Macaca fuscata yakui). We use social network analysis to describe each individual female’s position within the grooming network in relation to dominance rank and relative levels of infection. Our results suggest that the number of directly-transmitted parasite species infecting each female, and the relative amount of transmission stages that one of these species sheds in faeces, both increase with dominance rank. Female centrality within the network, which shows positive associations with dominance hierarchy, is also positively associated with infection by certain parasite species, suggesting that the measured rank-bias in transmission may reflect variation in exposure rather than susceptibility. This is supported by the lack of a clear relationship between rank and faecal cortisol, as an indicator of stress, in a subset of these females. Thus, socially mediated exposure appears to be important for direct transmission of nematode parasites, lending support to the idea that a classical fitness trade-off inherent to living in groups can exist.In wildlife populations, group-living is thought to increase the probability of parasite transmission because contact rates increase at high host densities. Physical contact, such as social grooming, is an important component of group structure, but it can also increase the risk of exposure to infection for individuals because it provides a mechanism for transmission of potentially pathogenic organisms. Living in groups can also create variation in susceptibility to infection among individuals because circulating levels of immunosuppressive hormones like glucocorticoids often depend on an individual’s position within the group’s social structure. Yet, little is known about the relative roles of socially mediated exposure versus susceptibility in parasite transmission among free-living animal groups. To address this issue, we investigate the relationship between host dominance hierarchy and nematode parasite transmission among females in a wild group of Japanese macaques ( Primates are among the most social of animal taxa and the interaction between sociality and infectious disease transmission is hypothesized to have played a role in their social evolution Here, we ask whether patterns of social structure, defined by the number and direction of contact (grooming) events as well as the dominance hierarchy, are related to patterns of parasite infection and transmission in a wild primate: Japanese macaques , with a small human population . Much of the island is protected as a UNESCO World Natural Heritage site (since 1993) or by the prefectural government of Kagoshima. The endemic subspecies of Japanese macaque, M. f. yakui, exists relatively undisturbed within protected areas. Our study group, ‘Umi’, inhabits the protected western coastal forest, which consists of warm-temperate, broadleaf-evergreen vegetation with a mean annual temperature and rainfall of ca. 20°C and 3,000 mm and strong seasonality with temperatures ranging from a maximum of 38°C (μ  =  28°C) in August to a minimum of ca. 2°C (μ  =  11°C) in February . Umi group varied between 59 and 70 individuals during the study period, including 18 adult females (≥5 yo), 11–15 adult males (≥5 yo), 20–31 juveniles (1–4 yo), with 11 infants (<1 yo) born in 2008  and 6 infants born in 2009. The group ranged between altitudes of 0–250 m, with an estimated home range size of approximately 0.7 km2 . This research was conducted with permissions from Kagoshima Prefecture and the Yakushima World Heritage office, was supported logistically by Kyoto University’s Wildlife Research Center, and complied with the ethical guidelines for conducting research on non-human primates of the Kyoto University Primate Research Institute and Wildlife Research Center.Yakushima is a 500 kmWe observed Umi troop on 210 days over 16 months during 8 non-overlapping seasons from October 2007 through August 2009: fall (Oct – Nov), winter (Jan – Feb), spring (Apr – May), summer (Jul – Aug); each season being distinct in Japan’s temperate climate. All adults could be identified reliably based on a combination of facial and other physical characteristics, and allowed researchers to approach to within 5 m, facilitating observation and sample collection. We recorded all behaviours performed during 60-minute focal animal samples collected from all sexually mature individuals  observed regularly in the group. We categorized individuals into three age classes , estimated through a combination of physical characteristics, social relationships, and the age and number of offspring in the group. We selected focal animals based on visibility at least once/week, avoided re-sampling the same individual in a day, and distributed samples from each individual over different times of the day. For this study, we conducted 1179 focal samples with a mean±SD of 47.2±8.0 samples per individual .h´ = 0.40, P = 0.005) We determined the dominance rank order of females based on all dominance-related interactions, e.g. directed aggressive and submissive signals, displacement and avoidance, that we recorded during focal samples (N = 191) using MatMan v.1.1 American Journal of Primatology  for further information about these and other social network measures used in primate studies.We determined the social network position of each individual using grooming behaviour performed by or directed at the focal subject during focal sampling. From these grooming data, we built seasonal grooming matrices weighted according to the number of focal samples collected from each individual during a season. We omitted data from individuals that had been followed for less than 3 hours in a season to minimize false zeroes in the grooming matrices; there were no individuals that truly lacked at least one grooming partner at any point during the study. These grooming matrices were then analysed under a social network analysis framework with UCINET software For all measures, we examine both grooming received and grooming given. We predict that grooming strength, as an absolute measure of exposure time, should increase the risk of acquiring new infections irrespective of the individual being groomed. A relationship between grooming degree and infection would also suggest that contact with a greater number of individuals is a key component of increased infection risk. Finally, since centrality includes cascading effects in the contact network structure, we also predict that central individuals, which are generally better connected to a greater number of group members than peripheral individuals, will have a higher risk of exposure to parasite infective stages Streptopharagus pigmentatus and Gongylonema pulchrum (Spirurida), Oesophagostomum aculeatum (Strongylida), Strongyloides fuelleborni (Rhabditida), and Trichuris trichiura (Enoplida) O. aculeatum and S. fuelleborni, though the latter can also successfully infect hosts percutaneously), or embryonated eggs (T. trichiura) with which they come into contact on contaminated substrata O. aculeatum and S. fuelleborni develop into infective stage (L3) larvae within a few days of being shed in the feces and actively migrate away from feces in search of a new host, although Strongyloides spp. are known to have heterogonic life cycles, in which successive generations perhaps facultatively alternate between parasitic free-living stages Oesophagostomum spp. S. fuelleborni, and 2 to 3 months for T. trichiuraThere has been considerable work into the identification of gastro-intestinal nematode parasites infecting Japanese macaques We collected two faecal samples per month from each individual when possible to estimate parasitic infection among our focal animals. In total, we collected 449 samples from the 18 females immediately following defecation, placed faeces into sealable plastic bags, and stored ca. 2 g in plastic tubes containing 10% buffered formalin within 12 hours of collection. We analysed a mean of 24.9±2.6 samples per female across the study  using a modified formalin-ether sedimentation protocol to extract parasite eggs and larvae from faeces We estimated three indices of infection from these samples, pooled by season: species richness (number of concurrent infections), infection presence for each species separately, and EPG-intensity (hereafter EPG), which is a surrogate measure for intensity of infection (i.e. number of adult worms) per infected female only. A number of studies have found linear relationships between EPG and true worm intensity We collected faecal samples (N = 155) for faecal cortisol analysis between April 2007, and July 2008, from a subset of the females examined in this study (N = 13). Specifically, samples from the 5 youngest adult females in the group were not available for this analysis. Note that the sampling period for faecal cortisol overlaps only with the first year of that described in the above sections. The mean number of samples examined per individual was 11.62±1.39. Within 12 hours of collection, approximately 1 g of faeces from each collected sample was frozen unmixed at −30°C until processing and extraction at the Kyoto University Primate Research Institute.Prior to analysis, frozen faecal samples were thawed, dried in an oven and then pulverized by hand to separate the faecal powder from the fibers. We extracted faecal glucocorticoids following a method modified from Shideler et al. 2 = 0.99) over a range of 0–10 ng/ml. Parallelism was tested by serial dilutions of faecal extracts. The four slopes generated from the serially diluted samples were not significantly different from the standard curve slope . The assay had a sensitivity of 0.1 ng/ml, with an intra-assay coefficient of variation (CV) of 5.8% and inter-assay CV of 4.3%.Cortisol was measured using ELISA (Enzyme-Linked ImmunoSorbent Assay) kits  developed for the quantitative analysis of cortisol levels in biological fluids. The cross-reactivities of the kits were 100% with cortisol, 3.38% with corticosterone, 2.08% with cortisone, 2.00% with deoxycorticosterone, 0.39% with 17-hydroxyprogesterone, 0.05% with progesterone, 0.05% with androstenedione, 0.04% with testosterone, and <0.01% with aldosterone, dehydroepiandrosterone, estrone, estradiol, estriol. The cortisol concentrations for each sample were calculated by fitting the absorbance for standard curve using a curve-fitting program . Dose response and parallelism tests were conducted to assess the feasibility of using these kits with macaque faecal extracts. Dose response of the assay, assessed by spiking sample extracts  with a known amount of cortisol standard in increasing amounts, generated a curve with a slope of 1.20  network parameters: sqrt(strength) and sqrt. We also constructed generalized linear mixed-effects models (GLMM) using lme4 to examine the effects of the above factors on the third network metric, degree, with a distribution roughly Poisson in shape (X2 goodness-of-fit test: P>0.05). Strength and degree must depend on the number of focal samples collected from each female, and so this is included as a covariate in the models to reduce such sampling bias. Since centrality is related to these measures as well, we also include this term in those models.To examine variation in network position, we constructed general linear