It is widely acknowledged that there is a global divide on health care and health research known as the 10/90 divide.A retrospective survey of articles published in the BMJ, Lancet, NEJM, Annals of Internal Medicine & JAMA in a calendar year to examine the contribution of the developing world to medical literature. We categorized countries into four regions: UK, USA, Other Euro-American countries (OEAC) and (RoW). OEAC were European countries other than the UK but including Australia, New Zealand and Canada. RoW comprised all other countries.The average contribution of the RoW to the research literature in the five journals was 6.5%. In the two British journals 7.6% of the articles were from the RoW; in the three American journals 4.8% of articles were from RoW. The highest proportion of papers from the RoW was in the Lancet (12%). An analysis of the authorship of 151 articles from RoW showed that 104 (68.9%) involved authorship with developed countries in Europe or North America. There were 15 original papers in these journals with data from RoW but without any authors from RoW.There is a marked under-representation of countries in high-impact general medical journals. The ethical implications of this inequity and ways of reducing it are discussed. National and international bodies concerned with research ethics need to confront the greatest ethical challenge-the enormous inequities in global health research . Thus, lThe aim of this study is to investigate the publication bias beyond the field of psychiatry to determine the overall contribution of different regions of the world to the medical literature published in high-impact journals and, in particular, to quantify the developing world's contribution.The method used is the same as that which was used by two of the authors (AS and VP) in a recent survey of the international representation in the psychiatric literature . A retroFor the allocation of regions of the world, we categorized countries into four regions: UK, USA, OEAC (Other Euro-American countries) and RoW (Rest of the World). OEAC were European countries other than the UK but including Australia, New Zealand and Canada. RoW comprised all other countries including Eastern Europe, Central and South America, Asia and Africa. We scrutinized each article to examine the country of the authors' affiliation address with a view to categorizing them into relevant regions of the world. All authors were noted including multiple authors in large multi-center studies. We also scrutinized the methods section of all the original articles to ascertain the origin of data with special emphasis on whether the research was carried out in RoW countries. The affiliation of the first, last and corresponding authors was also noted. We worked with a negative bias against the USA and the UK from where the journals originated. Therefore articles, which included authors from the RoW, were considered as arising from the RoW even if the first author is from the UK, USA or OEAC. Similarly, articles from the OEAC, which involved collaborations from the UK or USA, were included in the OEAC category. In the event of a collaborative study between the USA and the UK, the allocation to region was based on the institutional affiliation of the first author. The RoW category included collaborative studies between any country in the RoW and developed nations.In some cases the origin of the author was difficult, particularly when there were two places named as their attached institutions. For an example when one was in USA while the other is in Kenya. We used our best guess in these instances. For an example the two authors AS and VP in this paper were based in RoW at the time we did this research but were employed in UK but with strong affiliations to the RoW countries where they were born and did their research. Attempts to analyse the nationality of the authors was therefore abandoned.The contribution of the RoW to the research literature surveyed in these five high-impact journals was 6.5%. In the two British journals, 7.6% of the articles were from the RoW, whilst the proportion in the three American journals was 4.8%. This averages hides the fact that there is considerable variation between journals; thus, around 3.5% of articles in the two journals of national medical associations of the UK (BMJ) and USA (JAMA) were from the RoW as compared to 12% in the Lancet articles  while the proportion of articles from the USA was highest in the three journals published in the USA. Table There were 118 original papers with at least one author from the RoW. Forty-five (38%) of them had a first author from the RoW; 32 (27%) had a last author from the RoW; and 36 (30%) had a corresponding author from the RoW. Only 25 (21%) of them had first, last and corresponding authors all from the RoW. There were 15 original papers in these journals with data from the RoW but without any authors from the RoW; of these 15, nine were in Lancet, four in BMJ and one each in JAMA and NEJM. Thus, the majority of the original articles originating from the RoW had contribution from the developed world authors.This study presents findings of a survey of articles published in five high-impact general medical journals with the objective of describing the developing world's contribution to research literature over a single calendar year.Our way of classifying countries into developed  and developing countries (RoW) has obvious inadequacies but we followed the same method adopted in an earlier paper . Other eThe key finding of our survey is that, only 6.5% of the publications in these journals have authors from countries where 90% of the world's population lives. There is a severe under representation of biomedical research from a vast section of the world in these five journals. In addition, there are a small but significant number of articles with data from the developing world without a single author from these countries. This is a troublesome finding that some would refer as 'safari research'. It is a separate ethical issue and journal editors need to look at it carefully.The reasons for under representation of researchers based in developing countries may include research barriers such as lack of funding, poor facilities, limited technical support and inadequate training. Many researchers from developing countries do not speak English as their first language. Fear of rejection by the journals, uncertainty about which journal would be best to publish research, a lack of the culture of publication, competing clinical commitments, different ministry and donor driven agendas for research, are some of the unseen barriers facing developing country researchers (10). The editors of leading medical journals may not have paid sufficient attention to these barriers, real and perceived, that clinical researcher in developing countries face .We acknowledge that many developing country researchers choose to publish their work in national or regional journals that are not as high-impact as the journals we have reviewed. However, many researchers, irrespective of the country of their origin, also prefer to publish their work in journals with a high impact factor and circulation. This, inevitably, leads to a focus on leading journals published from the UK or USA. However, journals may be under some pressure to publish material, which is relevant to the majority of their readership. Thus, it is not surprising that journals from the UK have the majority of articles from UK institutions and similarly, journals from the USA tend to have most of their articles from US institutions. The BMJ admits that although the BMJ aspires to be more international, they cannot forget that they reach 80% doctors in Britain . HoweverOur findings are in agreement with other published findings in this area . In a stThere are many reasons to strive for a more just international distribution of biomedical research in leading journals. The burden of disease in the world falls heavily on developing countries and the pattern of this burden is likely to change in the next twenty years. Diseases like TB, HIV, Malaria, Dengue, and viral hemorrhagic fevers are now no longer tropical with increase in international travel, global warming, refugees, economic and military intervention and conflicts. Newly emerging infections from tropics such as SARS and bird flu can have devastating effects far away from tropics. In addition, diseases such as diabetes and obesity can no longer be considered as diseases in the developed world. As the impact and burden of these diseases are more in developing countries more research publications are needed from South.Clinicians and policy makers in many developing countries have limited access to international journals because medical libraries often need to make a choice from a number of journals due to financial constraints. Often, it is the high-impact journal, which is subscribed to. Thus, the proportion of international representation in these leading journals may be a crucial factor in influencing health policies in many countries. The importance of research goes well beyond its impact on health policies . Thus, rProviding free journals electronically to the developing countries is a commendable step in correcting the thirst for new information . HoweverUltimately, we believe that strengthening the health research capacity in developing world and providing reasonable opportunities for publications arising from the developing world are critical, not only for achieving biomedical research publication equity, but also advancing medical science.We would like to state here that our conflict of interest if at all would be due to the fact that we come from the developing world.All authors were involved in all the components of this paper, right from the start, in formulating and developing the idea, collecting the data, drafting the first version and revising it and approving the final version.The pre-publication history for this paper can be accessed here:


