To achieve realistic Augmented Reality (AR), shadows play an important role in creating a 3D impression of a scene. Casting virtual shadows on real and virtual objects is one of the topics of research being conducted in this area. In this paper, we propose a new method for creating complex AR indoor scenes using real time depth detection to exert virtual shadows on virtual and real environments. A Kinect camera was used to produce a depth map for the physical scene mixing into a single real-time transparent tacit surface. Once this is created, the camera’s position can be tracked from the reconstructed 3D scene. Real objects are represented by virtual object phantoms in the AR scene enabling users holding a webcam and a standard Kinect camera to capture and reconstruct environments simultaneously. The tracking capability of the algorithm is shown and the findings are assessed drawing upon qualitative and quantitative methods making comparisons with previous AR phantom generation applications. The results demonstrate the robustness of the technique for realistic indoor rendering in AR systems. Augmented Reality (AR) involves the integration of virtual content into real environments . In AR aShadows play a major role in the production of realistic AR systems. This is because shadows produce the perceptual illusion of the virtual in real world empowering the observer to determine the distance between various objects enhancing object complexity and displaying more realistic environments. Shadows can also be employed to yield the light position among the lighting information rendering it more believable than what is the case with the virtual object in the real world.Many algorithms have been developed for shadow generation. However, these algorithms may not be suitable for the real time requirements of AR applications. For example, shadow volumes  are suffShadows are from among the most salient factors contributing to the AR system realism whose subject has been researched for the last fifteen years . ShadowsMuch research has been conducted on how AR environment shadows can be used and enhanced  18] 3] [3]18] [ [3]18]  20] con con20] cRecently, attempts have been made to employ Augmented Reality systems to produce shadows for virtual objects on flat surfaces so as not to reveal the absence of flexible soft and hard shadows on real and virtual objects  23] [24 [2423]  26]..26].Shadow volumes have been utilized in AR to produce shadows on real objects using an algorithm where a phantom model is produced to act as a real object . In thisShadow mapping was initially used in AR systems by Sugano et al.  through A soft shadow technique was introduced by Supan et al. . A shadoDynamic range environment maps were utilized by Madsen and Laursen  to show A soft shadow using projection shadows on flat surfaces was employed by Jensen et al.  under reConvolution Shadow Maps (CoSMs)  are one Madsen et al.  introducAR-related outdoor illumination conditions were predicted by Madsen and Lal  in termsA soft shadow technique with less aliasing was introduced by Castro et al. . The resIntegration of shadows and sky colour with respect to the sun’s position in AR is employed by Kolivand and Sunar , 39, 40 Recent research on shadows in augmented realty includes the one conducted by Nowrouzezahrai et al.  who applAs it is shown, most current systems for showing virtual shadows on real objects are based on static objects and fixed environments. These systems have their major limitations meaning that the objects in the real world could not be moved. In contrast, in our system real objects can be moved and the virtual shadows would adjust to their movement accordingly which has been achieved through the use of real time environment modeling.Numerous computer graphic techniques  42] hav hav42] hNewcombe et al.  investigLack of moving volume in space is a shortcoming for KinectFusion  which RoKeller et al.  extendedIn sum, all the reconstruction techniques mentioned here are based on the  49] and and49] aThere are many different issues influencing the perceived realism of 3D generated objects in computer graphics. Realism refers to some sort of measurement for the subjective difference between a real 3D environment and a 3D scene generated from computers . QuantifOne of the other issues with AR, is the need for exact illumination with respect to the environments to make the system maximally realistic  35] [53 [5335]  55]..55].Some researchers have explored the problem of virtual shadows in AR scenes. However, the majority of this work does not support casting and receiving the virtual shadows on real environments in real-time. The present research contributes to the literature on the topic in the following ways:(1) Real-time reconstruction of real scenes, (2) Generation of real-time phantoms for any AR systems 3) Presenting the literature with a method for casting virtual shadows on the real environments, and (4)Application of PCF , Cascade PresentiThis section takes up the question of various AR pipeline components and how these can generate virtual shadows being cast on real environments to create realistic AR systems. The virtual environments were initially modeled using 3D software such as 3D Studio Max. Subsequently, they were augmented onto the scene through a marker based tracking technique. The Augmented Reality system utilized the Metaio SDK  and the The LivePhantom technique is used for capturing the real environment, AR tracking, reconstructing the real scene as phantoms, and generating shadows in AR. The pipeline is illustrated in Capturing the real environments is the first stage of the pipeline. To produce virtual shadows on real environments, the phantom which is similar to the real one needs to be generated. To do this, the Kinect camera is used to reconstruct real scenes in real-time.sp and sq which is the neighbouring vector of sp and sq will be replaced by sp. Parameter d is flexible in that it reveals different accuracies for the phantoms between 0% and 15% at the first stage. To produce a complete point cloud, the real scene needs to be captured from different viewpoints and the data needs to be fused together.The Kinect camera can be utilized to capture the real environment using six degrees of freedom leading to a simple real-time depth map having a point cloud. The noisy data must be refined to simple and sufficiently accurate coherent data which is undertaken through removal of neighbouring surfaces having less angles between their normalized normal vectors than a deem degree. If There are two ways to reconstruct a more accurate and complete object; (1) capturing the object from a number of different viewpoints, and (2) fixing the Kinect camera and rotating the object in front of it. In the second method, the object fills the majority of depth map and so is better when a single object needs to be reconstructed.Camera tracking is the next step after capturing the environments and generating the raw depth map is the next step. This is described in more detail in the following section.Camera tracking is based on the Interactive Closest Point (ICP) algorithm of Besl and McKay , as descAlgorithm 1. 3D reconstruction trackingStep 1. Create the point cloudStep 2. Set the line segments between the pointsStep 3. Produce the implicit curve equations like f = 0Step 4. Parametric the curves like (x(p), y(p), z(p))Step 5. Calculate the triangles to be the surfaceStep 6. fProduce the implicit surface equations like gStep 7. Parametric the surfaces , y, z)C is the set of points with Nc points, the distance of point p to the set of C is:If s for segmenting two points p and q, then C. If ω is a triangle between three points p1, p2, p3 and p and ω could be calculated by t where R is a rotation matrix and T is translation matrix. Thus:μx is the centre of mass of measured point set χ and same for point set P with μp. ℜ is the 3 × 3 rotation matrix created by a unit rotation quaternion [The complete registration vector is aternion .R in translation T could be estimated byThe error between the two corresponding points in a rotation of Pk+1 = qk(P0) is applied until dk − dk+1 < ε.Finally, iterating the registration for Fusing the point clouds to create the required mesh involves the ICP algorithm . This fuThe proposed method makes it possible to employ a standard Kinect camera having an ordinary webcam to reconstruct the captured 3D objects as an AR system phantom. Any uncomplicated and minimal displacement of Kinect produces a separate viewpoint rendering the reconstruction objects more precise. Integrating different captured views from numerous viewpoints leads to increasingly precise phantoms but more extensive. To prevent this situation, the Kinect camera should be fixed. Otherwise, the real objects need to be moved. Another webcam provides the users the chance to observe the augmented objects from numerous viewpoints provided the objects had already been captured using the Kinect camera.The most challenging part of casting shadows on real environments is in the case of real-time and complex environments. Creating phantoms using 3D software does not support a complex environment and they cannot be implemented in real-time rendering. That is, it is not a real-time reconstruction if it is done before-hand.p =  at the time of t the depth is Dt(p). The specific 3D vertex in the Kinect camera coordinates will be:K is the calibration matrix of the Kinect infrared camera. For each vertex the normal vector is calculated using:To construct the 3D object from the depth map as can be seen in The main factors for evaluating the quality of the point cloud, are point density and accuracy . The senThe resolution of the Kinect and the pixel size of the disparity image are important for calculating the point spacing of the depth. Therefore, there is an inverse relationship between the point density and sensor distance.Generating a 3D mesh from the set of point cloud is employed by connectivity between neighbouring points, as discussed earlier. Of course, capturing the physical scene from different points of view can create sufficiently high quality, but there is no need to be more accurate due to invisibility of the phantoms. The difference between capturing from a single viewpoint and capturing from more viewpoints is illustrated in The 3D mesh reconstructs within milliseconds (less than 28 ms). This mesh is needed not only to receive the shadows but also to apply collider for having the interaction between virtual objects and real environments. α, β, γ) in the direction of  where α, β and γ are the coordinates of the marker. Orientation needs to be adjusted in real-time.The orientation of the reconstructed 3D environment is not aligned and does not fit the original captured data from the AR webcam when it moves away from the Kinect camera. The reconstructed data need to be adjusted during the rendering. In an indoor case such as a normal room or office the orientation is adjusted with  demonstrating the technique to be suitable for real-time rendering. The phantoms can receive the virtual shadows as a simple virtual object on virtual environments but can be observed in real environments due to the transparency of the phantom under no more tolerance in real-time.The phantoms generated using LivePhantom could be used as a collider. It means interaction between animation objects and real objects could be observed in the course of animating the virtual object.In the case of the shadow technique, semi-soft shadows are taken into account to enhance the realism of AR environments. Some recent and widely used shadow techniques have been employed in AR system. Conventional Shadow Maps, PCF, CSMs and HSMs are applied in a same scene to highlight the capability of LivePhantom.The results show that LivePhantom can conveniently be employed in real-time rendering environments. Employing different types of shadows and physical interaction shows that other phenomena such as illumination, animation and different types of visualisation can employ this technique. Moreover, it can be used for various reconstructions in engineering applications.As mentioned earlier, LivePhantom reconstructs 3D meshes within seconds. The main issue with LivePhantom is the lack of casting accurate shadows on real objects which move quickly. Enhancing the technique to generate the sufficiently high quality phantoms having fast rendering time and thus increasing the FPS is the issue to improve the current LivePhantom. Implementing the LivePhantom technique in outdoor AR system is another issue which must be taken into consideration.The interaction between virtual and real objects, such as exerting the colour, influence of real objects on virtual ones and vice versa can largely enhance the realism. Focusing on the colour sensor of a simple Kinect camera and Radiosity and Ray-tracing techniques is the next step to enhance the interaction between virtual objects and real environments.It is hoped that the present study could broaden researchers’ perspectives for applying this technique in both computer graphics and other related disciplines.


