Qatar Foundation Annual Research Conference Proceedings Volume 2016 Issue 1

Photosensitive molecules such as quinones in drugs may become activated by exposure to UV-A light (320–400 nm) of the solar spectrum and cause damages to biological materials such as amino acids, nucleic acids, lipids, etc.. 9,10-anthraquinone (AQ) and 1,4-naphthoquinone (NQ), based drugs are commonly used as antibacterial, antifungal, antiviral, antitumor and antimalarial. Synephrine (SY) is used in traditional Chinese medicine, mainly for anti-hypotensive, nasal and ophthalmic decongestant. Currently it has been used in treatment of digestive disorders, in emergency treatment of asthma, and more importantly used as anti-depressant. The study of photo induced interactions of the excited quinones and drug molecules having electron donating ability is expected to have some relevance in physical pharmacy. In this in-vitro study, our aim is to understand the photo induced reaction when the quinones AQ and NQ coexisted with SY in an organic medium and exposed to UVA light. The photo induced interaction between SY and above quinones in their triplet states has been studied using nanosecond laser flash photolysis in organic medium, ethanol. The triplet excited states of the above quinones, AQT and NQT were produced by excitation with 355 nm, 5 ns laser pulse, in the presence of SY and under both deoxygenated and oxygenated conditions. In this wavelength only the quinones can be excited to triplets but not the SY, leaving it always in its ground state. Transient absorbance of the products formed was monitored in the 300–700 nm wavelength range. Both quinones, in their triplet excited state have revealed similar reactivity towards the ground state SY. Kinetics probed at the characteristic wavelengths of the triplets and ion radicals show that the formation of the quinone radical anion and the decay of the corresponding triplet are synchronous. This confirms that the photo-induced excited triplets, AQT and NQT have been quenched by SY through electron transfer process forming AQ•–, SY•+ ion pair. The lifetime of the decay of the triplets of the quinones and the growth lifetime of the radical anion of the same quinones are about 3 μs under deoxygenated condition. The presence of oxygen in the medium influences the decay of the triplet and anion radicals of the AQ, but does not affect the decay of the triplet or anion of NQ. In the presence of oxygen, AQ•– radical anion interacts with oxygen and forms superoxide anion radicals, O2•–. The overall result from the current investigation is an evidence for the controversial role of SY in oxidative stress. The ability of SY to quench the photo excited quinones could give some insight to mitigate the drug induced photosensitivity and also could broaden the clinical usage of SY in other therapeutic areas.

Calcific aortic valve disease (CAVD) is the most common valvular disorder, affecting approximately 25% of the population aged over 65 years. The formation of calcific nodules on the aortic surface of the leaflets contributes to a progressive obstruction of the left ventricular outflow and leads ultimately to heart failure (Stewart et al., 1997). While CAVD has been described historically as a passive degenerative process, it has now emerged as a highly regulated pathology presumably triggered by a combination of conventional cardiovascular risk factors, mechanical and hemodynamic cues. As an important hemodynamic force, fluid shear stress (FSS) is the frictional force acting in the direction of blood flow on the leaflet endothelium. FSS is experienced by the ventricularis when blood flows past the leaflets during systole and on the fibrosa when blood pools into the sinuses during diastole. Previous studies showed that FSS affect the molecular mechanisms that eventually lead to formation of calcific nodules for CAVD. (Sun, Rajamannan, & Sucosky, 2013). A severely calcified aortic valve needs to be replaced with an artificial valve. Mechanical or prosthetic valves are durable but come with the lifelong anticoagulant treatment. An alternative approach is tissue engineered valves within which aortic valve cells can grow, enhancing the biocompatibility of the valve (Bezuidenhout, Williams, & Zilla, 2015). No matter the artificial valve is mechanical, prosthetic or tissue engineered, when placed into the patient, it should interact with blood flow with minimal disturbance in order for not causing additional complications. Therefore, these valves need to be tested experimentally for the hemodynamic performance. In this study, we have developed an experimental system to investigate hemodynamics for artificial aortic heart valves. The system is composed of Aptus pulsed duplicator system and GE Vivid-q ultrasonic medical imaging system. Aptus pulsed duplicator generates the flow environment for left ventricular outflow tract. Artificial aortic valves can be placed inside the system and these valves are exposed to natural blood flow environment (i.e. natural pressure, heart rate, ejection fraction). GE Vivid-q system enables us to visualize how valve leaflets open and close in each pulse via b-mode ultrasound imaging. M-mode enables us to measure valve orifice size at peak ejection. Doppler mode on the other hand enables us to measure flow velocities through valves, which then are used to estimate FSS levels. Pressure measurement probes inside the pulse duplicator gives simultaneous pressure readings which are then used to calculate pressure difference across the valve which is another parameter to define valve function. Aptus bioreactor platform is equipped with a holder system that enables testing virtually any material (including woven and knitted fabrics) as a scaffold for heart valve leaflet. The holder is build out of transparent PDMS to enhance optical visibility. The valve geometries that will be tested can be chosen at different wall thicknesses and other dimensions. For example, geometry of the sinuses and leaflets can be freely chosen/designed. This enables comparison of different prototypes for the optimized tissue engineered scaffolds. We will compare the performance of the scaffolds that are designed in our lab with commercially available prosthetic valves. In conclusion, we were able to develop an ultrasound based experimental flow system that will enable us to evaluate the tissue engineered heart valve scaffolds in natural heart environment.

References

Bezuidenhout, D., Williams, D. F., & Zilla, P. (2015). Polymeric heart valves for surgical implantation, catheter-based technologies and heart assist devices. Biomaterials, 36, 6–25. doi: http://dx.doi.org/10.1016/j.biomaterials.2014.09.013

Stewart, B. F., Siscovick, D., Lind, B. K., Gardin, J. M., Gottdiener, J. S., Smith, V. E., … Otto, C. M. (1997). Clinical Factors Associated With Calcific Aortic Valve Disease fn1. Journal of the American College of Cardiology, 29(3), 630–634. doi: http://dx.doi.org/10.1016/S0735-1097(96)00563-3

Sun, L., Rajamannan, N. M., & Sucosky, P. (2013). Defining the Role of Fluid Shear Stress in the Expression of Early Signaling Markers for Calcific Aortic Valve Disease. PloS one, 8(12), e84433. doi: 10.1371/journal.pone.0084433

Background

The X-linked inhibitor of apoptosis (XIAP) is a promising molecular target for the design of novel anticancer drugs aiming at overcoming apoptosis-resistance of cancer cells. Recent studies demonstrated that the BIR3 domain of XIAP where caspase-9 and Smac proteins bind is an attractive site for designing small-molecule inhibitors of XIAP. Embelin, identified primarily from the Embelica ribes plant, is one such compound shown to exhibit chemopreventive, anti-inflammatory, and apoptotic activities via inhibiting XIAP activity.

Material and Methods

Reagents

Embelin was purchased from Tocris (Cambridge, MA). TRAIL was purchased from Alexis Corporation (Lausen, Switzerland). Antibodies against Caspase 3, cleaved caspase-3 were purchased from Santa Cruz Biotechnology (Santa Cruz, CA, USA). Polyadenosine 5’-diphosphate ribose polymerase (PARP) was purchased from Cell Signaling Technologies (Beverly, MA). BD Cytofix/Cytoperm Plus Fixation and Permeabilization Solution Kit, Propidium Iodide Staining Solution, Annexin V Binding Buffer, Mitochondrial Membrane Potential Detection (JC-1) Kit, Stain Buffer (FBS), Annexin V-FITC antibody, H2AX (pS139)-Alexa Fluor 647 antibody, Rabbit Anti- Active Caspase-3- BV605 antibody and PARP Cleaved Form-AF700 antibody were obtained from BD Biosciences (NJ, USA). CellROX Deep Red Reagent was obtained from Molecular Probes, Life Technologies (CA, USA). (3-(4,5-dimethyl thiazol-2yl)-2,5-diphenyl tetrazolium bromide) solution (MTT) powder, DAPI, and N-Acetyl-L-Cysteine were obtained from Sigma-Aldrich (MO, USA). Apoptotic DNA ladder Kit was procured from Thermo fisher Scientific (USA).

Methodology

We used following assays and methods for this study.

Cell culture

Leukemic cell lines K562 and U937 leukemic cells were cultured in RPMI 1640 medium supplemented with 10% (vol/vol) fetal bovine serum (FBS), 100 U/ml Penicillin and 100 U/ml Streptomycin at 370C in humidified atmosphere containing 5% CO2. All experiments were conducted in 5% serum.

Cell viability

Experiments were performed following treatment with various doses of embelin with and without pre-treatment with NAC for 24 hours using MTT assay.

ROS Production

CellROX Deep Red Oxidative Stress Reagent is a fluorogenic probe designed to reliably measure reactive oxygen species (ROS) in live cells. The cell-permeable reagent is non-fluorescent or very weakly fluorescent while in a reduced state and upon oxidation exhibit strong fluorogenic signal. The signals from CellROX Deep Red Reagent are localized in the cytoplasm and measured by flow cytometry (Excitation 640 nm/Emission 665 nm). K562 cells were treated with embelin for indicated time periods and finally analyzed by flow cytometry.

Apoptosis

Apoptosis was measured using annexinV-FITC/PI staining and analyzed by flow cytometry. Cells were treated with embelin in the presence and absence of NAC for 24 hours. Following treatment, cells were harvested, washed with PBS and stained with annexin V-FITC/PI for 20 minutes at room temperature and apoptosis was measured by flow cytometry.

Western blot

Following treatment with embelin and NAC for 24 hours, cells were lysed and proteins were isolated. Equal amounts of protein were separated by SDS-PAGE, transferred to PVDF membranes and probed with specific antibodies.

Results

The results from our study showed that Embelin causes a dose dependent inhibition of cell proliferation in K562 and U937 leukemic cells. Anti-proliferative activity of Embelin correlated with induction of apoptosis. In addition, Embelin treatment of K562 cells decreased the constitutive phosphorylation/activation of AKT followed by the upregulation of proapototic protein Bax. Embelin also induced loss of mitochondrial membrane potential, as determined by JC1 staining, with subsequent activation of caspase-3 and polyadenosin-5’-diphosphate-ribose polymerase (PARP) cleavage. Pretreatment of K562 cells with N-acetyl-L-cystein, a scavenger of reactive oxygen species (ROS) prevented Embelin mediated apoptotic effects. Embelin also suppressed K562 derived progenitor colony formation, suggesting its antileukemic effect. Finally our data also showed that co-treatment of subtoxic doses of Embelin and TRAIL potentiated anticancer activity in leukemic cells.

Conclusion

Altogether, these findings suggest that Embelin causes inhibition of cell proliferation and induction of apoptosis via generation of ROS in leukemic cells, which raises the possibility that Embelin alone or in combination of chemotherapeutic agents may have a future therapeutic role in leukemia and possibly other malignancies with up-regulated XIAP pathway.

Keywords

Apoptosis, CML, ROS

The overlap stage is one of the most time- and space-consuming steps in de novo genome assembly. The huge size of output of Next Generation Sequencing (NGS), represented by small segments of multiple copies of the original genome, creates a serious computational challenge. The target is to find overlaps between each pair of sequences (reads) in order to build an overlap-based graph which constitutes the input for the assembly stage in which longer sequences (contigs) are sent to output. Finding overlaps between each pair of the input reads can be performed by solving the all-pairs suffix prefix problem (APSP) for these sequences. Such a problem, if not addressed effectively by designing new algorithms, data structures, and parallel processing techniques, can create an obstacle to the target of making genome assembly possible even with limited resources. This work presents a survey for previously presented solutions for APSP. We demonstrate and classify these techniques. Showing recent results regarding the time and space consumption for these solutions, we draw a conclusion regarding the best direction to tackle this critical problem. All-pairs suffix prefix is a well-known computer science problem. For a group of sequences G =  {S1, S2, S3, …. Sk), finding all pairs suffix prefix is to find the longest suffix prefix match for each ordered pair in G. For instance, let G =  {AACCGT, TAAAC, ACCCTA}. The solution to all-pairs suffix prefix for G is: (1,2) = {T}, {1,3} = {}, (2,1) = {AAC}, (2,3) = {AC}, {3,1} =  {A} and (3,2} = {TA}.

