In this hypothesis, we are proposing that the combination of D-Phenylalanine and N-acetyl-L-cysteine (NAC) - two substances that have never been utilized together - is an important advancement to treat Reward Deficiency Syndrome (RDS) . The keyThrough this particular cascade, the hypothalamic serotonergic system is stimulated, which causes stimulation of delta/mu receptors by serotonin and further enkephalin release. Initiation of the enkephalinergic system prompts a block on GABA transmission at the substantia nigra via enkephalin stimulation of GABA neuron mu receptors. GABERGIC activity is impacted by endocannabinoid and glutamate receptors. This inhibition of GABA transmission permits any slight changes in GABA activity. These changes allow for dopamine release at the anticipated region of the NAc (with permission ).Understanding the BRC provides the rationale for the hypothesis that the combination of D-Phenylalanine and NAC may be an effective RDS treatment. Since GABA is an inhibitory transmitter that fine tunes dopamine release at the VTA-NAc, it is a key target to control dopamine regulation. For example, if there is high GABA activity, the result will be a lower dopamine release at known reward sites (NAc) leading to a lack of well being, which is then linked to drug-seeking behavior. On the other hand, if GABA activity is low, then possibly too much dopamine is released at the NAc, leading to psychosis. This mechanism is essential in terms of treating all RDS behaviors by regulating GABA activity.For over 40 years, it has been recognized that the Dorsal Raphe Nucleus  and the Ventral Tegmental Area  are two of the more relevant brain reward areas, where electrical stimulation produces response at the highest rates and lowest thresholds . Although multiple studies have examined both the DRN and VTA and its contribution to reward, these studies have been focused on only serotonergic effects on reward. As a result, these investigations have produced conflicting results, and the true role of DRN to VTA circuitry in regulating motivated behaviors is still unknown. Contrary to the widespread idea that the major input from DRN to VTA is serotonergic, Qi et al.  found thAccordingly, we know that D-Phenylalanine (DPA) is an inhibitor of the enzyme  known to breakdown (catabolize) endorphins, especially enkephalins. Thus, if we increase brain enkephalins by administering DPA, the amount of enkephalins will increase in the brain as previously reported .Alcohol  deoxyglucose (FDG) . These rOne such study examined rsFC following challenges with levodopa (L-DOPA) or haloperidol . The L-DThe importance of these previous studies (above) is to provide a mechanism whereby DPA acts through stimulating both the delta and mu opiate receptors by enhanced brain enkephalins leading to a gentle blockade of GABA transmission, which causes a physiological release of dopamine at the brain pleasure site. Acceptance of this fact, coupled with a secondary, but equally important mechanism involving glutaminergic stimulation via NMDA receptors and subsequent action of GABA transmission at the substantia nigra, should represent a synergistic mechanism to the provider BRC regulation and Dopamine homeostasis. It is interesting that many believe that the glutaminergic system when dysregulated results in an inhibition of GABA neurotransmission and increases Dopamine release . It is oHowever, we also believe that since individuals with risk for all RDS behaviors may have genetic polymorphisms in the glutaminergic system leading to reduced activity and less GABA inhibition, it is noted that by using DPA to increase brain enkephalins, it seems useful to provide a mechanism for balancing the glutaminergic system to prevent an overload of extracellular dopamine, instead of the appropriate amount that could lead to dopamine homeostasis. On this basis, and never combined prior to this current thinking, the addition of N-Acetyl cysteine (NAC) should induce glutaminergic homeostasis and overcome any abnormal amount of dopamine being released at the NAc allowing for enhanced ability to achieve “dopamine homeostasis”. NAC treatment should enhance overall RDS treatment combinations.The effects of a cysteine-glutamate transporter enhancer on the neurochemical and behavioral effects of cocaine and amphetamine in nonhuman primates have been investigated by Bauzo et al. It was hAlthough all the clinical studies are preliminary and utilized relatively small sample sizes, the fairly stable anti-addictive properties of NAC postulate convincing proof that this medication, along with other composites that reestablish glutamate homeostasis, could possibly demonstrate to be successful pharmacotherapeutic support in the management of RDS when combined with DPA . In factThe NAc is a part of the brain found in the vertebrate basal forebrain and it has been implicated in drug addiction. Several neurotransmitters involved in NAc circuitry have been associated with different issues related with drug addiction, such as compulsive consumption and relapse. In particular, the glutamate system has been associated primarily to relapse after elimination of drug-seeking. The dopamine system has been associated largely to compulsive drug consumption . The gluFollowing repeated drug consumption, there is a surge in the deregulation of homeostasis, which causes glutamate release from the Pre-Frontal Cortex (PFC) to the NAc throughout relapse. Glial cells also play a central part in this hypothesis, where glial cells form the connections between the PFC and the NAc via changing glutamate levels in both synaptic and extra synaptic areas. On the other hand, cocaine self-administration and withdrawal causes growth of the surface expression of subunit glutamate receptor 1 (GluA1) of alpha-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid (AMPA) receptors at the NAc level. Cocaine self-administration and withdrawal also stimulate the development of subunit glutamate receptor 2 (GluA2), deficient of Ca2+permeable AMPA receptors (CP-AMPARs) at the NAc level. Antagonism of the CP-AMPARs decreases desires .It is accepted that cocaine and morphine stimulate alterations in dendritic spine morphology by adjusting actin cycling . These aVarious therapeutic drugs such as N-acetyl cysteine (NAC), modafinil, acamprosate, and topiramate have been confirmed in preclinical and/or clinical models for easing drug relapse . FurtherExtra synaptic glutamate exhibits dopamine function regulation in the mesocorticolimbic pathway, which plays a significant part in psycho stimulant behavioral pharmacology . GlutamaThe outcomes of a cystine-glutamate transporter enhancer on the neurochemical and behavioral results of cocaine and amphetamine use in nonhuman primates have been studied. It was theorized that enhancing extra synaptic glutamate release with N-acetyl-L-cysteine (NAC), a cystine prodrug, would offset cocaine- or amphetamine-stimulated surges in extracellular dopamine and their analogous behavioral-stimulant and reinforcing effects. In vivo, microdialysis was used to assess cocaine-induced alterations in extracellular dopamine (DA) in the caudate nucleus (n = 3) . NAC conOther compounds that may be added to enkephalinase inhibition for dopamine release include, but are not limited to sodium nitroprusside (SNP) , which aDPA, alongside morphine, acetylsalicylic acid and zomepirac sodium, were assessed for their anti-nociceptive effects in monkeys (M. fascicularis) taught to auto-regulate nociceptive stimulation using a discrete-trial, aversive-threshold model . Morphinrosea. In seventeen opioid addicts undergoing detoxification, we show that the KB220z in a liquid nano was successfully able to reduce withdrawal symptoms and in fact, instead of detoxifying opioid addicts with the combination of buprenorphine/naloxone , the utilization of KB220z liquid variant substituted for buprenorphine/naloxone not only in detoxification, but is also providing maintenance in 88.3 % of the studied patients [In an unpublished pilot study, one of us (KB) combined both DPA and NAC along with other amino-acid precursors, Chromium salts and Rhodiola patients .In the right direction, compounds that are enkephalinase inhibitors affect dopamine release. For example, the enkephalinase inhibitor sodium nitroprusside (SNP) was found to induce dopamine increase in striatum dialysates of spontaneously mobile rats. This compound by itself has not yet been studied as an anti-craving substance . ExistinIn animals, over expression of the dopamine D2 receptor via vector delivery of the D2 gene resulted in notable reduction of alcohol and cocaine consumption –35. KB22It is established that after prolonged abstinence from drugs of choice, individuals will experience a more euphoric high, which can lead to relapse. This clinically observed “super sensitivity” might point toward the existence of genetic dopaminergic polymorphisms . ParadoxSpecifically, Laakso et al.  reportedThese genetic and non-genetic (epigenetic) effects may even last in future generations and could explain a better compliance of amino-acid therapy, especially in carriers of the D2 receptor deficient DRD2 A1 allele. We suggest that “dopamine agonist therapy,” such as KB220 variants, can reduce methylation and increase acetyl groups to enhance DRD2 expression, even in DRD2 A1 allele carriers . This shFinally, Badgaiyan et al.  providedIt is uncertain whether or not attention deficit hyperactivity disorder (ADHD) is a hypodopaminergic or a hyperdopaminergic or a disturbed glutamatergic  disorderIt is our contention that the novel combination of DPA and NAC by itself and or in combination with KB220Z will provide a safe and effective natural way to induce dopamine homeostasis for the millions of sufferers of RDS. The simple message is that independent of either genetic antecedents or epigenetic impacts, this is a combination whereby DPA can effect dopamine release at the NAc via an endorphinergic mechanism, affecting GABA transmission and whereby NAC can also affect the glutaminergic system by inducing homeostasis together, creating a balancing effect that should promote required “dopamine homeostasis” in a synergistic manner. The goal is to convert the unhappy brain to a happy one by controlling the balance of GABA, serotonin and enkephalins.