P < 0.001). In addition, we found that AR expression is correlated with increased DFS in patients with luminal breast cancer (P < 0.001), and decreased DFS in TNBC . In addition, patients with HR+ tumors (Hormone receptor positive tumors) expressing low levels of AR have the lowest DFS among all receptor combinations. We also propose a novel prognostic model using AR receptor status, BRCA1, and present data showing that our model is more predictive of disease free survival compared to the traditional TMN staging system.In this study we sought to correlate androgen receptor (AR) expression with tumor progression and disease-free survival (DFS) in breast cancer patients. We investigated AR expression in 450 breast cancer patients. We found that breast cancers expressing the estrogen receptor (ER) are more likely to co-express AR compared to ER-negative cancers (56.0% versus 28.1%,  Such a heterogeneity leads to markedly different treatment approaches and outcomes, which in turn necessitates a deeper understanding of prognostic and predictive markers. In breast cancer, the oncogenic roles of nuclear steroid hormone receptor (HR) signaling mediated by the estrogen receptor (ER) and progesterone receptor (PR), respectively, have been extensively characterized. The findings provide the basis for receptor antagonist therapy today. In contrast, the roles of androgen receptor (AR), which is highly expressed in all breast cancers 60-70%) regardless of ER status , 2, rema− tumors . Howevert cancer –6, but i0-70% reg− tumors . Triple − tumors , and is − tumors , and the− tumors . In thisA total of 450 cases of primary invasive breast cancer were included in this cohort. Twenty-eight cases were censored for lack of follow-up, and AR expression could not be measured by IHC in 16 cases because of tissue core loss. Thus, 407 cases were included in the subsequent analyses. The clinical-pathological features of this cohort are summarized in Table Significant differences in AR expression patterns were observed among the different breast cancer subtypesP < 0 .001) and PR (P < 0.001) status but negatively with metastasis (P = 0.022). However, no significant correlation was observed with the other tumor characteristics  tumors but conferred a worse prognosis in patients with HR− tumors (both ER and PR negative). Combining HR and AR status revealed a worse prognosis for patients with HR+ARlow tumors but a superior prognosis for those with HR+ARhigh tumors compared with all other combinations  were associated with a worse prognosis compared with tumors with concordant ER and AR status (HR−ARlow or HR+ARhigh).Patients were followed for up to 144 months (median follow-up time = 91.0 months). Four hundred and twenty-two patients completed the follow-up, and 92 events were observed. In general, patients with ARs Figure . This prs Figure  but incos Figure . Stratifs Figure . Tumors P = 0.015), tumor size > 5 cm , and stage III cancer  were associated with a higher risk of disease relapse. Moreover, elevated AR expression indicated a higher risk of disease relapse , whereas higher BRCA1 expression was associated with a lower risk of disease events ; these findings were consistent with a Kaplan-Meier analysis demonstrating that nuclear BRCA1 expression was associated with a favorable prognosis in patients with TNBC . Thus, the traditional model  was as follows:When the correlations between DFS in patients with TNBC and each clinical-pathological variable were examined by univariate analysis, several factors demonstrated a significant association Table . PositivC Figure . Moreoves Figure . A stepwP = 0.026) and BRCA1 (P = 0.016) were identified as significant prognostic factors in a multivariate Cox model. The combined model (Mcombined) was as follows:With the inclusion of AR and BRCA1, TNM stage, AR (P < 0.001 for the AUC comparison).The relationship between sensitivity and the false-positive rate (1-specificity) is illustrated by a ROC curve. The AUC was 0.615 (95% CI 0.560-0.709) for the traditional model and 0.706 (95% CI 0.680-0.814) for the AR-BRCA1 combined model Figure , suggestAndrogen-based therapy in breast cancer was first described in the 1940s , its mec+AR− or ER−AR+) had a worse prognosis compared to concordant HR status (ER+AR+ or ER−AR−), with ER−AR+ tumors being associated with the worst prognosis [+ARlow status was associated with the worst prognosis among all combinations, potentially because of the inclusion of PR status in the definition of HR status and that we defined 45% positive nuclei cutoff as AR positive. These findings highlighted that patients with HR+ARlow tumors may have poor survival despite the luminal subtype, which is generally recognized as a favorable pathology. Therefore, more powerful adjuvant treatments should be directed to patients with HR+ARlow luminal breast cancer to prevent disease relapse.Consistent with findings in previous studies and preclinical studies , 7, 19, Preclinical studies have shown that AR inhibits ER activity by blocking it's downstream transcription targets, thus inhibiting ER-stimulated tumor growth in ER-positive cell lines , 20. The+ER− breast cancer, the 6-month clinical benefit rate was 19% for bicalutamide, which established the potential of targeting AR in ER- disease [clinicaltrials.gov: NCT01889238). Moreover, there are many upcoming clinical trials exploring the utility of AR-targeted therapies .Treating TNBC has always been challenging because of the heterogeneity and the absence of well-defined molecular targets. The new discovery of promising biomarkers for TNBC will help to resolve this crisis. BRCA1 and AR are representative markers related to the basal-like and LAR subtypes of TNBC, respectively . The rol disease . AnotherBRCA1/2-mutant TNBC tumors have shown promising clinical benefit [BRCA1 is famous as cancer susceptibility gene in familial breast cancer, and during preclinical research, depletion of BRCA1 impaired differentiation but promoted proliferation of mammary epithelial cells . which m benefit . TherefoTo the best of our knowledge, our study is the first to investigate the prognostic significance of the combined BRCA1 and AR status in TNBC patients. Our model suggest that the combination of BRCA1 and AR status in TNBC prognosis is more sensitive and accurate compared to the traditional prognostic markers, potentially offering additional information for oncologists to predict patients' prognosis.In conclusion, AR is associated with different prognosis depending on HR status, and patients with TNBC may benefit from new treatment options, such as anti-androgens or PARP inhibitors. Lastly, combining AR and BRCA1 status with traditional prognostic factors improves prognostic predictions.A total of 450 pathologically defined breast cancer samples were collected at the Department of Breast Surgery at FDUSCC  between August 2001 and January 2008. patients' enrollment process  and the For tissue microarrays (TMAs), samples from 207 luminal-like subtype cases, 93 HER2-enriched subtype cases and 150 TNBC cases were randomly collected from 4,179 cases that met the eligibility criteria before the initiation of cancer treatment . The TMA™ III), Which was presented in Supplementary Data.Immunohistochemical staining for AR and BRCA1 was performed following a two-step protocol (GT Visionhigh (tumors with high AR expression) and ARlow (AR negative tumors and those with low AR expression). For BRCA1, the TMAs were semi-quantitatively scored according to a staining index  which was defined in Supplementary Data. SI > 5 was defined as BRCA1-positive staining, whereas SI < 5 was defined as negative staining [A senior breast pathologist (AE) who was blinded to the clinical data reviewed each TMA twice to assess the TMA section evaluation, status and invasiveness. Tumors were considered AR positive if more than 10% of the nuclei were stained, independent of the intensity . A cut-ostaining . The aveP < 0.05. All analyses were based on the available data, and missing data were randomly distributed.All analyses were performed using SPSS . Disease-free survival (DFS) was defined as the time from primary surgery to the date of relapse, breast cancer-specific death or October 31, 2014. A chi-squared analysis or Fisher exact test was used to test for the association between AR expression and clinical-pathological characteristics. Survival data were evaluated by Kaplan-Meier analysis. We constructed models to predict DFS in patients with TNBC using univariate and multivariate Cox analyses. Risk scores and time-dependent receiver operating characteristic (ROC) curves were calculated as previously described . The are


This study was conducted to assess the effect of comorbidity, ethnicity, occupation, smoking and place of residence on allergic rhinitis (AR), acute rhinosinusitis (ARS) and chronic rhinosinusitis (CRS).2LEN  screening questionnaire was sent to a random sample of the Dutch population (n = 16700) in three different areas of the Netherlands.A GAFifty percent (8347) of the questionnaires sent were returned. A total of 29% respondents (27–31% in different areas) met the criteria for AR, 18% (17–21%) for ARS and 16% (13–18%) for CRS. Risk factors for AR were itchy rash, eczema, adverse response after taking a painkiller, asthma, CRS and ARS. Moreover, the risk of AR was twice as low for full-time housewives/househusbands than for people with jobs. The risk of ARS or CRS was significantly higher in respondents with a doctor’s diagnosis of CRS, AR, itchy rash or smoking. The risk of CRS was also significantly higher in respondents with an adverse response after taking painkillers, active smoking or asthma. Caucasians are generally less likely to have AR or CRS than Latin-Americans, Hindustani and African-Creoles, and more likely to have ARS than Asian, Hindustani, Mediterranean and African-Creoles.This study found shared and distinct risk factors for AR, ARS and CRS and therefore provides support for the belief that they have shared symptoms but are different diseases with different aetiologies. Allergic rhinitis (AR), acute rhinosinusitis (ARS) and chronic rhinosinusitis (CRS) are common upper airway diseases. –4 AccordAR is clinically defined as a symptomatic disorder of the nose induced after allergen exposure by an IgE-mediated inflammation of the nasal membranes. The symptoms include rhinorrhoea (anterior or posterior), nasal congestion, nasal itching, and sneezing.  There isThere is a lot of data about the effect of comorbidity , ethnicity, occupation, smoking and place of residence on the incidence of AR , but les2LEN survey was conducted under the auspices of The Global Allergy and Asthma European Network (GA2LEN). The associated questionnaire was designed to focus specifically on upper airway symptoms and particularly upper airway disease like rhinitis and rhinosinusitis, but also on some gaps in our scientific understanding of allergic disease and some risk factors such as adverse response to painkillers, occupation, ethnicity, smoking exposure, age and gender.The GAThere are theories about the association between AR and ARS and CRS. One theory is that allergy causes swelling of the mucosa, which obstructs the ostium of the sinuses and impairs mucocilliary transport, and possibly induces rhinosinusitis.  