The first optimal solution for APSP was introduced by Gusfield et al. (D. Gusfield, 1992). The algorithm was based on the generalized suffix tree and takes O(n+k2) time, where n is the total length of all k strings. The suffix tree data structure is one of the most important tools for string matching and its applications in bioinformatics. A suffix tree of a sequence S is an index structure in which each suffix of S is stored as a path from the root to a leaf. Obviously many suffixes will share partial path before they end in different leaves.

Despite the fact that suffix tree's performance in solving many genome analysis problems is considered optimal, suffix tree is expensive in term of space. A pointer-type suffix tree typically requires O(n log n) space, whereas the original text over an alphabet of size requires only O(n log) bits. In addition, suffix tree has a bad locality of memory reference, which causes a remarkable slowdown in cached processor architectures.

A practically faster and less space-consuming solution for APSP was presented by Ohlebusch and Gog in 2010 (E. Ohlebusch and S. Gog, 2010), using the enhanced suffix array (M. Abouelhoda, 2004). Suffix array has emerged as a substitute to suffix tree in order to avoid its high space consumption, and to achieve better locality. The suffix array SA of a string S is an array of integers including the positions of the lexicographically sorted suffixes of S; i.e., for any two integers 0 i’ < i’’ <  n, S[SA[i’]] is lexicographically less than S[SA(i’’)]. Several indices were introduced in the last decade as compressed versions of suffix trees and suffix arrays. Those indices were considered a miracle since they don't just offer indexed searching, but also extract any text substring from the original text. With these self-index data structures, the original text is unnecessary and can be discarded. The term self-index highlights the fact that text is not stored explicitly but it can be derived from the index. FM index and RLCSA are examples for compressed suffix array, while Sadakane tree is a good example for compressed suffix tree.

Simpson and Durbin (J.T. Simpson and R.Durbin, 2012) used the FM index (P. Ferragina, 2004) to solve APSP in an indirect way as follows. The index is constructed for all strings after concatenating them in one string. The index is then queried by the reads, one by one, to find prefix-suffix matches. The time complexity of this algorithm is not as optimal as the one of (D. Gusfield, 1992), because one examines more suffixes than the output size. (This limitation stems also from the fact that the FM index lacks structural information to run the algorithms of (D. Gusfield, 1992) or (E. Ohlebusch and S. Gog, 2010) on it.). However, its space consumption is much less than that of the previous algorithms. The resulting assembler was called SGA.

Rachid et al. (M. H. Rachid Q. M., 2014) presented two solutions to solve APSP using a Sadakane suffix tree. The Sadakane suffix tree is a self-index and fully functional in a similar way to the uncompressed version of suffix tree. It offers the typical suffix tree operations such as checking if a node is a leaf, moving to the next sibling, using a suffix link, or even performing lowest common ancestor queries which can be expensive in term of time with other compressed data structure such as FM. Rachid et al. (M. H. Rachid Q. M., 2014) took advantage of the different components of this tree to solve APSP. The authors also utilized these components in building two different parallel implementations of these solutions. Rachid et al. (M. Haj. Rachid, 2014) also presented a solution to APSP using RLCSA. RLCSA is a compressed suffix array, which is introduced in (J. Sirén, 2008), (J.Sirén, 2010), and (V. Mäkinen, 2009). Both solution achieved considerable space reduction, but with a big slowdown.

Readjoiner (G. Gonnella & S. kurtz, 2012) was recently proposed as an efficient genome assembler that, in the overlap stage, finds suffix-prefix matches with a minimal length ℓ by grouping all relevant suffixes in buckets. Each bucket is identified by a common prefix for all suffixes inside it. Then, after sorting suffixes inside each bucket, it finds suffix-prefix matches using the lcp-intervals concept which is introduced in (M.I. Abouelhoda, 1994). The overlap stage in Readjoiner achieved best time and space consumption over all earlier solutions. Rachid and Malluhi (M. H. Rachid Q. M., 2015) presented a solution, called SOF, for APSP using a compact prefix tree. A prefix tree is a tree in which every read is represented by one path from the root to a leaf. The internal nodes represent common prefixes between reads. SOF could not achieve better results than Readjoiner using a single thread; however it shows better scalability and better time and space consumption in a multithreading environment. Figures 1 and 2 show the time and space consumptions for 7 different solutions to APSP when running on randomly generated data (M. H. Rachid Q. M., 2015).

Figure 1. Time consumptions for 7 solutions running on randomly generated data

Figure 2. Space consumptions for 7 solutions running on randomly generated data

We conclude that using suffix tree/array-based solutions, with standard or compressed forms, is not the best direction to solve APSP, despite the fact that they may possess an optimal time complexity. It turns out that other techniques which are based on LCP interval can achieve practically superior results in term of time without the large space which a suffix tree/array requires.

Bibliography

D. Gusfield, G. L. (1992). An efficient algorithm for the all pairs suffix-prefix problem. Inf. Process. Lett, 41(4):181–185.

E. Ohlebusch and S. Gog. (2010). Efficient algorithms for the all-pairs suffix-prefix problem and the all-pairs substring-prefix problem. Inf. Process. Lett, 110(3):123–128.

G. Gonnella, & S. kurtz. (2012). Readjoiner: a fast and memory efficient string graph-based sequence assembler. BMC Bioinformatics, 13:82.

J. Sirén, N. V. (2008). Run-Length Compressed Indexes Are Superior for Highly Repetitive Sequence Collections. in Amihood Amir; Andrew Turpin & Alistair Moffat, pp. 164–175.

J. Sirén. (2010). Sampled Longest Common Prefix Array. CoRR abs.

J. T. Simpson and R. Durbin. (2012). Efficient de novo assembly of large genomes using compressed data structures. Genome research, 22(3):549–556.

M. Abouelhoda, S. K. (2004). Replacing suffix trees with enhanced suffix arrays. Journal of Discrete Algorithms, 53–86.

M. H. Rachid, Q. M. (2014). Using the sadakane compressed suffix tree to solve the all-pairs

suffix-prefix problem. BioMed research international.

M. H. Rachid, Q. M. (2015). A practical and scalable tool to find overlaps between sequences. BioMed Research International, 12.

M. Haj. Rachid, Q. M. (2014). A space-efficient solution to find the maximum overlap using a compressed suffix array. Biomedical Engineering (MECBME), 329–333.

M. I. Abouelhoda, S. K. (1994). Replacing Suffix Trees with Enhanced Suffix Arrays. Journal of Discrete Algorithms, 2, 53–86.

P. Ferragina, G. M. (2004). An alphabet-friendly fm-index. In SPIRE, 150–160.

V. Mäkinen, G. N. (2009). Storage and Retrieval of Individual Genomes. in Serafim Batzoglou, ed., ‘RECOMB’, Springer., pp. 121–137.

Background

Duncan-Hewitt and Austin (2005) argue that pharmacist education has shifted from apprenticeship into higher education. This shift created “a gap between education theory and education practice”. Therefore, the role education theory plays in educational practices should be examined.

Objectives

Analyze the PharmD programme at QU through the lens of a theory-informed CoPF comprising of six elements: enablers, challenges, curriculum, teaching strategies, assessment and outputs.

Methodology

Using a a case study methodology, the CoPF was used to examine the PharmD programme at QU. Data from Interviews and focus groups with programme stakeholders and programme documents were thematically analyzed using NVIVO software.

Results

The CoPF has proved useful in identifying, systematically, the elements of design needed for a fully integrated PharmD programme. Key CoPF elements existed in the PharmD at QU, whilst others were missing. For example, practitioners have not been involved in designing the programme, as anticipated in the Enablers, and they lack understanding of education theory, identified in the Challenges. This has led to the lack of collaboration in curriculum, teaching and assessment between faculty and preceptors. This has subsequently limited one of the outputs of CoP, which is the integration between theory, practice and research.

Discussion

Some elements were identified as significant to have in place for an effective PharmD programme which aligns with CoP. Specifically the collaboration between practitioners and faculty in the design phase, in education process comprising curriculum, teaching and assesment in order to reach the ultimate output of integration between theory, practice and research.

References

Braun, V. & Clarke, V., 2006. Using Thematic Analysis in Psychology Qualitative Research in Psychology, 3, 77–101. Bristol: University of the West of England.

Duncan-Hewitt, W & Austin, Z. 2005. Pharmacy Schools as Expert Communities of Practice? A Proposal to Radically Restructure Pharmacy Education to Optimize Learning. Am J Pharm Educ American Journal of Pharmaceutical Education, 69(3):54.

Lave, J. & Wenger, E. 2001. Legitimate peripheral participation in communities of practice. Supporting lifelong learning: Perspective on learning, 1:111–126.

Yin, R.K. 1994. Case study research: design and methods. Thousand Oaks: Sage Publications.

Background

Cystic fibrosis (CF) is a genetic disease affecting 70,000 individuals worldwide and results from mutations in the gene that encodes the cystic fibrosis transmembrane conductance regulator (CFTR). In the lungs, the mucociliary clearance mechanism is impaired and the airways of CF patients are often colonized by bacteria, yeasts and filamentous fungi. Among clinically significant fungi, Candida spp. are the most common yeasts but their prevalence rates vary greatly according to the different studies. It is still controversial as to whether Candida spp. are transient or persistent colonizers of the respiratory tract of CF patients. Candida dubliniensis is pathogenic yeast of the genus Candida which is phenotypically closely related to C. albicans. It is emerging yeast in the respiratory tract of patients with CF.

Aims and objectives

To determine the frequency of C. dubliniensis recovered from lower respiratory samples of CF patients and compare between pediatric ( ≤  18 year) and adult (> 18 year) CF patients. The secondary objective was to evaluate whether CF patients have persistent C. dubliniensis isolated in their lower respiratory secretions.

Methods

A prospective study of 52 CF patients (38 pediatric and 14 adult CF patients) over a period of 14 months. Each CF patient had at least two lower respiratory secretions either an outpatient or in-patient setting with interval 3–5 months between specimens during the study period. Sputum samples, deep pharyngeal swabs (taken from patients who did not produce sputum), and bronchoalveolar lavage (BAL) samples were collected and immediately delivered to the Mycology Laboratory at Hamad Medical Corporation, Doha, Qatar. Patients were excluded from the study if they had only one respiratory sample. Respiratory secretions were cultured for Candida species and identified by matrix-assisted laser desorption ionization-time of flight mass spectrometry (MALDI-TOF MS). Clinical data including body mass index (BMI) and the FEV1% (the volume of air forcefully exhaled in one second and then converted to a percentage of normal) were collected. Descriptive statistics and unpaired t test were used to analyze the data using SPSS 21software.

Results

Candida isolates were obtained from 40 CF patients (76.9%). There were 56.2% (77/137) of respiratory specimens positive for Candida species. C dubliniensis was the most prevalent Candida sp. 65%(50/77) isolated from 29 CF patients more often from adults than children (91.3% vs 53.7%; respectively). Other Candida spp. isolated was C. albicans 27.2%(21/77), C. tropicalis 6.5%(5/77) and C. glabrata 1.3%(1/77). In CF patients, two or more Candida spp. were never isolated from the same respiratory specimen. During the study period, C. dubliniensis was isolated repeatedly in 11 (27.5%) CF patients and transient isolates were found in 13 (32.5%) patients. C. dubliniensis was recovered from the first respiratory specimen followed by other Candida spp. in subsequent samples in 5 (12.5%) patients. C. dubliniensis has no significant effect on BMI and the FEV1% during the study period in each persistent and intermittent C. dubliniensis group respectively (P>0.05). None of the CF patients received antifungal therapy. The prevalence of C. dubliniensis was higher in adults harboring Pseudomonas aeruginosa, while in pediatric patients C. dubliniensis coexisted with Staphylococcus aureus.