mixed-effects models (LME) using the i,…xn), accounting for the error structure using the binomial distribution with logit link function. Our estimate of presence produced a binary response so we again modelled the error structure using the binomial distribution with logit link function. Previous work showed that the EPG-intensity distributions of all of these parasites are aggregated across the study subjects 10(EPG) as a Gaussian-distributed (X2 goodness-of-fit test: P>0.05) response variable. Note that our approach is akin to examining species abundance using a hurdle model, which first accounts for presence or absence in a binomial model, and then models the count portion of the data separately To examine variation in parasitism, we constructed mixed-effects models to test whether social variables influenced nematode richness and presence (GLMM), and EPG (LME). We were concerned that a global model containing combinations of the network measures used here would suffer from problems of multi-collinearity, and that eigenvector centrality is not truly independent of either strength or degree , although it does convey different information. We therefore constructed four models for each index of infection: (1) strength and degree for grooming received; (2) strength and degree for grooming given; (3) centrality in grooming received; and, (4) centrality in grooming given. Because some model terms thus appear in four models , we present the model-averaged estimates of these parameters. We treated richness as the sum of successes and failures  as a Gaussian-distributed (X2 goodness-of-fit test: P>0.05) response variable. As we did with network position and parasitic infection, we used the mean faecal cortisol values per female per season, such that each female is represented only once in each season. We examined the main effects of the following predictor variables in the model: age, rank, season, reproductive status, and the number of samples collected per female as a covariate to control for sampling bias. Since Japanese macaques are strongly seasonal breeders To examine variation in stress, we constructed an LME using The two overall social grooming networks constructed from all grooming observed throughout the study in each direction is illustrated in Seasonality was also a strong predictor of strength and degree in both grooming networks . StrengtThere was a clear negative association between the dominance hierarchy and parasite richness, with the latter decreasing linearly with rank ; Fig. 3.Oesophagostomum aculeatum prevalence toward high-ranking females across the study . Old adult females tended to exhibit higher levels than young adults . There wO. aculaetum, a potentially pathogenic parasite, as has previously been shown O. aculeatum (EPG) and S. fuelleborni (probability), we suggest that exposure to infective stages through rank-mediated social contact can be an important mechanism of transmission for certain parasite species, plausibly explaining this rank bias in infection.We asked whether patterns of social structure in female Japanese macaques, derived from dominance rank relations and their grooming contact network, relate to patterns of nematode parasite infection and transmission. Dominance rank, a trait central to the lives of many primates, was clearly observed to be an important predictor of nematode species richness and both the probability and estimated intensity of infection by Macaca fascicularisM. mulattaM. fascicularisWe also examined, albeit indirectly, the possibility that the effect of dominance rank on infection could be explained by socially-mediated susceptibility to infection, i.e. through the immunosuppressive effects of stress hormones. Our results show that faecal cortisol was not related in the same way as network centrality to a female’s position within the hierarchy, although there was some evidence for a bias toward mid-ranking females. Given the nepotistic and highly stable dominance structure of female Japanese macaques, we might have predicted that females of higher ranks would have had the lowest levels of social stress Oesophagostomum aculeatum and S. fuelleborni are characterized by having larval stages that emerge from their eggs either in the external environment, or in some cases (S. fuelleborni only) in the lumen prior to excretion T. trichiura larvae do not emerge until embryonated eggs are ingested by a subsequent host O. aculeatum and S. fuelleborni) versus passive (T. trichiura) transmission strategy may partly explain why the former two species were related to the grooming network among female macaques, while the latter was not.Our results show that transmission of worms that utilize the faecal-oral route does contain a social element, and that this element is likely related to variation in exposure to parasite infective stages. Nonetheless, we did not observe monotonic effects of social variables on infection, and this may be partly explained by examining each of these parasites’ life cycles, and in particular, their mode of transmission. While our results do indicate a role for grooming networks in exposure to certain parasites, they do not allow for strong conclusions about the exact mechanisms by which these social factors influence transmission. For example, although we found stronger links between the outward grooming network and all indices of infection, we also found some evidence that the inward network may also affect transmission, particularly given the much stronger effect of rank on grooming received than grooming given. Primates typically direct their grooming behaviour up the hierarchy, suggesting that high-ranking individuals may receive more contact from a greater number of individuals than those of lower ranks A further potential confound is that female Japanese macaques of adjacent ranks, being close of kin, may share genetic susceptibilities to infection not apparent in females further away in rank. That infection phenotypes are known to be inherited in domestic animals Oesophagostomum spp., Strongyloides spp., and Trichuris spp., are all potentially important disease agents infecting primates around the world O. aculeatum, it is logical to expect that infection may impose constraints on grooming behaviour which could explain the aggregation of grooming contacts within a network, influence contact decisions, and perhaps put an upper limit on the network reach of individuals within a population.Regardless of the exact mechanism, however, heterogeneous infection patterns resulting from heterogeneous contact network structures carry at least two important implications. The first is that high-ranking or otherwise central individuals are likely responsible for a disproportionately large number of transmission events because they become key hosts or super spreaders in the transmission dynamics of these directly-transmitted parasites O. aculeatum and S. fuelleborni), and this represents a potential cost to this behaviour. To our knowledge, the only other study to demonstrate disease transmission through a social grooming network under natural conditions showed that meerkats (Suricata suricatta) that groomed others most were at greater risk of acquiring tuberculosis (Mycobacterium bovis) In group-living primates, grooming undoubtedly plays a major role in social cohesion among group members. However, we show that grooming may also facilitate the transmission of certain nematode parasites with direct life cycles (e.g.


A 40-year-old male presented with complaints of difficulty in walking, decreased cognitive functions, and hardness of hearing since one year. Neurological examination revealed deficiency in cognitive functions of higher intellectual functions. The gait was markedly ataxic with abnormal tests for cerebellar function. Audiometry demonstrated bilateral sensorineural hearing loss. Magnetic Resonance Imaging (MRI) revealed hemorrhagic lesion in sellar-suprasellar region suggestive of pituitary adenoma Figures  and 3. TSuperficial siderosis is a rare chronic progressive neurological dysfunction characterized by classical triad of symptoms consisting of sensorineural hearing loss, cerebellar ataxia, and myelopathy.–3 There 1


The major allele homozygotes and minor allele carriers of each polymorphism are respectively associated with efficacy enhancement and loss, creating the possibility for genotype combination interactions that can be measured by clinical trial methodology.Pharmacogenetics involves complex interactions of gene products affecting pharmacodynamics and pharmacokinetics, but there is little information on the interaction of multiple genetic modifiers of drug response. Bucindolol is a β-blocker/sympatholytic agent whose efficacy is modulated by polymorphisms in the primary target  affinity for β1389 AR variants was measured in human explanted left ventricles.In a 1,040 patient substudy of a bucindolol vs. placebo heart failure clinical trial, we tested the hypothesis that combinations of β1389 Arg+α2C322–325 Wt major allele homozygotes  was non-additive for efficacy enhancement across six clinical endpoints, with an average efficacy increase of 1.70-fold vs. 2.32-fold in β1389 Arg homozygotes+α2C322–325 Del minor allele carriers. In contrast, the minor allele carrier combination (13% subset) exhibited additive efficacy loss. These disparate effects are likely due to the higher proportion  of high-affinity NE binding sites in β1389 Arg vs. Gly ARs, which converts α2CDel minor allele-associated NE lowering from a therapeutic liability to a benefit.The combination of β1389 Arg homozygotes), intermediate (β1389 Gly carriers+α2C322–325 Wt homozygotes), and no (β1389 Gly carriers+α2C322–325 Del carriers) efficacy.On combination, the two sets of AR polymorphisms 1) influenced bucindolol efficacy seemingly unpredictably but consistent with their pharmacologic interactions, and 2) identified subpopulations with enhanced (β Genetic determination of drug action, or pharmacogenetics, involves complex interactions of gene products affecting pharmacodynamics and pharmacokinetics. These interactions are difficult to investigate and quantify, in part because of the uncertainty of the modifier mechanism and the imprecision of measuring drug clinical responses.1 adrenergic receptor (AR), as well as in a modifier of the signaling mechanism for the primary target, cardiac neuronal norepinephrine (NE) release, modifies the response to this β-blocker/sympatholytic agent and possibly to other anti-adrenergic compounds. Although randomized trials have demonstrated that β-blockers improve survival and clinical outcomes in patients with chronic heart failure (HF) and reduced left ventricular ejection fractions (LVEFs) 1 AR resulting from a nucleotide position c.1165 C→G in the ADRB1 gene 2C AR resulting from a nucleotide position c.964–975 Del in the ADRA2C gene There is considerable evidence that genetic variation in bucindolol's primary target, the cardiac β1 AR variants are pharmacologically distinct. Compared with the β1389 Gly AR, the more-common β1389 Arg AR has 3-to-4–fold greater signal transduction capacity 1389 Arg vs. Gly receptors in part through inverse agonist activity 2C ARs are localized to cardiac prejunctional nerve terminals, where they mediate inhibition of NE