Another We wanted to look at whether different areas (with different levels of air pollution) in the Netherlands (Amsterdam and the east of the Netherlands) and/or ethnicity could play a role in the prevalence and severity of ARS, CRS and AR. This study was conducted to assess the relationships between AR, ARS and CRS and comorbidity, ethnicity, occupation, smoking and place of residence.2LEN questionnaire, which consists of 22 questions. The questionnaire was sent to a random sample of the Dutch population in three different areas of the Netherlands (Most of the data for the present study were obtained using the GAherlands  with dif2): 5000 questionnairesOuderkerk aan de Amstel, a suburban village close to Amsterdam (545 inhabitants/km2): 6700 questionnairesAmsterdam South East : 5000 questionnairesAlmelo, a city in a more rural area in the east of the Netherlands (1077 inhabitants/kmIn the surveys in Amsterdam and Almelo (sent in 2009), we included extra questions about acute rhinosinusitis (ARS) and ethnicity alongside the questions about chronic rhinosinusitis (CRS) and allergic rhinitis (AR).The questionnaire can be found in the supporting files . We sentAR: A positive answer to the question: Do you have any nasal allergies including hay fever?ARS: A positive answer to the question: In the past twelve months, did you have at least one episode of at least ten days with a blocked nose, discoloured nasal discharge and pain or pressure in the sinuses?CRS: A combination of two positive answers to the next questions (with at least a positive answer to either A or B):Has your nose been blocked for more than twelve weeks in the last twelve months?Have you had discoloured nasal discharge (snot) or discoloured mucus in the throat for more than twelve weeks in the last twelve months?Have you had pain or pressure around the forehead, nose or eyes for more than twelve weeks in the last twelve months?Has your sense of smell been reduced or absent for more than twelve weeks in the last twelve months?A doctor’s diagnosis of CRS: A positive answer to the question: Has a doctor ever told you that you have chronic sinusitis?Itchy rash: A positive answer to the question: Have you ever had an itchy rash that came and went for at least six months?Eczema: A positive answer to the question: Have you ever had eczema or any kind of skin allergy?Adverse response after taking painkillers: A positive answer to the question: Have you ever had any difficulty with your breathing within three hours after taking a painkiller?Active smoking: A positive answer to the questions: Have you ever smoked for as long as a year? AND Have you smoked at all in the last month?Asthma: A positive answer to the question: Have you ever had asthma? AND one of the following:Have you had wheezing or whistling in your chest at any time in the last twelve months?Have you woken up with a feeling of tightness in your chest at any time in the last twelve months?Have you been woken by an attack of shortness of breath at any time in the last twelve months?Have you been woken by an attack of coughing at any time in the last twelve months?Our institutional review board (ethics committee) decided that their approval was not needed to start this study because participants were not subject to any intervention.Statistical analyses were conducted with SPSS 21.0 statistical software.Univariate statistical analyses for all the different variables in each area were completed. The percentages were calculated using the frequencies and total available data for each area and variable . Significant differences between the areas were calculated using Chi-square or ANOVA  for each variable.Univariate analysis was then conducted for the three outcome variables ARS, CRS and AR using Pearson chi-square or t-test depending on binary or continuous data for each variable. The independent variables with a p-value of less than 0.20 in the univariate analysis were selected for multivariate analysis. Multivariate logistic regressions were fitted by using the backward elimination technique based on likelihood ratio to identify factors that affect ARS, CRS and AR separately. The association between independent variables was assessed using odds ratio (OR) and a 95% confidence interval (CI). Correlations were considered to be significant if the p-value was less than 0.05.Fifty percent (8347) of the 16700 questionnaires sent were returned .The mean age of the respondents was 46 years (range 6–90); 45% were male.A total of 2274 respondents met the criteria for ARS, of whom 841 also met the criteria for CRS. Those 841 patients were excluded from the ARS group since they will have answered ‘yes’ to this question given their CRS. The prevalence of ARS is therefore 18% (1433/8170). The prevalence of CRS was 16% (1281/8227). In total, 29% (2259/7804) of the respondents met the criteria for AR.All variables were compared for the different areas. AR, ARS, itchy rash, adverse response to painkillers, smoking (active and at least one year), occupation, ethnicity, CRS, asthma and age differed significantly between the areas.The risk of ARS was significantly higher in respondents with a doctor’s diagnosis of CRS (OR 2.14), AR (OR 1.70), itchy rash (OR 1.28) and eczema (OR 1.33), in female respondents (OR 1.39) or those with a history of smoking for at least one year (OR 1.22). Caucasians have a significantly higher risk of ARS than people of most other ethnicities in our survey. Getting older reduces the risk of ARS by an OR of 0.99 per year. The risk of CRS is significantly higher in respondents with a doctor’s diagnosis of CRS (OR 6.83), AR (OR 2.87), asthma , an adverse response after taking painkillers (OR 2.34), itchy rash (OR 1.71), or active smoking (OR 1.45). Caucasians were less likely to meet the criteria for CRS than people with some other ethnicities . CRS is also less likely in older patients. No significant relation was found with work/occupation, place of residence or gender.The risk of AR was significantly higher in respondents with an adverse response after taking a painkiller (OR 4.12), asthma (OR 3.24), CRS (OR 2.24) or a doctor’s diagnosis of CRS (OR 2.29), ARS (OR 1.74), eczema (OR 1.60), or itchy rash (OR 1.43). Active smokers were less likely to have AR (OR 0.74). Full-time housewives/househusbands were significantly less likely to have AR than respondents in employment (OR 0.46). Caucasians generally were less likely to have AR than African-Creoles, Latin-Americans and Hindustanis. Once again, the risk of AR declined with increasing age and no significant relation was found with gender or place of residence. We evaluated the risk factors for AR, ARS and CRS in an epidemiological study looking at three different locations in the Netherlands.2LEN questionnaire and so we were able to distinguish between ARS and CRS on the basis of symptoms reported by the patients and a possible doctor’s diagnosis of CRS.Most studies in the past have asked subjects whether they had ‘sinusitis’ (diagnosed by a doctor), often without distinguishing between ARS and CRS. –14 The pA doctor’s diagnosis of CRS and the diagnosis CRS based on symptoms are obviously related . But not all participants with symptom based CRS have a doctor’s diagnosis. They may be less care seeking or they may have less severe complaints. Also in the Dutch healthcare system, general practitioners are not always aware of the difference between acute and chronic rhinosinusitis., 16 Ther2LEN questionnaire, Tomassen et al. found that 62% of the subjects reporting CRS on the basis of symptoms also had objective abnormalities at endoscopy. [The strength of symptom based diagnosis of CRS is that participants that are not aware of their diagnosis can be found. We realise that we are not always able to distinguish perfectly between the different diseases: persistent AR and CRS, for example, are not always easy to separate on the basis of symptoms alone. However,doscopy.  A Koreandoscopy. .The strength of doctor’s diagnosed CRS is that a professional has combined symptoms and objective findings to make a diagnosis. However part of the patients will not visit their doctor and some doctors will not recognize CRS, leading to an underestimation of the prevalence of CRS.We have to keep in mind that there may be a participation bias. Individuals with nasal and sinus symptoms are more likely to respond to a questionnaire about these symptoms than individuals without these symptoms. Therefore the prevalence may be overestimated. The prevalence found in this study was slightly higher than reported for the Netherlands on the basis of the Ouderkerk data only (CRS 14.3%) and also confirms the relatively high prevalence of CRS in the Netherlands by comparison with the average in Europe (11%)  and the We also realise that some of the subjects reporting allergies tested negative in skin-prick testing and that others were not aware of the allergic basis for their complaints. In an Italian study, 79% of the participants reporting AR had either a positive skin prick test or at least one specific IgE measurement ≥ 0.35 kU/l.  Twenty-eThe associations found between AR, ARS, CRS and asthma and eczema concur with other studies evaluating the comorbidities of AR. , 25We found that Caucasians were less likely to have AR than most other ethnicities. In an English study in general practice, significantly fewer Southern Irish participants and significantly more West Indian women consulted a general practitioner for AR than the native British population.  By contrInterestingly, we found that full-time housewives/househusbands were significantly less likely to have AR than respondents with jobs. This is a new finding that could possibly be explained by occupational AR in the latter group. It is known that occupational exposure is related to upper airway disease. OccupatiOccupational status might reflect socioeconomic status and may be of influence on the prevalence of ARS, CRS and AR. In a recent study by Philpott factors such as occupation, highest academic qualification, rural/urban location, duration of residency, proximity to crops, postcode, annual income, ethnicity, household occupancy and social class were studied in relation to CRS. No significant differences were found after adjusting for age and sex.Hirsch used the history of receiving Medical Assistance as surrogate for socioeconomic status and found that this was associated with CRS.Kilty found that participants with an educational level of high school of less report higher sinus symptom scores than participants with post-secondary education. Their Lund MacKay score on CT however is not significantly different. This indConflicting results have been found in previous studies about the effect of smoking on AR. , 36–39 IIn our multivariate analysis, we did not find any association between place of residence and AR. However, several studies have found a link between living environment and nasal symptoms/AR. People living close to heavy traffic and in cities reported nasal symptoms more often. –42 It isThe present survey confirmed the findings in the literature indicating a significant correlation between asthma and CRS and AR, but not between asthma and ARS. –46 This The relation of an adverse response to painkillers and CRS  is not surprising because they often occur together with asthma as part of AERD (aspirin-exacerbated respiratory disease).Itchy rasWhen we look at the relation of urticaria with ARS and CRS in other studies, we found that chronic urticaria are often related to infections  in several studies.–50 PositIn this study, Caucasians tended to have a higher prevalence of ARS and a lower prevalence of chronic respiratory conditions as CRS and AR by comparison with other ethnicities. It is difficult to compare these data with previous studies because of differences in the definitions of race/ethnicity and rhinosinusitis (ARS and CRS were not studied separately elsewhere). Our data confirm an earlier study by Tan, in which the local population of Singapore had more CRS than the Caucasian population. The local population of Singapore consisted of Chinese , Malay , Indian  and other ethnicities .  A surveyWe found that women were more likely to have ARS, but not CRS. This concurs with the study by Hirsch.  Almost 1We found a positive link between smoking and CRS and ARS, confirming other studies. , 53, 54In conclusion, this study found new associations between different upper airway diseases and relevant factors. It is again clear that chronic upper airway diseases like AR and CRS are associated with other factors than acute diseases like ARS.More studies are required evaluating sensitisation and other objective signs of disease to further unravel these observations.S1 Appendix(PDF)Click here for additional data file.S1 Dataset(SAV)Click here for additional data file.