Conclusion

The present study reports the high and frequent occurrence of C. dubliniensis from the lower respiratory secretions of CF patients and has no effect on both BMI and FEV1%.

Introduction

This study was held on the in vitro tests for the bacteriophages and their efficiency comparing with the antibiotics susceptibility in destroying bacteria. Because the development of the resistance to chemotherapeutic agents is becoming an increasing problem. Antimicrobial phage therapy trials have demonstratedphage infection of the increasing incidence resistantbacteria against most or all known antibiotics especially (hospital-acquired) infections.

Rational

This had the potential to facilitate more rational thinking about the phages as antimicrobial therapy for the increasing incidence of bacteria resistant against most antibiotics.

Objectives

Isolating and Identifying the bacteriophage, examining the bacteriophage efficiency against bacteria and comparing them with the antibiotics susceptibility.

Methods

Bacteria isolation and identification: Escherichiacoli and Staphylococcus aureus were isolated from Soba Stabilization Station and subjected to test against bacteriophages isolated from the same location. Susceptibility of isolated bacteria: Toward antibiotics and bacteriophages was determining. One of the virus stocks was Chosen and dispended in the serial dilution the virus sample was mixed with a dense bacterial culture and melted with soft agar and then spread over the surface of a base agar plate and used to infectbacteria. The plaques produced were then counted according to the number adjusted for the dilution to investigate bacteriophage specificity toward thespecific bacteria. Protein profiles of the bacteria and their correspondings phages were done by Sodium dodocyl sulphate polyacrylamid gelelectrophoresis (SDS-PAGE). The Microsoft Excelprogram was used for the statistical analysis, and thebioinformatics programmes UN – SCAN – IT version5 and ImageJ 136b were used for the proteinmolecular mass weight analysis.

Results

Escherichia coli: E. coli showed sensitivity towards: Ciprofloxacin, Pefloxacin, Ofloxacine, Tetracycline, Amikacin, Gentamicin, Piperacillin and Ceftizoxime, the largest inhibition zone was shown with Ciprofloxacin as 29 mm diameter. E. coli wasresistant to Chloramphenicol, Cefotaxime, Co-Trimoxazole and Ampicillin. Staphylococcus aureus: he S. aureus was sensitiveto Lincomycin, Cloxacillin, Ciprofloxacin, Tetracycline, Ofloxacine, Ampicillin/ Sulbactam and Cephalexin and the largest inhibition zone was shown with Lincomycin as 42 mm diameter. S. aureus showed resistant towards: Roxythromycin, Gentamicin, Pefloxacin, Cefotaxime, and Co – Trimoxazole. In broth media the affection of the bacteriophage interactions with bacteria showed increasing of the bacteriophages and decreasing of bacteria due to culture clearance, where the readings of the turbidity for the first and second infection showed statistical significant of E. coli phages samples’ transmission due to place of samples collections; from the anaerobic and facultative ponds P>0.05, facultative and maturation P < 0.05 and anaerobic and maturation P>0.05. Whilst, the S. aureus phages samples’ transmission from the anaerobic and facultative P < 0.05, facultative and maturation P < 0.05 and anaerobic and maturation P>0.05. On solid media the affection of the bacteriophage was recognised by the phage plaque formation on bacterial cultures. The antibiotics susceptibility against the bacteria showed statistical significant P < 0.05 for E. coliand P < 0.05 for S. aureus. The phage proteins were separated by Sodium Dodecyl Poly Acrylamide Gel Electrophoresis technique, the protein profiles of E. coli bacteriophage showed three major bands with molecular weight mass of 47, 34 and 16 kilo Dalton and 34 and 20 kDa for S. aureus phage, the band of 35 kDa was the common shared peak between the phage and the bacterial host due to the bacteriophage lytic cycle. The efficiency of isolated phage against E. coli and S. aureus showed remarkable inhibition of growth of the bacteria at both solid and liquid media this might bedue to physio-chemical changes and difference inmotility of these two bacteria. The mechanical action of bacteriophage on selected bacterial species dependon their receptors that adsorb them to their hosts, there lation between the bacteria and their corresponding phages.

Conclusion

The study showed approximately similar results for the mechanical action of the bacteriophage on the selected bacteria species and the mode of action of antibiotics. It is preferably to manipulate bacterial infections by the Bacteriophage therapy in case of the antibiotic resistant bacteria.

The key challenge with Epidemics includes its ability to spread rapidly and impact several large communities with high fatality rates. These characteristics make it difficult and very expensive to manage epidemics once it has broken out. History is replete with several cases of epidemic out breaks spreading from the point of origin and being transmitted to other areas resulting in the deaths of several thousands and in some cases millions of the inhabitants. The distance of the spread in the early 19th century was limited due to the limitations in travel speed and distance but this did not reduce the death rates of these diseases. The small pox disease was recorded to have killed more than 20% of the population of Athens in Greece. The great plague of London was recorded to have started in China in 1334 but spread along the trade routes wiping out entire towns. Florence in Italy lost a third of its entire 90,000 residents in the first six months with Europe losing an estimated 25 Million people. In 1633, Massachusetts which hitherto had been free from small pox became infected as settlers from France, Great Britain and the Netherlands brought the communicable disease with them resulting in the death of several millions. Other infectious diseases which have resulted in epidemics resulting in the deaths of several thousands of people in other regions of the world include the HIV/AIDS, H1N1, flu pandemic, the Severe Acute Respiratory Syndrome among other epidemics, these epidemics are usually spread by virtue of the cross border migration of the disease hosts. The UAE is gradually becoming the global holiday resort of choice while the UAE and Qatar are becoming the major transit hubs to India and China both of which account for over one billion of the world's population. Both regions are also bounded by Saudi Arabia which plays host to the world when they come to perform the holy pilgrimages to Mecca. This makes Qatar a location with a high potential for epidemic out breaks and necessitates the development of a robust real-time health monitoring systems capable of tracking possible epidemic causing diseases before they spread to the general population. The most effective means of containing the spread of epidemics is by monitoring the populace and quarantining any suspected victims or patient with a view to treating the case in isolation and controlling/preventing the spread of the epidemic to the general population. The transmission model for epidemics is represented by the branching process which shows the patient zero is the primary source of the diseases and the rate of spread of the disease is determined among other factors by the contagion probability of the disease.The current health management system does not provide a means of automatically identifying a likely epidemic and informing the relevant agencies to ensure the disease is contained by quarantining the patient zero. This work presents the development of an integrated health management system deployed as an application rining on laptops and tablets to be used by Doctors during consultation with patients for monitoring diseases occurrence in real time. It monitors patients and tracks in real time, the different diagnosis, patient location and possible epidemics by tracking the symptoms reported by the patients as they are examined in the consulting rooms and the results of the differett tests and examinations ordered by the doctors. It provides a means of alerting relevant healthcare authorities and all the other hospitals as soon as a case is identified in any consulting room. It harvests key diagnosis and monitors the number of occurrence of the reported ailments, the dispersion mechanisms and the possibility of the disease resulting in an epidemic. This data is transmitted and collated at a central health management unit. Different thresholds are set for the different ailments and dispersion mechanisms and when the thresholds are exceeded, the appropriate response mechanisms are deployed to the affected areas. When any of the known epidemics are detected in any consulting room, a high alert is sent to all the doctors in that hospital and containment systems deployed immediately to the affected hospitals for quarantining the patient and taking the necessary steps to ensure that the disease doesn't spread to the community. In the event of an epidemic, the application will generate the required emails to the relevant government agencies and send an SMS to the responsible parties to ensure appropriate action is taken. Relevant agencies in different countries can deploy this system and share information between their airports, immigration agencies, health management agencies etc, whenever any of such epidemic causing diseases break out or is reported in any of their hospitals. This will enable the different governments set up and deploy the relevant response teams and tools to ensure that the disease does not cross into their country and in the event that it arrives at the airport, the patient is immediately quarantined and investigated and the necessary medical treatment administered.

Background & objective

In order to survive the effects of the stress conditions, such as hypoxia and glucose starvation (GS) that exist in a tumor microenvironment, the regulatory mechanisms that control metabolism in cancer cells undergo change so that sufficient energy sources are available for proliferation, migration and invasion - thus facilitating metastasis. Via what is referred to as The Warburg Effect cancer cells primarily derive energy by metabolizing glucose through enhanced glycolysis even in the presence of an ample amount of oxygen. Thus, in principle, the non-specific cytotoxicity of traditional cancer chemotherapeutic agents will be reduced via a therapeutic strategy that targets the altered metabolism that is unique to cancer cells. Therefore, we predict that by using drugs, targeting cancer cell metabolism in combination with therapeutic strategies, which cause energy stress in cancer cells will result in a synergistic effect and enhance the likelihood of selectively killing cancer cells. Metformin, the most frequently prescribed, anti-diabetic drug has been shown to exhibit anti-cancer activity in different types of cancer cells thus supporting epidemiologic data that is suggestive that type 2 diabetic patients treated with metformin seem to be less likely to develop various types of cancers. Since angiogenesis is a key function of endothelial cells and aberrant angiogenesis is key to survival and growth of a tumor, we studied the effect of metformin on glucose-starved (GS) cancer microvascular endothelial cells with special reference to the Akt/mTOR pathway that is known to be dysregulated in many forms of cancer.

Materials & methods

In the present study mouse mile sven 1 vascular endothelial growth factor endothelial cells (MS1-VEGF; CRL-2460,

from ATCC, USA, of micro-vascular endothelial origin) cells were subjected to GS for 48 h in the presence & absence

of metformin (2 mM). Metformin treated and non-treated normal glucose (11 mM) exposed cells were used as suitable controls. MS1-VEGF cells were produced by overexpressing the primate VEGF-121 in the MS1 endothelial cell line that was derived from mice pancreatic microvasculature and immortalized with temperature sensitive SV40 large T antigen (1). These cells generate well-differentiated angiosarcomas in nude mice model (1). Following the experimental protocol cell lysates were prepared, total protein estimation was carried out and thereafter western blot analysis was performed to assess the levels of Sirt1, pAkt (S473), acetylated-p53 (K379), pmTOR (S2448), pRaptor (S792), p4E-BP1 (T36/47), pS6 (S235/236), pS6 (S240/244) and cleaved caspase-3. The band densities of the western blot images obtained were then quantified using the basic Quantity One software (Biorad, Inc. CA, USA). Trypan blue exclusion assay was carried out for cell viability analysis while MTS assay was carried out to analyze the cell proliferation status. Propidium iodide staining followed by FACS analysis on a BD LSRFortessa system (BD Biosciences, CA, USA) was performed for cell cycle analysis. All the data was analyzed using the statistical software GraphPad Prism 5.0 (GraphPad Software, Inc. CA, USA). Data is presented as mean ±  SEM. Statistical analysis was performed using one-way analysis of variance (ANOVA) and post-hoc comparisons between groups were performed by Tukey's multiple comparison tests. ‘p’ values less than 0.05 were considered to be statistically significant.