release in a negative feedback loop 2C four amino acid Del imparts a loss-of-function phenotype 1389 Arg/Arg and α2C322–325 Del/Del genotypes appears to synergistically increase the risk of HF in African Americans The 389 Arg vs. Gly β2C wild-type (Wt) 322–325 Del and postjunctional β1Arg389 Gly genetic variants are positioned in-series in the cardiac adrenergic neuroeffector pathway, and their potential interaction provides an opportunity to investigate the genetic complexity 1 ARs, we tested the subhypothesis that marked differences in NE affinity accounted for the disparate results.Prejunctional αP = 0.053. BEST contained a 1,040-patient DNA bank, which could be accessed by submission and successful peer review of a substudy protocol 1389 and α2C322–325 polymorphisms.The 2,708-patient BEST trial P<0.050 in the entire cohort. For efficacy analyses with genetic subgroups in this exploratory study, P values<0.050 in a two-tailed distribution were considered of interest and P values<0.010 were considered statistically significant based on a prespecified multiple comparison adjustment described for monotypes in the substudy grant application statistical section. A comparable multiple comparison adjustment for the four combination genotypes investigated in this study would yield a critical value of 0.0125.The protocol-defined primary statistical method was Cox regression analysis 1 ARs was determined in non-failing human left ventricles obtained from unused organ donors as previously described High-affinity “agonist” binding of L-NE to βThe BEST trial was conducted according to Declaration of Helsinki principles. All participating patients gave informed written consent for both the parent protocol and the DNA substudy. Non-failing human hearts were provided by Donor Alliance, the Colorado-Wyoming organ procurement organization, which obtained written consent for research use of tissue from donor family members.1389 Arg/Gly and α2CWt/Del combinations of major allele homozygote and minor allele carrier The patient population was classified by the four possible β2C322–325 Del alleles. Other differences among genotype combinations, such as more non-ischemic cardiomyopathy etiology in Group 3 vs. Group 4 and a greater proportion of patients with a history of hypertension in groups 2 and 4, are likely due to the racial imbalance. The small, clinically insignificant ANOVA  differences in age and systolic blood pressure are not statistically significant after a multiple comparison adjustment.Baseline characteristics of the genotype combination groups are given in 1389 Arg/Arg+α2C322–325 Wt/Wt) and 2 (β1389 Arg/Arg+α2C322–325 Del carrier), the six HRs and RCRs overlap with respective average effect sizes of 40% and 49%, with both groups exceeding the average effect size of 26% in the all-genotype 1,040-patient DNA substudy cohort. RES, which normalizes the effect size to that in the DNA substudy cohort, yielded average values of 1.70 and 2.32, respectively, in Groups 1 and 2. This means efficacy was increased by an average of 70% (Group 1) or 132% (Group 2) relative to the parent population containing all genotypes. However, the RES range for Groups 1 and 2 overlapped  or <0.05 .1389 major allele (Arg) homozygous monotype, the α2C322–325 Del variant does not exert any negative influence on bucindolol treatment effects despite Group 2 exhibiting a typical α2C322–325 Del variant-associated large decrease in NE (by 158 pg/mL compared with placebo), a degree of sympatholysis previously identified as compromising efficacy 2C AR gene, exhibited only the expected mild NE lowering (average of 46 pg/mL compared with placebo) in bucindolol-treated patients .The HR/RCR and RES data for Group 2 therefore indicate that when combined with the βpatients , a degre Group 1 , with re1389 Gly carrier+α2C322–325 Wt/Wt) exhibited HRs/RCRs that were generally greater (less efficacy) than in Group 1 or Group 1/2 and similar to those in the 1,040-patient DNA substudy cohort. Despite a sample size similar to Group 1, only cardiovascular mortality had a P<0.05, and no endpoint had a P<0.010. The average effect size for Group 3 was 22%, compared with 26% in the entire DNA substudy, and the average RES was 0.83. The upper bound of the Group 3 RES range, 1.22, did not overlap with either the Group 1 (1.48), Group 2 (1.49) or Group 1/2 (1.51) lower bound of the RES range. Strikingly, Group 4 (β1389 Gly carrier+α2C322–325 Del carrier) exhibited HRs/RCRs of ∼1.0 with an average effect size of −5.5%, or no evidence of any efficacy. The average RES in Group 4 was −0.14 , indicating higher event rates in the bucindolol group vs. the placebo group. This is comparable to respective average RES values of 0.40  and 0.22 (range −0.03–0.79) in the monotypes β1389 Gly carrier and α2C Del carrier, respectively (data not shown). The upper bound of the Group 4 RES range (0.17) does not overlap with the lower bound of the Group 3 RES range (0.40). Thus, when β1389 Gly carriers are combined with α2C322–325 Del carriers, an additive loss of efficacy occurs, compared with Groups 2 or 3, which contain only one monotype minor allele carrier. The reduction in NE at three months in Group 4 was expectedly large because of the presence of α2C322–325 Del alleles, and this degree of sympatholysis 1389 Gly receptors may have been the reason for efficacy loss.As shown in 1389 Gly carrier  and 96% for α2C322–325 Wt/Wt  vs. Del carrier . Thus, the differential efficacy gained by comparing Group 1/2 with Group 4 vs. the β1389 Gly carrier monotype is calculated as follows: 190%–136% = 54%. The advantage vs. the α2C322–325 Del carrier monotype is calculated as follows: 190%–96% = 94%.P = 0.13 and 0.093, respectively, for all-cause mortality and all-cause mortality or transplant, 0.073 for HFH days/patient, and <0.20 for two of the three other efficacy endpoints. In contrast to the efficacy endpoints, there was no evidence of an effect of bucindolol or genotype combination on time to non-cardiovascular hospitalization, with an average HR/RCR of 0.99 in the entire cohort and a range of 0.87–1.59 in genotype groups.Interaction tests with Groups 1/2, 3, and 4 as a continuous ordinal variable were P values in Group 3, and no curve separation (P = 0.021)  or the similar values for the 1,040-patient DNA substudy (P = 0.012) for ACM/Tx and 0.66  for HFP . 125[I]CYP (cyanopindolol) in a β1389 Arg/Arg  of 63 nM. Computer modeling yielded a two-site fit, with the high-/low-affinity percentages of β1 ARs estimated to be 63/37. When incubated with the non-hydrolyzable guanine nucleotide Gpp(NH)p, which uncouples high-affinity agonist binding, only low-affinity (KL 928 nM) receptors are identified. In contrast, in the competition curve from a left ventricle genotyped as β1389 Arg/Gly, there is no evidence of any high-affinity L-NE binding. In all, 6/7 Arg/Arg; 1/5 Arg/Gly; and 2/5 Gly/Gly left ventricles exhibited two-site fits in the absence of Gpp(NH)p, with an average KH of 74.9±87.0 nM. The low-affinity binding constant (KL) in all 17 left ventricles averaged 7,254±12,250 nM. 1 ARs in the three possible genotypes. Both heterozygotes (5.8%) and β1389 Gly homozygotes (11.6%) have much lower percentages of high-affinity L-NE binding sites than Arg homozygotes .To investigate the affinity of NE for β Arg/Arg  or a β13paration . In the 1 AR, compared with patients with a Gly allele at this position. Two of these endpoints  were also measured in the current study, and the other (time to first HFH) was the major component of time to HF progression in the current report. In another study 2C AR had therapeutic responses that were consistently better than in patients with a deletion of amino acids 322–325. This α2C AR 322–325 polymorphism-associated differential clinical response was found to be related to dysregulation of NE release in patients with Del genotypes, who had exaggerated sympatholytic responses to bucindolol that obviated efficacy. The major allele homozygotes of these two AR polymorphisms are therefore associated with enhanced response. In the case of β1389, this response is enhanced to a degree that tends to be greater than the response to standard β-blockers in all genotypes. In the case of α2C322–325, this response is enhanced to a degree comparable to standard β-blockers in all genotypes. Thus, the question arises as to whether the combination of two major allele genotypes would yield an even greater therapeutic response than in either monotype alone. This provides an opportunity to assess the interactive effects of two genetic variants that are intimately related to disease pathophysiology as well as drug response, a rare opportunity in pharmacogenetics. To test the hypothesis that the effects of each of these AR polymorphisms would be additive for HF clinical response, we investigated the effects of bucindolol vs. placebo on six clinical endpoints that included the three previously measured for β1389 Arg/Gly effects 2C322–325 Wt/Del effects Based on an analysis of three clinical endpoints, we have previously reported 1389 Arg/Arg+α2C322–325 Wt/Wt. That is, efficacy (as measured by the RES method) 1389 Arg/Arg+α2C322–325 Del carrier. The non-efficacy, non-cardiovascular hospitalization endpoint did not exhibit pharmacogenetic enhancement or decrement. In contrast, for carriers of β1389 and α2C322–325 minor alleles (Group 4) as a combination genotype, there was additive diminished efficacy to the point of complete efficacy loss (RES = −0.14). This indicates an average RES for which the bucindolol treatment effect is 14% worse than placebo and worse than in patients with the β1389 Gly carrier or α2C Del carrier monotype, for which the respective RES values indicated efficacies 40% or 22% better than placebo. In Group 4, the further decrement in efficacy compared with the β1389 Gly carrier monotype was due to the removal of the β1389 Gly carrier+α2C Wt/Wt combined genotype as Group 3. Compared with the α2C Del carrier monotype, this was due to the removal of the β1389 Arg/Arg+α2C Del carrier combined genotype to constitute Group 2. Thus the hypothesis that combining predictive individual monotypes into combined genotypes improves pharmacogenetic targeting was supported only for the minor alleles.Surprisingly, no additional therapeutic benefit of bucindolol was observed in the major allele homozygote combination of β1389 Arg vs. Gly receptors. Compared with its Gly counterpart, the β1389 Arg receptor has higher signal transduction capacity 1389 ARs appear to exert a dominant negative effect on NE high-affinity binding as well as on bucindolol's clinical efficacy. Therefore, in advanced HF patients, the 389 Arg version of the β1 AR is much better-equipped to support cardiac function in the face of marked NE lowering, where its higher-agonist binding affinity allows it to better utilize low levels of adrenergic activity. In contrast, the hypofunctioning, lower-NE affinity β1389 Gly version of the β1 AR needs higher NE levels to support the failing heart, and in the presence of the α2C322–325 Del-associated marked sympatholysis, likely cannot adequately support cardiac function, leading to an increase in mortality and hospitalizations that cancels bucindolol efficacy. These relationships likely explain the marked differences