Recent studies indicate there is a bidirectional interaction between AR and PPARγ, with each receptor influencing the expression and/or activity of the other within prostatic tissues. In this review, we examine how AR and PPARγ each regulate the growth and development of normal prostatic epithelial cells and prostate cancers. We also discuss interactions between the AR and PPARγ signaling pathways and how those interactions may influence prostate biology. Nuclear receptors are a superfamily of ligand-activated transcription factors that play critical roles in the regulation of normal biological processes and several disease states. Of the nuclear receptors expressed within the prostate, the androgen receptor (AR) promotes the differentiation of prostatic epithelial cells and stimulates production of enzymes needed for liquefaction of semen. Multiple forms of AR also promote the growth of both early and late stage prostate cancers. As a result, drugs that target the AR signaling pathway are routinely used to treat patients with advanced forms of prostate cancer. Data also suggest that a second member of the nuclear receptor superfamily, the peroxisome proliferator activated receptor gamma (PPAR The prostate is an integral part of the male reproductive system. This walnut sized organ is located directly below the bladder and in front of the rectum, above the muscles of the pelvic floor. The prostate manufactures a fluid that contains large amounts of prostate-specific antigen (PSA), a kallikrein-like serine protease that degrades proteins to promote liquefaction of semen –3. It al BRCA1 and BRCA2 gene mutations [One of the primary diseases that affect the prostate is prostate cancer. When one considers only nonskin cancers, prostate cancer is the most common cancer detected within American men. According to the American Cancer Society, there will be 161,360 newly diagnosed cases of prostate cancer in the United States in 2017 . In addiutations , 6. In autations . Prostatutations , observautations .γ). Both AR and PPARγ are ligand-activated transcription factors that bind to hormone response elements in DNA and regulate transcription in order to control expression of gene products that regulate multiple cellular processes, such as cell proliferation, cell survival, and metabolism. AR binds and mediates the biological effects of androgens such as testosterone and dihydrotestosterone (DHT) [γ include polyunsaturated fatty acids and derivatives of arachidonic acid as well as synthetic compounds. PPARγ was initially identified as a receptor that regulates differentiation of adipocytes. However, PPARγ is also expressed within the prostate and appears to influence the activity of prostatic cells. This review will discuss our current understanding of the role of AR and PPARγ within the prostate and how interactions between these two signaling pathways can influence the growth and development of normal prostate as well as prostate cancer.The nuclear receptor superfamily consists of receptors that play critical roles not only in normal prostate development but also in prostate cancer. Two members of the nuclear receptor superfamily that regulate prostate growth and differentiation are the androgen receptor (AR)  and the ne (DHT) . LigandsMultiple forms of AR have been detected within humans. The first AR cDNA sequence to be characterized was initially reported in 1988 , 14. ThiThe AR-FL is expressed in many tissues including the prostate and testes . Within 567es, AR13, AR-V14, and AR8) have been detected in tumor samples from patients with castration-resistant prostate cancer. Some ARVs also appear to be expressed in normal prostate tissue and benign prostatic hyperplasia. However, in these tissues the relative amount of ARV mRNA and/or protein expression is lower than that of AR-FL [567es, not only heterodimerize with AR-FL but also form homodimers [567es appear to regulate unique target gene sets that are distinct from those regulated by AR-FL [In addition to the 110 kD AR-FL, shorter AR variants (ARVs) have been observed in humans. Most of these ARVs retain the NTD and DBD but lack the LBD, making them constitutively active . ARVs, wof AR-FL . In prosof AR-FL , 53, 54.of AR-FL , 50, 53.of AR-FL , 56. Furof AR-FL . It has of AR-FL . Howevermodimers . Therefoby AR-FL , 60.In early stage prostate cancer, the ligand-activated AR-FL appears to be the form of AR that primarily regulates tumor growth. Huggins and Hodges discovered in 1941 that androgens, the ligands that activate AR-FL, play a vital role in prostate cancer . These aγ is a ligand-activated transcription factor that has a domain structure similar to that of AR and other members of the nuclear hormone receptor superfamily. It possesses a highly conserved DBD, a ligand-independent activation domain in the NTD, a hinge region, and a LBD. The unliganded form of PPARγ normally resides in the cell nucleus bound to regions of DNA known as PPAR response elements (PPREs). In this inactive state, PPARγ is associated not only with the retinoid X receptor (RXR) but also with corepressor proteins that suppress the receptor's transcriptional activity. Ligand binding induces disassociation of corepressors from the PPARγ/RXR heterodimer complex and recruits proteins such as RNA polymerase II and the coactivator proteins steroid receptor coactivator-1 (SRC-1) and peroxisome proliferator activated receptor coactivator 1 alpha (PGC-1α) to modulate transcription of PPARγ target genes within the prostate [γ function [γ can also be sumoylated within its NTD at Lysine 33 and Lysine 77 and LBD at Lysine 367. Sumoylation of PPARγ at Lysine 33 and Lysine 77 appears to inhibit PPARγ's ability to induce gene expression, while sumoylation within the LBD at Lysine 367 is required ligand-induced transcriptional repression by this receptor [γ gene is located on chromosome 3  and gives rise to two major PPARγ isoforms (PPARγ1 and PPARγ2) by alternative splicing [γ isoforms are expressed in prostatic epithelial cells from normal tissue and prostate cancers [γ1 is the predominant isoform present in prostate tumors [PPARprostate . Phosphofunction . PPARγ creceptor –74. In hsplicing –77. The  cancers , 79. Furγ appears to play a critical role in growth and differentiation. Jiang et al. demonstrated that conditional knockout of PPARγ within mouse prostatic epithelial cells results in the development of low grade prostatic intraepithelial neoplasia (PIN), a lesion which is believed to be a precursor of prostate cancer [γ knockout mice was associated with decreased differentiation of the secretory luminal epithelium as well as an increase in autophagy and oxidative stress [γ appears to function as a tumor suppressor that controls cell survival and differentiation within normal prostate epithelium. However, in certain contexts the presence of PPARγ may actually promote tumor growth. Ahmad et al. used a transposon-based “sleeping beauty” screen to identify additional genes that can enhance the development of prostate tumors. In their study, increases in PPARγ expression coupled with loss of the PTEN tumor suppressor enhanced prostate tumorigenesis [γ in prostate cancer development may vary depending on the expression levels of other tumor suppressors and proteins that control tumor growth.In the normal prostate, PPARe cancer , 80. Furigenesis . Therefoγ mRNA and protein have been detected within human prostate tumor tissue sections and prostate cancer cell lines. However, conflicting data exist regarding the relative expression of PPARγ in normal/benign prostate versus prostate cancers. An analysis of normal and prostatic adenocarcinomas performed by Mueller et al. in 2000 suggested that normal prostate contains a higher amount of PPARγ than prostate cancers [γ mRNA and protein than normal prostate epithelial cells [γ mRNA and protein have been detected in castration-sensitive as well as castration-resistant prostate cancer cell lines  and 15(S)-hydroxyeicosatetraenoic acid (15S-HETE) reduce proliferation and inhibit cell cycle progression in LNCaP, PC-3, and/or DU145 cells [γ, for concentrations of 15S-HETE that suppressed PC-3 cell proliferation were also effective in inducing expression of PPARγ target genes [γ antagonist GW9662 did not alter the ability of 15dPGJ2 to reduce prostate cancer cell proliferation. It therefore appears that 15dPGJ2 regulates proliferation via a PPARγ-independent pathway [γ ligands include a class of drugs known as the thiazolidinediones (TZDs). The TZDs troglitazone, rosiglitazone, ciglitazone, and pioglitazone decrease in vitro and in vivo proliferation of castration-sensitive (LNCaP) and castration-resistant  human prostate cancer cell lines [κB, cyclin D1, and GSK-3β [γ-dependent and PPARγ-independent signaling pathways [Compounds that have been identified as ligands for PPAR45 cells , 85–87. et genes . However pathway . Synthetll lines , 88–91. ll lines . In addill lines . The antd GSK-3β –102. Furpathways , 88–90.γ isoforms within the normal prostate. In these experiments, the authors used prostatic epithelial cell lines to examine the effect of each PPARγ isoform on AR activity. Their results revealed that stable transfection of PPARγ1 into mouse prostatic epithelial cells lacking PPARγ (mPrE-γKO cells) reduced AR transcriptional activity. However, restoration of PPARγ2 to mPrE-γKO cells increased activation of AR by the ligand DHT [γ may influence the function of AR in normal prostatic epithelial cells in an isoform-specific manner.Studies performed by Strand et al. have provided the most information regarding the regulation of AR signaling by PPARgand DHT . Therefoγ ligands alters AR signaling. However, the effect of PPARγ ligands on AR activity appears to vary between AR-positive, castration-sensitive and AR-positive, castration-resistant human prostate cancer cells. Hisatake et al. performed luciferase-based reporter assays in the castration-sensitive, AR-FL positive LNCaP cells to measure the effect of TZDs on AR transactivation. The results from these experiments showed TZDs pioglitazone and troglitazone significantly reduced ligand-induced activation of AR in the LNCaP cell line. In their study troglitazone also inhibited DHT-induced increases in PSA protein, which is directly regulated by AR [γ. Instead, decreases in AR signaling that were stimulated by high micromolar concentrations of troglitazone (≥40 μM) appeared to be mediated by proteasomal degradation of the transcription factor Sp1 [γ dependent mechanism to stimulate AR activation in C4-2 cells. However, ciglitazone inhibits AR-mediated transcription and the expression of AR target genes in LNCaP cells via a PPARγ-independent signaling pathway [γ ligands on AR signaling only within AR-positive, castration-sensitive prostate cancer cells. One commonly used endogenous PPARγ ligand, 15dPGJ2, does reduce AR activation in LNCaP [2 to reduce AR signaling is not associated with PPARγ activation. Instead, it appears 15dPGJ2 blocks AR function by forming adducts with AR, inducing AR sumoylation, and disrupting AR structure [γ antagonist GW9662 also regulates AR signaling within AR-positive, castration-sensitive prostate cancers. Work done by Tew et al. revealed that GW9662 reduced DHT-mediated increases in PSA-luciferase activity in LNCaP cells [γ inhibitor, GW9662 has also been reported to regulate cell proliferation via a PPARγ-independent pathway [γ-dependent or PPARγ-independent pathway. However, these data do provide additional evidence that multiple types of PPARγ ligands can modulate AR signaling within prostate cancer cells.Multiple reports have shown that treatment of human prostate cancer cells with PPARed by AR . In a seed by AR . Within ctor Sp1 . Studies pathway . Althougin LNCaP , 107 andin LNCaP  prostatetructure . A recenaP cells . Althoug pathway . At presγ by the AR signaling pathway in normal prostatic tissues. However, recent data from our laboratory suggest that AR activation can suppress PPARγ expression and/or activity within human prostate cancers. The AR agonist DHT at nanomolar concentrations produced a significant decrease in PPARγ mRNA and protein levels within two AR-positive human prostate cancer cell lines: the castration-sensitive VCaP cells and castration-resistant C4-2 cell line  may be one coactivator that modulates interactions between AR and PPARγ. PGC-1α was originally identified in 1998 as a protein that interacts with the DBD and hinge region of PPARγ and enhances the ability of PPARγ to induce target gene expression [α may also function as an AR coactivator. Through luciferase-based reporter assays this group demonstrated that PGC-1α increased AR-mediated transcription. Furthermore, they showed siRNA-mediated knockdown of PGC-1α reduced LNCaP cell proliferation and lowered expression of the AR target gene PSA [α reduced proliferation of AR-positive prostate cancer cell lines, specifically LNCaP and VCaP cells. However, in their hands PGC-1α did not enhance AR-mediated transcription. Instead they found that androgens used an AMPK-dependent signaling pathway to increase PGC-1α levels in prostate cancer cells [α is expressed in castration-sensitive and castration-resistant prostate cancer cell lines [α levels are elevated in a subset of human prostate tumors [α needs to be further clarified, it is clear that AR signaling and PGC1α are linked. Therefore, AR-PGC-1α crosstalk may compromise PPARγ function within prostate cancers. The transcriptional activity of PPARγ and AR is also enhanced by two members of the p160 family of coactivators, SRC-1 and TIF-2 [γ signaling pathways.The transcriptional activity of AR and PPARpression . Howevergene PSA . Subsequer cells . PGC-1α ll lines , 120. Innd TIF-2 –124. Thend TIF-2 , 126. Itγ agonists control AR function. Cyclin D1 (CD1) is a corepressor that inhibits ligand-induced activation of AR by physically interacting with the receptor's N terminus region within the nucleus of the cell [γ interactions. AR-mediated transcription can also be reduced by a second protein known as nuclear corepressor (NCoR) [γ activation within adipocytes by promoting phosphorylation of PPARγ at Ser 273 [γ transcriptional activity and reduces the effects of PPARγ agonists in PC-3 cells [γ ligands regulate NCoR expression or activity within prostate cancer cells. However, it is possible that activation of either receptor alters the availability of NCoR and other corepressors. This would increase the pool of corepressors that can suppress AR- or PPARγ-mediated transcription and ultimately result in a net decrease in receptor function.Regulation of corepressor levels appears to be one way PPARthe cell , 128. Ththe cell , 128. Wethe cell . CD1 mayr (NCoR) , 130. NC Ser 273 . NCoR al-3 cells . It is nγ signaling pathways can also be influenced by the amount of each receptor present within human prostate cancer cells. One group of molecules that are known to modulate AR and PPARγ protein levels via a posttranscriptional mechanism are microRNAs (miRNAs). miRNAs represent small noncoding RNA that regulate target mRNA expression by suppression of their translation and/or selective cleavage. Due to these activities, miRNAs can modulate protein expression and alter signaling pathways that control cell functions shifting cells toward cell proliferation, differentiation, and/or apoptosis. Multiple miRNAs, such as miR-27a, miR-27b, miR-130, miR-302, and miR-34, have been reported to suppress PPARγ levels [γ expression in C4-2 cells (data not shown). Additional studies are required to determine whether DHT-stimulated increases in miR-27a and/or miR-27b contribute to the DHT-mediated reductions in PPARγ mRNA within prostate cancer cell lines. Like PPARγ, AR levels can also be controlled within normal and diseased tissues by miRNAs. Work by Östling et al. suggests over 70 different miRNAs can modulate expression of AR within human prostate cancer cells [γ agonists within prostate cancer cells. However, it is possible that ligand-induced changes in expression of miRNAs that control the net amount of each receptor or its associated coregulators could influence the extent of AR-PPARγ interactions within normal prostate and prostate cancers.Crosstalk between the AR and PPARγ levels –137. Of γ levels . Furtherer cells . At presγ have each been recognized as a receptor that regulates prostate growth and differentiation. Studies performed by our laboratory and others strongly suggest that interactions between the AR and PPARγ signaling pathways may also influence prostate biology. On one hand, PPARγ ligands can either suppress or enhance the transcriptional activity of AR. In the normal prostate, the net effect of PPARγ on AR signaling is determined in part by the PPARγ isoform that is expressed within prostatic epithelial cells. In prostate cancers, the ability of PPARγ to regulate AR function varies depending on the ability of tumors to respond to castration. While PPARγ ligands suppress AR activation in AR-positive, castration-sensitive prostate cancers via mechanisms that are independent of PPARγ, ligand-induced activation of PPARγ increases AR signaling in AR-positive, castration-resistant prostate cancer cells. On the other hand, activation of AR reduces PPARγ levels and activity within human prostate cancers. This suggests that any reduction in AR signaling would increase the amount of functional PPARγ and enhance the antitumor effects of PPARγ within prostate cancers. Interactions between the AR and PPARγ signaling pathways are clinically relevant in light of the fact that AR ligands are used to treat hormone imbalances and various diseases of the prostate. AR antagonists and compounds that indirectly reduce AR function by altering the level of circulating androgens are routinely used to treat early and late stage prostate cancer as well as a second prostatic disease, benign prostatic hyperplasia. Injections of the AR agonist testosterone are used to treat male patients with delayed puberty or impotence. The PPARγ agonists rosiglitazone and pioglitazone were routinely prescribed for the treatment of type II diabetes during the early to mid-2000s. However, worldwide clinical use of these drugs in recent years has been curtailed due to concerns regarding drug safety. Rosiglitazone was pulled from the European market in 2010 and is now used rarely in the United States due to reports that rosiglitazone enhances the risk of cardiovascular events. Use of the PPARγ agonist pioglitazone has been also suspended in France and Germany due to concerns it may increase one's risk of bladder cancer. However, pioglitazone is still prescribed in the United States as a treatment for type II diabetes in patients without risk factors or a history of bladder cancer. It is therefore possible that AR expression and function are altered within the prostates of diabetic patients taking rosiglitazone or pioglitazone to manage their disease. As new AR and PPARγ ligands are developed for clinical use, we will need to consider how each compound influences the activity of both AR and PPARγ. In conclusion, the research published to date clearly indicates there is bidirectional crosstalk between the PPARγ and AR signaling pathways in human prostate. Additional studies should be conducted to fully understand the significance of this crosstalk in the biology of the normal prostate and other prostatic diseases.AR and PPAR


This study investigates the role of donor heart β2 as outcome parameter for maximal exercise in HTx recipients ≥9 months and ≤4 years post-transplant . Donor hearts were genotyped for polymorphisms of the β1-AR  and the β2-AR . Circumferential shortening of the left ventricle was measured using magnetic resonance based CSPAMM tagging.CPET measured peak VO2 was higher in donor hearts expressing the β1-Ser49Ser alleles when compared with β1-Gly49 carriers , and by trend in cardiac allografts with the β1-AR Gly389Gly vs. β1-Arg389 . Peak VO2 was highest for the haplotype Ser49Ser-Gly389, and decreased progressively for Ser49Ser-Arg389Arg > 49Gly-389Gly > 49Gly-Arg389Arg . Peak VO2 was not different for the tested β2-AR polymorphisms. Independent predictors of peak VO2 (adjusted R2 = 0.55) were β1-AR Ser49Gly SNP (p = 0.005), heart rate increase (p = 0.016), and peak systolic blood pressure (p = 0.031). Left ventricular (LV) motion kinetics as measured by cardiac MRI CSPAMM tagging at rest was not different between carriers and non-carriers of the β1-AR Gly49allele.Peak VO1-AR Gly49 or β1-Ser49Ser variant suggests exercise-induced desensitization and down-regulation of the β1-AR Gly49 variant as relevant pathomechanism for reduced peak VO2 in β1-AR Gly49 carriers.Similar LV cardiac motion kinetics at rest in donor hearts carrying either β Recipieansplant  suggesti1- and β2-adrenergic receptor (AR) subtypes [1-AR Ser49Gly, β1-AR Arg389Gly, β2-AR Arg16Gly, β2-AR Gln27Glu, and β2-AR Thr164Ile show distinct cardiovascular responses to sympathetic activation [Human cardiomyocytes predominantly express the βsubtypes  which pltivation –8. Howevtivation , 11 and tivation , 13. We 2 measured by cardiopulmonary exercise testing. Peak heart rate and systolic blood pressure are variables that determine maximal exercise capacity after HTx [2c-AR Del 322–325 variant, which strengthens activation of the adrenal gland chromaffin cell [The outcome parameter of this correlational study was peak VOfter HTx . Both vafin cell  with subfin cell .This study complies with the Declaration of Helsinki and was approved by the ethical committee of the canton de Vaud. Written informed consent was obtained from all patients. This is a substudy of the prospective epidemiological cohort study following solid organ transplant recipients in Switzerland . Inclusion criteria were stable adult HT recipients ≥9 months and <4 years post-transplant with a maximal cardiopulmonary exercise test (CPET) as defined by the achievement of a respiratory exchange ratio (RER) >1.1 . ExclusiDemographic and clinical data at CPET were collected from electronic charts. Standard laboratory tests included sodium, potassium, creatinine, hemoglobin, and brain natriuretic peptide (BNP) level.2, VO2AT (VO2 at anaerobic threshold), VE/VCO2 (ventilatory efficiency), ventilatory reserve and RER. Maximal exercise capacity was determined by the highest VO2 achieved during the last 30 seconds of maximal exercise. Heart rate, blood pressure, and 12-lead ECG were continuously recorded throughout exercise and recovery.All patients underwent maximal CPET. Patients were tested using an electrically braked cycloergometer  with individualized ramp protocol. Respiratory gas exchange was measured breath-by-breath with determination of peak VO1−49 genotype on LV function. All patients were scanned with a prototype slice followed balanced Steady State Free Precession (bSSFP) CSPAMM  tagging technique [1−49 genotypes groups (see above) unpaired Student’s t-tests corrected for samples of different sizes were used.Patients underwent cardiovascular magnetic resonance imaging in order to study the influence of the βechnique , 19. Allechnique , in the echnique  using a 1-AR Ser49Gly, rs1801253 for β1-AR Arg389Gly, rs1042713 for β2-AR Arg16Gly, rs1042714 for β2-AR Gln27Glu and rs1800888 for β2-AR Thr164Ile. Genotype assignments were obtained by fluorescence measurement using an ABI Prism 7500 Sequence Detection System with its allelic discrimination software (Life Technologies®).Donor genomic DNA was extracted from paraffin-embedded endomyocardial biopsy specimen using Purelink genomic DNA kit (Invitrogen®). Extracted leucocyte DNA provided by the STCS biobank was used for recipient genomic DNA analysis. Detection of AR polymorphism used Taq-Man single-nucleotide polymorphism genotyping assays (Life Technologies®). SNP ID were: rs1801252 for β2C-AR polymorphism was examined after amplification of recipient genomic DNA by PCR. Primers for PCR were: 5’-ACGTGGAGCCGGACGAGA-3’ (sense) and 5’-GTTCTTCCTGTCGCGCCG-3’ (antisense). The PCR consisted of 5 ng of genomic DNA, 1 pmol of each primer, 0.2 mM dNTPs, 1 unit of Gotaq DNA polymerase (Promega®), 4 μl of 5X GoTaq buffer and 5% DMSO in a 20 μl reaction volume. Reactions were started by an initial incubation at 94°C for 4 min, followed by 35 cycles of 94°C for 30 s, 65°C for 30 s, and 72°C for 30 s, followed by a final extension at 72°C for 10 min. PCR products were digested with HaeIII (Life Technologies®) at 37°C for one hour since α2C Del322-325 results in the loss of one of four HaeIII restriction sites in α2C.