The carotid body paraganglioma (chemodectoma) is a relatively rare neoplasm of obscure origin. These are usually benign and commonly present as asymptomatic cervical mass.Records of 12 patients  with carotid body tumors treated between 1982 and 2003, treated at our center were retrospectively reviewed. Data on classification, clinical presentation, and surgical treatment were extracted from the case records. Surgical complications and treatment outcome were noted and survival was calculated by actuarial method. The literature on carotid body paraganglioma was reviewed.The average age of the patients was 52 years (range 30–78 years). Eight of these cases presented as a large asymptomatic non-tender neck mass, and two each presented with dysphagia, and hoarseness of voice. As per Shamblin classification seven of tumors were type II and 5 were types III. In 7 cases subadventitial tumor excision was performed, while in 5 associated resection of both external and internal carotid arteries was carried out. The artery was repaired by end-to-end anastomosis in one case, with Dacron graft in one case, and with saphenous vein graft in 3 cases. There was no operative mortality. After a mean follow-up of 6.2 years (range 6 months to 20 years), there were no signs of tumor recurrence in any of the cases.Surgical excision is the treatment of choice for carotid body paragangliomas although radiation therapy is an option for patients who are not ideal candidates for surgery. For the tumors that are in intimate contact with carotid arteries, the treatment by vascular surgeon is recommended. Paraganglioma arising from the carotid body are relatively rare tumors but constitute majority of head and neck paragangliomas 60–70%) -6. The t0–70% -6.Between 1982 and 2003, 12 patients  with carotid body paraganglioma were surgically treated at the Institute for Cardiovascular Diseases, Serbian Clinical Centre. Mean age of the patients was 52 years (range 30–78 years). The records of these patients were retrospectively reviewed for clinical presentation, diagnostic work-up, surgical treatment, and outcome. Descriptive data was presented as frequency and percentage. Survival was calculated by actuarial method. World literature on carotid body paraganglioma was reviewed. The articles were extracted using the key words carotid body and paraganglioma.All the patients were followed-up periodically every 6 months for the first year, yearly for next 5 years, thereafter only select patients were followed. The patients who had undergone carotid artery repair were followed-up with yearly duplex scanning; two patients were followed by a computerized tomography (CT) scan, and one by regular magnetic resonance (MR) imaging.Eight cases presented as large non-tender neck masses located just anterior to the sternocleidomastoid muscle, two patients presented with dysphagia due to hypoglossal nerve compression, while two other had hoarseness of voice. The duplex ultrasonography and selective carotid angiography were used for diagnosis in the eleven cases, CT in five, and MR imaging in three cases Figure  and 2. I® graft, and other 3 were repaired with reversed saphenous vein graft.Intraoperatively on exploration of the neck seven of the cases showed a medium size tumor intimately associated and compressing carotid vessels (Shamblin II), and a large tumor involving carotid vessels in five cases (Shamblin III). In 7 cases of Shamblin II carotid body paraganglioma a subadventitial tumor excision was performed while in other 5 cases both external and internal carotid arteries were resected. One of these was repaired by end-to-end anastomosis, one with interposition of DacronThe histological examination showed no signs of malignancy in any of the tumors. In two cases transient hypoglossal nerve palsy was noticed. Another patient had unexpected postoperative hoarseness of voice due to the transient vagus nerve palsy. All these three cases subsequently recovered. There was no operative mortality. The patients were followed-up from the 6 months to 20 years (mean 6.2 year) no local, regional or distant metastasis was noticed. The actuarial survival was 100%.The carotid body was first described by von Haller in 1743 . It is hThe carotid body paraganglioma is more common in women ,20,25-28Carotid body paraganglioma often present as slow growing, non-tender neck masses located just anterior to the sternocleidomastoid muscle at the level of the hyoid. The tumor is mobile in the lateral plane but its mobility is limited in the cephalocaudal direction ,26,36-38Size of the tumor has a great importance not only for its clinical manifestations but also for treatment. In 1971, Shamblin introduced a classification system based on tumors size . They cl111In labeled anti-CEA antibody is also described in literature [The carotid angiography is the most useful diagnostic test for paragangliomas. The angiography demonstrates tumor blood supply and widening of the carotid bifurcation by a well-defined tumor blush ("lyre sign"), which is classic pathognomonic angiographic finding -39,42,43terature . The difterature .Resection of carotid body paraganglioma carries inherent risks of injury to the cranial nerves, carotid arteries as well excessive blood loss. Reigner first attempted resection of a carotid body paraganglioma in 1880, but the patients did not survive . Maydel The modern surgical techniques have reduced the risk of postoperative stroke in carotid body paraganglioma resection to less than 5% ,40,56. HEarly operative management is warranted to avoid the possibility of eventual metastasis and progressive local invasion to the point of inoperability. In case of tumors intimately contact with carotid arteries, the treatment by vascular surgeon is recommended.The author(s) declare that they have no competing interests.NilLBD: Preperation of draft manuscriptVBD: Literature search, data collectionDMV: Study design, data analysis, interpretation, preparation of draftRPS: Study coordination, data interpretation, manuscript preperationSND: Manuscript editing, preparation of final manuscript for publicationAll authors read and approved the manuscript.


Magnetically marked capsules serve for the analysis of peristalsis and throughput times within the intestinal tract. Moreover, they can be used for the targeted disposal of drugs. The capsules get localized in time by field measurements with a superconducting quantum interference device (SQUID) magnetometer array. Here it is important to ensure an online localization with high speed and high suppression of disturbing fields. In this article we use multipole expansions for the simultaneous localization and suppression of disturbing fields.We expand the measurement data in terms of inner and outer multipoles. Thereby we obtain directly a separation of marker field and outer disturbing fields. From the inner dipoles and quadrupoles we compute the magnetization and position of the capsule. The outer multipoles get eliminated.The localization goodness has been analyzed depending on the order of the multipoles used and depending on the systems noise level. We found upper limits of the noise level for the usage of certain multipole moments. Given a signal to noise ratio of 40 and utilizing inner dipoles and quadrupoles and outer dipoles, the method enables an accuracy of 5 mm with a speed of 10 localizations per second.The multipole localization is an effective method and is capable of online-tracking magnetic markers. The transport of capsules in the alimentary tract underlies complex influencing factors like the patients peristalsis, the hydration and the form and size of the capsules. A procedure which allows the instantaneous localization of the capsules supports a number of patient examinations as well as examinations of new drug forms -4. CapsuThe localization of magnetically marked capsules (magnetic markers) must be spatially accurate and with high temporal resolution. For the spatial localization the marker field must be separated from the external magnetic disturbing fields. This separation can be achieved by splitting the magnetic field in multipole moments . The metMultipole expansions are used also to model spatially distributed biological sources such as brain currents ,8.The application of multipoles for the localization of magnetic dipoles is described in ,10, and 3O4) which is subsequently magnetized up to saturation. The magnetic field measurement is performed within magnetically shielded rooms by the use of highly sensitive SQUID arrays. For the investigation at hand we conduct simulation runs to determine the performance of the multipole localization.Marking of capsules and pills takes place by partially filling them with black iron oxide . If the distance  between marker and origin is small compared to the distance  between a magnetic sensor and the origin, the field of the marker at the sensor position is given by the first elements of the multipole expansion. With the notationThe field of a magnetic marker located adjacent to the point of origin can be expressed by a multipole expansion in Cartesian coordinates  and equation (6) yields the field expansion for a magnetic marker with disturbing fields. We truncate this expansion after the octopole terms, and transcript it into a linear equation system for the determination of equivalent multipole moments Bmeas and c and the matrix F is given below in the formulas (15...24). The residuals 0(·) are sufficiently small, if the coordinates of the marker are small compared to the coordinates of the field sensors , and if the coordinates of the field sensors are small compared to the coordinates of the external disturbing field sources .The structure of the vectors Bmeas is a vector with the measurement values of the magnetometer sensor field in the positions  with the directions :F is built from the linearly independent form functions for inner and outer field sources given in equation (13). Their scalar product with the sensor normal directions  yields one row for every sensor:The matrix F is the sum of the numbers of inner and outer field functions used. Each column describes the field of one specific magnetic moment with unit strength measured by the sensor system. The Matrix F is called the forward matrix of all moments considered. The Matrix F is structured into submatrices for different moments:The number of columns of  and  are the forward matrices for inner and outer dipoles:Matrix  and  are the forward matrices for inner and outer quadrupoles. The size of  is (Nsen/5) with the rows belonging to quadrupole moments with indices .Matrix  and  are the forward matrices for inner and outer octopoles. The size of  is (Nsen/7) with the rows belonging to octopole moments with indices .Matrix c is composed of inner and outer dipole moments cd, quadrupole moments cq and octopole moments co:The vector of multipole moments  describe a dipole at the point of origin, the outer dipole moments  describe a homogeneous disturbing field:The inner dipole moments  represent a quadrupole at the point of origin. The  describe an external gradient field, whose field strength vanishes at the origin and which has no spatial derivations of 2nd or higher order. This field can be measured by five ideal gradiometers at the origin and can be compared with the creation of software gradiometers.The  represent an octopole at the origin. The  describe an external gradient field of 2nd order, which has no spatial derivations of 3rd or higher order and whose field strength and spatial derivatives of 1st order vanish at the origin. This field could be measured by 7 ideal second order gradiometers at the origin, it can be compared with the creation of software gradiometers of 2nd order:The  at position  as a good approximation. The field of this dipole isDue to its small spatial extension, the magnetic marker can be described as a dipole of strength With the Taylor series expansionfollows in analogy to equation (1)A comparison of coefficients of (1) and (27) yieldsand can be determined by the dipole moment . An equation system for the adjacent calculation of the dipole position  from the dipole strength  and the quadrupole moment  follows from (29) and (23):The dipole strength withm.This equation system is named shift equation in analogy to . It is oc, which are required for the localization of the marker dipole, from solving the overdetermined equation system (14) by means of the pseudo inverse of F:We get the multipole moments c = (FT·F)-1·FT·Bmeas.     (33)F must contain columns at least for the moments  and .Here, the matrix of form functions Iterative dipole localization for a fixed dipole (e.g. one time point) is achieved by using the localization position as a new point of origin. The step length of the last localization step serves as a stop criterion for the iterative localization procedure. This is justified by considering the residuals of equation (14) within the convergence range of the procedure, and will practically be shown by the results of the following simulations.The tracking of a moved dipole based on measurements at consecutive time steps works by updating both the point of origin and the measurement data set after each localization step Fig. . The loc-1/2 at 10 Hz. Three sensors form one orthogonal triplet in each case. The measurement plane with a diameter of 23 cm consists of 56 of those triplets. The reference array consists of seven SQUID sensor triplets located in the second level in a plane which is positioned parallel to the measurement plane at a distance of 98 mm. The third (196 mm above the first plane) and fourth (254 mm above the first plane) levels contain one triplet each . The ARGOS 200 system contains fully integrated planar SQUID magnetometers produced using Nb technology with integrated pick-up loops. The sensing area is a square of 8 mm side length. The intrinsic noise level of the built in 195 SQUID sensors is below 5 fT HzThe measurement system is positioned within a magnetically shielded room, consisting of 3 highly permeable shieldings and one eddy current shielding. The shielding performance is 38 db at 1 Hz, 55 db at Hz and 80 db at 20 Hz.The sensor arrangement in orthogonal triplets facilitates the measurement of all 3 spatial components of the magnetic field. Thus, the required field coverage for the localization of a magnetic marker with unknown dipole strength is achieved.The subdivision into 168 measurement and 27 reference sensors is meant for the creation of software gradiometers. We can use all sensors simultaneously for the multipole method which integrates the suppression of disturbing fields.With the above described measurement system we performed simulations with different signal to noise ratios.x, y, z) = , i.e. 30 cm below the measurement plane, with a dipole strength of 20 Amm2. This is a realistic dipole position for an examination within the digestive tract. The dipole field was superimposed by uncorrelated, Gauss distributed noise. The noise level in fT is also given as signal-to-noise-ratio (SNR), based on the channel with the strongest amplitude of the dipole field.We examined the localization characteristics of the multipole method by means of simulation runs at the sensor geometry of the measurement system Argos 200   Fig. .cm and for the outer moments cex as well. As a good approximation the interrelationship between noise level and localization error is linear, with raising proportionality factor for higher mode numbers. This corresponds to parallel translation of the curves in double logarithmic plotting.The localization was run up to a stable point. We define the localization error as the mean quadratic error of the 100 stable points based on the true dipole position. The localization error increases if we use higher order multipole moments. This holds true for the inner moments We examined the localization speed depending on the distance of the starting point to the dipole position. For any tested distance the starting point has been moved from the dipole position into 100 random directions. The remaining mean distance to the dipole position after one localization step is depicted in Fig. In the following we examined the interrelationship between the convergence distance at y-direction and the noise level. The maximum y-distance of the starting position to the dipole, at which the dipole could be found with 100 random noise distributions, is depicted in Fig. The computing time used for one localization step is 5 ms with an implementation in Matlab at a standard Windows PC with a 2 GHz clock frequency. With maximum 3 iterations per localization step and additional computing time needed for data transfer and a basic visualization, 10 localizations per second are possible. This rate is normally sufficient for marker localizations., but this is associated with a higher localization error. At a signal to noise ratio lower than 103 inner octopoles cannot be used. An SNR of at least 102 is required for a source positioned 30 cm below the measurement plane.The localization speed rises when using inner octopoles cex used enlarge the localization error depending on the uncorrelated sensor noise, as shown in Fig.  and possibly noise suppression of gradient fields using  are applicable. To ensure convergence, the starting point for the algorithm has to be within the convergence radius given in Fig. The outer moments The multipole localization is an effective algorithm because it unites a method for the suppression of disturbing fields with a localization method. It can be used iteratively and online for the tracking of magnetic marker timelines within the intestinal tract.


Harpagornis moorei. H. moorei  was 30%–40% heavier than the largest extant eagle , and hunted moa up to 15 times its weight. In a dramatic example of morphological plasticity and rapid size increase, we show that the H. moorei was very closely related to one of the world's smallest extant eagles, which is one-tenth its mass. This spectacular evolutionary change illustrates the potential speed of size alteration within lineages of vertebrates, especially in island ecosystems.Prior to human settlement 700 years ago New Zealand had no terrestrial mammals—apart from three species of bats—instead, approximately 250 avian species dominated the ecosystem. At the top of the food chain was the extinct Haast's eagle,  A phylogenetic analysis reveals the rapid increase in size of a New Zealand eagle, demonstrating the speed at which evolution can act on islands Harpagornis moorei (H. moorei was approaching the upper limit of body mass for powered flight [Hieraaetus), placed H. moorei as a sister species to Aquila audax, the Australian wedge-tailed eagle  [Since the discovery of the first fossil in 1872 the sheer size of s moorei A has fueingspan)  and may H. moorei specimens together with 16 extant eagles (b (cyt b) and ND2 genes were PCR-amplified, sequenced and analysed with data available on GenBank to build a maximum-likelihood tree , and not with A. audax. Moreover, the genetic distance separating H. moorei and the most recent common ancestor of the related Hieraaetus eagles is relatively small (1.25%). The lack of fossil calibration points for accipitrids precludes direct estimates of divergence times; however, when a molecular rate of 0.7%–1.7% per million years, as previously estimated for avian cyt b [H. moorei into New Zealand's South Island appears to have been a recent event, probably involving a small bird-eating Asian/Australian Hieraaetus eagle that thereafter increased rapidly in size.To further investigate the evolutionary history of this raptor we performed an ancient DNA study on the fossil remains of two extinct t eagles . Short, ood tree C and S1.ood tree . Surprissmall 1.2%. The laH. moorei is an anomaly in the context of the eagle phylogeny shown in Circus spp.), and a complete lack of terrestrial predatory mammals in New Zealand. The speed and magnitude of the increase in body mass seems unique within vertebrate lineages, and is more significant because it occurred in a species still capable of flight. The avian faunas of Islands such as Hawaii (Hawaiian goose), the Galápagos , Mauritius (dodo), and New Zealand (moa) are often cited as examples of rapid evolution of flightlessness, shifts in body size, and other specialisations in birds [H. moorei over its sister taxa is unrivalled. H. moorei therefore represents an extreme example of how freedom from competition on island ecosystems can rapidly influence morphological adaptation and speciation.An analysis of mean body mass using independent contrasts clearly demonstrated that the size of in birds ,6,7. Isoin birds , but theAquila, Hieraaetus, and Spizaetus, which are clearly paraphyletic. Assignment of species within these genera has traditionally been problematic  , so thi872) see . The incH. moorei bones (b and ND2 primers listed in Harpagornis bone was sent to an ancient DNA facility at University College London (I. Barnes) for independent replication, where identical sequences were obtained for two cyt b amplifications. Similar cyt b and ND2 tree topologies, in addition to multiple overlapping sequences, make it unlikely that we are detecting a nuclear pseudogene.DNA was extracted and amplified from two ei bones  as previb and ND2 were selected using a heuristic search as implemented in PAUP*4.0b10 [4 + I substitution model. The assumption of a molecular clock was tested using a likelihood ratio test in which the χ2 test statistic was two times the log likelihood difference between clock and non-clock models. For the cyt b tree the assumption of rate constancy was not rejected. Node support was evaluated for 1,000 bootstrap replicates. Bayesian Markov Chain Monte Carlo phylogenies were also generated on the cyt b dataset using BEAST [Maximum-likelihood trees for cyt P*4.0b10  under thng BEAST  and MrBang BEAST  under siH. moorei was estimated from femur length [H. moorei is clearly an “outlier” in the context of the phylogeny presented here.Using the maximum-likelihood tree in r length . A test r length . The resHieraaetus is H. pennatus ; therefore, the taxa grouping strongly with H. pennatus must remain in that genus. The close genetic relationship of H. morphnoides with H. pennatus firmly embeds this species in Hieraaetus. However, the New Guinea subspecies presently recognised as H. morphnoides weiskei is genetically, geographically, and morphologically distinct and warrants species status, which necessitates the new combination Hieraaetus weiskei . Harpagornis moorei is included in the clade with H. pennatus and H. morphnoides, and hence its generic assignment must reflect that. The name for the extinct Harpagornis moorei of New Zealand should therefore be amended to Hieraaetus moorei .The type species for the genus Figure S1(89 KB PDF).Click here for additional data file.Table S1(64 KB PDF).Click here for additional data file.Table S2(54 KB PDF).Click here for additional data file.http://www.ncbi.nlm.nih.gov/Genbank/index.html) under accession numbers AY754044 to AY754056.Sequences have been deposited in GenBank (