in bucindolol's clinical efficacy between Group 2 (has only β1389 Arg receptors) and Group 4 (contains ≥50% β1389 Gly receptors). Moreover, because of its much higher affinity for NE, the β1389 Arg receptor is an NE receptor, whereas the β1389 Gly variant is not, having an NE affinity that is similar to the β2 AR. The sympatholytic effects of bucindolol therefore preferentially inhibit β1389 Arg signalling, providing a basis for the selective clinical effects of bucindolol in β1389 Arg/Arg genotypes vs. any Gly-containing genotype.The differences between minor and major alleles in pharmacogenetic combination are likely due to the pharmacologic differences in β1389 and α2C322–325 combinations of genetic biomarkers conferred a nearly two-fold difference in averaged efficacy  between the efficacy-enhanced (β1389 Arg/Arg) genotype Group 1/2 and the loss-of-efficacy  genotype Group 4. The goal of pharmacogenetic targeting is to identify subgroups with large differences in treatment efficacy, or “outliers” 1389 and α2C combination genotypes yielded numerically greater degrees of high-low response differential efficacy compared with β1389 or α2C monotypes, by respective absolute amounts of 54% and 94%. Based on the above and non-overlap of RES ranges, combinations of β1389 Arg/Gly and α2C322–325 genotypes therefore identified a 47% subpopulation (Group 1/2 [β1389 Arg/Arg+any α2C]) with a bucindolol-enhanced clinical response profile compared with the parent population that generally exceeds effect sizes associated with other β-blockers in a variety of HF populations 1389 Gly carriers+α2C322–325 Wt/Wt]) with clinical responses similar to that in the parent population of all genotypes, and a small but non-trivial 13% subpopulation with complete loss of efficacy that should not be treated with bucindolol.The β1389 and α2C genotype combinations and treatment effects did not achieve statistical significance, two P values were <0.10 and most were <0.20. However, interaction tests, commonly used to assess heterogeneity of subgroups within a clinical trial population without regard to any particular mechanistic interaction with the tested treatment, have limited statistical power to detect pharmacogenetic efficacy differences that can be expected to be small, unidirectional, and present in limited sample sizes. The demonstration of statistically significant, robust treatment effects across multiple relevant clinical endpoints in one pharmacogenetic subset but not its allelic counterpart, especially when supported by biologic plausibility, achieves the goal of identifying a subset of patients highly likely to respond favorably to a treatment. The β1389 Arg/Arg genotype meets these criteria for a favorable response pharmacogenetic subgroup.Although tests for interaction between βThere are some limitations to this study. First, although the substudy was prospectively designed and hypothesis-driven, the pharmacogenetic data were generated and analyzed after the trial's main results were analyzed and published 2C322–325 minor (Del) allele on facilitating bucindolol's NE-lowering properties, where excessive NE lowering abolished efficacy when the β1389 Gly minor allele and low NE affinity AR were present but did not alter or even enhance efficacy in the presence of the major allele homozygous β1389 Arg genotype, which encodes ARs with a NE affinity of ∼100-fold more than 389 Gly ARs.The combinatorial interaction of two sets of AR polymorphisms that influence bucindolol's drug action resulted in unanticipated effects on HF clinical responses, non-additivity in efficacy enhancement for the major allele homozygotes, and additive effects for minor allele carrier-associated efficacy loss. An explanation for these disparate results was provided by the effects of the α1389 Arg/Gly and α2C322–325 Wt/Del genotype combinations accomplishes the goal of pharmacogenetics to identify response outliers from both ends of the therapeutic spectrum. Compared with the use of β1389 Arg/Gly or α2C322–325 Wt/Del monotypes, the differential efficacy gained by the use of genotype combinations was increased by respective amounts of 54% and 94%. The new identification of a completely unresponsive genotype, supported by biologic plausibility and bolstered by data consistency across multiple clinical endpoints, is especially important inasmuch as a major goal of pharmacogenetics is to identify patients with no likelihood of benefit who can then be spared drug side effects Combinatorial genotyping led to improvement in pharmacogenetic differentiation of drug response compared with monotype genotyping. The use of βin-silico predictions of combinatorial genetic effects will need to be supported by empirical data.Finally, the unexpected results of this study,  emphasizes that combinations of response-altering polymorphisms may behave in unpredictable ways and


We describe a family of spiking retina computational models for large-scale simulations of the visual pathways. The models reproduce the overall spatial, temporal, and chromatic structure of the receptive fields of midget and parasol retinal ganglion cells (RGCs) of the primate retina, as well as their contrast response, while using fairly simple models of bipolar, horizontal, amacrine, and RGCs. These retina models provide input to a realistic model of visual cortex, presented in a separate submission.The retina model simulates cone and bipolar cell dynamics using a damped wave equation. Parameters are so chosen that an impulse retinal input gives rise to a damped biphasic output current, and that a coherent stimulus elicits a substantially stronger response than an incoherent stimulus of the same power Figure . Static Desired latency encoding of input features is achieved by calibrating the parameters of the spiking RGC conductance dynamics. A near logarithmic latency to the first spike, for a step up in the input signal, provides for a good contrast invariance of the relative spike timing in the response. A combination of spike-latency and spike-count encoding of the input stimulus, together with the enhanced response of the simulated retina to coherent stimuli, results in an informative yet not too noisy spiking input to the LGN and V1; the information content analysis of the RGC spike-train vocabulary will be presented. This retina model was used to produce a fully-emergent orientation tuning in a spiking model [


The everyday practical capabilities of dementia patients have a direct influence on a patient’s independence and thus on the person’s quality of life and on the amount of care needed. These capabilities are therefore important as therapeutic goals and are also important from a health-economic point of view. To date, no economical and valid performance test is available. The E-ADL-Test developed by Gräβel et al. in 2009 is a short performance test that has, however, only been validated on a small sample thus far. The objective of the present study is to re-validate the E-ADL-Test and explore possibilities for further development.The data were obtained from an RCT with a sample of 139 dementia patients in 5 nursing homes in Bavaria (Germany). The internal consistency was calculated as a measure of reliability. An item analysis was performed for the sample and subgroups with various degrees of dementia. Criterion and construct validity were tested based on five hypotheses. For validation, the residents’ capabilities were examined using the Barthel-Index (BI), the Nurses’ Observation Scale for Geriatric Patients (NOSGER), the Alzheimer’s Disease Assessment Scale (ADAS), and the Mini-Mental Status Examination (MMSE).The internal consistency was .68 for the sample and .73 for the subgroup with severe dementia. The item analysis yielded good difficulty indices and discrimination power for moderate and severe dementia. The tasks were found to be too easy for mild dementia. The predictive criterion-related validity was confirmed by a correlation of r = .54 with the care level after 22 months and significant mean differences in the E-ADL-Test between persons with and without an increase in the care level. A differentiated correlation profile supported the three hypotheses on construct validity.The E-ADL-Test in its current form is a valid and reliable instrument for assessing the ADL capabilities of patients with moderate and severe dementia. More difficult items should be developed for use with mild dementia.http://www.isrctn.com Identifier: ISRCTN87391496 Limitations in cognition and everyday practical capabilities are the main symptoms of degenerative dementias. The patient’s everyday practical capabilities are decisive for independence -3. TheseA completely different approach is chosen by tests that are based on the Rasch model  to evaluate a multimodal non-pharmacological therapy in six nursing homes in the study region Mittelfranken  ,22. The The EADLTest, this aThe hypotheses on construct validity were confirmed for 8 of the 10 available parameters. Convergent and discriminant validity were verified by high correlation coefficients with other ADL/IADL measures and by low correlation coefficients with measures of mood and disturbing behaviour. This is independent of whether the reference test was a performance test (ADAS-cog) or an instrument for the assessment by others (NOSGER and BI). Only the correlation coefficient with the Barthel-Index was lower than expected. This may possibly be explained by the fact that each test had a different focus/emphasis: The Barthel-Index mainly records fundamental ADLs , and half of these ADLs depend on the ability to walk or stand. For the E-ADL, only the upper extremities need to be used, which was also an inclusion criterion. Therefore, people with a low Barthel-Index were able to perform some E-ADL tasks. This hypothesis should be revised in future studies.The second outlier refers to the NOSGER subscale “Social Behaviour”. Although, as expected, the E-ADL-Test was not correlated with mood and disturbing behaviour , there was a correlation of .39 with the “Social Behaviour” subscale, which is as high as the correlations with the cognitive parameters. This becomes feasible considering the inter-correlations of the NOSGER subscales. Here, the subscale “Social Behaviour” was more highly correlated with the subscales “Memory”, “ADL”, and “IADL” (each at .6) than with the subscales “Disturbing behaviour” and “Mood” (each at .2). Thus cognitive and everyday practical capabilities appear to be included in the subscale “Social Behaviour”, too.In addition, the E-ADL-Test enables a moderately reliable differentiation of the severity of the dementia syndrome, which concurs with the classification criteria of the dementia syndrome in ICD-10  and DSM-Validation in a representative sample of an expanded E-ADL-Test including items with lower difficulty indices  is thus recommended for future research.The E-ADL-Test in its present form is an economical, reliable, and valid instrument for measuring the everyday practical capabilities of patients with moderate and severe dementia. Compared to other ADL tests, it is characterised by considerably greater economy with equal reliability and validity. The E-ADL-Test can be used both in practice for quick, valid assessment of the dementia patient’s ADL capabilities and in therapy studies as a blinded outcome instrument. When tasks of greater difficulty are added, the E-ADL-Test will achieve greater differentiation with regard to mild dementia.The authors declare that they have no competing interests.KL took part in designing the study, was responsible for data collection, performed the statistical analysis and drafted the manuscript. AS took part in data acquisition and statistical analysis and was involved in drafting the manuscript. EG designed the study, supervised data analysis and interpretation and revised the manuscript. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-244X/12/208/prepubAppendix 2. E-ADL-Test.Click here for fileAppendix 1. E-ADL-TEST: Description, Application and Scoring.Click here for fileDistribution of the E-ADL score. Histogram of the E-ADL-test sum score.Click here for fileCoefficients of the E-ADL-Test with other procedures .Click here for file