Results

Glucose starvation for 48 h in MS1-VEGF cells reduced cell proliferation and showed a significant increase in the levels of pAkt (S473) and a significant decrease in the levels of acetylated-p53 when compared to normal glucose exposed cells. mTOR is known to be phosphorylated at S2448 by Akt. The GS induced increase in the levels of pAkt (S473) can be related to the observed significant increase in the levels of pmTOR (S2448). The increase in the levels of pmTOR (S2448) also caused increase in the levels of downstream pS6 (S235/236) and pS6 (S240/244) in the glucose starved cells when compared to normal glucose exposed cells. Treatment with metformin (2 mM) for 48 h in MS1-VEGF cells subjected to GS significantly reduced cell viability. This can be related to the significant decrease in the levels of Sirt1 and pAkt (S473), which in turn would contribute to the increase in the levels of acetylated-p53 and decrease in pmTOR (S2448) levels in the metformin treated glucose starved cells when compared to non-treated glucose starved cells. Inhibition of mTOR pathway was confirmed by the significant decrease in the levels of downstream p4E-BP1 (T36/47), pS6 (S235/236) and pS6 (240/244) in metformin (2 mM) treated glucose–starved MS1-VEGF cells when compared to non-treated cells subjected to GS. In addition, the levels of pRap (S792), a negative regulator of mTOR activation, significantly increased in metformin treated glucose starved cells when compared to non-treated glucose starved cells. Inhibition of the Akt/mTOR pathway provides an explanation for the decrease in cell viability as evident by the accumulation of cells in the G2/M phase of the cell cycle. In addition to G2/M arrest, a significant decrease in the G0/G1 phase was observed while the cells in the sub-G0/G1 phase increased indicating cell death in the metformin treated glucose starved cells when compared to the non-treated glucose starved cells. The significant increases in the levels of acetylated-p53 and cleaved caspase-3 indicate that the cells have entered the apoptosis pathway. Treatment with 2 mM metformin also reversed the glucose starvation induced pro-survival autophagic response as evidenced by a decrease in the levels of LC3A-II and LC3B-II and marked reduction in the formation of LC3B stained punctae, when compared to non-treated glucose starved cells. Knockdown of AMPK revealed that this effect of metformin on GS induced autophagy is independent of AMPK.

Conclusion

Our findings indicate that using metformin in combination with agents that modify cancer cell metabolism (such as glycolytic inhibitors) is a therapeutic strategy that will selectively promote cancer cell death.

This work was supported by the Qatar National Research Funds (QNRF): National Priorities Research Program (NPRP: 4-910-3-244, awarded to Dr. Chris R. Triggle), a Junior Scientist Research Experience Program (JSREP 03-016-3-009, awarded to Dr. Samson Mathews Samuel). We thank Ms. Aleksandra M. Liberska (Flow cytometry supervisor) and the Flow Cytometry Facility within the Microscopy Core at Weill Cornell Medicine-Qatar for contributing to these studies. The Core is supported by the “Biomedical Research Program at Weill Cornell Medicine-Qatar”, a program funded by Qatar Foundation.

Reference

[1] Arbiser, J. L., Larsson, H., Claesson-Welsh, L., Bai, X., LaMontagne, K., Weiss, S. W., Soker, S., Flynn, E., and Brown, L. F. (2000) Overexpression of VEGF 121 in immortalized endothelial cells causes conversion to slowly growing angiosarcoma and high level expression of the VEGF receptors VEGFR-1 and VEGFR-2 in vivo. Am J Pathol 156, 1469–1476.

Introduction

Warfarin has been the cornerstone oral anticoagulant for more than 60 years. Direct oral anticoagulants (DOACs) have been introduced to the market since 2008. In Qatar, dabigatran was introduced in 2011 followed by rivaroxaban in 2014 and both DOACs are currently used along with warfarin for the treatment and prophylaxis of different thromboembolic diseases. Despite the perceived advantages of the DOACs and their proven efficacy and safety in randomized controlled studies, their use is not as well-established as it has been expected likely due to the lack of antidote and their high cost. Little is known about the prescription pattern of oral anticoagulants and the extent to which DOACs replaced warfarin in Qatar.

Aim

In this study, we aim to explore the trends in oral anticoagulant use in Qatar over the past 5 years and to what extent did DOACs replace warfarin. We also aimed to determine the appropriateness of DOACs use based on the dose and the indication.

Methods

From electronic medical records, we collected all anticoagulant prescriptions dispensed as in- or out-patient from 2011 to 2015 in all Hamad Medical Corporation (HMC) hospitals. Prescriptions were stratified by the year, the medication prescribed and the dose. For every calendar year, we calculated the number and percentage of patients using each one of the anticoagulants prescribed. We also compared the clinical and demographics characteristics of patients prescribed warfarin versus those prescribed DOACs. Descriptive and inferential statistics were performed using SPSS.

Results

The attached table shows the change over the years in the number of patients prescribed warfarin versus those receiving DOACs. Overall, the percentage of patients receiving DOACs increased gradually from approximately 0.5% in 2011 to 20% in 2015. About 40% of patients receiving DOACs were previous warfarin users. DOACs were appropriately used in more 80% of the patients. Year/ Drug Warfarin Number (%) Dabigatran Number (%) Rivaroxaban Number (%) 2011 2078 (99.47%) 11 (0.53%) 2012 2364 (97.52%) 60 (2.48%) 2013 2567 (90.04%) 285 (9.06%) 2014 2823 (83.3%) 320 (9.44%) 246 (7.26%) 2015 2065 (80.54%) 196 (7.64%) 303 (11.82%).

Conclusion

DOACs have been gradually replacing warfarin in Qatar in a trend that is similar to other countries as well. However, warfarin use remains essential in more than 75% of patients requiring oral anticoagulant. It is important to continue educating healthcare providers to ensure appropriate use of these novel agents.

Several lines of evidence implicated the pathophysiological role of the endoplasmic reticulum (ER) stress in obesity-induced insulin resistance and diabetes. Using a targeted transcriptomic profiling approach consisting of the Heat Shock Response RT2 Profiler PCR Array, we previously reported impaired expression of DNAJB3/Hsp-40 cochaperone in obese and diabetic human subjects that was restored by physical exercise. In addition to DNAJB3/Hsp-40, three other genes showing differential expression between lean and obese human subjects were identified and GRP78 is the subject of our current investigation. Using histochemistry, immunofluorescence and western blots, our data show that GRP78 protein is increased in the adipose tissue obese subjects and thus, confirming the initial transcriptomic approach. More interestingly, higher levels of circulating GRP78 protein were found in obese compared to lean subjects and they correlated negatively with VO2, Max but positively with CRP and the obesity indicators such as BMI, body fat, and waist circumference. As GRP78 is the master regulator of the Unfolded Protein Response (UPR), we investigated the status of three arms of the UPR namely ATF6, IRE1a and PERK. Consistent with the finding on GRP78, our data indicated a marked increase in the expression and activity of these three arms in the adipose tissue from obese subjects. We finally tested the hypothesis that physical exercise could modulate the expression and release of GRP78 and its downstream targets. Here, we provide for the first evidence that physical attenuated significantly the endogenous expression and release of GRP78 with a concomitant reduction in the activity of IRE1a and eIF2a. Taken together, these results strongly suggest that exercise alleviated ER stress in obese subjects through attenuation of GRP78 signaling network.

Background

Foreign Body Aspiration (FBA) is a serious common problem in children, which needs prompt diagnosis and management; delays can result in devastating consequences. Physicians often struggle with the all too important, yet elusive, decision of “To bronch, or not to bronch” patients who present with a suspected FBA. In most cases, the history is often vague, with only subtle, if any, physical and chest radiograph abnormalities. With this study, we aim to use our local experience in Qatar to retrospectively analyze broncho-scopically proven cases of FBA in an attempt to determine the key statistically significant clinical predictors of foreign body aspiration in children.

Objective

To develop a clinical algorithm with a scoring system for aiding physicians to accurately predict patients with FBA, needing bronchoscopy, based on the patient's historical, physical and radiological findings at presentation.

Methods

This is a retrospective observational study, including all patients, aged 0 to 14 years, who were admitted to the pediatric department of Hamad medical corporation, Qatar between January 2001 to January 2011 with a diagnosis of suspected FBA. All patients underwent bronchoscopy, either flexible or rigid or both. Detailed data regarding the history, presenting clinical signs and symptoms, physician documented physical exam assessment as well as radiological findings were collected and analyzed. The bronchoscopy records were reviewed for bronchoscopy details like type (Flexible vs rigid), size and instrumentation used, outcomes including presence, type and location of foreign body (FB) and pre and post procedure complications. The focus of the data analysis was to determine the predictive accuracy of the various variables in diagnosing FBA. For this, the sensitivity, specificity, positive and negative predictive values of these parameters were calculated, using bronchoscopy diagnosis of FBA as the point of reference. Univariate and multivariate logistic regression methods were used to determine their statistical predictive value.

Results

Based on the inclusion criteria, a total of 300 children were included in this study. Male, female ratio of 1.2:1. The mean age was 2.1 ± 1.7 years. 46.3% of the patients were Qatari nationals. These 300 patients, cumulatively underwent a total of 410 bronchoscopies, which included both flexible and rigid bronchoscopies (88 patients underwent 2 bronchoscopies, 17 had 3, 4 patients had 4 and one patient underwent 5 bronchoscopies). A FB was found in the airway of 91 of these 300 children (30.3%). In all of these cases, the FB was successfully removed, in 67 cases (∼75%) with a rigid bronchoscopy and in 23 patients (∼25%), using a flexible bronchoscopy. 1 patient required a thoracotomy. Post bronchoscopy complications were reported in only 2.6% cases, with no procedure related mortalities. The most common site of FB lodging was the right main stem bronchus (47.3%), followed by left main stem bronchus, bilateral main bronchi, carina and trachea. The rest were recovered from segmental smaller airways. Organic FB accounted for 62.6% of the FB removed, with peanuts being the most common type. A complete list of the clinical signs and symptoms based on parent's history, physical exam findings and radiological findings in both groups of children i.e. those with a recovery of FB during bronchoscopy (FBA positive) and those without a FBA (FBA negative), can be viewed in Table 1. Using multivariable logistic regression analysis controlling for all other potential predictors, we found that the risk factors with the strongest association with FBA are witnessed choking crisis (adjusted OR 2.1, 95% CI 1.03–4.3.8; P = 0.041), noisy breathing/stridor/dysphonia (adjusted OR =  2.7, 95% CI 1.22–6.17; P = 0.015), new onset, recurrent or persistent wheeze (adjusted OR 4.6, 95% CI 1.77–11.76; P = 0.002) and unilateral reduced air entry (adjusted OR 2.9, 95% CI 1.53–5.52; P = 0.001). No significant interactions were found between the various otherhistorical signs and symptoms, radiological and physical examination findings. Figure 1 shows the cumulative proportion of children with proven FBA according to the above 4 risk factors. Only 8% of the children without any of these risk factors had a proven FBA, the likelihood increased significantly with an increasing number of risk factors. When all 4 risk factors were present, the likelihood of FBA was a 100%. 242 of these 300 patients were also analyzed and grouped based on whether they had normal or abnormal physical or radiological findings on presentation. (The remainder of the patients did not have a documented exam or a chest radiograph on record review). The results were as follows: in children with both abnormal physical and radiological findings, 47.2% had a proven FBA. If only one was abnormal (i.e. either physical exam or chest x-ray), the likelihood of FBAreduced to 32–33.3%. In children who presented with a completely normal physical exam and chest radiograph, only 7.4% had a FB removed by bronchoscopy (Fig. 2). Based on the above results, we designed a clinical algorithm, with a scoring system (Fig. 3), to aid in determining those children who require bronchoscopy to rule out FBA, and those who can be discharged on close follow up, without any intervention.

Conclusion

Accurately diagnosing FBA in children who need quick intervention will always be challenging. A high index of suspicion is required, along with a comprehensive historical account, detailed physical exam and a chest radiograph. The ultimate decision for bronchoscopy is based on the physician's clinical judgment as there is no 100% diagnostic predictor of FBA, perhaps with the exception of a radio-opaque foreign body. Our proposed clinical algorithm hopes to empower physicians dealing with such cases to accurately predict patients with a high likelihood of FBA and initiate prompt management, as well as avoid unnecessary intervention in those who have a very low probability of FBA.