This study presents an analysis of trabecular bone structure in standard radiographs using Fourier transforms and principal components analysis (PCA) to identify contributions to hip fracture risk.Az) discriminating the hip fracture cases from controls was calculated for each analysis.Radiographs were obtained from 26 hip fracture patients and 24 controls. They were digitised and five regions of interest (ROI) were identified from the femoral head and neck for analysis. The power spectrum was obtained from the Fourier transform of each region and three profiles were produced; a circular profile and profiles parallel and perpendicular to the preferred orientation of the trabeculae. PCA was used to generate a score from each profile, which we hypothesised could be used to discriminate between the fracture and control groups. The fractal dimension was also calculated for comparison. The area under the receiver operating characteristic curve (P < 0.05). No significant differences resulted from using the various ROI within the proximal femur. For the best three groupings of profile , method  and ROI (Az = 0.84 – 0.93), there were no significant correlations with femoral neck bone mineral density, age, or body mass index. PCA analysis was found to perform better than fractal analysis (P = 0.019).Texture analysis of standard radiographs using the fast Fourier transform yielded variables that were significantly associated with fracture and not significantly correlated with age, body mass index or femoral neck bone mineral density. The anisotropy of the trabecular structure was important; both the perpendicular and circular profiles were significantly better than the parallel-profile (Both PCA and fractal analysis of the FFT data could discriminate successfully between the fracture and control groups, although PCA was significantly stronger than fractal dimension. This method appears to provide a powerful tool for the assessment of bone structure in vivo with advantages over standard fractal methods. The NIH Consensus Statement defines Osteoporosis as "a skeletal disorder characterised by compromised bone strength predisposing to an increased risk of fracture" . Bone stTrabecular bone structure is visible on standard pelvic radiographs and many attempts have been made to quantify the quality of the structure and assess its relationship to osteoporosis and BMD. These range from visual scoring systems, such as the Singh index , throughIn this study we investigate the use of Fourier transforms and Principal Components Analysis to generate a mathematical model of the data which can be used to help classify individuals according to the presence or absence of a hip fracture. Principal component analysis (PCA)  is a datA set of digitised standard pelvic radiographs was available from a previous investigation into the morphology of the proximal femur . These rFive regions of interest (ROIs) were selected relative to the principal trabecular systems in locations known to be related to hip fracture via the Singh index  and BMD Each ROI was 256 × 256 pixels (11.3 mm square), to enable use of the fast Fourier transform, and were selected as follows. The upper region of the head (UH) lies on the upper part of the principal compressive trabeculae, the central region of the head (CH) is at the intersection of the principal compressive and tensile trabeculae, the upper region of the neck (UN) lies on the principal tensile trabeculae, the lower region of the neck (LN) is at the base of the principal compressive trabeculae and finally Ward's triangle (WA) which lies between these structures. The points and regions were identified using a macro written for Image Pro Plus software . The femoral head was described by a best-fit circle, calculated from a series of manually marked points around the outline of the femoral head. Between 15 and 20 evenly spaced points were used to describe the outline, depending on the size of the head. The radius and centre . A fast Fourier transform was generated for each ROI and three profiles were generated using data from the power spectrum. Firstly a global or circular profile (CircP) was generated, composed of the magnitude at each spatial frequency averaged across all angles, resulting in a profile with 128 data points. To create this profile, each pixel in the Fourier transform was assigned to the integer spatial frequency that most closely matched its' distance from the zero'th component.The angle of preferred orientation was calculated by finding the angle of the maximum value in the power spectrum for the first 25 spatial frequencies . The maxPrincipal component analysis  was usedslope) of a straight line fitted to each region was found; slopeA, a 'coarse' slope, where the log of the spatial frequency is less than or equal to 1.0, slopeB a 'medium' slope, where the log of the spatial frequency lies between 1.0 and 1.75 and slopeC, a 'fine' slope where the log of the spatial frequency is above 1.75. The fractal dimension was calculated for each slope using the formula suggested by Majumdar et al [Fractal analysis was performed on each profile using a method similar to the Fourier transform technique described by Majumdar et al . The avear et al Stepwise discriminant analysis was used to select principal components that could be combined to build a linear classifier. If the stepwise procedure failed to select any components, the most accurate of the individual components was chosen. The same procedure was used to discriminate between the groups using the fractal dimension. Measurement of the area under the ROC curve was used to compare the classifiers built using the discriminant analysis . A threeP = 0.001).There were no significant differences between the age, height, weight or body mass index (BMI) of the fracture and control groups Table . As expeAz) represents the performance of the classifier ranging from a value of 0.5 if it is no better than chance to 1.0 for a perfect discriminator. Table Az for PCA analysis by region for the circular, perpendicular and parallel profiles respectively, discriminating fracture and control cases. A wide range of values was observed . Some were little better than chance (Az = 0.5)  and the strongest ones were from the perpendicular profiles. The 5 largest areas under the ROC curve were obtained by PCA of the perpendicular profile of the lower neck, upper and central head regions , followed by PCA analysis of the circular profile in the upper head region (Az = 0.76) and, finally, fractal analysis of the parallel profile in the upper neck region (Az = 0.75). Femoral neck BMD lay between the third and fourth best texture measures (Az = 0.79 95% CI = 0.66 – 0.91). Plots of the ROC curves for the strongest combinations of image analysis classifier are shown in Figure The Receiver Operating Characteristic (ROC) curve is a plot of True Positive Fraction v False Positive Fraction (or Sensitivity v 1 – Specificity). The area underneath the curve (ns Table  (Az = 0.P > 0.05). The fifth placed classifier, fractal analysis of the parallel profile in the upper neck region, was the only one significantly associated with Neck-BMD (P = 0.034).Table P = 0.019) and that analysis of both the perpendicular and circular profiles performed significantly better than the parallel profile (P = 0.003 and 0.011 respectively). No significant differences were found between the different regions of the femoral neck (P = 0.241) (despite the apparently large differences in Az). The power of this test was 0.69, 0.97 and 0.15 for the investigation of differences due to the method of analysis, type of profile used and the region analysed respectively.A three-way analysis of variance was used to examine differences in performance due to the region, profile or type of analysis used. It showed that overall PCA analysis performed significantly better than fractal analysis , however when all the profiles were considered, no significant differences were apparent (P = 0.26).Table In these short series, this study found that texture analysis of standard radiographs using the fast Fourier transform can yield variables that are significantly associated with fracture but not significantly correlated with age, body mass index or Neck-BMD. Both PCA and fractal analysis of the FFT data could be used to discriminate successfully between the groups, although overall PCA was significantly stronger than fractal dimension. The best results from this study were not significantly correlated with femoral neck-BMD, age or BMI, indicating their potential for use as an independent predictor of fracture. The radiographic appearance of bone is known to be affected by factors including the size of the patient. As there was no significant difference in the BMI of the fracture and control groups, it is unlikely that this has influenced the results, however it is an issue that will need addressing in future studies.P < 0.01). One advantage of PCA that may contribute to this finding is the ability to summarise the information present in the dataset with a small number of components via an economical mapping of the variance present in the data. In addition, the property of orthogonality between these components ensures that the variables generated are linearly independent . Analysis in the perpendicular direction was strongest overall, although it was not significantly better than the circular profile. This accords with the increasingly anisotropic nature of trabecular bone with aging; bone loss is not evenly distributed but is lost primarily at angles perpendicular and oblique to the preferred orientation of the trabeculae [Previous studies using non-fractal analysis of the Fourier power spectrum have focussed on images of the spine or wrist, where the alignment of trabeculae is generally orthogonal -30. In sIn summary, this paper presents a new method for analysing the structure of trabecular bone from standard radiographs. It demonstrates that the Fourier transform can be used to describe structural information in images which may be related to fracture, independently of BMD. This study is limited by the small size of the data set and further analysis is needed to validate these findings. This should be performed on a similar series of radiographs, consisting of fracture and control subjects scanned at the same resolution. The methods from this study could then be applied directly to this group  to evaluate whether they were generally applicable. However the success of both this and our previous study, using similar techniques to analyse histological sections, indicates that this may be an effective method with clinical utility for describing bone quality statistically in terms of structural parameters.The authors declare that they have no competing interests.Author JG helped design the study, performed the image and data analysis and drafted the manuscriptAuthor AS collected the data/images used within this study and helped with writing of the paper.Author PU assisted with some of the practical approaches, and the writing of the paperAuthor DMR designed the initial case control study and assisted with interpretation of the results and writing the paperAuthor RMA helped with the design of the study, the interpretation of the results and the writing of the paper.All authors read and approved the final manuscriptThe pre-publication history for this paper can be accessed here:


Retroviruses are unique among virus families in having dimeric genomes. The RNA sequences and structures that link the two RNA molecules vary, and these differences provide clues as to the role of this feature in the viral lifecycles. This review draws upon examples from different retroviral families. Differences and similarities in both secondary and tertiary structure are discussed. The implication of varying roles for the dimer linkage in related viruses is considered. With relatively few genes compared to many other virus families, the retroviridae have evolved over the millenia to maximise the functions of their RNA genome. The genome serves as a versatile template from which various proteins can be translated by the use of splicing and by translational flexibility using scanning, IRES and frameshifting. It is also an RNA molecule capable of interacting with itself, and cellular and viral proteins. By these means, from an RNA around 7 – 12 kilobases long, the retroviridae have evolved to infect a wide range of species and cell types.A unique characteristic of retroviral genomes is the fact that they are dimeric. The reasons for this are as yet unclear, and are discussed below. In brief, it is thought that the diploid genome allows template switching during reverse transcription and may be linked to recombination in some viruses. It may also play a role in translation of proteins and packaging of the RNA.et al this issue [Much of the work on the nature, structure(s), and role of the dimer linkage has been based on Human Immunodeficiency Virus Type 1, and this has been recently reviewed ([is issue ). WhetheRetroviruses were discovered at the beginning of the 20th century ,4. The uRNA dimerisation in the primate lentiviruses, predominantly HIV-1, has subsequently been extensively studied .in vitro the RNA elements involved in the dimer linkage first observed by EM. It was shown that RNA transcripts comprising sequences from the 5' end of the viral genome would migrate as two species of RNA when subjected to electrophoresis. By this means many subsequent studies were able to focus on isolating the elements and structures involved in dimerisation, and to investigate the role of the viral structural proteins in this process.Since 1990  it has bAs yet investigators have not been able to agree on a distinct role for the dimer linkage. The fact that it is conserved amongst the retroviridae does not guarantee that its role will be the same in all retroviral families. The following section of the review will endeavour to explore some of the proposed roles, and examine the evidence from different retroviruses.Several studies have demonstrated that, in HIV-1 and MLV, the dimer linkage serves as a "hotspot" for recombination ,15. It iInterestingly, it has been suggested that the nucleocapsid protein (NC) promotes or stimulates the strand transfer reaction. As will be discussed below, NC and the precursor Gag protein both bind the RNA close to the DIS in HIV-1. In addition, there is evidence that the presence of a dimer in the virus particle facilitates the first strand-transfer reaction of reverse transcription .Alpha- and Gammaretroviruses, but not with DIS regions identified in the primate lentiviruses. Within the Alpha- and Gammaretroviruses GACG tetraloops are involved in the packaging of viral RNA [Work in our laboratory has shown that the Maedi Visna Virus DIS is centred on a helix terminating in a GACG tetraloop between positions 281 and 300 in the viral genome; a region which is highly conserved between the ovine and caprine lentiviruses , termed the DM region, rendered the virus severely packaging deficient. The mutation had been designed based on the mfold [In vitro studies using RNA transcripts comprising the leader region with and without the DM deletion, reveal that it does, indeed, render the viral RNA monomeric . Using antisense oligonucleotides, another group have demonstrated that this region may, in fact, play a role in the dimerisation process itself [Another possible role is that of the dimer linkage acting as a switch, its presence permitting or restricting the packaging of RNA. In HIV-2 two regions were originally suggested as dimer initiation sites, one analogous to the palindromic sequence identified as the principal DIS in HIV-1 (termed SL1), one close to the PBS -27. Recehe mfold ,30 predis itself . By freein trans, the latter uses predominantly a cis mechanism. One might postulate therefore, that, if retroviruses must package a dimeric genome, it is critical in the case of HIV-2 that the genome is dimeric before interacting with the Gag polyprotein. Hence, the effect of mutations in the DM region may be to render the RNA monomeric and thus to severely impair packaging.One of the key differences between HIV-1 and HIV-2 replication is their modes of packaging . Whilst trans mechanism is less dependent on a high affinity dimer linkage?It is attractive to speculate that the reason packaging itself is not affected by DIS mutations to the same degree in HIV-1  is this A recurring observation amongst investigators is the fact that mutation or deletion of dimer linkage sites causes viral infectivity to be decreased . One expin vitro [The DLS of Human T Cell Lymphotropic Virus Type 1 (HTLV-1) was identified as a 14-nucleotide sequence just downstream of the splice donor . Removalin vitro ,36. Whenin vitro . Likewisin vitro .et al showed that if the RNA of Rous Sarcoma Virus (RSV) was engineered so that it was monomeric, the virus was non-infectious [in vitro system, dimer formation appeared to inhibit synthesis of the Gag polyprotein precursor [Parent fectious . Interesfectious . This isrecursor .in vitro selection system it has been possible to demonstrate that the DIS has evolved to satisfy both constraints for optimal dimerisation affinity, and the potential to homodimerise [et al, examining the interaction of NC with elements of the packaging signal, of which loop B is one, showed that, in fact, both structures might exist, the flexible one allowing NC binding at high affinity [Undoubtedly the best defined dimerisation structure is that involved in the dimer linkage of HIV-1. The discovery of the sequences involved, the subsequent description of the RNA:RNA interaction, and the elucidation of the tertiary interaction are described elsewhere ) followedimerise . The dimdimerise ,45 and tdimerise  and loopdimerise -49. The affinity . There aaffinity ).Palindromes remain a theme throughout many of the viruses investigated to-date. As already mentioned, the DIS of HIV-2 is less well defined than that of HIV-1. Whilst there is a palindromic sequence at the top of a stem loop structure that closely resembles the HIV-1 DIS (see Figure CH, the strain used in the study. The other 11 sequences comprised three different variants. Eight contained a deletion of C736 (see Figure Recent work by Monie and colleagues  describeThe retroviral RNA genome structure does not stay static during the course of transcription, translation and ultimately packaging. Various investigators have suggested that this constantly changing RNA structure plays an intimate role in the viral replication -61. It sIn vivo data has revealed just how important an intact dimmer linkage may be to a retrovirus. For instance, there are intriguing differences in the effect of dimer mutations on viral infectivity depending on the cell type being infected [infected . What thinfected . One canTo sum up, retroviral dimeric genomes are linked by a variety of RNA structures, including kissing hairpins, GACG tetraloops and unusual CAG-tri loops. The differences in these interactions, and when or where they occur, may reflect different demands upon this unique feature, and highlight the elasticity of the RNA genome.None declared.


BRCA1 and BRCA2 predispose to breast and ovarian cancer. A multitude of mutations have been described and are found to be scattered throughout these two large genes. We describe analysis of BRCA1 in 25 individuals from 18 families from a Greek cohort.Germline mutations in BRCA1 gene, followed by sequencing of fragments suspected to carry a mutation including intron – exon boundaries. In patients with a strong family history but for whom no mutations were detected, analysis was extended to exons 10 and 11 of the BRCA2 gene, followed by MLPA analysis for screening for large genomic rearrangements.The approach used is based on dHPLC mutation screening of the BRCA1 was identified in 5/18 (27.7 %) families, where four distinct mutations have been observed. Single base putative pathogenic mutations were identified by dHPLC and confirmed by sequence analysis in 4 families: 5382insC (in two families), G1738R, and 5586G > A (in one family each). In addition, 18 unclassified variants and silent polymorphisms were detected including a novel silent polymorphism in exon 11 of the BRCA1 gene. Finally, MLPA revealed deletion of exon 20 of the BRCA1 gene in one family, a deletion that encompasses 3.2 kb of the gene starting 21 bases into exon 20 and extending 3.2 kb into intron 20 and leads to skipping of the entire exon 20. The 3' breakpoint lies within an AluSp repeat but there are no recognizable repeat motifs at the 5' breakpoint implicating a mechanism different to Alu-mediated recombination, responsible for the majority of rearrangements in the BRCA1 gene.A pathogenic mutation in BRCA1 gene in patients at high risk of carrying a germline mutation as determined by their family history. Furthermore, our results suggest that in those families with strong evidence of linkage to the BRCA1 locus in whom no point mutation has been identified re-examination should be carried out searching specifically for genomic rearrangements.We conclude that a combination of techniques capable of detecting both single base mutations and small insertions / deletions and large genomic rearrangements is necessary in order to accurately analyze the  BRCA1 and BRCA2 genes predispose individuals to breast and ovarian cancer. The lifetime risk of breast cancer in female carriers of a BRCA1 mutation is 60–80% while that of ovarian cancer is 20–40%. The median age of diagnosis of breast cancer is 42 years, i.e. 20 years earlier than the median of unselected women in the U.S.A. and Western Europe [BRCA1 is a large gene with 22 coding exons encoding a 220 kD protein [Germ line mutations in the  protein ,4.BRCA1 have been identified in 15–20% of women with a family history of breast cancer and 60–80% of women with a family history of breast and ovarian cancer [. Such mutations are detected by PCR-based screening methods such as the Protein Truncation Test (PTT), Single Strand Conformational Polymorphism (SSCP), Denaturing Gradient Gel Electrophoresis (DGGE), heteroduplex analysis (HA) and more recently denaturing high performance liquid chromatography (dHPLC) with varying degrees of sensitivity for each method. Direct DNA sequencing is used in order to confirm and characterize mutations detected by any of these approaches [A multitude of mutations scattered throughout the 5592 bp coding sequence have been described. In particular, germ line mutations in n cancer -9. The vproaches ,11. Whilproaches -16.BRCA1 gene by characterizing a deletion encompassing 3.2 kb of the gene including exon 20. In addition, we add more evidence supporting pathogenicity of a previously described variant, G1738R, which seems to be specific to the Greek population [In this study we document and extend previous work suggesting the necessity of screening for large genomic rearrangements in a complete program for mutation detection of the BRCA1 patients and their families were referred through the Oncology Departments of Hygeia Hospital and other hospitals throughout Greece. Patients were included on the basis of affected family members, types of cancer present in the family and the age at diagnosis of breast cancer in the proband. The families were subdivided into high risk when multiple cases of breast and ovarian cancer were diagnosed, medium risk if there were only 2–3 cases of breast cancer, and low risk in isolated cases of breast cancer with diagnosis before the age of 40 years. The study population consisted therefore of 12 high risk families, 2 with medium risk, and 4 families at low risk as determined by their cancer history. Ethical approval was obtained from the hospital's advisory committee and all patients signed informed consent. Screening has been completed in 25 individuals from 18 families. Testing was initially carried out on DNA from an affected family member and upon detection of an inactivating mutation the rest of the family members were directly tested for this mutation.Genomic DNA and RNA were purified from peripheral blood leukocytes using standard extraction protocols.BRCA1 including splice junctions was amplified by PCR. Similarly, exons 10 and 11 of the BRCA2 gene were amplified in 3 of the patients. Primers used have been chosen from the BIC database . In addition primers: mBRCAF: GAG TTT GTG TGT GAA CGG ACA CTG and mBRCAR: GTG CCA AGG GTG AAT GAT GAA AGC, designed during the course of this study, were used for amplification of cDNA from the patients found to carry a deletion of exon 20 of the BRCA1 gene.The complete coding sequence of 2, 200 μM each dNTP, 1.5 U Taq DNA polymerase  or 2.5 U Optimase polymerase  and 12.5 pmol of each primer.Reactions of 50 μl were heated on a PTC-200 MJ Research Thermocycler  at 95°C for 5 min then cycled 35 times of denaturation at 95°C for 40 sec, annealing at the appropriate temperature for 30 sec and extension at 72°C for 30 sec, followed by a final extension step at 72°C for 6 min. Reaction mixture was 20 mM TrisHCl (pH 8.4), 50 mM KCl, 1.5 mM MgClThe WAVE DNA Fragment Analysis System  and associated WAVE-Maker™ software were used as previously described .