α2 with demographic and clinical parameters, or AR SNPs was tested using univariate regression analysis with peak VO2 as the dependent variable. Peak VO2 was expressed as the percentage of the predicted value (% predicted), which is already adjusted for age, BMI and gender [1−49 genotype was considered as Gly carriers when homozygous or heterozygous, in accordance with the literature [2 of each AR genotype suggested a dominant and a recessive model for the β1−389 and the β2 genes, respectively. Thus, β1−389 genotype was considered as homozygous Arg389Arg or Gly389 carriers; β2 genotype was considered homozygous Arg16Arg or Gly16 carriers and homozygous Glu27Glu or Gln27 carriers; and α2C genotype was considered as homozygous WT or carriers of the deletion 322–325. Because of the low number of patients carrying the β2 Ile164 variant (n = 2/41), this SNP did not enter into the final analysis.Allele frequencies were computed by standard gene-counting methods. Association of peak VOd gender . Thus, tterature , 23. Thep-value <0.05 was considered as statistically significant.Secondary clinical variables included continuous and categorical clinical variables. Categorical variables were defined as non-treated or treated by a certain drug. Cut-off for BNP and N-terminal propeptide BNP (NT-proBNP) levels were 100 ng/l and 300 ng/l, respectively, in accordance with the heart failure guidelines of the European Society of Cardiology. Continuous clinical data were expressed as mean±S.D.; a p<0.10 was performed to estimate the association between explanatory variables and peak VO2. Association of a β-AR genotype with peak VO2 was considered statistically significant when p was <0.0125 since 4 β-AR SNPs entered the final analysis.Multivariable logistic regression using backward analysis of parameters correlating with A total of 59 HTx recipients was screened; 18 patients met the following exclusion criteria: consent refusal (n = 2), age <18 years (n = 2), CPET not performed (n = 12), endomyocardial biopsy obtained late after CPET (n = 1), ≥moderate severity of comorbidity (n = 1).Echocardiographic left and right ventricular systolic function indices were in the lower normal range . Mean lateral E/E’ ratio was 8.3± 3.0. The mean creatinine level was increased (139±42 μmol/l), the estimated glomerular filtration rate (eGFR) using the CKD-EPI (Chronic Kidney Disease Epidemiology Collaboration) was 60±28 ml/min; 55% of the patients presented an eGFR ≤60 ml/min. Mean hemoglobin level was 125±19 g/l; levels of BNP or NT-proBNP were increased in 49% of study patients.All patients were on immunosuppressive drugs. Cardiovascular medications at the time of cardiopulmonary exercise testing included diuretics (41%), β-blockers (metoprolol) (32%) and calcium channel blockers (amlodipine) (22%).No study patient had histological signs of acute rejection in the endomyocardial biopsy obtained before CPET.2 was 17.1±6.2 ml/kg/min corresponding to 57.0±14.8% of the predicted value adjusted for age, BMI and gender; the mean peak power output was 107±51 Watts. VO2AT was 12.0±4.1 ml/kg/min corresponding to 41±12% of the predicted value of AT. Ventilatory efficiency (measured by the VE/VCO2 slope) was 33.2±5.7; peak ventilatory reserve was 43±16%. The RER was 1.27±0.14 at maximal exercise level.CPET parameters are shown in Resting heart rate (HR) was 93±13 beats per minute (bpm), peak HR was 126±22 bpm, chronotropic reserve (ΔHR) was 33±16 bpm. Chronotropic incompetence, defined as failure to achieve 85% of the age-predicted maximal HR [Frequency of β-AR variants in donor hearts of study patients matched with β-AR variant distribution in the European population  8, 25–2–225–29.2 as a function of β-AR variant expression in the allograft. Patients with grafts carrying the β1-AR Gly49 allele had a significantly lower predicted percentage of peak VO2 when compared to homozygotes Ser49Ser . β1-AR Gly49 carriers had also more chronotropic incompetence than Ser49Ser group even if this was not significant  . Polymorphism of β2-AR 16 in the donor heart did not affect peak VO2 (p = 0.947), whereas peak VO2 was by trend lower in β2-AR Glu27Glu patients when compared to Gln27 carriers . α2C polymorphism did not interact with peak VO2 (p = 0.347), chronotropic reserve (p = 0.729), systolic (p = 0.971) or diastolic BP (p = 0.967) (= 0.327) . There w= 0.967) .2 adjusted for recipient age, BMI and gender with chronotropic reserve , HR recovery , peak systolic blood pressure (BP)  and Δsystolic BP . Furthermore, peak VO2 was reduced with renal dysfunction (eGFR ≤60 ml/min) , increased BNP or NT-proBNP levels , or reduced hemoglobin concentration . Peak VO2 was reduced with diuretic therapy   . None of1-AR Gly49 variant of the donor heart (p = 0.005), along with ΔHR (p = 0.016) and peak systolic BP (p = 0.031) were independently associated with peak VO2 (adjusted R2 = 0.55)  . The β1-2 was not different by ANOVA between the haplotypes of β1-49Gly+β1-Arg389Arg, β1-49Gly+β1-389Gly, β1-Ser49Ser+β1-Arg389Arg, β1-Ser49Ser+β1-389Gly. Nevertheless, peak VO2 correlated with the different haplotypes fitting to a linear regression  with lowest mean peak VO2 values for β1-49Gly+β1-Arg389Arg and β1-49Gly+β1-389Gly  when adjusted for other modalities affecting peak VO2 .Peak VO1-389Gly . This co1-AR Gly49 variant (n = 4) and patients with the β1-AR Ser49Ser variant (n = 5). Groups were without significant difference at any time of the cardiac cycle as assessed at the time point of largest difference .Nine patients  were scanned. Circumferential strain measurements were obtained as described above; one slice with artifact was not included in the analysis (n = 1/27 slices). Patients were grouped into carriers of the β2, the present study adds to the pathophysiological understanding of limited maximal exercise capacity in HTx recipients with normal left ventricular function at rest.By showing that β-adrenergic receptor polymorphism in the donor heart is a determinant of peak VO2c-AR affects maximal exercise capacity after orthotopic HTx was tested in a prospective cohort study design including consecutive patients. HTx recipients were not included when transplanted less than 9 months ago because maximal exercise capacity increases after transplantation reaching a plateau only after the first 9 postoperative months [2 adjusted for age, BMI, and gender as well as hemoglobin and creatinine levels are similar to characteristics reported for HTx recipients >1 year post-transplant in other exercise studies [2, and, chronotropic reserve remained predictive for peak VO2 even when β-blocker treatment was forced into the predictive model. Furthermore, Doesch et al. reported unchanged peak VO2 in their exercise study, which assessed HTx recipients before and during high β-blocker treatment (mean metoprolol dose: 147±53 mg/d) [The hypothesis that polymorphism of the donor heart β-AR or the recipient αe months –32. In ae months . Becausee months –32, 34. e months –32, 34.  studies , 32. How studies , 32, 35.53 mg/d) . Altoget2c-adrenoceptor did not interact with peak VO2, chronotropic reserve, systolic or diastolic BP suggesting that the minor allele is not associated with a distinct exercise-associated phenotype in HTx recipients. This interpretation is in accordance with the absence of a distinct phenotype of the minor allele in populations with other cardiovascular disease [In this study, the deletion variation of the α disease  but has  disease , 27.1- or β2-AR alleles correspond to respective reports from the California Donor Transplant Network [Sα expression [1-49Gly and the β1-Arg389 variants exhibit greater agonist-promoted desensitization when exposed to saturating catecholamine concentrations while the β1-Ser49 variant is resistant to agonist-promoted downregulation [1-Gly49/Arg389Arg shows more rapid agonist-promoted receptor down-regulation and desensitization in vitro when compared with other haplotypes [1-Ser49Ser variant was associated with significantly higher peak VO2 values when compared with the β1-AR Gly49 variant while there was no significant correlation with the β1-AR Arg389 or the various β2-AR variants tested. Moreover, the donor heart Ser49Ser+Gly389Gly haplotype was related with the highest peak VO2 levels while peak VO2 decreased progressively for the haplotypes Ser49Ser+Arg389Arg > 49Gly+389Gly > 49Gly+Arg389Arg. We thus identified β1-AR polymorphism at position 49 and the haplotype combination of β1-AR49 + β1-AR389 polymorphisms as independent predictors of exercise performance after orthotopic HTx.Frequencies of the donor heart β Network  and the  Network –29 suggepression  but thispression . Therefogulation , 40, 41.plotypes . In the 2 values in carriers of either β1-AR 49Gly or β1-AR 389Arg variant, or the haplotype 49Gly/389Arg [2, circumferential cardiac fiber shortening kinetics at rest, and chronotropic reserve were not different between carriers of the β1-AR Gly49 and β1-AR Ser49 variant suggesting that the lower peak VO2 in β1-AR 49Gly carriers should relate to a relative decrease of myocardial contractility at peak exercise. This conclusion is compatible with the substantial down-regulation of β1-AR 49Gly membrane expression shown for cells exposed to high catecholamine levels (27). The β1-AR Ser49 variant, however, seems to maintain agonist promoted stimulation of myocardial contractility during peak in the HTx recipient because of its resistance to agonist-promoted downregulation (27). Finally, physiological studies in HTx recipients have shown the important role of the β2-AR for heart rate , which can explain why β1-AR Gly49Ser variants impact on myocardial contractility at peak exercise without affecting peak heart rate.Studies in patients with coronary artery disease or heart failure, however, have shown higher peak VOy/389Arg , 44. The1-AR Gly49 variant, direct proof is missing. However, proof of β-AR down-regulation with peak exercise in vivo or measurement of circumferential shortening at maximal exercise in the cardiac MRI is not feasible. Quantification of circumferential cardiac kinetics by echocardiography may be an alternative but may miss differences due to larger standard deviation.This study collective includes only a small number of patients. However, demographic and clinical characteristics of the study population as well as distribution of allele frequencies are in accordance with reports from other populations. Despite of the fact that this study provides solid indirect evidence suggesting that exercise induces desensitization and down-regulation of the β2 is reduced in HTx recipients carrying a donor heart expressing the β1-AR 49Gly variant. The results of the present study suggest that HTx recipients carrying this polymorphism in their donor heart should benefit from high-dose β1-AR blockade.Reduced exercise capacity remains a concern after HTx because more recent advance in immunosuppression permits long survival, which is why quality of life aspects such as daily physical activity gain importance. This study demonstrates that maximal exercise capacity as measured by peak VOS1 Fig2 was plotted according to exercise modality, BNP or NT-proBNP levels, treatment by diuretics, peak HR, chronotropic reserve (ΔHR) or HR recovery at 1 min, peak or Δsystolic BP (peak or delta systolic BP), hemoglobin levels, creatinine blood levels and the glomerular filtration rate estimated (eGFR) using the CKD-EPI formula adjusted for weight. Box graphs represent median, upper/lower quartiles and maximum/minimum values. Mean ± S.D of peak VO2 with r2 and p value are shown on top of each box. Linear regression curves are represented in blue.Changes in peak VO(TIF)Click here for additional data file.S1 TableLVEF = left ventricular ejection fraction, LVMI = left ventricular mass index, TAPSE = tricuspid annular plane systolic excursion, eGFR = estimated glomerular filtration rate; BNP = brain natriuretic peptide; NT-proBNP = N-terminal pro-brain natriuretic peptide; ACE-I = angiotensin converting enzyme-inhibitor; ARB = angiotensin II receptor blocker type 1.