Chemical composition of fingerprints includes the presence of salts, ions, fatty acids, lipids, amino acids, nucleobases, nucleotides, and nucleic acids. Many methods used to detect latent fingerprints on porous surfaces such as paper exploit the reactivity of amino acids with a number of different reagents, including ninhydrin and lawsone (2-hydroxy-1,4-naphthoquinone; HNQ). HNQ, also known as hennotannic acid, is a natural yellow-orange dye present in the leaves of henna plant (Lawsonia inermis) as well as in the flower of water hyacinth (Eichhornia crassipes). It is used as natural dye to color hair and skin. HNQ has been shown to react with amino acids, accordingly used to detect fingerprints on paper. HNQ has also been shown to be a sensor for the detection of anions (changes its color from yellow to orange-red in the presence of anions such as OH-, CN-, etc.). The presence of nucleobases, nucleotides and/or nucleic acids that are also part of the chemical composition of fingerprints, has not been exploited to detect latent fingerprints. In this study we propose utilize the reactivity of HNQ, nucleobases and nucleotides to detect and enhance the detection of latent fingerprints. HNQ reacts with amines and form Schiff-bases that are expected to be strongly colored, whose colors can be further enhanced upon exposure to a base (NH3) or anions (OH- and/or CN). In this regard, we have synthesized a series of HNQ-amine derivatives using microwave green synthetic methods (reactants dissolved in methanol and the reaction carried out at 150°C for 5 min). The compounds formed in the above reactions are strongly colored as judged visually and by spectrophotometry. Under similar conditions, adenine and guanine bases or adenosine and guanosine nucleosides (with amine substituents) also react with aromatic aldehydes to form Schiff-bases. The aromatic aldehyde derivatives of these purine nucleobases or nucleosides are expected to be highly fluorescent. Again, we have synthesized a series of aromatic imine derivatives of adenine, guanine, adenosine and guanosine as above. As judged visually and by spectrophotometry, these compounds exhibit strong fluorescence. The spectroscopic characterization of the compounds described above is on-going. Further, we have used these compounds to detect and enhance detection of latent fingerprints. The latter involved (a) application of powdered HNQ, adenine, guanine, adenosine or guanosine on latent fingerprints or cyanoacrylate coated latent fingerprints, (b) powder deposition aromatic amines or aldehydes, (c) followed by microwave synthesis of Schiff-base derivatives directly on the surface of the fingerprints using a commercially available domestic microwave oven (medium power for 3–10 min). The resulting fingerprints developed as above with HNQ and aromatic amines are strongly colored. Further exposure of thus formed colored fingerprints to NH3 strongly enhanced their color. The fingerprints developed as above using purine nucleobases or nucleosides with aromatic aldehydes were strongly fluorescent. Through this study, we have successfully synthesized Schiff-base derivatives of HNQ and aromatic amines as well as purine nucleobases or nucleosides and aromatic aldehydes. Further, we also suggest a novel method for the detection of latent fingerprints and its successful application on nonporous surfaces using the newly synthesized compounds.

Introduction

Dissatisfaction with health care performance is an important source of information about health care reforms as perceived by the public as it is associated with negative beliefs about health system. Previous studies have shown that dissatisfaction with health care has a long-term negative impact on the health care users' relationship with healthcare providers, health related behaviors, and health outcomes. In addition, a recent study conducted in Qatar, showed that approximately 24% of the studied population who used health care in the past 12 months prior to the study were dissatisfied with health care services provided in the country. Given that dissatisfaction with care can negatively impact on help-seeking behaviors, this finding could have grave public health implications. This has been witnessed in the context of high prevalence of chronic health conditions in Qatar where long-term relations with healthcare professionals are necessary for better chronic disease management, reduced disease-related complications, and mortality. This study aims to identify the sources of dissatisfaction with medical care among adults, Qataris and white collar migrants aged eighteen years or older.

Methods

This study is based on secondary data from a larger national survey, which was conducted during the fall of 2012 for the purpose of collecting household-based information on health services utilization and health-related expenditures. Disproportionate stratified probability sampling was employed to select a representative sample of households. A final sample of 3,080 completed face-to-face interviews (1,528 Qataris and 1,552 White Collar Migrants) using computer assisted personal interviewing (CAPI) method for a raw response rate of 78.1%. The sample included individuals who may or may not have used Qatar's health care system during the 12 months prior to survey administration. Respondents were asked to discuss the reasons for their discontent with healthcare services in Qatar by selecting pre-coded categories of dissatisfaction including: Waiting time to see the provider, language used to communicate, clarity of how things are explained to the patient, poor services provided (such as cleanliness, reception, respect, and parking), inability to choose provider or doctor, high costs and other reasons to be specified by respondents. A total of 711 open-ended responses to the “Other” category were translated, coded and analyzed qualitatively. “Crowdedness”, “staff and physicians' incompetence”, “medical errors”, “discrimination”, “disrespect”, and “lack of staff and services” are all themes that emerged as reasons for dissatisfaction. Analysis Arabic responses were translated into English and researchers discussed any dissimilar results until an agreement was reached on all translated responses. Upon reviewing the responses, themes, which were different from the pre-specified answer choices of the questionnaire, emerged. The researchers then coded the responses by assigning codes to each response, then compared against each other. Coding discrepancy was discussed until an agreement was reached. The codes of the open-ended responses were later merged with those of the pre-specified categories and the corresponding frequency for each coding category was calculated using STATA. The Alberta Quality Matrix for Health was used to guide the analysis of the themes based on the six dimensions of health system quality.

Results

The analysis of the open-ended responses that probed into reasons for respondents' dissatisfaction revealed thirteen categories of dissatisfaction that were related to four different dimensions of quality of healthcare, based on the Alberta Quality Matrix for Health. The most common dimension of dissatisfaction with health care in Qatar was accessibility, which refers to the provision of health service in the most optimum setting and within “reasonable time and distance”. Safety was the second most common dimension reported by the respondents. This construct relates to minimizing any threats that could cause harm. Acceptability, such as the provision of respectful and patient-centered health services was the third dimension identified, followed by efficiency, which is mainly related to the optimal use of resources, to achieve the best desired health outcomes.

Conclusion

Identifying the roots of dissatisfaction with health care services among distinct social groups can be achieved by analyzing responses to simple open-ended questions in routinely administered population health surveys. This is important for monitoring the quality of care in heterogeneous population contexts as well as engaging the public in the process of developing a world-class health care system as per Qatar's national vision of 2030. This research highlights priority needs to be addressed by the Qatari government in order to increase health care satisfaction as part of the quest for better health care in the country.

The Developmental Origins of Health and Disease (DOHaD) concept describes how the environment impinges on intra-uterine development and early childhood and how it induces changes in the development that have long term impact on later health and disease risk. Environmental exposures including parental lifestyle and diet, obesity and chemical exposure have been shown to modulate disease risk. The effects do not simply disrupt development or induce disease themselves, but can affect how rapidly disease develops. Epigenetic changes are plausible molecular mechanisms that can explain disease development trajectories. We hypothesize that early life exposures can alter DNA methylation patterns, thereby predisposing the child to develop respiratory allergy (RA) later in life. We have used two longitudinal birth cohorts and biobanked samples in Belgium to discover and confirm DNA methylation signatures that can differentiate between RA cases and controls. Blood and saliva samples of 11-year old children from the discovery cohort were analyzed using Illumina Methylation 450K BeadChips (20 RA cases and 20 controls). Saliva is proposed as a DNA source that can be easily collected in a decentralized manner in children. In addition, we analyzed biobanked cord blood samples of the same children in order to detect if altered DNA methylation marks could be detected at birth, as a proxy for intra-uterine changes. The discovered methylation signatures were studied in blood and saliva samples in a second cohort of 5-year old children (N = 78). We installed an analytical pipeline for sample processing and data analysis. R-based software was used for data normalization and Comb-p tool was used to identify differentially methylated regions (DMR). The Illumina Methylation 450K BeadChips showed that the methylation status was comparable between blood and saliva, with ± 11% of the probes having a differential methylation pattern (Padj < 0.05 and |Δβ| >0.1). The results suggest that saliva is a suitable biofluid for genome-wide DNA methylation studies and that there is a substantial overlap with blood profiles. A comparison between RA cases and controls revealed 83 DMR in blood of the 11-year old children; CB 26 DMR in cord blood and 5 DMR in saliva. Two DMR were identified as being in common between blood, saliva and cord blood samples using a Venn diagram analysis. The DMR were located in genes involved in IL4 signalling, Th2-response and phagocytosis; pathways that are implicated in RA disease. These 2 DMR were confirmed by iPLEX MassArray analysis in the same birth cohort (N = 40) as well as in a second cohort (N = 78). This project provided novel insights in the molecular mechanisms that may predispose children to chronic disease development, such as RA. We have identified DNA methylation marks in saliva and blood of children that are relevant for RA. We have also observed these methylation marks in the children's biobanked cord blood taken many years before RA development. We are among the first to show the utility of saliva to study DNA methylation changes in children. Or results contribute to the DOHaD concept that has very important implication for many societies and for global health policy.

North Carolina Research Campus, 500 Laureate Way, Kannapolis, NC 28081, United States Abstract Chronic hyperglycemia is an important risk factor involved in the onset and progression of secondary complications of diabetes. Aldose reductase (AR) has been implicated in the etiology of diabetic eye diseases, diabetic cardiomyopathy and/or nephropathy. High glucose levels activate AR, which is one of the key rate limiting enzymes to use NADPH to reduce glucose to sorbitol in the polyol pathway. The depletion of NADPH is correlated to the production of GSH which increases intercellular oxidative stress. Since inhibition of AR plays an important therapeutic value in preventing and or alleviating diabetic complications. At present there are many AR inhibitors such as Sorbinil, Dilantin, Epalrestat, Tolrestat, Zopolvestat and Minalrestat. However, most of these compounds have serious side effects such as Steven-Johnson syndrome and hypersensitivity reaction. In recent years nutraceuticals have garnered interest for their potential as dietary and natural health promoting properties. Hence, the purpose of this study was to investigate the inhibitory activity of phloretin from apple, ( − )-epigallocatechin 3-gallate (EGCG) from green tea and [6]-gingerol from ginger against aldose reductase as indicator or their potential in the alleviation of diabetic complications. These three compounds were selected out of 9 bioactive compounds based on their activity in cell culture assays. Human retinal pigment epithelial (HRPE) cells were subjected to different concentrations of glucose (10–100 mM) for 1 and 4 days during which cell viability and aldose reductase activity were evaluated. Results show that cell viability decreased to 93 ±  3%, 83 ±  6%, 65 ±  4% and 39 ±  3% at 10, 25, 50 and 100 mM of glucose on day 1 with further drastic decrease in cell viability to 73 ±  5%, 61 ±  3%, 35 ±  2%, and 11 ±  6%, respectively, on day 4 compared to the untreated cell. The activity of aldose reductase was found to increase 5 folds at 10 mM from day 1 to day 4, whereas at 25, 50 and 100 mM concentrations of glucose the AR activity was increased to almost 2 folds. The specific activity of aldose reductase was found to be 8.92 ±  1.6 U/mg protein at 100 mM glucose on day 4. The apparent Michaelis constant (Km) of the substrate glyceraldehyde and NADPH was estimated to be 4.5 mM and 68.96 μM, respectively. Pre-treatment of cells with phloretin, EGCG and [6]-gingerol at 25 μM improved cell viability to 72 ±  4%, 77 ±  5% and 78 ±  4%, at day 1 respectively, whereas EGCG further improved cell viability on day 4 to 89 ±  5%, but phloretin and [6]-gingerol could marginally increase to 76 ±  3%, 81 ±  4% when compared to the untreated cells. The three compounds could inhibit AR activity up to 90 % at 12.5 μM of phloretin, EGCG and [6]-gingerol with IC50 values of 4.1 μM, 3.7 μM, and 2.4 μM, respectively. The enzyme inhibition kinetics showed non-competitive mode of inhibition for phloretin and EGCG, since it did not alter the Km but the maximum velocity (Vmax) decreased in the presence of the compounds, whereas [6]-gingerol indicated uncompetitive type of inhibition against AR, where it decreased both Km and Vmax upon binding. The above cell culture findings were further validated in mouse model. Male C57BL/6J mice 5 weeks old, were divided into eight groups of 11 mice each. The animals had free access to food and water and were fed with either a standard laboratory diet (8604 Teklad Rodent diet, Harlan, TM) or a high fat diet (HFD) (TD 110716, Teklad Research Rodent Diet, Harlan, TM). Animals were randomly assigned to the different treatment groups (N =  11 / group): (i) Normal diet, (ii) HFD, (iii) HFD + EGCG 25 mg/kg, (iv) HFD + EGCG at 75 mg/kg, (v) HFD + phloretin 25 mg/kg, (vi) HFD + phloretin 75 mg/kg, (vii) HFD + [6]-gingerol 25 mg/kg, (viii) HFD + [6]-gingerol 75 mg/kg. All test solutions were prepared freshly every day prior to use and were administered intraperitoneal injection (i. p.), once daily and three times in a week over a period of sixteen weeks. Body weight was recorded every day, while blood glucose levels were determined weekly with a commercially available micro-draw blood monitoring system. After sixteen weeks, the animals were sacrificed; heart, eyes and kidney were examined for AR activity. The results shows that the HFD group had developed diabetes, with blood glucose levels 260 ±  27 mg/dL, whereas the control with normal diet showed about 130 ±  20 mg/dL. The groups treated with EGCG, phloretin and [6]-gingerol at 75 mg/kg significantly decreased blood sugar levels to 128 ±  8, 125 ±  15 and 132 ±  9 mg/dL, respectively. The groups treated with EGCG, phloretin and [6]-gingerol at 25 mg/kg also decreased the blood sugar levels to 198 ±  15, 180 ±  16 and 170 ±  19 mg/dL, respectively. The eye lens of the mice from HFD group had developed cataract and the AR activity increased to 4 fold compared to the group fed with normal diet. All the compounds at 75 mg/kg, prevented/delayed the formation of cataract by 80%, whereas dosing at 25 mg/kg showed signs of cataract but AR activity was decreased to two folds when compared to the HFD group. The HFD enhanced the aldose reductase activity to two and three folds in the heart and kidney. Data from this study suggest the promising potential of these dietary compounds in providing cytoprotection and inhibiting a key enzyme associated with the onset of diabetes-related complications. Upon validation of this benefit in vivo, such dietary compounds could be of interest to dietary supplements and pharmaceutical industry as complementary treatment of secondary complications in diabetic patients.

Fine needle aspiration (FNA) biopsy is an established procedure by which to sample thyroid nodules to ascertain etiology and produce a diagnosis conveying risk of malignancy with recommended patient follow-up. This procedure is well-tolerated and endorsed given the accessibility and vascularity of the thyroid gland. FNA cytopathology has proven efficacious for the primary assessment of thyroid nodules. Well-differentiated papillary thyroid carcinoma (PTC) and benign lymphocytic (Hashimoto) thyroiditis (HT) are distinct thyroid lesions that may be reported with diagnostic confidence based on their characteristic cytomorphologic features. However depending on the adequacy of FNA sampling and the morphology of aspirated cellular material, thyroid nodules with coexisting PTC and HT may pose diagnostic pitfalls. This may be dependent upon: (a) the architectural nature of the coexisting lesions in-vivo; (b) whether both lesions are adequately sampled through FNA; and (c) which of the cell types and cytomorphologic features appear in predominance to support interpretation. Such cases may prove diagnostically challenging in adult patient assessments particularly in the setting of hypothyroidism which may also include multi-focal hyperplastic nodularity. Likewise, diagnostic problems may arise in the pediatric setting as thyroid nodules are relatively rare; marked lymphocytic pleomorphism and anisonucleosis may raise concern of lymphoproliferative malignancy; and as intra-thyroid lymphadenopathy can occur. This two-lesion entity is therefore impactful in both the adult and pediatric thyroid FNA practice. This report aims to raise awareness of this entity through a case of thyroid FNA in a 27 year old female, with ultrasonographic, cytopathologic and histopathologic findings. We conducted an English language literature review to explore the experience pertaining to the coexistence of PTC and HT as identified through FNA of the thyroid, and reviewed clinical, prognostic and ancillary testing data that may facilitate diagnosis. Incidentally, as the Sidra Medical and Research Center in Doha, Qatar, is a comprehensive woman's and pediatric hospital, we also investigated the published pediatric experience in correlation with this case. Thyroid FNA Case/

Materials and Methods

The cytopathology service (at King Abdulaziz Medical City Hospital, Riyadh, Saudi Arabia) assisted in an ultrasound-guided thyroid FNA procedure on a 27-year old female presenting with isthmus and bilateral lobe nodules to rule out malignancy. She had no remarkable medical history or previous thyroid disease. Image-guided FNA was performed using 22-gauge stylet needles without syringes attached. Under ultrasound guidance, the needle was advanced as close as possible to the nodule (with the stylet engaged) then the stylet was removed and the needle advanced then into nodule. The passes were performed in different directions inside the nodule. Two needle passes were performed on the right thyroid and isthmus nodules, but three passes were performed on the left thyroid nodule. Aspirated material from each pass was promptly and carefully smeared between two glass slides whereby, with mirror-image smearing, one slide was fixed in 95% ethanol for Papanicolaou staining, and the second slide remained air-dried for Diff-Quik staining. All needles were rinsed with saline, but no cell blocks were prepared due to insufficient needle rinse material. Ultrasonographic Findings: No nuclear medicine studies were performed prior to the thyroid FNA procedure for this patient. Thyroid, isthmus (Fig. 1): Transverse gray-scale ultrasound showed a predominantly solid, well-defined, non-calcified nodule with heterogeneous echo-texture, measuring 1.2 ×  1.8 cm in diameter. Thyroid, right lobe (Fig. 2): Transverse gray-scale ultrasound showed a predominantly solid nodule with ill-defined margins located in the lateral aspect of the mid right thyroid lobe, with heterogeneous echo-texture, measuring 1.0 ×  0.45 cm in diameter. Thyroid, left lobe (Fig. 3): Transverse color Doppler ultrasound showed an ill-defined, non-calcified hypo-echoic avascular nodule measuring 0.6 ×  0.6 cm in diameter. Fine Needle Aspiration Microscopic and Diagnostic Findings: All smears revealed an adequate cellularity of follicular cells. Upon low power microscopic analysis, the smears from the left and right nodules revealed scattered small clusters of benign follicular cells and isolated Hurthle cells in backgrounds of predominating polymorphous lymphocytes. However, the smears from the isthmus nodule included scattered variably-sized clusters/groups of disorganized abnormal follicular cells with pseudo-papillary architecture, marked cellular crowding and depth of focus, against a background of predominating lymphoid cells of various levels of maturity including immature and mature forms, scattered plasma cells, scattered robust Hurthle cells with abundant fragmented eosinophilic cytoplasm, erythrocytes, and proteinaceous/cellular debris with clotting artifact (Figures 4, 5 and 6). With high power microscopy, these follicular cells showed abnormal nuclear features with moderate anisonucleosis: round/oval shapes, irregular envelope contours, evenly-dispersed coarse chromatin clumping, and moderate hyperchromasia, but without marked nuclear envelope wrinkling. Intranuclear invaginations and grooves were rare (Fig. 7). Follicular cell cytoplasm was moderately-abundant and micro-vacuolated, with a blue-grey staining reaction through Diff-Quik staining and basophilic with Papanicolaou staining (Figures 6, 7 and 8). Fragments of connective tissue were also noted intermixed amongst the abnormal follicular cells, as were rare, intact, micro-follicles (Fig. 8 and 9). Deposits of thick colloid were scattered with thin colloid being scarce (Fig. 10). Based on these microscopic findings, cytopathology interpreted the left and right thyroid nodules as being consistent with lymphocytic (Hashimoto) thyroiditis, Bethesda Reporting Category II. The isthmus nodule was interpreted as being suspicious for papillary thyroid carcinoma associated with lymphocytic (Hashimoto) thyroiditis, Bethesda Reporting Category V. Lesion coexistence was suspected. The ensuing recommendation referred to the algorithm as published through the Bethesda reporting system, being that of thyroidectomy. Histopathologic Findings: Total thyroidectomy was performed. Tissue sections from the thyroid isthmus nodule revealed PTC, while the non-neoplastic thyroid tissues showed HT with multi-focal hyperplasia (particularly in the right lobe). Neither definite extrathyroidal tumor extension nor lymphovascular invasion was noted; but deposits of metastatic carcinoma were identified in 5 of 14 dissected lymph nodes. Surgical biopsy confirmed the coexistence of PTC and HT in the isthmus nodule; demonstrating two distinct, characteristic lesions resting adjacently separated by bands of connective tissue (Figs. 11, 12 and 13). Notation: Post-surgery nuclear I131 scanning showed complete ablation of the thyroid tumor.

Conclusions

The HT cytomorphologic template includes polymorphous lymphocytes, plasma cells, robust Hurthle cells, and follicular cells that may occasional have intranuclear invaginations and grooves. In this case, FNA cytopathology conveyed diagnoses of lymphocytic (Hashimoto) thyroiditis for the left, right and isthmus nodules sampled based on the characteristic cytomorphology noted in the smears. The isthmus nodule diagnosis also emphasized suspected coexistence of well-differentiated PTC mainly based on the scattered groups of atypical follicular cells with abnormal nuclear shapes and sizes, chromatin features, and pseudo-papillary 3D architecture with depth of focus. We favored a conservative diagnosis for PTC bearing in mind the following considerations: the possible inflammatory effects of florid HT upon epithelial cells; the possibility of diffuse nodular follicular hyperplasia; and the rarity of intranuclear invaginations and grooves observed. The overall cytomorphologic findings in the smears from the isthmus nodule closely resembled the histologic patterns of well-defined PTC and HT separated by connective tissue. Multi-focal follicular hyperplasia was also identified in the left, right and isthmus thyroid nodules in this case. The lesions were coexisting but physically isolated, and the ultrasonographic detection of heterogeneous echo-texture may reflect this phenomenon. This case emphasizes the importance of adequate FNA technique to ensure the various aspects of thyroid nodules are sampled and proportionally represented through FNA processing and, particularly, for nodules with heterogeneity upon imaging. Also, screening, interpretive and cytopreparatory expertise with optimal fixation and staining are equally critical. HT is also termed chronic lymphocytic or autoimmune thyroiditis, first described by Hakaru Hashimoto. HT is believed to result from a combination of genetic susceptibilities and environmental factors. It is estimated that HT occurs 10–15 times more frequently in women compared to men, with a global incidence of approximately 0.3–1.5 cases per 1,000 individuals. HT is associated with circulating antibodies to thyroid antigens and hypothyroidism due to follicular cell depletion secondary to the effects of chronic inflammation. The possible association between HT and well-differentiated PTC has been described since 1955. Women with HT and any solitary ‘cold’ thyroid nodule upon radio-nuclear scanning should receive ultrasound-guided FNA due to the increased risk of coexisting thyroid cancer. Meta-analyses demonstrate a near three fold risk for patients with HT to also harbor PTC relative to patients without HT. Epidemiologic studies suggest that the detection of PTC in patients with histologically confirmed HT may reach 39%, and that in the presence of HT, the outcome and prognosis of PTC is more favorable relative to patients with PTC only. These data have been used to suggest a ‘protective’ phenomenon resulting from autoimmune targeting of follicular epithelial cells. However the increased risk of tumor suggests that the proliferative changes of the thyroid epithelium are a risk for tumor development, although this may have a better prognosis, again possibly due to local growth factors in the regenerating thyroid. This also suggests HT is a promotor of tumors rather than being protective, though the tumors that develop are less aggressive. An alternative hypothesis is that the developing tumor promotes or initiates an inflammatory response. Tumor infiltrating lymphocytes and immunity are very topical with numerous recent reviews in a wide range of tumors, but in this case it is curious that the tumor showed considerably fewer lymphocytes than the background thyroid as if the tumor expressed fewer immune targets to the lymphocytes and showing some immune avoidance. The role of the immune system and thyroid cancer is complex. The prevalence of coexisting HT and PTC varies globally and this is thought to reflect ethnic, geographic and cytopathologic reporting differences. However, the sensitivity of FNA to detect PTC in patients with HT exceeds 90%. FNA of thyroid in the pediatric population may prove challenging depending on the nature of the lesions sampled, the likelihood of excessive hemorrhage and the possible need for patient sedation. Thyroid nodules in childhood and adolescence are relatively rare: prevalence varies between 0.2–1.44%, and are 5–10 times less common than in adults. However, the mean malignancy risk in pediatric patients with thyroid nodules exceeds 26% with over 90% of cancers being the PTC type. Therefore any thyroid nodule discovered in this age group ought to be investigated with a high degree of suspicion and an aggressive FNA approach. The prevalence of HT in childhood is estimated to be 1.3–9.6%; whereas the prevalence of HT with PTC ranges between 1–30% reflecting geographic and ethnic diversity. As also noted for the adult population, coexisting PTC with HT in childhood is associated with favorable prognoses arguably due to the ‘protective’ immune phenomenon controlling the proliferation of malignant cells. Patient management meta-analytical studies demonstrate favorable outcomes and prognoses in patients with coexisting PTC and HT. For such patients at presentation, the typical clinical parameters include: a female gender prevalence, multifocal nodularity, no extrathyroidal extension, no lymph node metastases and longer recurrence-free survival rates. Nevertheless, the biological coexistence of HT and PTC remains controversial. Some researchers have suggested that HT induces PTC, but conversely, that lymphocytic infiltration in HT may result from an autoimmune reaction against tumor-specific antigens from pre-existing PTC. Recent work reports a higher prevalence of activating point mutations in BRAF V600E in cases of PTC with an associated poor prognosis. Relevant studies on Korean patients demonstrate the presence of BRAF V600E mutation to be linked with a higher likelihood of lymph node metastases and a lower frequency of HT. Therefore, these findings support the hypothesis that HT may pose a ‘protective’ immune response in patients with concomitant PTC.

Autism Spectrum Disorder (ASD) is a lifelong neurodevelopmental disorder characterized by deficits in social communication and interaction, repetitive and restrictive behavior, extensive clinical and etiologic heterogeneity. ASD underlying genetic basis, range from effects of single genes to that of multiple genes and chromosomal regions, hallmarking the multifactorial and complex etiology. While a genetic etiology is identifiable in about one quarter of the cases, in the remaining three quarters it remains elusive. A family with two males affected by ASD was studied to identify the genetic basis of ASD in the family. Two siblings, a brother and his sister, each had a male child with ASD through marriage to their respective unrelated spouses. The first family [F1] has one affected male child; the second [F2] has one affected male and one unaffected female children. The father of F1 and the mother of F2 are brother and sister. No aneuploidy or deletion/duplication defects were detected by Whole-Genome SNP CNV analyses. WGNGS for all members, comparative genome analyses and data mining are as follows: [Only exonic variants considered, prioritized according to increasing population frequency (0–1%), damaging effects according to mutation prediction models and will be presented in table format]. 1. The two ASD events are unrelated and due to individual de-novo variants. Trio analyses for identified 36 de novo variants in F1 and 32 in F2. Variants in KCNH1, ANKRD36C, FRG2C, LOC12989375 were in common 2. The two ASD events are due to heterozygous variants inherited from the related parents. In F1, 370 father-to-son heterozygous variants, in F2, 398 mother-to-son heterozygous variants identified with 132 in common. 3. The related parents are protected from the damaging effects of ASD predisposing variants transmitted to their respective children by protective variants that were not transmitted, hence ASD in their offspring. Analyses were for heterozygous variants shared among the related parents but not transmitted to their affected children. 4. The non-related parents contributed rare predisposing variants, which in synergy with the inherited variants from the related parents exceed a disease onset threshold in the affected offspring. For F1 mother-to-son heterozygous variant transmission; For F2 father-to-son heterozygous variant transmission examined. Complex comparative genome analyses are required to decipher the genetic basis of ASD in families with multiple affected individuals. WGNGS, analyzed for the exome data, is a powerful tool for studying the genetic causes of ASD producing superior results than exome data in which other enrichment technologies are used. WGNGS, even when analyzed only for the exome data, provides clues to novel ASD risk genes, that can be pursued clinically, bioinformatically and functionally.

To answer questions from parents of children autism spectrum more than 300 children from various Arab countries as well as Arab expatriates residing in the foreign and Arab countries. We found that 90% of children have been exposed to neglect inadvertently leaving them in front of children's channels in the first year for a long time or screens devices in the first year or second. The most of them left by parents to watch the channels that repeat content and songs. We also found more cases that led to leaving the child of the TV is:

1. Working mother

2. Expatriate mother or traveling

3. Pregnant another child early

4. Busy father

5. Ignorance of the seriousness of the TV.

6. Addiction mother on social networking sites such as Face book.

We also found the answer from the mothers of the children and some of the videos that the child's behavior after the birth and to the pre-watch TV normally be in terms of sounds, movement and visual communication, hearing, especially in the first 6 months.

Symptoms of TV autism spectrum

- Lack of eye contact - Lack of attention to the appeal - Link TV or screens - Age-stop linguistic and stop mental age where he does not fit the true age - Non-participation of children playing - Trouble sleeping and eating Repetitive movements - problems in some senses such as smell - touch - taste - and the sensitivity of sound.

We have reached the symptoms depend on several factors and varies from child, including:

1- In any month of the child's age began to watch TV for a long time in the first year it led to a mental age and freeze them know mental age of a child.

2- How much the period that lasted for Child Show TV screens or devices and the way parents interact with the child and that will affect the senses and by how the brain works and the impact of television addiction children how we came to cause these symptoms TV and how it works to freeze the mind and the senses.

The idea of therapy

By how the brain works for the Very young child's mind when they are born to be his mind Loader with operational program acquired genes. This operational program provides for the is

1- To pay attention to what is repeated.

2- Pay attention to visual and auditory stimuli.

3- The basis of learning is repetition and stimulate the senses Comes from the interaction, in order for this program works must interact with the child to stimulate the child's mind and its cells nerve The most important year of the child is the first year then the second and child neglect in the first two years whether to let him watch TV or maid or not to interact with it leads to stop some senses and stop the mental and linguistic age of the child.

The child is born and all the senses memory empty and the sense of each storage and retrieval program it must be filled to the age of 18 months and the formation of memory for each sense. Repetition is the basis of learning, the basis for the work of the senses is the interaction what happens when you watch the child to repeat content channels and songs and cartoons

How the impact of the TV screens in the senses and the mind happens

1- The sense of sight To operate the sense of sight must be watched repeated things and stores it in memory of sight colors, sizes and shape as well as the normal speed stored in memory in order to be considered and very young children learn best by relating to real live people. In the case that the child was TV it stores the two-dimensional images without the size without touching without smell. What happens in a child's memory - will not be storage size and shape and the smell will not prolong the consideration of the fact things Because he used to watch Photos shown great speed and two-dimensional resulting in lack of eye contact of the child Things really are not two-dimensional

2- Example hearing Natural that a child hears different intensity, size and level far and close sounds and different directions And heard his name many times and pay attention to the call and stores voice his name and repetition soon be named in memory of hearing When you call it retrieves the sound of the voice memory and quickly analyze the mind and pay attention to the call quickly In the case of watching TV heard voices and one level - from one direction - will store specific sounds like what you watch from songs and animation films - Due to the channels repeating the content of the songs and songs will be stored these sounds in the audio memory and where the child spends a long time without having heard the sound of his name or Call it will become the voice of his name store down memory because the foundation is repetition will lose the sound of his name and therefore will not respond to the call of his parents, although he pay attention to the voices of the TV - also cause sensitivity of the hearing because the ear will be used on a one-level sounds also happen speech problems Because child labor channels to repeat songs, therefore the child tends to happen almost addictive frequencies songs to find that the child does not respond to the call of his father, but as soon as the employment of children are attracted to channel quickly even if the child was in another room

3- The lack of movement and sitting in front of the TV for a long time Problem will happen in the system estimate distances, balance and touch

4- Eating natural person is an important topic when watching TV in a mind will not eat cares tastings - this is what happens to the child while watching TV will be attentive to the TV will weaken the sense of taste and also in the future and also will not be digested without eating has swallowed digest TV addiction will lead to feelings and not to freeze the growth of social relations and do not care even in the absence of the mother in some cases.

5- Speech and becomes a child receives only laziness happens to think and speak weaken the speech where language acquisition results from the interaction with others and not to watch TV and weaken the sense of touch, smell, at least in this moment of interaction depends mental age As the American Academy of Pediatrics recommended preventing children less than two years of watching TV and that our recommended weaning in two years and we recommend that leaving the child less than two years to television is crime.

We demand from channels that repeat content and songs put a warning on the channel to prevent viewing of less than two years for the prevention of the spread of autism spectrum Recommendation prevent children less than two years to watch TV once, especially in the first year of interaction with the child as much as possible with sound and movement and smile and touch. There are some people messages, most of which prove that the child is exposed to neglect is intentional to leave him in front of children's channels, especially with a nanny does not speak baby language was the mother is busy with work or pregnancy in the most important months needed for the child to interact and evolve and also busy mothers to the Internet and social networking sites and it is clear that children channels a major reason for the increased prevalence of autism spectrum leaving the child who is less than two years, is to watch TV screens is a crime.

Can restart the mind and the senses again by reverse engineering and without medication starts to work the mind and the senses notice of appeal identifying himself and prolong the matter and get ready to learn and make up for lost and begin the appearance of improvement in the first week.

Channels affecting children and that repeated content

Channels of the most influential in the children come to the fore Channel Toyyour aljannah TV by 70% and it shares Space Toon – BRAAEAM TV - Tom and Jerry.

Message from one of the mothers of children born harmony boy and girl Posted says that the child has a lack of eyes contact - do not pay attention to the appeal - does not realize what around him - not following orders - the child likes to eat only cake and yogurt An inquiry was made of them Does the child and the girl child and how much TV they been seen an hour and why his sister was not affected The answer is as follows: From the age of 6 months, the child watches TV more than 7 hours per day Is his sister was watching TV a period equal to the period of her brother or less? The answer is that the mother of his twin sister was watching TV a period of not less concerned with road a lot - and always come out with me and leave the other child sits at home with his grandmother.

Background

Endothelial cells line blood vessels and the heart where they release cardio-protective hormones that prevent thrombosis. Available replacements to treat heart valve diseases are limited by the lack of the endothelial cell layer, making them susceptible to calcification and thrombosis, which limits utility and increases the need for multiple replacements[1]. A suggested solution is to adapt tissue engineering techniques to formulate intelligent instructive scaffolds decorated with specific molecules to enhance the adhesion and population of circulating progenitor endothelial cells from the blood.

Aim

In this study, we aim to modulate nanofibrous scaffolds fabricated from the biodegradable polyster polycaprolactone (PCL) to provide a viable environment for endothelial cells from blood progenitors (blood outgrowth endothelial cells; BOECs) to adhere, proliferate and function successfully. To date we have (i) compared the behaviour of BOECs to endothelial cells isolated from human heart valves (hVECs) under shear conditions, (ii) tested the compatibility of PCL with BOECs by assessing cell viability and inflammatory responses on modified PCL films, and their ability to populate structured PCL scaffolds.

Methods

BOECs were isolated from the blood of healthy volunteers by selective plating of peripheral blood mononuclear cells (PBMCs), and phenotyping was assured by measuring the expression of endothelial cell markers using fluorescent activated cell sorting (FACS). hVECs were isolated from human aortic valves by collagenase digestion. Shear stress was studied using a cone and plate model. PCL films were prepared by solvent evaporation method, and sterilized with ethanol for 30 min, or modified by plasma oxidation at 30 w and 0.1 m bar for 30 min. PCL Films were coated with extracellular matrix proteins before cell seeding. After 72 hr of culture, cell viability was measured using alamar blue and cell secretory function measured by the release of CXCL8, endothelin-1 (ET-1) and prostacyclin by ELISA. Finally, the ability of these cells to populate 3D structured nanofibrous PCL scaffolds fabricated by jet spraying technique2 was determined by confocal microscopy of phalloidin stained cells.