A case with reversible symmetrical sensorineural hearing loss following hydroxychloroquine therapy is described.A 57-year-old, human immunodeficiency virus (HIV) positive man was referred to the HIV clinic of Imam Khomeini Hospital, Tehran with chief complaint of bilateral slowly progressive hearing loss starting from two months ago. The man had history of rheumatoid arthritis diagnosed from 3 months ago and was administered hydroxychloroquine 200 mg and prednisolone 5 mg twice daily. Audiometry test showed moderate to severe neuronal hearing loss and reduced speech recognition in both ears of the patient. With suspicion of hydroxychloroquine-induced hearing loss, this drug was discontinued. After 2 months of hydroxychloroquine discontinuation, his audiometry findings were improved.A few cases of hydroxychloroquine-induced hearing loss have been reported. All of the cases were non-HIV positive individuals. Irreversible hearing loss was developed following long-term therapy with hydroxychloroquine. The present case was a HIV-positive man who developed hearing loss following short course (one month) hydroxychloroquine therapy and his problem was resolved following discontinuation of hydroxychloroquine and continuation of prednisolone.Hydroxychloroquine-induced hearing loss may reversibly occur following short term therapy in HIV patients. Hydroxychloroquine (HQ), a quinoline compound, rarely causes ototoxicity. Its ototoxicity is associated with varying degree of destruction of the cochlear sensory hair cells, a decrease in neuronal population, alteration in supporting structures and atrophy and vacuolization of the stria vascularis as a possible consequence of ischemia ,2. CliniA 57-year-old HIV positive man was referred to the HIV clinic of Imam Khomeini Hospital, Tehran, Iran, with chief complaint of bilateral slowly progressive hearing loss starting from two months ago. He had no previous cochleo-vestibular symptoms and the hearing loss was described without tinnitus, vertigo or balance changes. He had no history of head trauma prior to the beginning of the hearing loss. He was a known case of HIV infection following blood transfusion from 2 years ago. In his medical history, RA was diagnosed from 3 months ago when he was receiving HQ 200 mg and prednisolone 5 mg twice daily. He did not consume any antiretroviral supplements or herbal products.His laboratory findings showed CD4 count of 107/L and CD4/CD8 ratio of 0.13. All the other routine laboratory parameters were within the normal range. Based on the patient clinical status and his CD4 count, antiretroviral regimen including lamivudine, zidovudine and efavirenz was started. Also sulfamethoxazole/trimethoprim and isoniazid was considered for prophylaxis of pneumocystis and tuberculosis respectively in this patient.Otolaryngological consultation reported normal otoscopic and neurologic examinations for the patient. Pure-tone (air and bone conduction) and speech audiometry showed moderate to severe neuronal hearing loss and reduced speech recognition in his both ears (45 and 40 dB in the right and left ears respectively) Figure . AbsenceWith suspicious of HQ-induced hearing loss, the drug was discontinued and prednisolone was continued to control his RA symptoms. Two months later, his audiometric findings improved. Pure-tone and speech audiometry revealed mild to moderate hearing loss and slight to mild disability in speech recognition in the right and left ears, respectively Figure . His acoet al. reported tinnitus, a sense of imbalance and nerve deafness after prolonged chloroquine administration [Idiopathic sudden sensorineural hearing loss usually occurs 5–20 per 100,000 populations mostly due to viral infections, vascular occlusion with microcirculatory disturbances, immunologic diseases, or intralabyrinthine membrane breaks . Some drstration .Only a few cases of HQ-induced hearing loss have been reported. First case was a 44-year-old woman and the second case was a 44-year-old man with lupus erythematous. Both of these patients developed irreversible hearing loss following several years of HQ treatment . The thiAll of the previous cases were non-HIV positive individuals. In these patients HQ-induced ototoxicity developed following long term HQ administration. In most of them, hearing loss was irreversible. Our case was a HIV-positive man who developed hearing loss following short course (one month) HQ therapy and his problem was resolved following HQ discontinuation.HQ is structurally related to chloroquine and shows similar ototoxicity pattern. Chloroquine-induced hearing loss is reversible if prompt chloroquine cessation and steroid administration is done . Our patOur case is the first report of reversible symmetrical hearing loss following HQ therapy in a HIV-infected patient. The patient received daily HQ with dose of 200 mg twice daily for 3 months. No other causes of hearing loss were detected in this patient. Hearing loss in HIV infected persons may result from opportunistic infections such as cryptococcal meningitis or neurosyphilis  and ototAccording to the Naranjo probability scale , hearingCorticosteroids are only confirmed effective treatment of sudden sensorineural hearing loss. It is important to notice that prednisone should be started as soon as possible after the onset of hearing loss .In conclusion HQ-induced hearing loss may appear following short-term administration especially in patients with underlying viral infections and may be reversible by corticosteroid therapy.Written informed consent was obtained from the patient for the publication of this report and any accompanying images.The authors declare that they have no competing interests.HK: Followed the case and edited the manuscript. FD: The case was detected and followed by FD in HIV clinic of the hospital. She also drafted the manuscript. AD: Did clinical assessment of the patient. All authors read and approved the final manuscript.


The development of minimally invasive procedures such as the balloon dilation Eustachian tuboplasty (BET) is an alternative to the grommet tympanum membrane. BET is applied in the cases where, after elimination of all factors influencing the ET and middle ear functioning, no sufficient improvement is observed. The aim of this study was to present the therapeutic benefits of the BET method in the treatment of ETD caused by disorders in the middle ear ventilation. The BET procedure was offered to four patients (3 men and 1 woman) after subjective, physical, otorhinolaryngological and audiometric examinations including pure tone audiometry, tympanometry and pressure-swallow test. As the method was novel, preinterventional CT angiography of the carotid arteries was performed in all patients. Any complications were noticed during and after the procedure  in any patients. Our clinical studies assessed the feasibility and safety of the BET during a short-term period—only a 6-week observation. Although patients revealed a significant improvement of ET score, longer long-term studies are necessary to determine whether this method will demonstrate lasting benefits and safety in the treatment of chronic Eustachian tube dysfunction. In other investigations, improvement was found to be time dependent. Hearing and its dysfunctions irrespective of their causes determine the quality of life. Even a slight hearing loss, feeling of blocking or check-a-block in the ear provide discomfort independent of the reasons for the disorders. They may be presbyacousis, chronic inflammation, proliferative process or posttrauma changes. One of the elements important in the process of hearing is the proper functioning of the Eustachian tube (ET). The Eustachian tube dysfunction (ETD) often co-exists with a subjective feeling of hearing loss. Although that we know anatomopathological causal of ETD, the diagnosis and treatment are persistent and laborious.Result of ETD in infantile is the adenoids or/and pathological secretion within the rhinopharynx due to repeated infections of upper airways, regardless of age, the pathogenesis of ETD, chronic infections of the upper airways, allergy, gastroesophageal reflux, mechanical obstruction , anatomical abnormality , primary ciliary dyskinesia or different neuromuscular dysfunctions regardless of its courses , 2.In most common pathological causes, pharmaceutical treatment with anti-histaminic or anti-inflammatory medicaments  as well as a proper nasal toilet is often affective. If pharmacological treatment is ineffective while internal ear ventilation disorders caused by poor pathology of ET and chronic inflammatory process with exudation lead to partial hearing loss, surgery should be performed. There is a necessity to remove any pathological changes within the nose and the rhinopharynx and input the grommet tympanum membrane to remove the exudation from the ear. One of the methods is a less invasive procedure, the tuboplasty of the Eustachian tube  introduced thanks to the development of endoscopic technology in laryngology. BET is applied in the cases where, after elimination of all factors influencing the ET and middle ear functioning, no sufficient improvement is observed.The aim of the study was to present the therapeutic benefits of the BET method in the treatment of ETD caused by disorders in the middle ear ventilation.The BET procedure was approved by Ethics Committee of Military Institute of Medicine and was performed in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki. All patients gave their informed consent prior to their inclusion in the study.The BET procedure was offered to patients after subjective, physical and otorhinolaryngological examinations. The following clinically vital symptoms of poor ET function were recognized: feeling of lasting or periodic, but without regression to the norm, uni- or bilateral partial hearing loss as well as feeling of obstruction or clicking noises, which are reversible or not, after the Valsalva maneuver, yawning or swallowing.Standard otorhinolaryngological of nose and rhinopharynx examination were followed by a transnasal endoscopic evaluation and microscopic examination of the ears. The Valsalva maneuver was carried out in all patients. Additionally, all patients underwent audiometric examinations . Average air-bone gap for 500, 1,000 and 2,000 was evaluated. At the moment of qualification for the procedure, all patients denied any dysfunctions on their circulatory and respiratory systems, did not take any drugs at present, did not suffer allergy, any head or acoustic trauma or undergo any transnasal operations in the past.As the method was novel, preinterventional CT angiography of the carotid arteries was performed in all patients. All patients were treated with BET under general anesthesia. A specially designed 600 µm diameter balloon catheter (Spiggle and Theis Company) was applied in the procedure. The catheter was inserted into the pharyngeal orifice of ET, in the first instance Fig. . The balBET was offered to four patients (3 men and 1 woman). Three of them had bilateral ET dysfunction. We did not notice any complications during and after the procedure  in any patients.Postoperative hearing examinations were performed at 1 week and 6 weeks after BET  assigned to right-hand BET. He reported temporal, ipsilateral, muco-serous exudate in the middle ear (without exudate for three years) and hearing loss which was reversible after the Valsalva maneuver. Periodical treatment against idiopathic rhinitis. Microscopic examination of the ears: left tympanic membrane anatomically and functionally without changes, right tympanic membrane-abnormal position , single cicatrices and calcifications, residual reflex. Endoscopic examination of nose and rhinopharynx: small edema of mucous membrane. Otherwise no change. Valsalva maneuver on the right side-negative, on the left side-positive. One week after operation the patient reported reduced feeling of hearing loss. Microscopic examination of the ears: present state as before operation. Six weeks after operation without hearing loss. Valsalva maneuver was not obligatory. Microscopic examination of the ears: tympanic membrane in correct position. The patient reported reduced feeling of hearing loss.Patient P.W. (61 years old) assigned to bilateral BET. Medical history: chronic, persistent mucoserous otitis despite pharmacological treatment, bilateral hearing loss. Bilateral grommet tympanic membrane three times (the last one was removed 4 years before BET), the feeling of blocked ears, ringing and increased pressure in both ears was reported. Status postcardiac infarct (2001), without pharmacological secondary prevention. Microscopic examination of the ears: retraction of tympanic membranes , single cicatrices in the both ears. Endoscopic examination of nose and rhinopharynx: small edema of mucous. Otherwise no change. Valsalva maneuver in the both side—negative. One week after operation reduced feeling of hearing loss was reported. Microscopic examination of the ears: present state as before operation. Six weeks after operation without hearing loss. Valsalva maneuver was unnecessary. Microscopic examination of the ears: tympanic membranes in correct position.Patient C.M. (38 years old) assigned to bilateral BET. Medical history: the feeling of blocked ears, increased pressure in both ears and primary hypertension—actually without drugs. Microscopic examination of the ears: tympanic membranes in abnormal position (retraction pars flaccida and pars tensa) in the both ears. Endoscopic examination of nose and rhinopharynx: small edema of mucous. Otherwise no change. Valsalva maneuver in the both side—negative. One week after operation reduced feeling of hearing loss was reported, especially in the right ear. Microscopic examination of the ears: present state as before operation in the left ear, smaller retraction in the right ear. Six weeks after operation felling of hearing loss in the left ear at the same level, in the right ear improvement was reported. Valsalva maneuver ought to be done. Microscopic examination of the ears: present state as before and one week after operation.Patient D.Ł. (23 years old) assigned to bilateral BET. Medical history: chronic, persisting, mucoserous otitis despite pharmacological treatment, the feeling of blocked ears, bilateral hearing loss treated with catheterization of ET , asthma and Scheuermann’s disease—without drugs since 2007. Valsalva maneuver in the both side—negative. Microscopic examination of the ears: retraction of tympanic membranes, level of liquid in middle ear in the both ears. Endoscopic examination of nose and rhinopharynx: small edema of mucous. Otherwise no change. One week after operation reduced feeling of hearing loss was reported. Microscopic examination of the ears: smaller retraction in the both ears. Six weeks after operation without hearing loss. Valsalva maneuver ought to be done occasionally. Microscopic examination of the ears: tympanic membrane in correct position. Reduced feeling of hearing loss was reported. Level of the postoperative pain in all patients just and in the first day after operation were between 0 to 2 points .The development of minimally invasive interventions in the fields of urological, otolaryngological, gastrointestinal or vascular and cardiac procedures has become a fact , 2. The Already, in 1983, Yamashita utilized the fiberscope with an inflational canal to widen pharyngeal orifice and lumen of the ET . The metThe BET procedure is difficult because of the variety of ETD mechanisms leading to its creation. Our clinical studies assessed the feasibility and safety of the BET in a small patient cohort during a short-term period—only a 6 weeks observation. It is in accordance with results of studies of balloon dilation techniques including small groups of patients described by other authors up to date. Although patients revealed a significant improvement of ET score, longer long-term studies are necessary to determine whether this method will demonstrate lasting benefits and safety in the treatment of chronic Eustachian tube dysfunction. In other investigations, improvement was found to be time dependent.


Phosphenes are commonly evoked by transcranial magnetic stimulation (TMS) to study the functional organization, connectivity, and excitability of the human visual brain. For years, phosphenes have been documented only from stimulating early visual areas (V1–V3) and a handful of specialized visual regions  in occipital cortex. Recently, phosphenes were reported after applying TMS to a region of posterior parietal cortex involved in the top-down modulation of visuo-spatial processing. In the present study, we systematically characterized parietal phosphenes to determine if they are generated directly by local mechanisms or emerge through indirect activation of other visual areas. Using technology developed in-house to record the subjective features of phosphenes, we found no systematic differences in the size, shape, location, or frame-of-reference of parietal phosphenes when compared to their occipital counterparts. In a second experiment, discrete deactivation by 1 Hz repetitive TMS yielded a double dissociation: phosphene thresholds increased at the deactivated site without producing a corresponding change at the non-deactivated location. Overall, the commonalities of parietal and occipital phosphenes, and our ability to independently modulate their excitability thresholds, lead us to conclude that they share a common neural basis that is separate from either of the stimulated regions. Phosphenes are brief visual percepts caused by mechanically or electrically induced depolarization of cells in the retina or visual brain TMS-evoked phosphenes are a straightforward means to map the functional organization of visual cortical areas in both intact humans Phosphenes are also used to assess the relative excitability of visual cortex Phosphenes have traditionally been studied in early visual areas (V1–V3) of occipital cortex, where they tend to appear as small stationary blobs or shapes  Recently, Marzi et al. The IPS is a region of visual association cortex located fairly rostrally along the dorsal visual stream. As such, it receives visual input through the slow retino-geniculo-striate pathway, via extastriate areas, as well as the fast retino-tectal pathway, via the pulvinar and other thalamic nuclei In addition to receiving feed-forward visual input, the IPS has feedback projections onto multiple cortical and subcortical visual structures The broad goal of the present study was to determine whether parietal phosphenes are generated directly by local mechanisms or emerge through indirect activation of other visual areas. To accomplish this goal, we directly compared phosphenes evoked in two discrete regions of visual cortex: the intraparietal sulcus in right posterior parietal cortex and early visual areas of the right occipital pole. In the first of two experiments, we used a custom-made documentation system, developed in-house to electronically record the subjective features of phosphenes evoked as participants fixated in different locations. In the second experiment, we examined the interdependence of parietal and occipital phosphenes using low frequency (1 Hz) repetitive TMS (rTMS) to temporarily deactivate each site in separate sessions All participants (n = 23) consistently reported phosphenes following single pulse TMS to early visual areas in right occipital cortex and the intraparietal sulcus region in right posterior parietal cortex. At both locations, phosphenes conformed to inclusionary criteria: they appeared in the side of visual space contralateral to the stimulated hemisphere and were perceived regardless of whether participants' eyes were opened or closed. Importantly, phosphenes were not systematically reported following sham stimulation of phosphene regions or real TMS of non-phosphene regions.t(8) = −3.71, p<0.01.As illustrated in F's<1.2, all p's>0.1. As depicted in t(8) = 1.025, p>0.1. t(6) = 0.17, p>0.5. In sum, while occipital phosphenes tended to be larger than parietal ones, no significant group-level differences were observed with regard to either measure of phosphene size, area or length.Considering phosphene size, the 2 (TMS site)×3 (fixation location) ANOVA for area , indicated no significant main effects of the phosphene site or the fixation location and no significant interaction, all Finally, a qualitative examination of drawings made by participants using the Laser Tracking and Painting (LTaP) system F = 34.851, p<0.001; and time of stimulation (Time), F = 4.586, p<0.05. These results demonstrate that the intensity required to elicit phosphenes  was different for occipital and parietal stimulation and also varied with time . In addition, the ANOVA revealed a significant interaction between the rTMS target and phosphene site, F = 8.642, p<0.01) and between rTMS target, phosphene site, and time, F = 19.729, p<0.001. This suggests that 1 Hz rTMS produces discrete and temporary changes in phosphene thresholds relative to the site of stimulation.The 2 (rTMS target)×2 (phosphene site)×3 (time) repeated measures ANOVA revealed a significant main effect for site of phosphene induction (TMS), z(38) = −4.17, p<0.001. As depicted in t(19) = −3.89, p<0.001; as well as a slight decrease in the occipital threshold, which was not significant after correcting for multiple comparisons, t(19) = 2.27, p>0.01. By comparison, t(19) = −4.11, p<0.001, and no change for parietal threshold, t(19) = −0.3, p>0.1. Regardless of the rTMS condition and site of induction, all thresholds measured 60 minutes after rTMS were not statistically different from baseline, all t's<2.3, all p's>0.01. Finally, as depicted in r(20) = 0.581, p<0.01, indicating the response of these regions to TMS is governed by related factors. On the other hand, neither occipital nor parietal phosphene thresholds were correlated with motor thresholds, all r's<0.24, all p's>0.1, reflecting differences in the response to TMS between motor and visual cortices.These results confirmed our findings from Experiment 1 of higher thresholds for parietal than occipital phosphenes. Moreover, the results from Experiment 2 demonstrated that reducing excitability at either cortical location exclusively elevated the threshold from the site receiving rTMS, but did not significantly modulate phosphene thresholds elicited from the non-stimulated site. Thus, in spite of the similarities of occipital and parietal percepts documented in Experiment 1, these results indicate that at both sites, local mechanisms contributing to phosphene generation are independent.In accordance with the results of Marzi et al. The driving hypothesis of this study was that phosphenes induced by TMS should reflect the intrinsic attributes of the neurons being stimulated These results cast doubt on the neural basis of parietal phosphenes. It has been suggested that phosphenes might be generated by stimulation of the optic radiations To investigate this hypothesis, the parietal phosphene threshold was measured before and immediately after deactivating the occipital phosphene site with 1 Hz rTMS. If the generation of parietal phosphenes depends on activity in early visual areas, suppression of occipital excitability should alter the parietal phosphene threshold. In contrast, the results show that deactivation of the occipital phosphene site temporarily increased the phosphene threshold at that location, but did not change the threshold for parietal phosphenes. This indicates that parietal phosphenes are not dependent on activity in the occipital phosphene site. The inverse of this relationship produced the opposite results: applying 1 Hz rTMS to the IPS region increased the threshold for parietal, but not occipital phosphenes. Overall, these results demonstrate that parietal and occipital phosphenes are functionally independent from each other, and that the source of parietal phosphenes is not the region of early visual cortex we targeted for occipital phosphenes.A reconciliation of the commonalities of parietal and occipital phosphenes with their functional independence is possible if neither of the stimulated areas generates the perception of the phosphene. In this view, both the occipital and parietal phosphene sites represent independent nodes that, when stimulated by suprathreshold TMS, direct the activation of a common third region or network on which the two systems might converge. Thus each phosphene is the product of activity of local circuits as well as neurons in the third region. The former govern factors such as the excitability threshold and can be independently modulated by rTMS, while the latter confer features upon phosphenes based on intrinsic neural properties and are not susceptible to the effects of remotely applied rTMS.In support of such a hypothesis, Taylor et al. The region most likely to serve as the source of phosphene awareness is the primary visual cortex (V1). Lesions of V1 (or its input) result in the loss of conscious perception of incoming visual stimuli. Even in the absence of V1, some retinal input makes its way to higher visual areas  via the tecto-pulvinar pathway, however this information does not reach the level of awareness, hence the term blindsight In sum, this study provides confirmation that stimulation of a region near the intraparietal sulcus in posterior parietal cortex reliably produces genuine phosphenes. Rather than adopting features associated with the intrinsic attributes of IPS neurons, these percepts appear similar to those evoked from stimulating visual areas V2–V3 in occipital cortex. Despite these commonalities, deactivation of the occipital and parietal sites revealed their functional independence. Thus we conclude that the perception of IPS and V2–V3 phosphenes occurs not from local TMS-induced activity, but rather from indirect activation of a common third region. Given its preeminent role in visual awareness and functional connectivity with both of the targeted regions, the strongest and most compatible interpretation is that V1 is the locus of phosphene perception for both IPS and V2–V3 stimulation.The present study comprised two independent experiments. Experiment 1 consisted of a single session per participant and compared the characteristic features of phosphenes induced in posterior parietal cortex to those generated by stimulating the pole of the occipital cortex. Experiment 2 required two sessions per participant and explored the functional dependence of the same two locations by using 1 Hz rTMS to modulate phosphene thresholds.All forms and procedures used in the study received approval by the Institutional Review Board at Boston University School of Medicine. All participants provided written consent upon enrollment in the study, and were thoroughly screened for exclusion criteria with regards to the risks of TMS A total of 23 healthy adults  of mean age 27.9 years (range = 21.8–45.5) with no known history of neurological disease participated in one or both experiments of the present study . The coil was held against the scalp with the center tangential to the site of stimulation and pulses were delivered either by stepping on a pneumatic foot switch or by pressing the trigger button on the front of the stimulator. Pulses were spaced at least 5–10 seconds apart (≤0.2 Hz); this rate served both to limit the temporal predictability of pulse onset and to avoid the lasting cumulative effects of rTMS In Experiment 2, rTMS was applied using an air-cooled 70 mm figure-of-eight focal coil (Magstim) attached to a Magstim SuperRapid biphasic stimulator. The coil was kept fixed in place for the duration of stimulation with the assistance of a multi-joint adjustable Magic Arm . The sequence of pulses was programmed and initiated using Magstim Rapid Session Software (v 4.0). The pattern of stimulation consisted of one pulse per second (1 Hz) for 15 minutes  at 90% of the local phosphene threshold value, which was determined separately from baseline threshold using the air-cooled coil and SuperRapid stimulator. Based on prior research Z) for M1 ; 2 cm dorsally and 2 cm laterally from the inion for V2–V3 , and directly over EEG coordinate P4 for the IPS region . The use of EEG coordinates to guide TMS placement over functional brain areas represents an economical and practical tradeoff over more precise neuroimaging-based methods. With consequence for the present study, the relationship of P4 to the right IPS has been validated by several studies TMS was directed to scalp locations overlying three cortical sites: the pole of the right occipital cortex, corresponding most likely to early visual areas V2–V3, although stimulation of V1 cannot be ruled out We used the following established inclusion criteria for occipital phosphenes: a brief and spatially circumscribed visual percept, appearing in the left visual hemifield , immediately following real TMS only, and occurring regardless of whether the participant's eyes were opened or closed. The inclusion criteria for parietal phosphenes were the same as for occipital, although we would accept percepts that were less circumscribed and without restriction on visual field location, since there is some debate as to whether neurons in the human right IPS have bilateral or purely contralateral representations of visual space. A small number of potential participants (n = 3) were not included in the study on for the following reasons: an inability to perceive phosphenes in either of the two locations; reporting visual percepts following TMS that did not adhere to the aforementioned criteria or proved highly inconsistent; or reporting visual percepts following sham TMS to visual regions or real TMS to non-visual regions.In both experiments we measured phosphene thresholds for the occipital and parietal sites. Additionally, in Experiment 2, we assessed the motor threshold at M1. Regardless of site, the same protocol was used at all times: with intensity initially set at 50–60% of the maximum stimulator output, we applied a series of at least 5 pulses at a maximum of 0.2 Hz and recorded whether each pulse produced a visible muscle twitch of the contralateral thumb or index finger (TMS to M1) or the unambiguous report of a qualified phosphene (TMS to V2–V3 and IPS). When assessing the occurrence of phosphenes, participants were instructed to respond verbally by stating “yes” if they definitely perceived a phosphene, “no” if they definitely did not perceive a phosphene, or “maybe” if they perceived something, but were unsure if it was a phosphene or some other sensation such as an eye blink. A “maybe” response was not counted as a positive or negative report, but instead initiated a follow-up pulse. Based on these responses, the stimulation intensity was subsequently adjusted using the following algorithm: if at least four consecutive pulses resulted in a “no” response, the stimulation intensity was increased by 10%; if at least four successive pulses resulted in a “yes” response, stimulation intensity was decreased by 10%; otherwise, if the series of pulses resulted in a mixture of “yes” and “no” responses, stimulation intensity was adjusted in smaller increments (1–5%). This process was repeated until reaching the minimum intensity value that resulted in positive reports from 50% of at least 10 delivered pulses. If no single intensity resulted in an occurrence of exactly 50%, we used the criteria of at least 40%, but no more than 60% positive reports. The advantage of this approach, which is similar to methods used in other phosphene studies A subgroup of nine adults  of mean age 26.4 years (range = 22.5–32.0) with no known history of neurological disease, including one of the co-authors of the study (PJF), participated in this experiment. Seven out of the nine participants were naïve to TMS-induced phosphenes, nonetheless they did not require significant training to consistently perceive and report them. The aim of this experiment was to characterize phosphenes evoked from applying TMS to the IPS region of posterior parietal cortex and compare their features  to those induced by stimulating early visual areas of the right occipital cortex.2) room, at a distance of approximately 45 cm (measured from nasion) in front of a dual-sided projection screen  so that it filled their entire visual field, and given a modified green laser pointer  that was held in their dominant hand. The participant was instructed to fixate on a point at the center of the projection screen while single pulses were delivered to occipital and parietal locations at 110% of the phosphene threshold recorded for each site. After each pulse, participants were asked whether they perceived a phosphene and if so, to trace the outline on the screen using the laser pointer. The Laser Tracking and Painting (LTaP) system  documented the path of the laser