Realities remote from the objective value of molecular allergology / component-resolved diagnosis may explain the gap in clinical implementation between Europe and North America. If the latter is to assert a dominant role in the field of allergy, its professionals will have to embrace change and provide leadership in molecular allergology. As for sublingual immunotherapy, inaction on the part of allergy professionals will leave to commercial and industrial interests the definition of the business model and ultimately the patients' health care options.Was America sleeping on its laurels or just snubbing molecular allergology / component-resolved diagnosis? The clinical implementation of molecular allergology testing in Europe dates back to the early 2000's. Although the importance of major allergens seems to have been readily recognized by allergy professionals in North America, more exhaustive exploration and clinical use of molecular allergology is still waiting. In this day and age of instant communication and worldwide professional collaboration, it is surprising that such a gap could have developed. A review of factors that may have led to this situation represents an opportunity to identify important dynamics that sometimes hinders the introduction of valuable science and/or technologies to our patient care. In France, the model of physician remuneration may have set up the opportunity for the professional cooperation that developed the science and its integration to government-sponsored healthcare services. In Canada, the lack of expertise and demand for molecular allergology services has hindered the country-specific certification process of laboratory technology otherwise widely recognized. In the US, the FDA is still restricting its endorsement to the "Peanut-You-Know" portion of Thermofisher's line of molecular allergy testing products. All the while and until recently, pioneering US-based research in oral immunotherapy (OIT) neglected basic data concerning peanut allergy molecular profiles at a time when comprehensive protocols were routine clinical practice in some French centers. Whereas


Graphs are used to model chemical compounds and drugs. In the graphs, each vertex represents an atom of molecule and edges between the corresponding vertices are used to represent covalent bounds between atoms. We call such a graph, which is derived from a chemical compound, a molecular graph. Evidence shows that the vertex-weighted Wiener number, which is defined over this molecular graph, is strongly correlated to both the melting point and boiling point of the compounds. In this paper, we report the extremal vertex-weighted Wiener number of bicyclic molecular graph in terms of molecular structural analysis and graph transformations. The promising prospects of the application for the chemical and pharmacy engineering are illustrated by theoretical results achieved in this paper. The past 35 years have witnessed the conduction of investigations of degree or distance based topological indices. Topological indices are numerical parameters of molecular graph, which play a significant role in disciplines such as physics, chemistry, medicine, and pharmacology science. The vertex-weighted Wiener number, as the extending version of Wiener index, reflects both the melting point and boiling point of chemical compounds  = f(G2) if G1 and G2 are isomorphic. Topological indices', which function as numerical descriptors of the molecular structure obtained from the corresponding molecular graph, several applications have been found in theoretical chemistry, especially in QSPR/QSAR study. For instance, scholars introduce Wiener index, Zagreb index, harmonic index, and sum connectivity index to reflect certain structural features of organic molecules. There were several papers contributing to determine these distance-based indices of special molecular graph  and E(G), respectively. One terminology issue we should clarify here is that the term “molecular graph” represents a chemical structure in many articles, whereas, in our paper, we consider the extremal vertex-weighted Wiener number of bicyclic molecular graphs, and the bicyclic molecular graph which reaches the minimum vertex-weighted Wiener number may not represent a real molecular structure in chemical sciences. From this point of view, we relax the restricted, and the term “molecular graph” represents all graphs in our paper. The Wiener index of molecular graph G was defined asd is the distance between u and v in G.The molecular graphs that have been considered in this paper are of simplicity and of relevance. The vertex and edge sets of λ is a real number. Moreover, the hyper-Wiener index was defined asSeveral Wiener related indices for molecular structures were introduced. For example, as the extension of Wiener index, the modified Wiener index is denoted byG was introduced by Došlić [W = (1/2)∑u,v∈V(G)w(u)w(v)dG, where w : V(G) → ℕ+ is a weighting function. Hence, formula (The (singly) vertex-weighted Wiener number of molecular graph y Došlić  as4)WvGd Gutman  which isWvGd GutmSeveral papers have contributed to the Wiener index and related numbers. Klavžar and Rho  studied Although several advances have been made in Wiener index, Zagreb index, PI index, hyper-Wiener index, and sum connectivity index of molecular graphs, the study of vertex-weighted Wiener number for special chemical structures has been largely limited. In addition, bicyclic related structures are widely used in medical science and pharmaceutical field for their function as widespread and critical chemical structures. For example, bicyclic molecular graph is one of the basic chemical structures that exists widely in benzene and alkali molecular structures. Because of these, tremendous academic and industrial interests have been attracted to research the vertex-weighted Wiener number of this molecular structure from a mathematical point of view.In this paper, we study the minimum vertex-weighted Wiener number of bicyclic molecular graphs.V(G)| = n and |E(G)| = m as the number of vertex and edge in molecular graph G, respectively. A leaf is a vertex of degree one, a stem is a vertex adjacent to at least one leaf, and pendant edges are edges incident to a leaf and stem which is denoted simply by K2. We set Pn, Cn, and Kn−11, as the path, cycle, and the star with order (vertex number) n, respectively.In what follows, we set |c(G) = m − n + 1 be a cyclomatic number of a connected molecular graph G. A molecular graph G with c(G) = k is called a k cyclic molecular graph. We specifically call G as a bicyclic molecular graph if c(G) = 2. Let ℬ(n) be the set of all bicyclic molecular graphs with n vertices, and there are two basic cycles Cp and Cq in each graph G ∈ ℬ(n). All the molecular graphs in ℬ(n) can be divided into three classes according to the relationship between the two basic cycles:(i)p, q)⊆ℬ(n) is the set of bicyclic molecular graphs such that two cycles Cp and Cq have only one common vertex.Θ((ii)p, q)⊆ℬ(n) is the set of bicyclic molecular graphs such that two cycles Cp and Cq have no common vertex.Γ((iii)Ω⊆ℬ(n) is the set of bicyclic molecular graphs such that Cp and Cq have a common path of length l ≥ 1.Let p, q), Γ, and Ω are manifested in Figures Ω = Ω = Ω.The structures of three classes of bicyclic graph Θ(E′⊆E(G) (or W⊆V(G)); we denote the subgraph of G obtained by deleting the edges (vertices) or E′ (or W) as G − E′ (or G − W). For any two molecular graphs G1 and G2, we denote this molecular graph as G1vG2 if there exists a common vertex v between them. We denote it as G1uvG2 if there exists a bridge uv between G1 and G2 with u ∈ V(G1) and v ∈ V(G2). If there are copies of molecular graphs G1, G2,…, Gl (l ≥ 2) with all molecular graphs sharing one common vertex v, this molecular graph is denoted by G1vG2v ⋯ vGl.Let We will introduce some molecular graph transformations, which will decrease the vertex-weighted Wiener number of molecular graphs.Transformation A. Let G1 and G2 be 2-edge-connected molecular graphs with |V(G1)| ≥ 2 and |V(G2)| ≥ 2, and uv be an edge of G1uvG2. G1uG2uK2 is the molecular graph transformed by G1uvG2 using Transformation A, described in Now, as preparation knowledge, we present some useful lemmas.G1uG2uK2 be a molecular graph obtained from G1uvG2 by Transformation A; then Wv(G1uG2uK2) < Wv(G1uvG2).Let G1∗ = G1uvG2, G2∗ = G1uG2uK2, G1′ = G1 − u, and G2′ = G1 − v.For convenience, we set Wv(G2∗) < Wv(G1∗) in terms of dG1∗(u) ≥ 3 and dG1∗(v) ≥ 3.By applying the definition of vertex-weighted Wiener number, we have We emphasize here that any bicyclic molecular graph can be changed into a bicyclic molecular graph with all the edges that are not on the cycles but pendant edges by repeating Transformation A. Moreover, the vertex-weighted Wiener number of the molecular graphs decreased after such changing.Transformation B. Let u and v be two vertices in molecular graph G. Vertices u1, u2,…, us are the leaves adjacent to u, and vertices v1, v2,…, vt are the leaves adjacent to v. Set G′ = G − {vv1, vv2,…, vvt}+{uv1, uv2,…, uvt}, G′′ = G − {uu1, uu2,…, uus}+{vu1, vu2,…, vus}, and |V(G0)|≥3. The explanation for Transformation B was presented in G′ and G′′ be molecular graphs deduced from G in view of Transformation B. Then, one infers Wv(G) > Wv(G′) or Wv(G) > Wv(G′′).Let G0∗ = G0 − {u, v}. By means of the definition of vertex-weighted Wiener number, we yield Let Similarly, we have Wv(G′) − Wv(G) ≥ 0, then we yield Wv(G′′) − Wv(G) ≥ 0; thus, If Therefore, we complete the proof.It is obvious that after repeating Transformation A, if continue repeating Transformation B, any bicyclic molecular graph can be changed into a new bicyclic molecular graph so that all the pendant edges are attached to the same vertex. Meanwhile, the vertex-weighted Wiener number of the graphs decreased after changing.G′ and G′′ be the molecular graphs described in G0∗ = G0 − {u, v}. Then, Wv(G′) < Wv(G′′) if dG0(u) > dG0(v) and ∑x∈G0∗dG0∗(x)dG0∗ < ∑x∈G0∗dG0∗(x)dG0∗; otherwise, Wv(G′) > Wv(G′′).Let Using the definition of vertex-weighted Wiener number, we obtain Thus, we haveTherefore, one gets the desired result.G is a molecular graph of order n ≥ 7 gotten from a connected molecular graph G0≇P1 and a cycle Cp = v0v1 ⋯ vp−1v0  by identifying v0 with a vertex v of the molecular graph G0  > Wv(G′).Suppose that G0′ = G0 − v, Cp′ = Cp − {v, vq−1}, and Cp−1′ = Cp−1 − v. We divided the proof into two cases according to the parity of p.For convenience, we set Case 1 (p ≡ 0 (mod 2)). Consider the following:p ≥ 4.Similarly, we have Case 2 (p ≡ 1 (mod 2)). Similar to Case 1, we deduce p ≥ 5 when p is odd.Similarly, we get Thus, we complete the proof.In the last part of this section, we present the previously known result as follows, which will be used in our proofs.Cn be the cycle of order n, and v is a vertex on Cn. Then Let In fact, the first equation in In this section, we present lower bounds for the vertex-weighted Wiener number in bicyclic molecular graphs.p, q). Let Sn be a molecular graph in Θ so that n + 1 − (p + q) pendent edges are attached to the common vertex of Cp and Cq, and let Sn′ be a molecular graph in Θ which satisfies that n + 1 − (p + q) pendent edges are attached to the vertex v of Cp or Cq. See In this subsection, we determine the bicyclic molecular structure with the smallest vertex-weighted Wiener number in Θ is a molecular graph of order n, then Wv) < Wv(G).If G′ such that all the edges not on the cycles are the pendant edges attached to the same vertex v can be obtained in terms of repeating Transformations A and B on molecular graph G. In view of Lemmas Wv(G) ≥ Wv(G′) with the equality if and only if all the edges that are not on the cycles are also the pendant edges attached to the same vertex in G. Let u be the common vertex of Cp and Cq. Clearly, v ≠ u if G′≇Sn.A new molecular graph v is on the cycle Cp and G′≅Sn′ is manifested in G0 = CpuCq and G0∗ = G0 − {u, v} in Sn and Sn′. We infer that dG0(u) = 4 > dG0(v) = 2 and ∑x∈G0∗dG0∗(x)dG0∗ = 2∑x∈G0∗dG0∗ < 2∑x∈G0∗dG0∗.Without loss of generality, we assume that Wv) < Wv), and thus Wv) < Wv(G). This completes the proof.By the proof of (1)Wv) ≥ Wv);(2)p ≥ 3 and q ≥ 3, Sn is the unique graph with the smallest