® 310 Genetic Analyzer using the Big-Dye Terminator Cycle Sequencing Kit. Sequences obtained were aligned, using Sequencher® PC software, with normal sequences from Genbank  and examined for the presence of mutations. All nucleotide numbers refer to the wild-type cDNA sequence of BRCA1 as reported in GenBank (accession number U14680).Purification of the PCR products was performed using the Concert Rapid PCR purification or gel extraction system kits . Automated cycle sequencing for both strands was performed with the ABI Prism® 310 Genetic Analyzer  using TAMRA-500  as size standard. A peak pattern of 34 peaks ranging in size from 127 to 454 nt is obtained [MLPA was carried out using the P002_BRCA1 kit  as instructed by the manufacturer. Fragment analysis was carried out on ABI Prismobtained .BRCA1 exon 20 was confirmed by long PCR using the GeneAmp XL PCR System  according to the manufacturer's instructions. PCR was carried out in 50 μl reactions consisting of 1 × buffer II (supplied with the enzyme), 12 pmole each primer, 0.2 mM each dNTP and 2.4 U rTth DNA polymerase, XL . After 2.5 min denaturation at 95°C PCR was carried out for 19 cycles of 95°C for 30 sec, 58°C for 30 sec and 68°C for 8 min followed by 15 cycles of 95°C for 30 sec, 58°C for 30 sec and 68°C for 4 min with a time increment of 10 sec per cycle. A final extension step was carried out at 72°C for 10 min. PCR products were separated by agarose gel electrophoresis and visualized by EtBr staining.The deletion in Total RNA was extracted from whole blood of patients from family D using Trizol  according to the manufacturer's instructions. First strand synthesis was performed by denaturing approximately 500 – 1000 ng total RNA, random hexamers  for 4 min at 70°C, followed by snap freezing on ice and addition of dNTPs , 1 U/μl recombinant RNase inhibitor  and 200 U MMLV reverse transcriptase . The mixture was incubated at 37°C for 1 hour followed by denaturation of the enzymes at 95°C for 5 min. 4 μl of cDNA were used for subsequent PCR amplification.BRCA1 locus. A pathogenic mutation was identified in five families, where four distinct mutations have been observed. In addition, 18 polymorphisms, including a novel silent polymorphism in exon 11 of the BRCA1 gene, have been detected .BRCA1 locus revealed a missense mutation 5331 G > A. The mutation results in substitution of a Glycine by an Arginine at codon 1738. The mutation was not detected in the patient's unaffected sister. Unfortunately, no other family members were available for analysis.In family B there were seven cases of breast cancer and one case of colorectal cancer at age 50. Mutation analysis at the In family C there were 4 cases of breast cancer in addition to cancer of the larynx, ovaries, lung and the genitals. A single base substitution, G > A at nucleotide 5586 was identified. This mutation causes a splicing defect resulting in a protein lacking exon 23. Unfortunately, no DNA was available from other family members in order to test the correlation of this mutation with the other tumor types.BRCA1, failed to reveal a mutation. This prompted the analysis of other genes, namely BRCA2 and p53 in order to try and characterize the phenotype in this family, but no mutation was identified. For this reason, we decided to use the MLPA technique [BRCA1 mutations. MLPA analysis of the proband  families, where four distinct mutations have been observed. In addition, 18 polymorphisms have been found to be present in more than one family.A total of 18 breast cancer families have been examined for mutations at the in vitro [In family B a missense mutation, 5331 G > A, was identified. The exact effect of this single amino acid change, G1738R, on the protein function is unclear. The altered glycine is located on the surface of the coil structure of the BRCT linker region and the mutation therefore may disrupt the interface or affect protein interaction . This muin vitro ,23. BaseBRCA1, failed to reveal a mutation. This prompted the analysis of other genes, namely BRCA2 and p53, but without finding a mutation. For this reason, we decided to use the MLPA technique [BRCA1 mutations [BRCA1 gene, namely exon 20.Our results indicate, as has been documented by others that family history is the major determinant of the risk of breast cancer. As can be seen in Table echnique  to screeutations -16. ThisAluSp repeat. The deletion described here, therefore, is different to the majority of rearrangements described so far for the BRCA1 gene, since they have been shown to result from homologous recombination of Alu repeats [Deletion of exon 20 has been previously described in an Italian family . However repeats ,25. In tBRCA1 mutations and the risk of CRC are not conclusive. Two recent studies carried out on Ashkenazi Jewish patients suggest that there is no correlation [BRCA1 mutation carriers [In 2/5 pedigrees in whom a pathogenic mutation was identified there was one case each of colorectal cancer (CRC). In particular, in family D Figure  the diserelation ,27. Othecarriers ,29. UnfoBRCA1 unaffected mutation carriers at the ages of 39 and 55. The penetrance and age of onset of disease in BRCA1 mutation carriers is variable. Various reports have suggested the existence of modifying genetic and environmental factors on the penetrance of BRCA1 and BRCA2 mutation carriers [A further interesting point observed in this study is the identification of two carriers ,31. In tBRCA1 in a Greek family. Although our sample group is quite small identification of 1 genomic rearrangement in 5 mutations detected, suggests that in yet another population this type of mutations contribute to the BRCA1 mutation spectrum. This therefore warrants use of a combination of techniques capable of identifying both single base mutations in addition to large genomic rearrangements. In this respect, we have found that use of dHPLC for single base mutations and MLPA for large genomic rearrangements is a reliable combination for use as an initial screening step followed by sequencing for characterization of the mutations identified.To our knowledge this is the first report of a genomic rearrangement identified as the underlying mutation of BRCA1 locus in whom no point mutation has been identified re-examination should be carried out searching specifically for genomic rearrangements.Furthermore, our results suggest that in those families with strong evidence of linkage to the dHPLC denaturing High Performance Liquid ChromatographyMLPA Multiplex Ligation – dependent PCR AmplificationPCR Polymerase Chain ReactionRT-PCR Reverse Transcription Polymerase Chain ReactionCRC Colorectal CancerNone declared.IB carried out mutation detection by dHPLC and sequencing for the patients analyzed. AA carried out MLPA, the molecular characterization of the deletion, and drafted the manuscript. MM contributed in the molecular studies and preparation of the manuscript and figures, ER, SL, AP, VG, AK NP, PK and DY provided the patient material, diagnosis and management,, KK and AH carried out molecular genetic analysis of the p53 gene, GN conceived of the study, and participated in its design and coordination. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:


The lifetime prevalence of Social Phobia (SP) in European countries other than Italy has been estimated to range from 3.5% to 16.0%. The aim of this study was to assess the frequency of SP in Sardinia  in order to verify the evidence of a lower frequency of SP in Italy observed in previous studies (from 1.0% to 3.1%).th International Classification of Diseases (ICD-10).A randomised cross sample of 1040 subjects, living in Cagliari, in rural areas, and in a mining district in Sardinia were interviewed using a Simplified version of the Composite International Diagnostic Interview (CIDIS). Diagnoses were made according to the 10Lifetime prevalence of SP was 2.2%  whereas 6-month prevalence resulted in 1.5% . Mean age at onset was 16.2 ± 9.3 years. A statistically significant association was found with Depressive Episode, Dysthymia and Generalized Anxiety Disorder.The study is consistent with findings reported in several previous studies of a lower prevalence of SP in Italy. Furthermore, the results confirm the fact that SP, due to its early onset, might constitute an ideal target for early treatment aimed at preventing both the accumulation of social disabilities and impairments caused by anxiety and avoidance behaviour, as well as the onset of more serious, associated complications in later stages of the illness. Several epidemiological studies have attempted to describe the prevalence, socio-demographic characteristics, comorbidity, and severity of clinical manifestations of Social Phobia (SP). Quality of life and functional status of affected individuals have also been investigated . LifetimThis study, part of an extended epidemiological investigation "Health in Sardinia," aimed to assess the prevalence rates of SP in Sardinia  in order to confirm the evidence of low SP prevalence rates ranging from 1.0% to 3.1% observed in previous research projects in Italy -6. The sThe sample, which had already been examined and described in greater detail in a previously published study , consist2 = 1.2, 1DF, P = 0.25). 6-month prevalence rates were lower . Table 2 = 5.8, 1DF, P = 0.06). Mean age at onset was 16.2 ± 9.3 years.Estimates of lifetime SP prevalence of 2.2% were found , with no statistically significant difference between the sexes  out of the 16 subjects who had been diagnosed with SP over the past six months had been taking low doses of anxiolytics . 