(TIF)Click here for additional data file.S2 TableAT = anaerobic threshold; RER = respiratory exchange ratio; HR = heart rate; BP = blood pressure; ΔBP = Peak BP- resting BP(TIF)Click here for additional data file.S3 TableLVEF = left ventricular ejection fraction, LVMI = left ventricular mass index, TAPSE = tricuspid annular plane systolic excursion, eGFR = estimated glomerular filtration rate; BNP = brain natriuretic peptide; NT-proBNP = N-terminal pro-brain natriuretic peptide; ACE-I = angiotensin converting enzyme-inhibitor; ARB = angiotensin II receptor blocker type 1. AT = anaerobic threshold; RER = respiratory exchange ratio; HR = heart rate; BP = blood pressure.(TIF)Click here for additional data file.S4 Table= left ventricular ejection fraction, LVMI = left ventricular mass index, TAPSE = tricuspid annular plane systolic excursion; HR = heart rate; ΔHR = Peak HR—resting HR; BP = Blood Pressure; ΔBP = Peak BP- resting BP; eGFR = estimated glomerular filtration rate; BNP = brain natriuretic peptide; NT-proBNP = N-terminal pro-brain natriuretic peptide; ACE-I = angiotensin converting enzyme-inhibitor; ARB = angiotensin II receptor blocker type 1.LVEF (TIF)Click here for additional data file.


The aim of this study was to reveal the pathogenesis of aortic stenosis (AS) and regurgitation (AR) by comparing differences in mechanical and biochemical alterations. We applied scanning acoustic microscopy (SAM) to measure the speed of sound (SOS) through valves to estimate the elasticity and monitor sensitivity to protease treatment, as the SOS is correlated with the stiffness of materials, which is reduced after digestion by proteases. The fibrosa of both the AS and AR groups were stiffer than the fibrosa of the normal group. The AR group displayed significantly stiffer fibrosa than the AS group, with the exception of calcified areas. The AS group showed significantly decreased SOS values following protease digestion, whereas the AR showed little reduction. The AS group presented type III collagen in the fibrosa and the ventricularis. In the AR group, both type I collagen and type III collagen coexisted in the fibrosa and the ventricularis. Upon immunostaining for advanced glycation end-products, the AS group showed sparse, weak staining, whereas the AR group presented a strong, band-like positive reaction in the fibrosa. In conclusion, tissue remodelling associated with damage and repair is associated with AS pathogenesis, whereas static chemical alterations with slow collagen turnover induce AR. During an average human life span, heart valves open and close approximately 3 billion times and withstand various mechanical stresses, including fluid shear stress and stretch bending. Aortic valves (AVs) are composed of living tissues and hold the ability to repair and remodel in response to damage. However, structural changes in AVs due to ageing can be accompanied by biochemical and functional alterations, causing aortic stenosis (AS)  or aortiResected AVs from elderly patients undergoing AV replacement surgery often show the following two distinct morphological characteristics: (1) thickened leaflets with nodular calcification and (2) transparent thin leaflets with rare calcification. The former corresponds to valves typical of AS, and the latter corresponds to valves typical of AR. The aim of this study was to reveal the pathogenesis of AS and AR by comparing differences in mechanical and biochemical alterations.Investigations of the morphological and functional changes that occur in AVs during ageing require basic histological and biological knowledge. AVs consist of three distinct layers, the fibrosa, spongiosa, and ventricularis, which are composed of extracellular matrix that is rich in collagen, proteoglycans, and elastin. The elastic fibres of the ventricularis on the flow side of the valves are radially aligned and elastic. They extend when the valves open and recoil when the valves close. Proteoglycans in the middle layer, or the spongiosa, function as cushions for absorbing tension and friction. The fibrosa contains circumferentially oriented type I and type III fibrillary collagen fibres, which confer stiffness and strength to the valves , 4.c is the SOS (m/s), K is the elastic bulk modulus (N/m2), and ρ is the density (kg/m3). Thus, the SOS increases with the stiffness (the resistance of an elastic body to deformation by an applied force) of the material, whereas it decreases with the density. Excluding bones (1.750 g/cm3) and fats (0.9094 g/cm3), the average soft tissue density is approximately 1 g/cm3 [Scanning acoustic microscopy (SAM) can be performed to calculate the speed of sound (SOS) through tissues, and plotting these data sets allows users to create images of the tissue under examination , 6. The  bones 1.50 g/cm3 We previously reported soft tissue elasticity –13, whicIn this study, we used formalin-fixed, paraffin-embedded (FFPE) sections of AVs of elderly patients, including those exhibiting normal and diseased AR or AS, to evaluate differences in mechanical and biochemical alterations.μm and 10 μm were used for light microscopy (LM) and SAM examinations, respectively. For LM, sections were observed with haematoxylin-eosin and elastica Van Gieson (EVG) staining to distinguish elastin fibres from collagen fibres.AV leaflets were obtained from surgical specimens of elderly patients undergoing AV replacement for AS or AR . As contAll human sections were acquired from the Hamamatsu University Hospital archives. This research protocol, using stored samples without a link with patient identities, was approved by the Ethics Committee of the Hamamatsu University School of Medicine. Informed consent was obtained from all living patients or the families of the deceased for autopsy cases. The methods were carried out in accordance with the approved guidelines.To calculate the average AV leaflet thickness, the width of the middle third portion of each leaflet without calcified nodules was measured using the LM sections. To calculate the average thickness of the fibrosa, the width of the fibrosa was measured at a minimum of 6 points in the midportion of the leaflet without calcified nodules using the EVG-stained slide.2 or 1.2 × 1.2 mm2 was measured via X-Y scanning. The SOS measurements of 300 × 300 points in each scan were plotted to construct images [The microscope used for SAM AMS-50SI) was supplied by Honda Electronics  and was equipped with a 400-MHz transducer . A single pulsed wave was used. The SOS within 2.4 × 2.4 mmt images . Because0SI was sμm. Unstained flat 10 μm sections were used for scanning. A detailed explanation of the methods is available in the supplemental information .The resolution of the 400-MHz transducer was approximately 3.75 2 at pH 7.4) or pepsin  solutions at 37°C for 1 or 3 h, respectively. The same sections were used for repeated digestion. After digestion, the sections were washed in distilled water and observed via SAM.Deparaffinized sections were soaked in collagenase  , and (5) anti-LOX . Heat-mediated antigen retrieval  was performed for the sections with either pH 6.0  or pH 9.0  buffer prior to IHC staining.IHC studies were performed using a commercially available ChemMate Envision kit . The primary antibodies used to detect collagen types, advanced glycation end-products (AGEs), and LOX were as follows: (1) anticollagen I , (2) anticollagen III , (3) anti-AGE , (4) anti-NP < 0.05 considered statistically significant.Prior to the statistical tests mentioned below, we confirmed the normal distribution using a test for the difference between means. One-way ANOVA was used to evaluate the thickness of AVs, the thickness of fibrosa, the SOS through fibrosa, and the SOS after protease digestion. Significant differences were evaluated based on multiple comparisons using Tukey-Kramer's test, with P < 0.05) than the AR group  than the normal group. The AR group presented higher values (P < 0.01) compared with the AS and normal groups. High SOS values were observed for calcified nodules in valves from AS cases, although the other areas, including atherosclerosis or lipid deposition portions, exhibited variable lower values. The SOS of the fibrosa in AR showed homogenously higher values (P < 0.01) for the collagen fibres  3 h after collagenase digestion compared with the SOS values at 0 h  compared with those at 0 h  only at 3 h after digestion. The AS group exhibited more susceptibility to protease digestion than the AR group.The SOS values of the fibrosa of the AS and AR groups were significantly decreased  of proteins primarily takes place at o groups . Amadorio groups . Glycatio groups . Accordio groups , 23. Theo groups .Recent data suggests that calcific AV disease is an active cellular process that develops within valve leaflets , 26. MecTo date, there is little information regarding the mechanical properties of diseased AVs due to the need of relatively large tissue samples for standard mechanical test methods . Atomic The total valve elasticity depends on the SOS values of the three layers in addition to the ratio and connection of these layers. In thick AS valves with calcification, the fibrosa occupies almost half of the total valve thickness. In contrast, in thin AR valves without calcification, the fibrosa occupies only one-third of the entire thickness. The borders among the layers are indistinct in AS but distinct in AR. The width of the spongiosa in AS is variable due to the infiltration of collagen or elastic fibres, whereas that in AR is constantly maintained. Proteoglycans in the spongiosa function as a cushion for absorbing tension and friction. Thus, the total properties of elasticity are stiff in AS and elastic in AR.Regarding the examined samples, we used routine formalin-fixed, paraffin-embedded (FFPE) tissues for this study. Compared with unfixed tissues, formalin fixation induces tissue stiffness due to cross-links among proteins, which is detected by increased SOS values . In our In conclusion, we showed that AS and AR valves have distinct structural differences related to the ageing process. AS valves display tissue remodelling upon damage and repair, whereas AR valves exhibit static chemical alterations due to ageing with slow collagen turnover. This study using both SAM and immunohistochemical methods revealed correlations between biomechanical and biochemical alterations that provides a novel tool for studying mechanism(s) associated with AV diseases.Supplemental Methods S1 Observation method by scanning acoustic microscopy (SAM) was explained.