vertex-weighted Wiener number in Θ.for all The following facts hold:p ≥ 3 and q ≥ 3, Sn is the unique molecular graph with the smallest vertex-weighted Wiener number in Θ by the conclusion presented in e = uv be an edge of cycle Cp (by the symmetry of p and q), using grafting Transformation A on Sn. Then Sn can be changed into the molecular graph G′ and e is changed into a pendent edge adjacent to u(v) ) > Wv(G′) by applying G′ can be changed into G′′ ) by continuously applying Transformation C on G′, and we further get Wv(G′) > Wv(G′′).For the fixed Sn, it can be changed into Sn, and we further infer Wv) > Wv) if p ≥ 3 and q > 3 or p > 3 and q ≥ 3. Finally, we deduce Wv) ≥ Wv) for all molecular graphs in Θ with p ≥ 3 and q ≥ 3, and the equality holds if and only if G≅Sn.In terms of repeating Transformations A, B, and C on In addition, by means of the definition of vertex-weighted Wiener number, we havep, q) is (3n2 + n − 16)/2, and the lower bound is obtained if and only if G≅Sn.That is to say, the smallest vertex-weighted Wiener number in Θ. Let Tnr be the molecular -graph generating by connecting Cp and Cq by a path of length r and the other n + 1 − p − q − r edges are all attached to the common vertex of the path and Cp; see In this part, we determine the bicyclic molecular graph with the smallest vertex-weighted Wiener number in Γ, the length of the shortest path connecting Cp and Cq in G is r, then(1)Wv(G) ≥ Wv) with the equality if and only if G≅Tnr; or(2)Wv(G) ≥ Wv) with the equality if and only if G≅Tnr.If r ≥ 2, then Wv) < Wv).If Wv) ≥ Wv) with the equality if and only if p = q = 3.Consider the following: Wv) is the unique molecular graph with the smallest vertex-weighted Wiener number among all molecular graphs in Γ for all q ≥ 3 and p ≥ 3.The Wv) is (3n2 + 11n − 52)/2, which is the smallest vertex-weighted Wiener number in Γ.Note that the vertex-weighted Wiener number of Ω. Let θnl be the molecular graph obtained from the molecular graph in n + 1 + l − (p + q) vertices to one of its vertices with degree 3 . Then Wv(G) ≥ Wv(G4) with the equality if and only if G≅G4, where G4 is the molecular graph presented in Let G′ with all the edges that are not on the cycles but are the pendant edges being attached to the same vertex v0 can be obtained via repeating the Transformations A and B on molecular graph G; that is, G′ is one of the molecular graphs in Wv(G) ≥ Wv(G′) with the equality if and only if all the edges that are not on the cycles are also the pendant edges attached to the same vertex in G.A new molecular graph W1 = ux1x2 ⋯ xl−1v be the common path of Cp and Cq of the molecular graph G′, W2 = uy1y2 ⋯ yrv and W3 = uz1z2 ⋯ ztv be the other paths are from u to v on Cp and Cq, respectively. Here, r = p − l − 1, t = q − l − 1, r ≥ 0, t ≥ 0, l ≥ 1, and r + t + l ≥ 3.Let e = xy in G1 satisfying that the degrees of x and y are both equal 2, then a molecular graph G1′ can be obtained in terms of contracting edge e and attaching a pendant edge e′ = uu′ to u, and we further have Wv(G1) > Wv(G1′) according to G1′, G1′ is changed into the molecular graph G1′′ such that the pendent edge is transferred to the vertex u and Wv(G1′) > Wv(G1′′) by G will finally be changed into G4. Consider that Wv(G) ≥ Wv(G4), and the equality holds if and only if G≅G4.If there exists an edge e1 and e2 in G2 so that the degrees of their end-vertices are equal to two, then we can obtain a molecular graph G2′ by means of contracting the edges e1 and e2 and attaching two pendant edges to xi; or if there exists an edge e in G2 such that the degrees of its end-vertices and e2 are equal to 2, a molecular graph G2′ can be obtained by contracting the edge e and attaching a pendant edge to xi. Using Lemmas Wv(G2) > Wv(G2′). By continuously repeating the operations above, we verify that Wv(G2) ≥ Wv(G3) and equality holds if and only if G≅G3.If there are two edges Wv(G3) = (3n2 + 11n − 64)/2 and Wv(G4) = (3n2 + n − 18)/2. Thus, Wv(G3) − Wv(G4) = 5n − 23 > 0 since n ≥ 5.Furthermore, it is easy to calculate that θn1≅G4, we will use this notion in the last subsection.Noting that Finally, we give the bicyclic molecular graph the smallest vertex-weighted Wiener number.θn1 is the unique graph with the smallest vertex-weighted Wiener number among all bicyclic molecular graphs with n  (n ≥ 6) vertices.Sn, Tn1, and θn1 ) > Wv) > Wv) if n ≥ 6. Therefore, θn1 has the smallest vertex-weighted Wiener number among all bicyclic molecular graphs with n vertices.By immediately computing, we have In our paper, we mainly report the extremal vertex-weighted Wiener number of bicyclic molecular graph with the help of molecular graph structural analysis and mathematical derivation. The vertex-weighted Wiener number is widely used in the analysis of both the melting point and boiling point for chemical compounds and QSPR/QSAR study. Thus, the promising prospects of the application for the chemical and pharmacy engineering will be illustrated in the theoretical conclusion that is obtained in this paper.


Moreover, using the in vivo microdialysis technique, we measured the effect of acute and chronic salsolinol injection on l-DOPA-induced dopamine release in the rat striatum. The behavioral data demonstrated that both acute and chronic salsolinol administration antagonized l-DOPA-mediated hyperactivity. An ex vivo neurochemical experiment indicated that chronic but not acute salsolinol administration partially inhibited the l-DOPA-induced increases in the concentration of dopamine and all of its metabolites in dopaminergic structures. Additionally, the in vivo dopamine release data obtained from the microdialysis experiments clearly indicated that the differences in the effect of salsolinol on the activities of l-DOPA depended on the mode of salsolinol treatment. Acute injection of salsolinol enhanced the l-DOPA-induced elevation of dopamine release , whereas chronic administration of salsolinol completely blocked the l-DOPA-induced elevation of dopamine release in the rat striatum. These data demonstrated that chronic administration of salsolinol significantly impaired the response of dopaminergic neurons to l-DOPA administration. In conclusion, we propose that an elevated salsolinol level in parkinsonian patients may represent a serious risk factor of the clinical efficacy of l-DOPA therapy.1-Methyl-6,7-dihydroxy-1,2,3,4-tetrahydroisoquinoline  is a well-known endogenous compound that has been proposed as a factor involved in the pathogenesis of Parkinson’s disease. In the present study, we investigated the impact of acute and chronic salsolinol (100 mg.kg i.p.) administration on  Although available medications provide some symptomatic relief to nearly all patients, none of these drugs have been shown to significantly slow or halt disease progression  is the progressive degeneration of dopaminergic neurons in the nigro-striatal pathway. This process leads to a dramatic decrease in the dopamine concentration in the substantia nigra. The classical cardinal signs of PD are rigidity, bradykinesia, resting tremor, and postural instability. Oral administration of the dopamine precursor ion Lang . Recent ion Lang . 1-Methyion Lang , 2014. Iion Lang . Salsoliion Lang . Additioion Lang . Salsoliion Lang , b. Weinion Lang  demonstrion Lang . Our preion Lang . As demoion Lang .l-DOPA-mediated activities using both behavioral and neurochemical studies in rats. To this end, we examined the effect of salsolinol on l-DOPA-induced locomotor hyperactivity, dopamine release in the striatum, and changes in dopamine metabolism in different brain structures in vivo.The aim of the present study was to examine the effects of acute and chronic administration of salsolinol on The experiments were performed on male Wistar rats whose initial body weight was 220–240 g. All animals were provided with free access to standard laboratory food and tap water and were maintained at room temperature (22 °C) under an artificial light/dark cycle .) once or chronically for 14 consecutive days. In the combined treatment group, l-DOPA (100 mg/kg i.p.) was administered once 15 min after the final salsolinol administration. Control rats were treated with an appropriate solvent. The rats were euthanized via decapitation 2 h after the final drug injection, and different structures of the brain were dissected. These experiments were performed between 9:00 and 16:00.The rats were administered with salsolinol at a dose of 100 mg/kg intraperitoneally  were obtained commercially. These compounds were dissolved in a 0.9 % NaCl solution.Salsolinol and l-DOPA (100 mg/kg i.p.) was acutely administered 15 min after salsolinol administration; the control group was treated with saline. Horizontal locomotor activity was assessed for 30 min. Six animals per group were used.Locomotor activity was examined using actometers Opto-Varimex activity monitors  linked on-line to a compatible IBM-PC. Each cage (43 × 44 × 25 cm) was surrounded by a 15 × 15 array of photocell beams located 3 cm from the floor surface as reported previously  were measured via high-performance liquid chromatography (HPLC) using an electrochemical detection system (Hewlett Packard 1049A). The tissue samples were weighed and homogenized in ice-cold 0.1 M perchloroacetic acid containing 0.05 mM ascorbic acid. After centrifugation , the supernatants were filtered through RC 58 0.2-µm cellulose membranes . The HP 1050 chromatograph  was equipped with C18 columns. The mobile phase consisted of 0.05 M citrate–phosphate buffer (pH 3.5), 0.1 mM EDTA, 1 mM sodium octyl sulfonate, and 3.5 % methanol. The flow rate was maintained at 1 ml/min. The potential was 800 mV. Dopamine and its metabolites were quantified via comparison to the peak heights of the corresponding standards measured on the day of analysis. Seven to ten animals per group were used.Two hours after the final salsolinol injection, the rats were euthanized via decapitation, and the substantia nigra and striatum were immediately dissected. The obtained tissue was frozen on dry ice (−70 °C) until further use for biochemical assays. Dopamine, its metabolites 3,4-dihydroxyphenylacetic acid (DOPAC), 3-methoxytyramine (3-MT), and homovanillic acid (HVA), and the 2, 1 mM MgCl2, 0.3 mM NaH2PO4, and 1.7 mM Na2HPO4, pH 7.4, at a flow rate of 1.5 μl/min using a microinfusion pump . Samples were collected from freely moving rats at 20 min intervals after a 3 h wash-out period. Salsolinol was injected i.p.  at a 50 mg/kg dose, and the samples were collected for 180 min. In the combined treatment groups, l-DOPA (100 mg/kg i.p.) was administered once 40 min after final salsolinol administration. All probes were immediately frozen on dry ice (−70 °C) until use for biochemical assays.The rats were anesthetized using ketamine (75 mg/kg) and xylazine (10 mg/kg) and secured in a stereotaxic frame . Vertical microdialysis guides  were implanted in the striatum (STR) at the following stereotaxic coordinates: A/P +1.0 and L/M +2.5 from Bregma and V/D −3.5 mm from the dura (G. Paxinos and CH Watson). On the seventh day after surgery, the microdialysis probes were placed inside the guides, and the striatum was perfused with artificial cerebrospinal fluid (aCSF) consisting of 140 mM NaCl, 2.7 mM KCl, 1.2 mM CaClDopamine (DA) was measured in dialysates (20 μl) via HPLC using an electrochemical detection system. The HP1050 chromatograph  was equipped with C18 columns. The mobile phase consisted of 0.05 M citrate–phosphate buffer, pH 3.5, 0.1 mM EDTA, 1 mM sodium octyl sulfonate, and 3.5 % methanol. The flow rate was 1 ml/min.The chromatographic data were processed using ChemStation software , and dopamine and its metabolites were quantified based on comparison to the peak height of corresponding standards measured on the day of analysis. At the end of the experiments, frozen slices from the brains were examined histologically for appropriate probe placement. Six animals per group were taken in microdialysis study.Two-way analysis of variance (ANOVA) was used to determine the overall significance of the behavioral assay results (locomotor activity). Differences between the control and experimental groups were assessed using Duncan’s test for post hoc analysis. The microdialysis data  were measured via one-way ANOVA with repeated measures. The results of chronic administration of salsolinol were analyzed via two-way ANOVA with repeated measures followed (if significant) by Duncan’s test for post hoc analysis.n = 7).The results of the biochemical experiments were analyzed via two-way ANOVA followed by Duncan’s test when appropriate. The total catabolic rate of DA was assessed as the ratio of the concentration of the final DA metabolite HVA to that of DA and was expressed as the catabolic rate index ([HVA]/[DA]) × 100 as previously described in detail  induced a significant elevation of horizontal locomotor activity by the rats (P < 0.01). However, salsolinol administered alone at a dose of 100 mg/kg i.p. did not change their locomotor activity  produced a significant elevation in horizontal locomotor activity of rats (P < 0.01). In the combined treatment group, multiple treatment with salsolinol significantly (P < 0.05) reduced l-DOPA-induced hyperactivity  administration of salsolinol (100 mg/kg i.p.) did not change the locomotor activity of rats  on the dopamine concentration  nor the interaction between salsolinol and l-DOPA was significant . Duncan’s post hoc analysis demonstrated that acute injection of l-DOPA strongly increased the concentration of dopamine . In contrast, single injection of salsolinol did not alter the dopamine concentration. Additionally, salsolinol administered in combination with l-DOPA did not influence the l-DOPA-induced elevation of the dopamine concentration  on the concentration of DOPAC in the substantia nigra  and interaction of salsolinol versus l-DOPA  was not significant. The post hoc analysis indicated that acute administration of l-DOPA produced massive elevation of DOPAC concentration . A similar effect was observed when salsolinol was given combined with l-DOPA  on the level of 3-MT  nor the interaction between salsolinol and l-DOPA  was significant  but that salsolinol did not influence this effect of l-DOPA  on the HVA concentration  nor the interaction between salsolinol and l-DOPA was significant . Post hoc analysis revealed that l-DOPA administration strongly increased the level of HVA , and this effect was similar to that in the combined treatment group  on the rate of dopamine metabolism measured as [HVA]/[DA]  nor an interaction between salsolinol and l-DOPA  on [HVA]/[DA]. Duncan’s post hoc analysis demonstrated that acute administration of l-DOPA strongly increased the rate of dopamine metabolism ; a similar effect was observed when salsolinol (100 mg/kg) was administered in combination with l-DOPA  on the dopamine concentration  nor the interaction between salsolinol and l-DOPA  was significant. Duncan’s post hoc test showed that acute administration of l-DOPA increased the dopamine concentration , and acute injection of salsolinol did not alter this effect of l-DOPA  on the level of DOPAC  nor the interaction between salsolinol and l-DOPA  was significant. Post hoc analysis demonstrated that treatment with l-DOPA induced a massive elevation in the level of DOPAC (by approximately 1800 %). Acute administration of salsolinol did not alter this effect of l-DOPA  on the 3-MT concentration in the rat striatum  nor the interaction between salsolinol and l-DOPA was significant . Duncan’s post hoc test showed that acute administration of l-DOPA reduced the level of 3-MT (by approximately 45 %). A similar effect was observed in the combined treatment group.Two-way ANOVA demonstrated a significant effect of acute administration of l-DOPA  on the level of HVA in the rat striatum. In contrast, neither the effect of salsolinol  nor the interaction between salsolinol and l-DOPA  was significant. Post hoc analysis demonstrated that treatment with l-DOPA induced a strong increase in the level of HVA (by approximately 1400 %). Salsolinol did not alter this effect of l-DOPA  on the rate of dopamine metabolism measured as [HVA]/[DA]  nor an interaction between salsolinol and l-DOPA  on [HVA]/[DA]. Duncan’s post hoc analysis demonstrated that acute administration of l-DOPA increased the rate of dopamine metabolism ; similar effect was observed when salsolinol (100 mg/kg) was administered in combination with l-DOPA (by approximately 900 %)  on the dopamine concentration  on the level of dopamine. The interaction between chronic administration of salsolinol and acute administration of l-DOPA was not significant . Duncan’s post hoc test showed that acute administration of l-DOPA induced an increase in the dopamine concentration . Additionally, in the combined treatment group, chronic administration of salsolinol (100 mg/kg) partially blocked the l-DOPA-induced increase in the concentration of dopamine   on the DOPAC concentration in the rat substantia nigra  nor the interaction between salsolinol and l-DOPA was significant . Post hoc analysis revealed that l-DOPA induced a massive increase in the DOPAC concentration  and this effect was partially inhibited by chronic treatment with salsolinol  nor an interaction between chronic administration of salsolinol and acute administration of l-DOPA  on the level of 3-MT  on the 3-MT concentration was significant. Duncan’s post hoc test showed that acute administration of l-DOPA induced an increase of 3-MT concentration . A similar effect was observed in the combined treatment group when salsolinol (100 mg/kg) was chronically administered followed by acute injection of l-DOPA   on the HVA concentration in the rat substantia nigra  nor the interaction between salsolinol and l-DOPA was significant . Post hoc analysis showed that l-DOPA induced a massive increase in the HVA concentration ; chronic treatment with salsolinol did not alter this effect of l-DOPA  on the rate of dopamine metabolism measured as [HVA]/[DA]  nor an interaction between salsolinol and l-DOPA  on [HVA]/[DA]. Duncan’s post hoc analysis demonstrated that acute administration of l-DOPA strongly increased the rate of dopamine metabolism , and in the combined group, salsolinol enhanced this effect of l-DOPA  nor any interaction between chronic administration of salsolinol and l-DOPA  on the dopamine concentration . Post hoc analysis indicated that acute administration of l-DOPA increased the level of dopamine ; this effect was partially antagonized by chronic treatment with salsolinol  on the DOPAC concentration in the rat striatum  nor the interaction between salsolinol and l-DOPA was significant . Post hoc analysis revealed that l-DOPA induced a massive increase in the DOPAC concentration ; chronic treatment with salsolinol did not alter this effect of l-DOPA  on the 3-MT concentration in the rat striatum  nor the interaction between salsolinol and l-DOPA on the level of 3-MT was significant . Duncan’s post hoc test showed that l-DOPA decreased the level of 3-MT ; this effect was not altered by chronic treatment with salsolinol  on the HVA concentration  nor the interaction between chronic administration of salsolinol and l-DOPA was significant . Post hoc analysis demonstrated that l-DOPA strongly increased the HVA concentration ; this effect was enhanced by chronic treatment with salsolinol  and acute administration of l-DOPA  on the rate of dopamine metabolism measured as [HVA]/[DA] . Duncan’s post hoc analysis demonstrated that l-DOPA induced an increase in the rate of dopamine metabolism (by approximately 700 %); chronic administration of salsolinol significantly enhanced this effect of l-DOPA  on the 3-MDOPA concentration in the rat striatum ; this effect was not altered by either acute or chronic treatment with salsolinol (100 mg/kg i.p.)  on dopamine release into the extracellular space . However, the effect of time  and the interaction between time and treatment was significant . Duncan’s post hoc analysis showed that acute l-DOPA administration induced a significant (P < 0.05) and persistent increase in dopamine release in the rat striatum (by approximately 500 %)  (P < 0.01) in the rat striatum  or  space  on dopamine release , but neither the effect of chronic administration of salsolinol (treatment 1)  nor the interaction between salsolinol and l-DOPA  was significant . Additionally, the interaction between time and treatment 1 , between time and treatment 2 , and between time, treatment 1, and treatment 2  were significant. Duncan’s test indicated that acute l-DOPA administration induced a significant (P < 0.01) and persistent increase in dopamine release in the rat striatum (by up to 500 %); this effect was completely inhibited by chronic administration of salsolinol  is considered to involve both environmental factors and endogenously produced toxins, such as 1BnTIQ and, to a lesser extent, salsolinol. The concept that salsolinol contributes to the pathogenesis of PD arose from the observation that its chemical structure was similar to that of MPTP, a selective dopaminergic neurotoxin which evokes a syndrome resembling the clinical profile of the disease in humans and animals , a precursor of dopamine, causes a significant increase in the dopamine concentration, dopamine metabolism, and the concentration of all dopamine metabolites in extrapyramidal brain structures, including the substantia nigra and the striatum. Comparing the results from the behavioral and biochemical experiments (both ex vivo and in vivo), we concluded that salsolinol does not always act in the same direction. A single dose of salsolinol (100 mg/kg) did not change l-DOPA-mediated hyperactivity based on the behavioral assay  are directly responsible for the regulation of the rate of dopamine metabolism and release. Somatodendritic D2 autoreceptors in the SN inhibit the excitability of dopamine neurons and modulate the firing rate by activating a hyperpolarizing potassium current , although salsolinol does not directly affect AADC activity  treatment. In the behavioral assay (Fig. 00 mg/kg um Table . Similarnt Table . In thatnt Table . Moreovent Table  and MAO nt Table . Salsolint Table  and to int Table . In factace Fig. b. Intereace Fig.  concludeace Fig. . As receace Fig. , salsoliace Fig.  demonstrl-DOPA metabolite 3-MDOPA, after l-DOPA administration (Table l-DOPA is well understood as a direct substrate of COMT, and its metabolism leads to the production of 3-MDOPA. COMT is responsible for both the metabolic inactivation of extraneuronal dopamine via its conversion to 3-MT and the metabolism of l-DOPA into 3-MDOPA (Kopin Based on these in vitro studies it is clear that salsolinol may act toxic on the dopaminergic neurons by complex mechanisms. It is known that in vitro experiments are not always in agreement with in vivo research. Generally, it belongs to take under consideration that in vitro toxicity can differ from in vivo obtained results, which are dependent on complicated interactions among different neurotransmitters in the brain. Additionally, we investigated the effect of acute and chronic salsolinol administration on COMT activity, which was analyzed indirectly as the concentration of the PA Kopin . Finallyl-DOPA. Therefore, we propose that an elevated salsolinol level in parkinsonian patients may represent a serious risk factor of the clinical efficacy of l-DOPA therapy.Combining the results of our behavioral, biochemical ex vivo and in vivo studies, we suggest that chronic, but not acute, administration of salsolinol disrupted the function of dopaminergic neurons and significantly impaired the effects of


Preparing the public health workforce to practice evidence-based decision making (EBDM) is necessary to effectively impact health outcomes. Few studies report on training needs in EBDM at the national level in the United States. We report competency gaps to practice EBDM based on four U.S. national surveys we conducted with the state and local public health workforce between 2008 and 2013.We compared self-reported data from four U.S. national online surveys on EBDM conducted between 2008 and 2013. Participants rated the importance of each EBDM competency then rated how available the competency is to them when needed on a Likert scale. We calculated a gap score by subtracting availability scores from importance scores. We compared mean gaps across surveys and utilized independent samples t tests and Cohen’s d values to compare state level gaps. In addition, participants in the 2013 state health department survey selected and ranked three items that “would most encourage you to utilize EBDM in your work” and items that “would be most useful to you in applying EBDM in your work”. We calculated the percentage of participants who ranked each item among their top three.The largest competency gaps were consistent across all four surveys: economic evaluation, communicating research to policymakers, evaluation designs, and adapting interventions. Participants from the 2013 state level survey reported significantly larger mean importance and availability scores  and smaller mean gaps  compared to the 2008 survey. Participants most often selected “leaders prioritizing EBDM” (67.9%) among top ways to encourage EBDM use. “EBDM training for specific areas” was most commonly ranked as important in applying EBDM (64.3%).Perceived importance and availability of EBDM competencies may be increasing as supports for EBDM continue to grow through trends in funding, training, and resources. However, more capacity building is needed overall, with specific attention to the largest competency gaps. More work with public health departments to both situate trainings to boost competency in these areas and continued improvements for organizational practices (leadership prioritization) are possible next steps to sustain EBDM efforts. Applying an evidence-based framework to public health practice is essential for effective program and policy planning, implementation, and evaluation and has the potential for improved population health outcomes ,2. An evIn order to engage in EBDM one needs a specified mix of knowledge, understanding and skills, or “competencies”  for EBDMThe recognition of the importance of these competencies has led to the development of a variety of tools, resources and trainings to support the application of EBDM. For example, publicly available online tools such as the Community Guide , Cancer Identifying training needs for EBDM competencies is crucial to understand where more competency-based efforts to build capacity could be targeted through training, use of analytic tools, and other resources. However, representative, national level data on EBDM competencies are lacking. To address this gap, we compare perceptions of EBDM competencies reported in four U.S. national surveys we conducted with the public health workforce at the local and state level.We conducted four U.S. national online surveys of the state and local public health workforce. The main objective of the current study is to compare and contrast perceptions of EBDM competencies across these surveys. Participants were state and local public health department employees. Participants in all four surveys answered questions on ten competencies needed for EBDM. The four national sets of participants included in the current study are as follows. The first group is 441 U.S. state health department chronic disease prevention staff that completed a 2008 survey that assessed barriers to practice EBDM at the state level. The second group of respondents is 904 U.S. state health department chronic disease prevention staff from a 2013 survey that examined perceptions of state level support to practice EBDM. The third group is 517 local health department directors that completed a 2012 survey and the fourth group of respondents included in the current study is from a 2013 survey with 332 local health department program managers identified by the third group. The third and fourth groups of participants received the same survey, which sought to examine organizational support and barriers for EBDM at the local level. We describe the survey methods in the paragraphs that follow.In 2008, we administered an online survey with state level staff working in chronic disease prevention in all 50 states, District of Columbia, and U.S. territories. The 74-item survey derived from previous work  and inclAll NACDD members were contacted via email to explain the survey’s purpose. A week later, participants received another email with a link to the online survey. Research staff completed follow-up via telephone and email until the survey closed in August 2008. As an incentive, participants were entered into a drawing to win one of numerous $20 gift cards or 25,000 airline miles. Of the 469 total participants (65% response rate), we included in this study the 441 state health department staff working in the 50 U.S. states and District of Columbia. The Saint Louis University Institutional Review Board reviewed and granted human subjects approval. Further details on the sampling methods and data collection are reported elsewhere .We administered an online survey in spring of 2013 with staff working in chronic disease prevention at the state level in all U.S. states and U.S. territories. The 68-item survey tool was based on our previous work in the 2008 survey mentioned above ,24–26 anResearch staff identified a list of program managers and staff chronic disease prevention through state health department websites, NACDD contact lists, and contact lists from partnering organizations. Contacts from the list were sent email invitations with a survey link in Qualtrics . ParticiBetween December of 2012 and February of 2013, we conducted two surveys with local health departments; the first with local health department directors and the second with program managers. For both groups, we used a 66-item survey tool similar to that used in the 2013 state level survey and was based on previous work ,21,24,29We selected a random sample  of 1,067 local health departments from the National Association of County and City Health Officials database. Project staff sent survey links in Qualtrics  to the dEach of the surveys described above asked participants to rate perceived importance and availability of ten specific EBDM competency items. Participants first rated the “importance of each of the skills to you” then rated “how available each skill is to you when you need it either in your own skill set or among others’ in your agency”. Both were rated on an 11-point Likert scale 0 = not important to 10 = very important and 0 = not available to 10 = very available. A total of eight EBDM competency items were identical or highly similar (same basic concept with only minor wording differences) across the surveys. These eight EBDM competency items are included in this study: action planning, adapting interventions, communicating research to policy makers, economic evaluation, evaluation designs, prioritization of program and policy options, qualitative evaluation, and quantitative evaluation.In the 2013 state health department survey, participants also ranked three incentives that “would most encourage you to utilize EBDM in your work” and three training modalities that “would be most useful to you in applying EBDM in your work” from provided response option lists. Participants could also type in and rank “other” responses.To summarize participant characteristics, we conducted descriptive analyses of participants in each of the four survey groups. Following previously utilized methods , we creaTable Competencies with the largest training gaps were consistent across all four survey groups: economic evaluation, communicating research to policymakers, evaluation designs, and adapting interventions Table . Table 3Figure Items to encourage use of EBDM that were most often ranked in the top three by the 2013 state level staff were agency leaders prioritizing EBDM (67.9%), easy access to EBDM data resources (63.0%), and direct supervisors prioritizing EBDM (46.8%)  may be narrowing. However, the largest gaps remain in how to use economic evaluation data, adapt interventions, and design evaluations; and in communicating research to policymakers (despite improved scores in this area). Exact interpretation of the findings is difficult as possible reasons for narrowing gaps are likely many, complex, and compounded. Below, we offer some discussion of factors contributing to possible improvements followed by training needs indicated for the largest reported gaps.Continued and growing trends to include requirements for and/or encouragement of EBDM processes in various public health funding streams may be a possible contributing factor for narrowing gaps and growing perceived availability of EBDM competencies. Many CDC funding announcements require grantees to use evidence-based processes through the implementation of evidence-based interventions, and in some cases, provide a menu of interventions to select from –43. For Along with funding trends, the growth of online tools and toolkits . While not all, many of the identified gaps in EBDM competencies can be addressed through training programs. Thus, enhancing training capacity for these consistently reported gaps is necessary.We found that competency to adapt interventions was among the largest gaps reported for all respondent groups and the gap did not narrow between 2008 and 2013 for the state level staff. While supplied intervention menus may be evidence-based , many health departments may be uncertain how to adapt them to ensure they have the expected impact given their population and context. This coincides with recent evaluation efforts of the National Comprehensive Cancer Control Program which found 78% of states reported the need for technical assistance in adapting evidence-based cancer interventions  and suggSimilarly, we found that economic evaluation was the largest reported gap in importance and availability among all four respondent groups. This parallels Wilcox and colleagues’  recent sIn addition to increasing capacity for competency specific training, more attention to the tailoring of EBDM training and resources may be important as some competencies may simply be more difficult to master. Research in developing evidence-based competencies proposes three tiers  of difficulty level for EBDM competencies . Of the While growing supports for EBDM competencies are suggested in the current study, it should be noted that EBDM as a process faces more than just the challenge of competency achievement or training. Organizational factors such as high staff turnover and the ability to sustain and make time for ongoing training for newly hired staff are commonly reported challenges to EBDM practice among public health agencies ,62. EvidSeveral limitations are worth noting. In the current study, we provide only self-report data from cross-sectional surveys. In addition, sampling methods and response rates for each survey varied, which may suggest response bias. For example, program managers identified by local health department directors for the 2013 local level survey may have been identified based on general responsiveness to emailed surveys, knowledge, or other unknown and varying factors. In addition, the two state level surveys included those working mainly in chronic disease prevention whereas the two local level surveys represented broader areas of public health practice . This may limit our findings as we were not able to compare our local level data to state level data representing broader areas of practice outside of chronic disease prevention. Next steps for research should explore variations in capacity for EBDM across program areas  and level of public health practice . In addition, this study did not explicitly examine health department characteristics, such as size and population jurisdiction, which have been shown to be associated with varying levels of department performance ,64. FurtGaps in EBDM competencies may be narrowing as awareness and prioritization of skill development continue to grow through trends in funding, training, and resources for EBDM. However, across multiple sectors of the public health workforce, more capacity building is needed overall, with specific attention to the largest gaps in economic evaluation, communicating research to policymakers, adapting interventions to different settings and populations, and evaluation designs. More work with public health departments to both situate trainings to boost competency in these areas and continue to improve organizational practices are possible next steps to sustain EBDM efforts.


There is no doubt that the main reason for an internal grauloma is a traumatic event. The trauma may be physical or chemical as in the case of caries or coronal pulpectomy. In most of the cases it is diagnosed by hazard or, when in case of fracture or mobility, extraction is the only therapy to be performed. If diagnosed in time root canal treatment may be adequate.In the presented case no single specific event could be determined being the cause of this large internal granuloma extending from the coronal third of the root canal to the whole crown just leaving an eggshell of enamel that fractured and mimicked mobility of the whole tooth to the patient finally causing him to attend the clinic. As the patient presented severe aggressive periodontitis and mobility of all teeth it first was assumed that periodontitis was the ethiological reason in this case. Due to secondary trauma the front teeth were labially positioned thus probably being exposed to traumatic insults more frequently. Clinically the upper right medial incisor appeared discoloured darkly not showing the typical pink spot. Without any force the coronal part of the right medial incisor could be removed manually and the root was extracted using a periostal extractor. As it was not suitable to leave the patient with a missing tooth in the front the wound was sutured and as a temporary solution the tooth was reconstructed with composite intraorally and fixed to the neighbour teeth adhesively. The histopathology of the internal granuloma and the crown was investigated. Internal pulp granuloma is a very rare disease that is usually caused by traumata. According to Schroeder , internaIn the case presented here, no single specific event could be identified as being the cause of this large internal granuloma. It extended from the coronal third of the root canal into the whole crown, just leaving an eggshell of enamel that fractured within the gingival attachment border. Thus, mobility of the whole tooth was mimicked to the patient perception, finally causing him to attend the clinic. Because the 23-year-old patient presented with a severe generalized aggressive periodontitis, showing mobility in all of his teeth, this diagnosis was assumed to be the etiological reason. Due to secondary trauma, the front teeth were positioned labially, thus probably being exposed to traumatic insults more frequently. Clinically, the upper right medial incisor appeared discolored darkly, and not showing the typical pink spot Fig. ..Fig. 1CThe coronal part of the right medial incisor was very carefully removed, so as not to destroy the remnants of the crown. After removal of the crown, a large internal granuloma was visible Fig. . The rooThe coronal part of the tooth was stored in 0.7 % NaCl containing 0.1 % thymol. After dehydration in graded acetone, the crown was critical point dried and sputtered with gold-palladium. Resorption patterns of the inner surface of the crown were studied with a scanning electron microscope (Philips XL 30 FEG) at 20 kV beam current. The surface structure was described in terms of its roughness, regularity/irregularity, structure and texture.3, sectioning after embedding in paraffin, and then staining with azan. According to the light microscopic investigation of the internal granuloma cell types, the composition and structure of the resorbing granulation tissue were described.The root with the internal granuloma was fixed in 3.5 % formalin and prepared for light microscopy by decalcification in 5 % HNOThe histology of the granuloma showed four characteristic zones. The first zone showed tissue necrosis within the upper third of the crown pulp Fig. , resultiInternal root resorption is a rare remodeling process  that is Concerning ultrastructural features of odontoclasts resorbing enamel, it could be demonstrated that these tartrate-resistant acid phosphatase-positive multinucleated cells were quite similar to the cells resorbing dentine or cementum . Rich inCytochemical studies revealed that H+ and K+ ATP-ase of odontoclast origin facilitate extracellular demineralization of inorganic crystals and hydrolytic enzymes, such as trimetaphosphatase and p-nitrophenyl phosphatase, and are responsible for intra- and extracellular digestion of organic components of the dentin and enamel, such as collagenous fibers . SeveralLossdörfer et al.  assume tOur results suggest that internal granuloma causes hard dental tissue resorption under pathological conditions, leading to different morphological patterns in dentin and enamel. Internal granuloma leads to irregular, distinct, shallow, but rigorous resorption patterns that could be demonstrated by SEM investigation. Light microscopy revealed 4 zones within the internal granuloma, namely, 1. necrosis, 2. areas of exacerbated inflammation with micro-abscesses, 3. chronic inflammation, and 4. an apically located zone of unaffected vital tissue of the root pulp.Written informed consent was obtained from all patients treated in the dental clinics of Witten/Herdecke University for publication of case reports and any accompanying images. A copy of the written consent is available for review at Witten/Herdecke University School of Dentistry.


E).This study aimed to measure the absorbed doses in selected organs for prospectively ECG-triggered coronary computed tomography angiography (CCTA) using five different generations CT scanners in a female adult anthropomorphic phantom and to estimate the effective dose  using the conversion coefficient of 0.014 mSv∙mGy-1∙cm-1 for the chest region.Prospectively ECG-triggered CCTA was performed using five commercially available CT scanners: 64-detector-row single source CT (SSCT), 2 × 32-detector-row-dual source CT (DSCT), 2 × 64-detector-row DSCT and 320-detector-row SSCT scanners. Absorbed doses were measured in 34 organs using pre-calibrated optically stimulated luminescence dosimeters (OSLDs) placed inside a standard female adult anthropomorphic phantom. HE was received from 2 × 32-detector-row DSCT scanner (6.06 ± 0.72 mSv), followed by 64-detector-row SSCT (5.60 ± 0.68 and 5.02 ± 0.73 mSv), 2 × 64-detector-row DSCT (1.88 ± 0.25 mSv) and 320-detector-row SSCT (1.34 ± 0.48 mSv) scanners. HE calculated from the measured organ doses were about 38 to 53% higher than the HE derived from the PKL-to-HE conversion factor.Both breasts and lungs received the highest radiation dose during CCTA examination. The highest HE as low as 1.34 and 1.88 mSv can be achieved in prospectively ECG-triggered CCTA using 320-detector-row SSCT and 2 × 64-detector-row DSCT scanners.The radiation doses received from a prospectively ECG-triggered CCTA are relatively small and are depending on the scanner technology and imaging protocols. H According to the latest update published by the American Heart Association , cardiovCCTA was first approved by the U.S. Food and Drug Administration (FDA) in 2004 using 64-slice CT. The 64-slice per gantry rotation can be achieved using either 64-detector-row, or 32-detector-row with a strategy to double the slice number by alternating the focal spot of the X-ray source . Being aE) as high as 12 to 21 mSv have been reported in CCTA using 64-detector-row CT scanners [E as low as 0.4 to 1.2 mSv can be achieved for an average sized patient in prospectively ECG-triggered CCTA [PKL) reported in the CT console [While conventional angiography may expose the patient with radiation dose in the range of 3 to 9 mSv, effective dose . Dose measurement was carried out using five CT scanners of different generations located at five different centers. The recommended CCTA imaging protocols were used according to the manufacturers’ guidelines.A female adult anthropomorphic phantom  assembled with multiple holes for the placement of the OSLDs  was used. The phantom represented a female adult of 160 cm height and 55 kg weight. The phantom is made of tissue-equivalent materials that simulate average soft tissues, average bone tissues, cartilage, spinal cord and disks, lung, brain and sinus, where the linear attenuation coefficient of the materials are within 3% of the actual tissues for photon energies ranged 40 to 150 keV . The phaAl2O3:C). It is in disk-shaped of 5 mm diameter and 0.2 mm thickness, wrapped in a light-tight 10 × 10 × 2 mm3 black plastic carrier with a density of 1.03 g.cm-³  system , 64-detector-row SSCT system , 2 × 32-detector-row dual source CT (DSCT) system , 2 × 64-detector-row DSCT system  and 320-detector-row SSCT system . The prospectively ECG-triggered CCTA imaging protocols recommended by the respective CT manufacturers were used. The protocols include Snapshot Pulse Acquisition –thereafter referred as “protocol A”, Step and Shoot Cardiac Acquisition –thereafter referred as “protocol B”, Adaptive Cardio Sequence Acquisition –thereafter referred as “protocol C”, Flash Spiral Acquisition –thereafter referred as “protocol D”, and Volumetric Cardiac Acquisition –therefore referred as “protocol E”.The anthropomorphic phantom pre-loaded with 244 OSLDs from brain to femora was positioned on the CT scanner table . The scaA total of three measurements were done for each imaging protocol. Each measurement was obtained by averaging the results from five exposures. The OSLD signals were analyzed and converted to absorbed dose using the calibration curve. Organ doses were obtained by multiplying the absorbed dose with individual tissue weighting factors recommended by the International Commission on Radiological Protection Publication (ICRP) Publication 103 .E was estimated using two different approaches in this study and the results were compared. First, the HE was computed by summing up all the organ doses measured from the anthropomorphic phantom. Second, the HE was calculated by multiplying the air kerma-length product (PKL) (previously known as dose length product) recorded from the CT console with the EKL conversion factor as following [The Hollowing , 21:HE=KL is region-specific, PKL normalized HE (mSv.mGy-1cm-1) conversion factor. The EKL for chest, 0.014 mSv.mGy-1cm-1 as recommended by the European Commission (EC) and Public Health England (PHE) ) was used in this study [Where Eis study , 23.The statistical analysis was performed using a commercially available software package . Continuous variables were presented as mean ± standard deviation. The organ doses measured from all the protocols were compared using one-way ANOVA, followed by post-hoc Fisher’s LSD test to identify the significance of the differences between each data pair. 95% confidence interval was used in all the statistical tests.The organ doses measured from the anthropomorphic phantom are tabulated in E obtained by summing up all the organ doses from the phantom measurement (measured HE) and by computing using the PKL-to-HE conversion factor (computed HE) is shown in E was higher than the computed HE by 38.3 to 53.2%. Protocol C contributed the highest HE, followed by protocol A, B, D and E.The comparison of HTo our knowledge, this is the first report comparing the direct measured organ doses from prospectively ECG-triggered CCTA using 64-, dual source 2 × 32-, dual source 2 × 64- and 320-detector-row CT scanners and a standard female adult anthropomorphic phantom. The dose measurement setup in this study followed exactly the procedures of a typical CCTA examination of a female patient, that include the positioning, scout scanning (or scan projection radiograph), bolus tracking or test bolus and prospectively ECG-triggered CCTA imaging. The imaging parameters recommended by different CT scanner manufacturers are used according to the CT scanner model. Low heart rate of 60 bpm was used during ECG-triggered CCTA considering that this is the average heart rate in most of the clinical cases after beta blocker is applied. Low heart rate is desirable to guarantee a better image quality and lower radiation dose to the patient during prospectively ECG-triggered CCTA .The data from this study show that, if excluding skin, breasts received the highest radiation dose, followed by lungs, oesophagus, liver, stomach, sternum and heart. It is therefore important to note that, although heart is the organ of interest in CCTA imaging, other organs such as breasts, lungs, oesophagus, liver and stomach receive relatively higher radiation dose due to their higher sensitivity towards ionizing radiation. According to ICRP-103 publication, heart is one of the most radioresistant organs which are categorized as “remainder tissues” when considering its tissue weighting factor. Although spleen was not included in the FOV, it still received comparable dose as the scapula, ribs and thoracic spine due to scattered radiation from the nearest organ such as liver. The scattered radiation doses received by other organs were negligible.E was 1.34 ± 0.48 mSv while computed HE was 0.81 ± 0.02 mSv. It is the current latest CT system that has wide z-axis coverage of 160 mm, enabling the whole heart to be imaged in a single tube rotation. This configuration allows