3 (18.7%) were on antidepressants, one of whom (6.2%) at non-therapeutic doses, and 1 subject (6.2%) was undergoing cognitive behavioural psychotherapy. The remaining 6 subjects (37.5%) were not on any treatment.Six out of the 10 treated subjects (60%) were being supervised by their general practitioners (GP), 1 (10%) by a neurologist and 2 (20%) by psychiatrists. All subjects presented some degree of comorbidity with Depressive Episodes (DE), Panic Attack Disorder (PAD), and agoraphobia (AP). Only 1 subject (10%) was undergoing cognitive behavioural therapy with a psychologist/psychotherapist.Table Several epidemiological studies carried out in Europe  and BaFindings for six-month prevalence show lower frequencies than those evidenced in the recent studies: 1.5% against 4.0% in Iceland  and agaiIt should be underlined that 60% of subjects undergoing treatment  chose their general practitioner (GP). This view is corroborated by the fact that those patients treated by a psychiatrist invariably presented comorbidity with DE, PAD, and AP, thereby representing the more severely affected from a psychopathological point of view. Overall however, the low rate of patients with SP treated with first line-treatments is alarmingly low.In the future, serious attempts should be made to improve the GPs' abilities to recognise SP in order to prevent the use of inappropriate treatments, such as insufficient doses of benzodiazepines, which may be linked to the physician's incorrect diagnosing of the disorder. Due to the fact that subjects affected by SP most frequently refer to their GP, the importance of preventing SP as opposed to other types of disorders, as well as the markedly incapacitating nature of SP reinforce this necessity for a better training of GPs.It is however mandatory to briefly acknowledge some potential limitations of this study. First, the number of cases and the sample size is too small to allow firm conclusions to be drawn concerning the true rate and the degree to which they might actually differ from previous studies with higher estimates. Secondly, differences in the assessment strategy might have resulted in a diminished comparability.The study is consistent with findings reported in several previous studies of a lower prevalence of Social Phobia in Italy and confirms the fact that onset of the illness occurs primarily during childhood and adolescence. Furthermore, the results confirm the fact that SP, due to its early onset, might constitute an ideal target for early treatment aimed at preventing both the accumulation of social disabilities and impairments caused by anxiety and avoidance behaviour, as well as the onset of more serious, associated complications in later stages of the illness, or many years after onset of SP.The authors declare that they have no competing interests.MGC participated in the design of the study, performed the statistical analysis and drafted the manuscript. UHW participated in the statistical analysis and drafted the manuscript. MCH, MC, BC, LDO, MAR conceived of the study, and participated in its design and coordination. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:


Hospitals and regional health authorities must set priorities in the face of resource constraints. Decision-makers seek practical ways to set priorities fairly in strategic planning, but find limited guidance from the literature. Very little has been reported from the perspective of Board members and senior managers about what criteria, processes and parameters of success they would use to set priorities fairly.We facilitated workshops for board members and senior leadership at three health care organizations to assist them in developing a strategy for fair priority setting. Workshop participants identified 8 priority setting criteria, 10 key priority setting process elements, and 6 parameters of success that they would use to set priorities in their organizations. Decision-makers in other organizations can draw lessons from these findings to enhance the fairness of their priority setting decision-making.Lessons learned in three workshops fill an important gap in the literature about what criteria, processes, and parameters of success Board members and senior managers would use to set priorities fairly. Hospitals and regional health authorities in Canada and elsewhere are facing significant resource allocation challenges. Priorities must be set among competing opportunities because demand for health care exceeds available resources. Board members and senior administrators are looking for practical ways to improve how they set priorities under resource constraints. The priority setting literature describes priority setting in various health care contexts -9. It idFairness is a key ethical goal of priority setting when health care resources are scarce. Experience shows that there is often disagreement on what principles should be used to make fair allocation decisions  ,17. ThisTo assist decision-makers in developing fair priority setting processes, we conducted one-day workshops for Board members and senior administrators at three Canadian academic health science centres , who were seeking ethics advice on how to improve priority setting in their organisations. Each organization was faced with setting priorities among their clinical services to guide resource allocation under significant budget constraints. The goal of each workshop was to help decision-makers develop a strategy for fair priority setting based on the conditions of A4R. Using case-based plenary sessions to introduce the key concepts  and facilitating consensus through small and large group discussions, we assisted workshop participants in reaching agreement on: a) the criteria decision-makers would use to set clinical service priorities, b) the processes they would follow, and c) the parameters according to which they would evaluate the success of the priority setting exercise.We summarize key lessons learned from these workshops to help decision-makers in other health care organizations develop their own fair priority setting strategies and to improve understanding of researchers and policy makers about priority setting from the point of view of decision-makers.When decision-makers were asked what criteria they would use to set clinical service priorities, we found that responses clustered around eight (8) criteria Table . As a st'Strategic fit' described the extent to which clinical services contributed to advancing the strategic directions of the organisation, i.e., "fit" with the organization's vision, mission, values, and goals. This criterion was consistent with the idea that strategy should be a key driver of operational planning as a counterpoint to planning based on historical or short-term political considerations.'Alignment with external directives' identified existing government mandates and legislated obligations as relevant considerations for setting priorities. For example, each organisation had government directives to provide particular health services at prescribed volumes. This criterion recognised explicitly the limited degrees of freedom within which priorities could be set, but also highlighted the importance for decision-makers of participating with government in achieving regional and provincial health service objectives.'Academic commitments' consisted of two sub-criteria reflective of each organization's close affiliation with a local university and medical school. The 'education' sub-criterion emphasised the role of clinical programs in educating future health care professionals and in facilitating the integration of these activities with health service delivery. The 'research' sub-criterion emphasised the role of academic health science centres in establishing best practice standards, in generating new medical knowledge (including practice-based and bench research), and in developing technological innovation. Workshop participants felt that this criterion affirmed the unique role of academic health science centres in advancing society's health care knowledge and capacity.'Clinical impact' was defined primarily in terms of the service volumes necessary to ensure the clinical competence of medical staff to provide safe and effective care to patients. Other relevant factors included: evidence of effectiveness in health promotion and disease prevention, uniqueness of the health service in the local area, and quality of the service provided. Workshop participants expressed concern about their ability to measure clinical impact given the limitations of their institutional decision support capabilities . However, they felt that by identifying these factors, this could provide direction for the collection of appropriate data and information.'Community need' described the health service needs of patients in the organisation's local catchment area. This included current demand for health services, which could be measured on the basis of utilisation rates and waiting list data, as well as future demand based on population data and trends . Community need was further defined in terms of the availability of other health service providers. For example, community need was seen to be greater if the organisation were the sole provider of a health service to patients in the region than if there were other local providers whom patients might access for care.'Partnerships' highlighted existing formal agreements and commitments with other organisations in coordinating delivery of health care to defined populations . Partnerships were seen as effective ways to enhance service quality and to optimise resource utilisation within the region or local catchment area.'Interdependency' described the coordination and collaboration between clinical services within the organization to enhance service quality  or to use institutional resources more efficiently. In the two organisations that had achieving a "healthy" workplace as a strategic goal, workshop participants also related this criterion to quality of work life factors as key enablers of effective clinical coordination and collaboration.'Resource implications' included a cluster of factors related to the mobilisation and use of human and fiscal resources. Although recognising that strategic planning should not be over-determined by operational issues, workshop participants felt that the resource context was relevant for setting clinical service priorities. For example, the implications of prioritisation depended in part on the source of funding , the availability of staff  and capital resources , the flexibility of contractual agreements , and the model of health service delivery, which could be more or less efficient in using available resources.When asked what key process elements would be needed in order for priority setting to be accountable and fair, workshop participants identified ten (10) elements Table . Some ofWorkshop participants identified a number of preparatory steps that should be taken before priority setting can begin:(1) The organisation should establish, refine, or confirm its strategic plan. This is to ensure that the clinical service priorities that emerge through the priority setting process align with and advance the organisation's mission and strategic goals. In effect, workshop participants felt that they needed to know first where the organisation was going so that they could set the right priorities for getting there.(2) The programmatic architecture of the organization  should be clarified in order to set clinical service priorities relative to current activities. This step was also felt to be important for defining precisely what order of clinical service activity was to be prioritised and for creating an accurate inventory of clinical services for prioritisation.