The androgen receptor (AR), a ligand activated transcription factor plays a number of roles in reproduction, homeostasis and pathogenesis of disease. It has two major polymorphic sequences; a polyglutamine and a polyglycine repeat that determine the length of the protein and influence receptor folding, structure and function. Here, we review the role the folding of the AR plays in the pathogenesis of spinal-bulbar muscular atrophy (SBMA), a neuromuscular degenerative disease arising from expansion of the polyglutamine repeat. We discuss current management for SBMA patients and how research on AR structure function may lead to future drug treatments. The androgen receptor  is a 110 kDa protein and belongs to the ligand activated nuclear receptor superfamily. The AR is widely expressed in the body with high levels in the epididymis, prostate and skeletal muscles. The principal endogenous ligands of the AR are testosterone and its more potent analog dihydrotestosterone (DHT), both of which control phenotypic male sexual development, maintenance of bone mass and musculoskeletal development. Aside from its role in various physiological and homeostatic processes, the AR has also been directly implicated in a number of diseases such as hypogonadism, androgen insensitive syndrome (AIS), benign prostatic hyperplasia (BPH), initiation and progression of prostate cancer, spinal-bulbar muscular atrophy (SBMA), as well as male pattern baldness and osteoporosis . Ho. Ho22]. Changes in the content of the secondary structure and folding of the NTD are modulated by the length of the poly-Q repeat. Circular dichroism analysis of the AR-NTD revealed a dynamic picture of secondary structure content depending on the presence and length of the poly-Q repeat. The AR-NTD cloned from the genomic DNA of a patient with Kennedy's disease, with Q45, showed a modest increase in α-helix and decrease in β-structures . SignifiStructural analysis of the poly-Q repeat in the NTD of the Huntingtin protein (Htt), responsible for Huntington's disease, similarly demonstrate the plasticity in protein conformation and the importance of flanking sequences for the folding, misfolding and secondary structure content of the poly-Q repeat. For example, the C-terminal flanking polyproline sequence promoted a polyproline type II-like helix and inhibited β-sheet structure in the poly-Q repeat; leading to the conclusion that the flanking sequence influenced the ‘threshold’ at which aggregation could occur  while anBased on extensive biochemical, cellular and animal studies it has been suggested that poly-Q repeat diseases share a similar mechanism of pathogenesis, which involves the expanded poly-Q tracts acquiring a nonnative conformation, which then aggregate and form inclusions. Aside from poly-Q expanded AR, inclusions contain chaperone and co-regulatory proteins and components of the ubiquitin–proteasome system which possibly attempt to refold or degrade mutant proteins  30]. Ho. Ho30]. As testosterone plays a critical role in the regulation of AR action, this hormone has been implicated in pathogenesis of SBMA. Chevalier-Larsen and colleagues observed that transgenic male mouse models of SBMA developed more severe motor dysfunction and presented with an earlier disease onset than females. Castrated symptomatic mice also showed an improved phenotype over time . Heterozkhan sh, watt k, kumar r, mcewan ij, unpublished data]. Therefore, trehalose may act at different steps, including protein folding, to reduce AR toxicity , which stabilizes the receptor facilitated hormone binding and recruitment of coregulators. Genetic mutation of this motif and the use of ligands, such as the antiandrogen bicalutamide and selective androgen receptor modulators  , that prLigand dependent and independent post translational modifications of the AR have been shown to play a role in neurotoxicity. Phosphorylation of the AR has been shown to be dependent on poly-Q length, where an expanded repeat induces a conformational change that activates the MEK-1/2 pathway and enhances serine phosphorylation of mutant AR. Phosphorylation of serine-514 promotes cytotoxicity by augmenting caspase-3 cleavage of the AR creating amino-terminal fragments containing poly-Q repeats that are cytotoxic  40]. By. By40]. The neurodegeneration observed in SBMA has been associated with increased activation of the JNK pathway by poly-Q expanded AR which inhibits binding of kinesin-1 to microtubules, which, in turn, disrupts fast axonal transport leading to neuronal dysfunction . In a reAcetylation of the AR has also been implicated in SBMA pathogenesis. Expanded poly-Q AR is hyperacetylated thus stabilizing the mutant AR and promoting nuclear aggregation. Pharmacologic reduction and mutations to inhibit acetylation at lysine 630, 632 and 633 significantly decreased aggregation and completely abolished toxicity in motor neurons. Furthermore, Montie and colleagues showed that SIRT1, a deacetylase of the AR protects against neurotoxicity by deacetylating expanded poly-Q AR . LysinesAlthough the pathogenic mechanism of SBMA seems complex, and is likely to involve multiple steps, the above studies emphasize that an androgen-dependent activation of an expanded poly-Q AR is necessary for the neurodegeneration observed in SBMA and posttranslational modification of the receptor can enhance or ameliorate receptor toxicity.As with other ‘protein-misfolding’ diseases, palliative care is offered to SBMA patients to minimize disability and improve their quality of life at each stage of disease as there is currently no effective pharmacologic therapy. Symptoms such as weakness and wasting of limb muscles are managed by the use of walkers, canes or braces. In later stages of disease, patients are confined to a wheel chair or other assistive device . PatientAs the knowledge of disease mechanism continues to increase, a number of therapeutic interventions to prevent or cure SBMA have been investigated. Androgens have been shown to play a significant role in pathogenesis, hence androgen ablation therapy could be an effective first-line target . LeuprorSignificantly, in a randomized, placebo-controlled Phase II clinical trial administration of leuprorelin to 50 recruited SBMA patients for 144 weeks, led to better motor functional scores and improved swallowing parameters were observed in treated patient as against those given placebo . In addiIn as much as animal studies show convincing evidence for the use of androgen depleting compounds in SBMA therapy, clinical trials in humans has not establish efficacy. There is, therefore, a need to look beyond hormone therapy in the treatment and management of this slowly progressive condition in humans.Although the number of compounds going from preclinical to clinical trials are very limited, this has not deterred researchers investigating novel therapies to treat SBMA. One strategy has been to target the molecular chaperone machinery and in a recent paper Lieberman and co-workers elegantly demonstrated that regulation of the Hsp70 chaperone complex could reduce neurotoxicity and promote turnover of the AR. Of particular significance was the identification of a small molecule, YM-1, that allosterically activated Hsp70  55]. In. In55]. Drosophilia motor neurons [Reversal of fibrillar aggregates to nontoxic annular ones can also have a therapeutic potential. Melatonin was shown to cause poly-Q expanded AR to form annular oligomers in neuronal cells in culture or  neurons . By cont neurons . As formDecreasing the expression of poly-Q AR may be a feasible way of tackling SBMA. Adeno-associated virus vector mediated delivery of the microRNA, miR-196a was shown to ameliorate SBMA phenotypes in mouse models by inhibiting the expression of CELF2. In fibroblast samples obtained from patient with SBMA, this intervention was found to downregulate both AR and CELF2 mRNAs. A similar observation was made in thoracic spinal cord of subjects .Another approach has been to target different kinase pathways that affect AR signaling. For example, Morfini and colleagues proposed the JNK pathway as a promising target . The 5-HActivation of the PI3K/Akt signaling by IGF-1 was shown to protect motor neuron cells against toxicity of poly-Q AR . IntrapeGenistein, an isoflavone found in soybean and also regarded as a broad spectrum tyrosine kinase inhibitor was shown to promote dissociation of AR from ARA70 by phosphorylating AR at serine-515. This induces protein degradation and inhibits neuronal accumulation of mutant AR. In transgenic mice models, there was an improvement in motor performances and muscle pathology upon long term oral treatment .To date the most promising therapeutic approaches have targeted the ligand activation of the AR or the folding/aggregation and turnover of the mutant receptor. However, as androgen ablation therapy alone seems to be inefficacious in clinical trials, the treatment of SBMA may ultimately lie in the use of a combination therapy approach.Androgen receptor: The androgen receptor is an intracellular receptor protein that binds the hormones testosterone and DHT and functions as a ligand-activated transcription factor.Spinal-bulbar muscular atrophy: SBMA or Kennedy's disease is a late-on-set, progressive neuromuscular degenerative disease. SBMA results from expansion of a polyglutamine repeat to more than 40 residues.Intrinsic disordered structure: Intact proteins or protein domains maybe described as being intrinsically disordered. This refers to a lack of a single stable structure and where conformation is best described as an ensemble of confers which can be more or less folded.Osmolyte: Osmolytes such as disaccharide, trehalose, and the polyalcohol trimethylamine N oxide are natural small molecules that have been shown to help proteins fold and adopt native structures.Expansion of the large polyglutamine repeat in the amino-terminal domain of the AR is responsible for the neuromuscular degenerative disease spinal-bulbar muscular atrophy.Hormone binding and nuclear translocation of the receptor have both been implicated in the pathology of the disease; and may be considered necessary but not sufficient for disease progression.Novel drug treatments for spinal-bulbar muscular atrophy are currently focusing on hormone binding, protein folding and degradation and receptor posttranslational modifications as the means of preventing or reducing the appearance of nuclear inclusions that contain aggregates of the androgen receptor and co-regulatory and chaperone proteins.