volumetric whole heart imaging during the diastole of one R-R interval and the entire heart is imaged without temporal delay [Among all the CT scanners, 320-detector-row SSCT system gave lowest radiation dose to most of the organs. The measured Hal delay . Howeveral delay .E obtained from the 2 × 64-detector-row DSCT scanner was higher than the 320-detector-row SSCT scanner, the doses delivered to the breasts were actually lower. This was a promising result as breast is one of the most radiosensitive organs in CCTA examination.Although the two models of 64-detector-row SSCT scanners and one model of 2 × 32-detector-row DSCT scanner used in this study have the same total number of detector row, the radiation doses contributed by the SSCT scanners were generally lower than the DSCT scanner by 7 and 17%, respectively. This may be due to the wider z-coverage per gantry rotation (40 mm) in 64-detector-row SSCT scanners, compared to only 19.2 mm z-coverage per gantry rotation in 2 × 32-detector-row DSCT scanner. Consequently, the 2 × 32-detector-row DSCT scanner requires more than 2 times acquisition time in order to achieve the same volume coverage. Since there is slight overlap in each acquisition slice , this may result in higher dose. Fortunately, this first generation DSCT scanner has now been replaced by the second generation DSCT scanner. Several improvements have been introduced in the second generation DSCT system. First, the detector row was increased from 2 × 32-detector-row to 2 × 64-detector-row with z-coverage of 38.4 mm. Second, the gantry rotation speed was boosted to 280 ms compared to 330 ms in the first generation system. Third, the scan field-of-view (in the x/y plane) of the second detector (Detector B) was widened from 26 to 33 cm to provide better coverage of patient anatomy. Fourth, a new tin-based selective photon shield was used to filter unnecessary low energy photons from the high energy X-ray tube spectrum. This helps to reduce patient dose and enables the separation of high energy and low energy X-ray spectra during dual-energy imaging. Finally, a new “Flash” scanning mode was introduced in the system, which uses fast gantry rotation time in conjunction with a high table pitch of up to 3.2. With such high pitch, the system can acquire cardiac images in a quarter of heartbeat or 250 ms in a single diastolic phase, compared to scanners that may require several cardiac cycles for image acquisition, hence eliminating additional radiation dose from overlapping slices. In this study, it was observed that, although the HE, the mean difference observed from this study ranged between 38.3 and 53.2%. These findings were consistent with the findings from Hurwitz et al where the measured HE were higher than the computed HE [PKL-to-HE conversion factor as recommended by the EC and PHE was applied [E were more reliable than computed HE because the radiation doses were directly measured from all the organs, including those located outside of the primary beam during the CCTA imaging. The use of PKL-to-HE conversion factor of 0.014 mSv.mGy-1cm-1 may underestimate the overall radiation exposure from CCTA imaging, hence this method may need to be reviewed and improved. In fact, Gosling et al. [-1cm-1 would give a better estimation of the HE in cardiac-specific imaging.In the comparison of measured versus computed Hputed HE . In this applied , 23. In g et al.  and Akmag et al.  have botE in prospectively ECG-triggered CCTA, followed by 64-detector-row SSCT scanners, 2 × 64-detector-row DSCT scanner and 320-detector-row SSCT scanner. Although the HE varied from 1.34 ± 0.48 to 6.06 ± 0.72 mSv among different generations of CT scanners and imaging protocols, the radiation doses were relatively low compared to many other CT examinations. A study carried out by Akmal et al. [E between genders, however body mass index (BMI) is identified as the main factor that significantly affects the radiation dose. This is also confirmed by a recent study using latest CT model [From our results, the 2 × 32-detector-row DSCT scanner contributed highest Hl et al.  found noCT model .The radiation doses reported in this study provide medical practitioners with data that can be used to assess risk versus benefit of CCTA examination in patients. However, our study has some limitations. First, since this was a phantom study, only one body type was used. The actual doses will vary from patient to patient, depending on patient body habitus, tube current setting, heart rate and z-axis coverage. Second, only five most commonly used CT scanner models for CCTA examination were used in this study, while the most recent CT scanners such as 128-detector-row SSCT scanner, 256-detector-row SSCT scanner, third generation of DSCT scanner and second generation of 320-detetor-row SSCT scanner were not included in our data acquisition because the latest CT scanners are not available yet in many clinical centers .E of 1.21 ± 0.41 mSv in prospectively ECG-triggered CCTA using 128-detector-row CT scanner. For 256-detector-row CT scanner, HE ranged from 0.18 to 1.22 mSv was reported in prospectively ECG-triggered CCTA at a cut-off heart rate of 67 bpm [E of 0.4 mSv at heart rate up to 70 bpm in prospectively ECG-triggered CCTA. The authors further concluded that heart rate viability is not significantly related to image quality of CCTA. Using second generation DSCT scanner, Scharf et al. [E of 2.1 and 2.8 mSv were reported for patient with heart rate < 65 and ≥ 65 bpm, respectively [Hou et al.  reportedf 67 bpm  reportedf et al.  reportedectively . Finallyectively , 33. ThuE estimation from prospectively ECG-triggered CCTA examination using five commonly used different generations CT scanners and imaging protocols. Although the heart is the organ of interest in CCTA imaging, breasts and lungs received the highest radiation dose due to their high radiosensitivity towards ionizing radiation. The use of CCTA especially in young women should be considered carefully in conjunction with clinical indications, benefits versus risks and alternative imaging modalities.This study provides the most recent data on specific organ dose measurement and H


Kaposi Sarcoma (KS) is an angioproliferative tumor associated with human herpes virus 8 (HHV-8).  Often known as one of the acquired immunodeficiency syndrome (AIDS)-defining skin diseases, pulmonary involvement in KS has only been discussed in a handful of case reports, rarely in a non-HIV patient. Herein we report the case of a 77 year-old- male who presented with a 6-week history of progressive dyspnea on exertion accompanied by productive cough of yellow sputum and intermittent hemoptysis. His past medical history was significant for Non-Hodgkin’s Follicular B-Cell Lymphoma (NHL). Patient also had biopsy-confirmed cutaneous KS. His physical exam was notable for a 2cm firm, non-tender, mobile right submandibular lymph node.  Lungs were clear to auscultation. He had multiple violet non-tender skin lesions localized to the lower extremities. CT scan of the chest showed numerous nodular opacities and small pleural effusions in both lungs. A thoracenthesis was performed, showing sero-sanguineous exudative effusions. Histopathology failed to demonstrate malignant cells or lymphoma. A subsequent bronchoscopy revealed diffusely hyperemic, swollen mucosa of the lower airways with mucopurulent secretions. Bronchoalveolar lavage PCR for HHV-8 showed 5800 DNA copies/mL.  It was believed that his pulmonary symptoms were likely due to disseminated KS.  This case illustrates the potential for significant lung injury from KS. It also demonstrates the use of PCR for HHV-8 to diagnose KS in a bronchoalveolar lavage sample in a case when bronchoscopic biopsy was not safe. Furthermore, this case is unique in that the patient did not match the typical KS subgroups as HIV infection and other immune disorders were ruled out. Recognition of this syndrome is critical to the institution of appropriate therapy. As such, this case should be of interest to a broad readership across internal medicine including the specialties of Pulmonology and Critical Care. On admission, he denied fever, chills, chest pain, sick contacts, recent travel, or tuberculosis exposure and history. His past medical history was significant for Non-Hodgkin follicular B cell lymphoma (NHL) diagnosed in 1997, treated with Rituximab, Cyclophosphamide, Hydroxydaunorubicin, Oncovin and Prednisone (RCHOP) three times. Last treatment was completed 1 year prior to presentation. He also had biopsy-confirmed cutaneous Kaposi’s Sarcoma (KS), identified within the same year of presentation, treated with pegylated liposomal doxorubicin 20 mg/mOn admission, he had a low grade fever and was tachycardic. His physical exam was remarkable for a 2 cm firm, non-tender, mobile right submandibular lymph node. Lungs were clear to auscultation bilaterally. He was grossly anasarcic with 4 (+) pitting edema of the lower extremities. He also had multiple violet, non-tender skin lesions localized to the lower extremities, mainly around the medial aspect of his ankles and anterior thighs bilaterally.3 with no leukocytosis. Manual differentiation of the white blood cells showed 28% neutrophils, 48% lymphocytes, 17% monocytes and 5% eosinophils. Urinalysis and urine culture were negative for infections. Blood cultures were positive forStreptococcus pneumoniae.His labs revealed a normal cardiac panel, a white blood cell (WBC) count of 8,100/mmA chest X-ray done on admission showed a right lung consolidation consistent with pneumonia thus the patient was started on empiric vancomycin 1gm every 12 hours and piperacillin-tazobactam 4.5gm every 8 hours for a duration of 8 days. A computerized axial tomographic (CT) scan of the chest, abdomen and pelvis, showed numerous nodular opacities throughout each lung which were suspected to be consistent with KS as well as small pleural effusions in both lungs .Despite completing a course of antibiotics for pneumonia, his symptoms did not improve. A follow-up CT scan of the chest demonstrated that the bilateral pleural effusions had worsened . PatientPneumocystis jiroveci PCR and fluid cytology were also negative but PCR for HHV-8 showed 5800 DNA copies/mL. The patient had a HIV p24 rapid antigen test done which was negative.A bronchoscopy was also performed, revealing diffusely hyperemic and edematous mucosa of the lower airways with mucopurulent secretions . Biopsy After two weeks of supportive treatment, the patient’s symptoms began to improve. He continued to have numerous indurated confluent lesions on his body and face consistent with KS. His pulmonary symptoms were thought to be due to disseminated KS. Following significant discussions with the patient and his family regarding the poor prognosis of his disease, he decided not to undergo any further antineoplastic treatments and eventually was discharged home with hospice.2. It is one of the AIDS-defining skin diseases and is strongly linked to male homosexual behavior4. Four clinical variants of KS have been described: classic, African, iatrogenic and AIDS-related10. The classic variant mainly affects elderly men of Eastern European Jewish and Mediterranean origin9. The African, or endemic type, affects primarily men in the 4th decade of life in East and Central Africa10. Its clinical presentation is similar to the classic form but with a more aggressive variant that responds poorly to conventional treatment10. The third variant, iatrogenic KS, is related to chronic immunosuppressive drugs used in organ-transplant recipients or cancer patients10. This variant tends to be more aggressive, involving lymph nodes, mucosa and visceral organs. AIDS-related KS is an aggressive epidemic form that commonly affects patients with immunosuppression from AIDS5.Kaposi Sarcoma (KS) is an angioproliferative tumor associated with human herpes virus 8 (HHV-8)16. This is likely due to the lack of published evidence of KS in general, as well as the presence of multiple co-morbidities in most patients which may mask clear identification of pulmonary KS. In most cases, it occurs in conjunction with more extensive muco-cutaneous disease16. Unique manifestations that distinguish KS from other pathologic processes in the lungs have not been identified. The most common characteristics of pulmonary KS include peri-broncho-vascular and nodular opacities, thickened interlobular septa and pleural effusions21.Pulmonary involvement in KS has only been discussed in a handful of case reports, very few of which were in non-HIV patients21.Signs and symptoms such as shortness of breath, hypoxemia, and dry cough are common in pulmonary KS. Hemoptysis, fever, chest pain and respiratory failure can also occur. Additionally, enlarged mediastinal lymph nodes are frequently seen in patients with this disease22. Radiographic findings in pulmonary KS are varied and include segregated pulmonary nodules, pleural effusions, and hilar or mediastinal lymphadenopathy, all of which were also evident in our patient25. Several polymerase chain reaction (PCR) assays employing primers unique for HHV-8 have been described27. HHV-8 DNA can be identified using PCR in biopsies of KS, including AIDS-associated KS, classic KS, and endemic KS. Studies have also shown that HHV-8 DNA can be detected in the BAL of patients with pulmonary KS, as was evident in our case30.The diagnosis of pulmonary involvement in KS can often be made by a combination of clinical, radiographic and laboratory findings, in conjunction with results of a transbronchial biopsy5. Our patient, however, demonstrated both dermatologic and pulmonary manifestations suggesting a disseminated and aggressive form of the disease.Our patient did not match the typical subgroups as HIV infection and other immune disorders were ruled out. Furthermore, it has been shown that KS, in non-HIV patients, clinically resembles classic KS but occurs at a younger age, is limited to the skin, and is associated with a good prognosis34. At the time of this case report, we are aware of only a few prospectively randomized trials to date that compare different treatments for KS, most of which were for AIDS-related KS37. This is likely due to the lack of published evidence of the disease and the presence of co-morbidities in most patients, which may limit treatment options such as in our case.The published literature on the treatment of KS consists mostly of retrospective series and case reports33. The first-line treatment for KS in patients with CD4 counts greater than 350 cells/μL is still unclear and treatment has generally been palliative in nature.Currently, antiretroviral therapy (ART) is the first-line therapy for pulmonary KS as it is often seen in patients with HIV/AIDS38. These include pegylated liposomal doxorubicin, vinblastine, alone or in combination with bleomycin, paclitaxel, oral etoposide, vinorelbine, gemcitabine and the immunomodulator recombinant interferon alfa (IFNa). Overall response rates for all of these therapies have been reported to be high and the treatments are generally well tolerated, even in the elderly population. Only one randomized trial has been conducted in which two different systemic therapies, etoposide and vinblastine, were compared in non-AIDS related KS35. That study showed no significant differences between the two treatments with regard to response rate or survival.Only systemic treatments, including chemotherapy and immunomodulators, have shown potential to cause regression in all sites of disease38.Despite the lack of randomized trials demonstrating superiority, most clinicians consider pegylated liposomal doxorubicin the first-line therapy of choice based on a retrospective multicenter series of patients with classic KS without evidence of HIV which showed ≥50% decrease in the number of measurable lesions and the absence of new cutaneous lesions for at least eight weeks in 71% of treated patientsOur patient received treatment with liposomal doxorubicin prior to admission resulting in improvement of his cutaneous lesions. Doxorubicin was planned to be started prior to discharge, but the patient declined further chemotherapy, electing to establish hospice care.40.Radiotherapy is also an accepted treatment for all forms of KS. However, due to the tendency of new lesions to develop as well as the persistence of HHV-8, despite improvement of local lesions and symptoms, there is no consensus as to when to choose radiotherapy over systemic therapyKS in a non-immunocompromised patient is an infrequent occurrence and pulmonary involvement makes the diagnosis even more difficult as only a handful of cases in this patient population are present in the literature. Traditional measures of treatment are aimed at curbing the underlying immunosuppression, making it difficult to treat in individuals with normal immune function. Pulmonary involvement can be ascertained by a combination of clinical, radiographic and laboratory findings, in conjunction with results of a transbronchial biopsy. et al. presented a case of KS that involved the pulmonary in a HIV negative patient. This patient has past medical history of NHL and cutaneous KS. PCR for HHV-8 in BALF showed 5800 DNA copies/ ml and bronchoscopy showed diffusely hyperemic and edematous mucosa of lower airways. The authors claimed that this patient’s pulmonary symptoms were likely due to disseminated KS and the useful of PCR for HHV-8 to diagnose KS in a BALF sample in a case when bronchiscopic biopsy was not safe.KS is thought to originate from HHV8 infected lymphatic endothelial cells. HHV8 is recognized as an essential and necessary factor in the pathogenesis of KS. However, not all HHV-8 infected individuals will develop the disease. The authors examined PCR for HHV-8 in BALF sample; however, it will be more convincing if the author could provide pathological results to demonstrate the patient pulmonary symptoms were likely due to disseminated KS.In this case, the past medical history of this patient was significant for Non-Hodgkin’s Follicular B-Cell Lymphoma. NHL may also lead to nodular opacities throughout both lungs.The abnormal cells of KS form purple, red, or brown patches, plaques or tumors on the skin. It will be better if the authors could provide some pictures of cutaneous lesions.It is a little puzzled that the “lung were clear to auscultation.”, whereas CT scan showed pleural effusions on both lungs.Arber KodraI have read this submission. I believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. This very nice case report serves to remind practitioners everywhere the Kaposi's sarcoma both occurs independently of HIV disease, and can affect organ systems other than the skin. Modern diagnostic techniques and imaging, used as described in this report, allow us to document manifestations of Kaposi's that were previously undocumented.I have read this submission. I believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.


Variations in porin proteins are common in Gram-negative pathogens. Altered or absent porins reduce access of polar antibiotics across the outer membrane and can thus contribute to antibiotic resistance. Reduced permeability has a cost however, in lowering access to nutrients. This trade-off between permeability and nutritional competence is the source of considerable natural variation in porin gate-keeping. Mutational changes in this trade-off are frequently selected, so susceptibility to detergents and antibiotics is polymorphic in environmental isolates as well as pathogens. Understanding the mechanism, costs and heterogeneity of antibiotic exclusion by porins will be crucial in combating Gram negative infections. Escherichia coli is controlled by the pore size of the porin proteins OmpF and OmpC, which are not specific for particular solutes. Optimal nutrient access is favoured by larger porin channels as in OmpF protein or additional, solute-selective proteins like LamB glycoporin in the outer membrane [Pseudomonas aeruginosa porins like OprB and OprD [E. coli through reduced outer membrane porosity and the increased proportion of smaller OmpC channels in the outer membrane [Gram-negative bacteria are often poorly susceptible to antimicrobials. A contributing reason is that Gram-negatives have an intrinsic permeability barrier known as the outer membrane ,2,3. Hydmembrane ,5 or thrand OprD ,7. High membrane ,2,3; seeE. coli, but the relative proportion of the two varies subject to factors such as medium osmolarity, temperature, growth phase and the concentration of certain antibiotics in the medium [E. coli [Normally, the sum total amount of OmpF plus OmpC proteins is fairly constant in e medium ,8,9,10. [E. coli  and this[E. coli ,12 is imPseudomonas aeruginosa and Acinetobacter baumannii [Enterobacter [Neisseria gonorrhoeae highly resistant to the expanded-spectrum cephalosporins [Under more extreme environmental conditions, strong selection is present for altering outer membrane permeability through mutations affecting porins. The extent of the native regulatory control of porin levels is insufficient to provide fitness under either nutrient starvation (when diffusion across the outer membrane becomes limiting) or when inhibitory molecules including antibiotics are present . Structuaumannii . Porins robacter  as well osporins .In this communication, we consider the broader question of environmental situations when permeability either needs to decrease  or increase (under extreme nutrient limitation). We also then discuss how the evolutionary constraints imposed by the sequence changes in porins leads to trade-offs between nutrition and resistance. We then discuss the inevitable heterogeneity imposed by a structural constraint trade-off, and how the shape of this trade-off affects bacterial diversity. Finally, the implications of porin heterogeneity in emerging antibiotic resistance are discussed.In every Gram-negative bacterium investigated, two kinds of change relevant to porins are selected in mutationally acquired resistance. A common finding is a regulatory reduction in the quantity of porin, especially the larger-channel OmpF-like porins but sometimes all porins. A second mutational target is the structure of the porin protein itself, whose channel can be modified to change the structural or size-selectivity of the porin. These will be described in turn.E. coli [Klebsiella pneumoniae and Enterobacter aerogenes with high-level ertapenem resistance lacking both of the major non-specific porins. Other examples include variable patterns of OmpC and OmpF expression in E. cloacae with lower-level ertapenem resistance [E. coli [E. coli is also associated with loss of both the OmpC and OmpF porin proteins and Salmonella typhimurium exposed to progressive increases in cephalosporin concentration exhibited mutations in regulatory genes  that reduced expression of OmpC, OmpD, and OmpF porins [Acinetobacter species and Pseudomonas aeruginosa through diminished expression of porin is also common [Treatment with a number of antibiotics is associated with a heritable decrease in porin expression. For example, regulatory mutations in OmpR  lead toE. coli . RegulatE. coli  and examsistance . OmpF an[E. coli . CefoxitF porins . Resistao common .E. coli such as to attack by the neutrophil bactericidal/permeability increasing protein [S. flexneri [Salmonella [The associated costs of down-regulating porins are especially poorly understood. The absence of porins is deleterious in competing for nutrients as considered below, but further effects may be also involved. For example, mutations in porin regulation can involve regulatory protein like OmpR, RpoS, H-NS, RpoE, Lrp or small RNAs  that hav protein . Anotherflexneri  and Salmlmonella , which iE. coli [K. pneumoniae belonging to various clonal complexes [Down-regulation of porins has a multiplier effect in terms of antibiotic susceptibility because all polar antibiotics access the cell through porins. So reduction in OmpF may be selected with one antibiotic  but this also reduces susceptibility to structurally unrelated antibiotics  . It shouE. coli  or varioomplexes ,28. Efflomplexes ,30.The detailed 3-dimensional structures of OmpF and C porins are known ,32 and cMany of the structural changes in permeability affect the homologous L3 loop that protrudes into the water-filled channel at its constriction point in both porins, as illustrated in E. coli OmpF and other porin sequences and The L3 loop sequence is conserved between the It is important to remember that the main natural role of porins is the uptake of polar nutrients, including sugars, amino acids and ions . The difAs is amply evident from the above properties, there is a negative correlation between nutrient permeability and the resistance characteristics of porins; this is the essence of a trade-off between two traits. Trade-offs rule out that both traits are optimized at the same time so the optimisation of one cellular property occurs at the expense of another. It is a consequence of the constraint that larger channels are more generally permeable that causes the trade-off, and this is known as a structural constraint trade-off.It is not generally appreciated by microbiologists that the shape of a trade-off is not necessarily linear between two negatively correlated characteristics and the curvature shown by intermediate settings of the trade-off has long been known to influence coexistence and heterogeneity in a species ,46. As sE. colis [E. coli  indicatE. colis . It was [E. coli A. This iThe continuum found also suggests that the trade-off is constantly reasserting, and this can be demonstrated in the laboratory. A strain which is less fit but more resistant can rapidly mutate in a nutrient limited environment to be fitter but less resistant, as shown in E. coli in the urinary tract [The selection of porin mutations, as with all drug resistance, is best understood in the context of fitness in the host environment . When bory tract . The overy tract ,55. Futury tract .