(3) The specific responsibilities of the Board and senior management in relation to the priority setting process should be clarified explicitly and upfront. Decision-makers identified some confusion about these responsibilities given that clinical service priority setting involved an overlap of the strategic responsibility of the Board with the operational responsibility of Senior Management. During the workshop, Board members and Senior Managers drafted a memorandum of agreement delineating their respective roles and responsibilities in the priority setting process.Workshop participants also identified a number of elements that were critical to the design of the priority setting process itself:(4) The executive decision-making group should be multidisciplinary and its role should be clearly and explicitly defined in advance of priority setting. Workshop participants emphasised the importance of shared accountability for priority setting across the clinical and administrative leadership. Engaging the medical leadership in a decision-making role was identified as key to developing a successful priority setting process. The engagement of other non-medical clinical leaders  was also thought to be important for ensuring the legitimacy of the priority setting process.(5) Stakeholders should be engaged in the priority setting process. Although the organisational executive would ultimately be accountable for making the priority setting decisions, workshop participants felt that stakeholders could be engaged particularly as key informants through expert and broader stakeholder consultation. This consultation should include both internal stakeholders  and external stakeholders .(6) Priority setting criteria should be clearly defined and understood by decision-makers and stakeholders. Data/information should be collected to support their application in the priority setting process. Workshop participants felt that the criteria identified in the workshop could be further refined through stakeholder engagement and tested with decision-makers to ensure a common interpretation of each criterion and consistency in their implementation.(7) An effective communication strategy should be developed to ensure a transparent priority setting process. The purpose of the communication strategy should be to ensure that stakeholders know and understand the scope and necessity of priority setting decision-making, the degrees of freedom within which priority setting would take place (including explicit identification of any "sacred cows" that would be immune from priority setting), and the particularities of the priority setting process . In addition, the rationales for priority setting decisions should be communicated to stakeholders and should clearly demonstrate how these decisions are defensible in light of the priority setting criteria and available data/information.(8) Decision review processes should be developed to incorporate opportunities to revisit and review decisions. Workshop participants saw these as additional opportunities to engage stakeholders around difficult priority setting decisions, although they also expressed concern that this might invite conflict between stakeholders and decision-makers. However, it was generally felt that this could be mitigated if decision review processes were focused explicitly on providing a vehicle for new data/information to be brought forward, material errors in the original decision to be corrected based on available data/information, and procedural inconsistencies to be addressed.Workshop participants identified additional elements that were important to improve quality and strengthen capacity for fair priority setting in their organisations over time:(9) Process monitoring and formal evaluation strategies should be developed to ensure quality improvement and to realise a commitment to organizational learning. Workshop participants felt that the process should be monitored for adherence to the conditions of A4R, thus allowing for mid-course corrections to enhance fairness as the priority setting process unfolded. A formal evaluation process after priority setting would allow institutional good practices as well as opportunities for improvement to be captured so that this information could lead to improved priority setting in the future. For example, Martin & Singer have developed an ethics-based quality improvement model that focuses on evaluating and improving the fairness of priority setting processes .(10) The priority setting process should be supported by leadership development and change management strategies to strengthen institutional capacity for priority setting decision-making. Capacity strengthening should focus in particular on middle managers, who may not be among the decision-making group but who would play key roles in communicating with staff and in implementing the priority setting decisions.When asked how they would know that the priority setting process had been a success, workshop participants identified both outcome and process parameters Table . In eithOutcome parameters focused on the effects of priority setting on organizational priorities and budget, on staff, and on the community. Effects on organizational priorities and budget concerned the extent to which the priority setting process was successful in changing organizational priorities and shifting resources, in supporting and/or enhancing the mission of the organization, in contributing to conditions for growth, and in balancing the organizational budget. Effects on staff involved an evaluation of the impact of priority setting on staff satisfaction and morale, organizational recruitment and retention initiatives, and overall understanding of new priorities across the organization. Effects on the community focused on how external stakeholders, including members of the public, regional partners, health care peers , and affiliated academic institutions, responded to the priority setting initiative.Process parameters focused on the efficiency and fairness of the priority setting process. Efficiency of the priority setting process could be evaluated in terms of whether priority setting improved institutional capacity for allocating resources and making priority setting decisions, and whether stakeholders and decision-makers felt that the priority setting process provided a worthwhile return on the time invested to set priorities. Fairness of the priority setting process could be evaluated in terms of whether stakeholders understood and felt engaged in the priority setting process, whether priority setting decisions were justified and seen to be reasonable, and whether 'winners' and 'losers' both felt that they had been fairly treated.ex post facto.It was interesting to us that, although A4R was presented as an ethical framework for fair priority setting, workshop participants did not specifically identify conformity with its conditions as a parameter of success related to fairness. The importance of these conditions is clearly evident, however, among the fairness considerations they cited as well as the process elements they identified as key to setting priorities. Moreover, we had been invited to work with these executive teams precisely because they were seeking an ethical framework through which to improve how they set priorities in their organisations. This suggests to us that A4R was seen by workshop participants primarily as an ethical framework for process design rather than for the evaluation of priority setting processes Our findings from these three priority setting workshops illuminate the complex challenges faced by decision-makers in managing scarce health care resources. The range of criteria identified in the workshops provides insight into the competing goals  and multiple stakeholder relationships that decision-makers must consider in setting clinical service priorities. This is consistent with previous findings that efficiency considerations or simple technical solutions have only limited influence on decision-making and are not sufficient alone to guide priority setting decision-making ,17,24,25Although we report only on three health care organizations, the organisations were all academic health science centres facing similar resource challenges. Consensus around priority setting criteria and processes emerged independently among workshop participants in their large and small group discussions. However, this does not mean that these findings are exhaustive of the priority setting criteria that might be relevant for setting clinical service priorities  or the process elements that would be necessary to ensure a legitimate and fair priority setting process. Moreover, although our approach was based on the notion that fair priority setting requires a normative grounding in procedural justice – in this case, A4R – this does not mean that these findings are normatively 'right' for clinical service priority setting in all health care organisations. An evaluation of the normative 'rightness' depends to some extent on the specific institutional circumstances under which priority setting is taking place, the stakeholders who are affected, and the strategic goals that are being pursued. Experience shows, moreover, that the conditions of A4R are sufficiently general to guide fair priority setting in various institutional settings ,16,20,27Our experience shows that, from the perspective of Board members and senior leaders, our practical approach using A4R offers useful guidance for developing fair and publicly accountable priority setting processes under resource constraints. However, alternative priority setting approaches may also be beneficial. For example, program budgeting and marginal analysis, an economics-based approach, has been used with senior health care administrators in Canada and elsewhere to improve how priority setting optimises health and non-health benefits within available resources . A compaDespite these possible limitations, the lessons we report here fill an important gap in the literature about the criteria, processes, and parameters of success decision-makers would use to set priorities using an ethical framework. We expect that decision-makers in other health care organizations may find themselves in the workshop participants' experience of priority setting and may use these findings as a basis for discussing how they could enhance the fairness and public accountability of their own priority setting processes.• Hospitals and regional health authorities must set priorities in the face of resource constraints.• Decision-makers seek pragmatic ways to set priorities fairly in strategic planning, but find limited guidance from the literature.• We facilitated workshops for board members and senior leadership at three organizations to assist them in developing a strategy for fair priority setting.• Workshop participants identified 8 priority setting criteria, 10 key priority setting process elements, and 6 parameters of success that they would use to set priorities in their organizations.• Decision-makers in other organizations can draw lessons from these findings to enhance the fairness of their priority setting decision-making.The authors were compensated by the health care organizations for facilitating the priority setting workshops and continue to consult with these and other health care organizations.JLG conducted the workshops on which this paper is based, collated and analysed the data, and drafted the manuscript.DKM participated in analysing the data and commented on earlier drafts of the manuscript.PAS conducted the workshops on which this paper is based, participated in analysing the data, commented on earlier drafts of the manuscript, and conceived of the paper.All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here: