. The dimension for which we considered that information would most often be missing was trade-offs; i.e. knowledge of the preferences or utility values of those affected. Additional problems were identified in relationship to complex interventions and counselling, particularly with the USTFCPS and USPSTF systems. It was pointed out that the USTFCPS system addressed this problem by including availability of information about the intervention as part of its assessment of the quality of evidence.Most of the systems were assessed to require subjective decisions at least to some extent. The OCEBM system again stood out as being assessed more favourably, although it may be related to omission of dimensions that require more subjective decisions. Judgement is clearly needed with any system. The aim should be to make judgements transparent and to try to protect against bias in the judgements that are made by being systematic and explicit.Inclusion of dimensions that are not within the constructs being graded was not considered a problem for most of the systems by most of us. Several people considered that it might be a problem for the USTFCPS and USPSTF systems. On the other hand, all of the systems were evaluated to be missing at least one important dimension by at least one person. The challenge of missing dimensions were considered less of a problem for the ACCP and ANHMRC systems. There was not agreement about any of the systems having a clear and simple approach to aggregating the dimensions, although this was considered to be less of a problem for the ACCP, SIGN and USTFCPS systems.There was also not agreement on the appropriateness of how the dimensions were aggregated. This was considered to be more of a problem for the ANHMRC and USTFCPS systems than the other four systems, all of which were considered to have taken an approach to aggregating the dimensions that was at least partially inappropriate by more than half of us.Most of us considered that most of the systems had sufficient categories, with the exception of the ANHMRC system. There was almost agreement that the USPSTF system has sufficient categories. We agreed that it is possible to have too many categories as well as too few, the OCEBM system being an example of having too many categories.There was not agreement that any of the systems are likely to discriminate successfully, although everyone thought that the ACCP, SIGN and USPSTF systems are somewhat to highly likely to discriminate. Lastly, we largely agreed that we were not sure how reproducible assessments are using any of the systems, although half of us considered that assessments using the ANHMRC system are unlikely to be reproducible and about 1/3 considered that assessments using the OCEBM and ACCP systems are likely to be reproducible.We identified 22 additional organisations that have produced 10 or more practice guidelines using an explicit approach to grade the level of evidence or strength of recommendations. Another 29 have produced between two and nine guidelines using an explicit approach. These systems include a number of minor variations of the six systems that we appraised in detail.There was generally poor agreement between the individual assessors about the scoring of the six approaches using the 12 criteria. However, there was general agreement that none of these six prominent approaches to grading the levels of evidence and strength of recommendations adequately addressed all of the important concepts and dimensions that we thought should be considered. Although we limited our appraisal to six systems all of the additional approaches to grading levels of evidence and strength of recommendations that we identified were, in essence, variations of the six approaches that we had critically appraised. Therefore we are confident that we did not miss any important grading systems available at the time when these assessments were undertaken.Based on discussions following the critical appraisal of these six approaches, we agreed on some conclusions:• Separate assessments should be presented for judgements about the quality of the evidence and judgements about the balance of benefits and harms.• Evidence for harms should be assessed in the same way as evidence for benefits, although different evidence may be considered relevant for harms than for benefits; e.g. local evidence of complication rates may be considered more relevant than evidence of complication rates from trials for endarterectomy.• Judgements about the quality of evidence should be based on a systematic review of the relevant research.• Systematic reviews should not be included in a hierarchy of evidence (i.e. as a level or category of evidence). The availability of a well-done systematic review does not correspond to high quality evidence, since a well-done review might include anything from no studies to poor quality studies with inconsistent results to high quality studies with consistent results.• Baseline risk should be taken into consideration in defining the population to whom a recommendation applies. Baseline risk should also be used transparently in making judgements about the balance of benefits and harms. When a recommendation varies in relationship to baseline risk, the evidence for determining baseline risk should be assessed appropriately and explicitly.• Recommendations should not vary in relationship to baseline risk if there is not adequate evidence to guide reliable determinations of baseline risk.Based on discussions of the strengths and limitations of current approaches to grading levels of evidence and the strength of recommendations, we agreed to develop an approach that addresses the major limitations that we identified. The approach that the GRADE Working Group has developed is based on the discussions following the critical appraisal reported here and a pilot study of the GRADE approach . Based o and a discussion list.The GRADE Working Group has continued to grow as an informal collaboration that meets one or two times per year. The group maintains web pages DA has competing interests with the US Preventive Services Task Force (USPSTF), PAB has a competing interest with the US Task Force on Community Preventive Services (USTFCPS), GHG and HS have competing interests with the American College of Chest Physicians (ACCP), DH, SH and DO'C have competing interests with the Australian National Health and Medical Research Council (ANHMRC), BP has competing interests with the Oxford Centre for Evidence-Based Medicine (OCEBM). Most of the other members of the GRADE Working Group have experience with the use of one or more systems of grading evidence and recommendations.DA, PAB, ME, SF, GHG, DH, SH, AL, DO'C, ADO, BP, HS, TTTE, GEV & JWW Jr as members of the GRADE Working Group have contributed to the preparation of this manuscript and the development of the ideas contained herein, participated in the critical assessment, and read and commented on drafts of this article. GHG and ADO have led the process. GEV has had primary responsibility for coordinating the process.The pre-publication history for this paper can be accessed here:American College of Chest Physicians (ACCP), a brief description of the ACCP approach.Click here for fileAustralian National Health and Medical Research Council (ANHMRC), a brief description of the ANHMRC approach.Click here for fileOxford Centre for Evidence-based Medicine (OCEBM), a brief description of the OCEBM approach.Click here for fileScottish Intercollegiate Guidelines (SIGN), a brief description of the SIGN approach.Click here for fileU.S. Preventive Services Task Force (USPSTF), a brief description of the USPSTF approach.Click here for fileU.S. Task Force on Community Preventive Services (USTFCPS), a brief description of the USTFCPS approach.Click here for file