pointer as X–Y coordinates and briefly displayed the outlined shape of the phosphene for near-instantaneous feedback degree is the transformed value, pixel is the native value obtained from the LTaP system, R is the ratio of the resolution output of the projector to the size of the projected image (12.5 pixels/cm) and D is the distance between the participant and the projection screen (45 cm). These transformed, standardized coordinates allowed us to calculate the area of phosphenes . These data were averaged by participant, TMS site, and fixation location and entered into a 2 ×3  repeated-measures analysis of variance (ANOVA) with a 95% confidence interval (α = 0.05). Mauchly's test indicated that the assumption of sphericity had been violated for the main effect of Fixation location, χ2(2) = 7.59, p<0.05), therefore degrees of freedom were corrected using Huynh-Feldt estimates of sphericity (ε = .6). For all other effects and interactions, the assumption of sphericity was met, all χ2's<2, all p's>0.1, allowing us to use uncorrected degrees of freedom. Pair-wise comparisons were computed using two-tailed paired-samples t-tests, with a more conservative 99% confidence interval (α = 0.01) to account for multiple comparisons. In addition, occipital and parietal phosphene thresholds were compared using a two-tailed paired-samples t-test.We recorded the following data for each participant: two phosphene thresholds  and 30 arrays of X–Y coordinates, each corresponding to the outline of a single perceived phosphene. Each X and Y value was transformed from a pixel value to a degree of visual angle using the following formula:A low number of phosphenes  were perceived as straight lines rather than enclosed shapes, thus their extent could only be measured in terms of total length. These data were averaged for each participant independent of gaze direction due to the small number of samples and compared using a two-tailed independent-samples t-test. A small number of phosphenes  were excluded from all analyses because a software error resulted in a truncated recording.A subgroup of 20 adults  of mean age 28.2 years (range = 21.8–45.5) with no known history of neurological disease, including three co-authors of the study , participated in the experiment. An additional five had participated in the previous experiment, while nine were naïve to TMS-induced phosphenes. As with the previous experiment, participants required only minimal training to consistently perceive and report phosphenes. The aim of this experiment was to determine whether parietal and occipital phosphenes were independent and generated by local mechanisms, or interdependent, reflecting a common neural basis.As illustrated in 2(2) = 6.06, p<0.05), therefore degrees of freedom were corrected using Huynh-Feldt estimates of sphericity (ε = .83). For all other effects and interactions, the assumption of sphericity was met, all χ2's<5, all p's>0.1, allowing us to use uncorrected degrees of freedom. Post-hoc and planned pair-wise comparisons were computed using z-tests (for n≥30) and paired-samples t-tests (for n<30), using a more conservative 99% confidence interval (α = 0.01) to account for multiple comparisons. In addition, we used a Pearson's coefficient (r) to examine the correlations between baseline motor and phosphene thresholds, with a 95% confidence interval.Data collected for each participant consisted of one motor threshold and three pairs of phosphene thresholds per session. To assess the effect of 1 Hz rTMS, phosphene thresholds were entered into a 2 ×2 ×3  repeated-measures ANOVA with a 95% confidence interval (α = 0.05). Mauchly's test indicated that the assumption of sphericity had been violated for the main effect of Time, χ


Background. Pregnancy with concomitant chorioangioma and placental mesenchymal dysplasia (PMD) coexisting with a normal viable fetus is very rare. The literature was reviewed to explore the incidence and genetic origin of this condition. Case. The case was first identified by prenatal ultrasonography, but the prenatal diagnosis only included chorioangioma. PMD was then confirmed during postnatal evaluation, which included gross and histologic examination of the placenta. The macroscopic and microscopic findings were consistent with concomitant chorioangioma and placental mesenchymal dysplasia during pregnancy. Genetic findings confirmed genetic similarity of the chorioangioma and vesicle-like villi with the fetus. Conclusions. The case represents a rare placental abnormality whose pathogenesis and molecular basis need further research. Detailed histologic and genetic analyses are essential for accurate and differential diagnosis. Chorioangioma, a benign vascular tumor arising from chorionic tissue, is the most common tumor of the placenta . Large l+3 weeks of gestation in preterm labor. Ultrasonography examination revealed polyhydramnios, with an increase in the amniotic fluid index to 37.5 cm. She was admitted for tocolysis, but this management was unsuccessful. One day after admission a 740 g female was delivered vaginally with Apgar scores of 5 and 8 at 1 min and 5 min, respectively. The maternal serum β-human chorionic gonadotropin (β-hCG) was 4611 milli-international units/mL at 2 days postpartum and was undetectable at 3 weeks postpartum.An asymptomatic 30-year-old Chinese primigravida underwent her initial routine ultrasonography examination at 25 weeks of gestation. Sonographic examination confirmed a structurally normal fetus with an estimated gestational age of 25 weeks. The placenta appeared bulky and contained a well-defined 83 × 30 × 56 mm mixed-echogenic mass  and areaKIP2 in the villous cytotrophoblast was investigated by immunohistochemical examination with Streptavidin-Peroxidase (SP)  . On the Pregnancy and a live birth with concomitant chorioangioma and PMD are very rare. To our knowledge, only 3 cases of concomitant chorioangioma and PMD have been reported . The rarPlacental mesenchymal dysplasia (PMD) was first described in 1991 by Moscoso et al.  and has No specific clinical symptomatology is associated with PMD. However, PMD has been associated with fetal growth restriction, stillbirth, and Beckwith-Wiedemann syndrome . Large oPMD should be considered in the differential diagnosis of cystic placenta. Ultrasonographic features of this abnormality closely resemble those of partial hydatidiform mole. The coexistence of a large cystic placenta with a phenotypically well-formed fetus is highly unlikely in molar pregnancy and should increase the possibility of a PMD diagnosis. The 2 entities are distinguished primarily by karyotype analysis. Partial moles are triploid, whereas PMD carries a 46,XX karyotype . In the KIP2), H19, IGF-II, and KVLQT [KIP2 protein as a diagnostic marker may prove helpful in distinguishing PMD from molar pregnancy [A review of the literature indicates that approximately 25% cases of PMD are associated with Beckwith-Wiedemann syndrome (BWS), a condition characterized by macrosomia, exomphalos, macroglossia, omphalocele, internal visceromegaly, placentomegaly, and increased susceptibility to childhood tumors . The patnd KVLQT . There hregnancy ; howeverThe molecular basis of the placental changes in PMD remains unclear. The presence of 2 distinct cell lines in the placenta of some patients with PMD suggests androgenetic-biparental mosaicism as an etiology . The andMany pathologists are unfamiliar with PMD, which may account for the underdiagnosis and underreporting of this entity. Our case documents the salient features of PMD and the distinguishing features from those disorders mimicking this condition, the most important of which is a partial mole.In conclusion, pregnancy with concomitant chorioangioma and placental mesenchymal dysplasia is very rare. Our case illustrates the importance of a careful gross and histologic examination of the placenta in making an accurate diagnosis. Our findings confirm those of others and suggest that chorioangioma and PMD have the same pathologic origin. Both are derived from the mesoderm, and in our case, the chorioangioma, vesicle-like villi, and the fetus shared an identical genetic profile. However, the pathogenesis and the molecular basis of PMD need further research.


In the last 20 years, a large number of GMTs have been generated, characterized and field tested to evaluate their agronomic behaviour and their potential performance for technological applications.Therefore, important knowledge has been gained from these studies on the potential of GMTs whereas biosafety concerns have been raised on the plantation of transgenic trees in the field. The European Cooperation in Science and Technology (COST) action FP0905 on the biosafety of forest transgenic trees aims to help forthe building and implementation of EU policy directives to ensure a safe development and practical use of GMTs in the future. This Action is expected to generate important benefits thanks to the experience gained by the research community, to provide general information on these studies as well as to address public concerns about biosafety issues raised by transgenic tree plantations, and finally to help for the establishment and implementation of EU policy directives in the view of a future deployment of GMTs cultivation in Europe. Within this action, the objective of the working group 1 (WG1) is to gather the existing knowledge on genetically modified forest trees (GMTs) including both field trials and greenhouse experiments. More specifically, the action of WG1 is focused on the compilation of:- Data from literature and methods developed on gene flow and containment strategies- Data available on the traits targeted and the function of the gene introduced, on their intended and eventually unintended effects- Data on host species characteristics especially related to biosafety issues such as their biological cycle, their way of pollination and the characteristics of pollen and seed dispersal.http://www.cost-action-fp0905.eu/index.php?option=com_kunena&Itemid=74&func=view&catid=4&id=11]This information will be collected from published papers in books and reviews as well as from reports from different agencies available on the web. Moreover, additional data will hopefully be gained through the responses of expert scientists from public or private institutions to an ongoing survey accessible at the website of the COST Action FP0905: [The information collected will be used to:- 1) establish a list of protocols for the control of transgene flow and gene containment.- 2) establish the present state of the art in gene targeting strategies for site specific integration of transgenes.- 3) get an appraisal on the types of construct and genes inserted in GMTs in the past; in the present and in the future.This information will be compiled in a database that will be made available to the scientific community as well as to the European policy makers.The results of this work will enable the participants and end-users to get a clear factual overview of the global status of GMTs and especially the status of Europe compared to non-European countries. Furthermore, the information gathered will also be useful for assessment of environmental impacts of GMTs that is the object addressed in the WG2 of the COST Action FP0905.