Results

BOECs colonies appeared at between 7 and 21 days of culture. FACS analysis of expanded cells showed positive expression of the typical endothelial cell markers CD31, CD90, VE Cadherin, CD44, and CD105. Also, BOECs stained negative for the (non-endothelial) exclusion markers CD14, CD45, and CD133. In shear stress studies, BOECs and hVECs aligned similarly to ventricular flow (ie. directional shear stress). Both cell types displayed similar viability responses when grown on PCL which was ∼40% less than achieved when cells were grown on control glass slides. Modifying PCL with plasma oxidation or extracellular matrix coating did not improve viability of either cell type. Both BOECs and hVECs released CXCL8 and ET-1 when grown on control glass slides which was not increased in cells cultured on PCL. In addition, both cell types released the cardio-protective hormone prostacyclin when grown on glass or PCL, suggesting that they would provide a viable anti-thrombotic surface. Regarding to 3D structures, BOECs were able to populate both modified and unmodified aligned nanofibrous PCL scaffolds, and appeared to align with the direction of the fibres.

Conclusions

BOECs expressed the requisite endothelial cell markers and, as we have shown previously, responded appropriately to shear and released CXCL8, ET-1 and prostacyclin 3; suggesting that BOECs are suitable seeding cells for tissue engineering. For the endothelialization of tissue engineered heart valves, the target cells that BOECs need to mimic are hVECs. Our preliminary studies show that BOECs and hVECs profile similarly in population of PCL, alignment with shear stress and with endothelial cell hormone release. In addition, BOECs are able to align with the direction of PCL fibres, mimicking the native valve endothelial cells that were previously reported to align with the direction of the collagen fibers[4]. These results are promising and indicate the potential of BOECs as a cell source to populate PCL nanofibrous scaffolds designed to replace heart valves. Nevertheless, our data shows that standard PCL platforms are not optimal in terms of cell viability. This may be improved by biofunctionalizing PCL with specific molecules to support BOECs adhesion and proliferation. For that, we are currently studying the potential of linking the BOECs specific peptide (TPS) to PCL.

References

[1] Kasimir MT, Weigel G, Sharma J, Rieder E, Seebacher G, Wolner E, et al. The decellularized porcine heart valve matrix in tissue engineering: platelet adhesion and activation. Thromb Haemost 2005, 94(3): 562–567.

[2] Sohier J, Carubelli I, Sarathchandra P, Latif N, Chester AH, Yacoub MH. The potential of anisotropic matrices as substrate for heart valve engineering. Biomaterials. 2014; 35(6):1833–44.

[3] Reed DM, Foldes G, Kirkby NS, Ahmetaj-Shala B, Mataragka S, Mohamed NA, Francis C, Gara E, Harding SE, Mitchell JA. Morphology and vasoactive hormone profiles from endothelial cells derived from stem cells of different sources.Biochem Biophys Res Commun. 2014 12;455(3-4):172–7

[4] Deck JD. Endothelial cell orientation on aortic valve leaflets. Cardiovasc Res. 1986; 20:760–767.

Klinefelter Syndrome (KS) was first described 73 years ago. Surprisingly KS yet remains underdiagnosed in the population. Lack of awareness about symptoms and the guidelines of KS diagnosis among paediatricians and General Practitioners (GP) could be the main reason. Failing to perform a thorough physical examination, not considering or unable to get cytogenetic confirmation on suspected patients are causative factors for delayed diagnosis. Hence long standing comordities such as learning disabilities, psychosocial problems and Attention Deficit Disorder in children remain under-recognized behind an undiagnosed clinical condition. The benefits of early diagnosis at prepubertal age are much higher with the available technologies such as sperm retrieval from testes biopsy and intracytoplasmic sperm injection. This could drastically improve fertility and quality of life (QoL). As prenatal diagnosis is not promising, population screening is suggested to be the way of ensuring timely diagnosis. We reviewed KS patients in Oman presented over a decade at our tertiary care centre and compared our finding with review of literature available. We realized that lack of awareness, cultural reasons and early marriage among men is some of causes for late diagnosis. Hence we propose that prepubertal diagnosis should surely be the focus to improve fertility and QoL in KS patients. This is the first report of KS from the Omani population.

Klinefelter syndrome (KS) is a well-known sex chromosomal disorder in men, affecting 0.1–0.2% of the male population. About 80–90% of KS patients show 47,XXY and the remaining lesser percentage of them present in either mosaic (47,XXY/46,XY) forms or with additional sex chromosomes (48,XXXY,48,XXYY,49,XXXXY) or structurally abnormal X chromosome acquired through non-disjunction during maternal or paternal gametogenesis. KS results from a nondisjunction event in the father, in nearly half of the cases. The prevalence of KS is much higher even among men with infertility (azoospermia) ranging from ∼3%–13%. It remains underdiagnosed with significant number of patients being unidentified, while only a 10% of prepubertal KS being diagnosed. Moreover in adulthood it was estimated that only one fourth (25%) of affected males are diagnosed, mostly due to their investigation for infertility.

Comorbidities of this syndrome are more prominent than symptoms of hypogonadism and hence the underlying disorder remains undiagnosed while the comorbidity gets treated. KS is characterized by a genetic, whole gonadal dysfunction affecting germ cells from early fetal life. Signs may vary depending upon gonadal dysfunction and sex hormone deficiency during early life (young adults) to infertility in an adult male without any other signs of hypogonadism. During pre-pubertal years, the condition is underdiagnosed because of low androgen levels and non-production of sperms. Any mild developmental disorders or cryptorchidism should be an alerting signs. There are no symptoms that reliably indicate KS in prepubertal patients. Hence, suspected KS can be diagnosed by thorough physical examination (testosterone deficiency and testicular size) or chance observation during treatment of concomitant disease. The goal should be to achieve timely diagnosis. Isidori et al, (2008) claims ultrasound can suggest KS as early as puberty stage, before any signs are noticed on clinical examination.

Prenatal diagnosis of KS is a chance finding with no specific indication of ultrasound marker feature or serum screening marker. Hence, no effective way is currently available to screen the population prenatally, apart from cytogenetic(karyotype) analysis. Thus, it is only possible when amniocenteses are performed due to advanced maternal age and are likely to have the opportunity of ‘chance-diagnosis’. Although maternal age is a well-known risk factor for meiotic non-disjunction (especially for Down Syndrome); Bojesen et al found a 4-fold increase in the prevalence of KS cases with maternal age being greater than 40 years when compared to those below 24 years.

KS is also the most frequent genetic cause of azoospermia. A significant proportion of men with KF remain undiagnosed, probably because of the wide phenotypic variability and lack of knowledge of the symptoms among health professionals. From the data based on patient registries in Denmark, it is suspected that, only 25% of all KS patients are diagnosed in their lifetime. Therfore, awareness regarding KS is important among health care professionals and General Practitioners (GP). Careful clinical examination to rule out KS, followed by cytogenetic confirmation helps in early detection. This might enable early treatment which in turn might improve fertility and their quality of life (QoL). The incidence of KS may vary across different populations, however studies suggest a higher prevalence in Australian and Asian population. To date, there are no reports on KS published from Omani population.

Therefore, we have made an observation/assessment of age at diagnosis of KS, and the reasons for delayed presentation/diagnosis, from patients encountered at our centre, over the past decade. Based on our experience and the review of data available from other population, we hereby present our data from Omani population studied at our tertiary care centre. As prenatal diagnosis is not promising in detecting KS foetus, population screening is likely to the best option of ensuing timely diagnosis for these patients. We also suggest early diagnosis could possibly improve fertility and QoL among KS patients.

Background

Vascular calcification and increased mortality is now well linked in hemodialysis (HD) patients. Among the inhibitors and promoters of calcium-phosphate and bone metabolism, we studied Sclerostin, a glycoprotein mainly expressed by osteocytes, involved in regulating bone formation by inhibiting Wnt–β-catenin signaling. Studies demonstrated, in experimental CDK animal model, a positive association between Sclerostin production and dietary phosphate intake.

Materials and Methods

We investigated the relation between Sclerostin levels (SL) and dietary habits in 49 Caucasian HD patients (age 36–90, M/F 31/18, dialysis vintage 1–144 months). Nutrient intake was analyzed with 24 h-recall method. Serum Sclerostin was measured by ELISA method. Statistically analysis was performed by SPSS software.

Results

Mean calcium and phosphate intake were 705 ± 584 and 1196 ± 498 mg/day, respectively. Serum SL (3356 ± 2118 pg/ml) were increased in HD patients. Positive correlation was found between serum SL and calcium (r = 0.33, p = 0.025) and phosphate intake (r = 0.34, p = 0.021). Patients with SL higher were older (p = 0.003), showed higher protein (p = 0.012), calcium (p = 0.017) and phosphate (p = 0.004) intake. Multiple linear regression testing Sclerostin as dependent variable (dialysis vintage, age, body-weight, serum calcium and phosphate, serum PTH, calcium and phosphate intake as independent variables) found that dietary phosphate intake was the only significant determinant of SL (r = 0.356, B = 1.5, p = 0.004). In Patients with calcium carbonate or acetate therapy (n = 31), serum SL was positively correlated with dietary calcium (r = 0.433, p = 0.017) and phosphate intake (r = 0.377, p = 0.04).

Conclusions

The dietary phosphate and calcium intake may influence serum Sclerostin levels and potentially affect bone remodeling or soft tissue calcification in HD patients.

Introduction

Cirrhosis is an abnormal liver condition, mainly caused by viral hepatitis B or C, fatty liver diseases and alcoholism. Ascites is common complication of cirrhosis, associated with poor quality of life, abnormal cognitive functions, increased work disability and increased risk of infection, consequently development of hepatic encephalopathy1. Studies have suggested that inflammation caused by secondary infection with hyper ammonia act as synergistic factor responsible for hepatic encephalopathy in cirrhotic patients2. Magnetic resonance imaging (MRI) is the most commonly used method to observe brain abnormalities in in cirrhotic patients. These patients showed hyperintensities in basal ganglion on T1-weighted MRI and abnormal brain metabolites such as increased Glx, decreased myo-inositol and choline level on MR spectroscopy (MRS), decreased magnetization transfer ratio, and increased mean diffusivity on diffusion tensor imaging MRI 3,4,5,6,7,8. Though different neuroimaging studies investigated structural, diffusion, functional and metabolic brain changes in adult cirrhotic, the regional changes in gray matter and structural brain connectivity are not yet studied in pediatric cirrhotic patients. In this study, we evaluated the gray matter changes and global and regional topological properties of structural brain networks in pediatric cirrhotic compared to pediatric controls.

Materials and methods

Institutional regulatory board and ethics committee approved the current study protocol. 22 pediatric cirrhotic (mean age 11.6 ± 3.4 years, no prior HE), and 17 age and sex matched heathy controls were included in this study. Written informed consent was obtained from each individual prior study. Cirrhosis was diagnosed by the presence of a combination of high serum-ascites albumin gradient ascites, splenomegaly, large varices without EHPVO, irregular liver surface, portal vein ≥  13 mm and collaterals. Magnetic resonance imaging (MRI) was performed at 3-T clinical MR Scanner (GE Healthcare Technologies, Milwaukee, WI, United States) using a standard quadrature head coil. Conventional T2-, T1-weighted imaging and high-resolution T1-weighted structural imaging using a fast spoiled gradient echo BRAVO pulse sequence (TR =  8.4 ms; TE =  3.32 ms; inversion time =  400 ms; FA =  13°; matrix size =  512′512; FOV =  240′240 mm²; slice-thickness =  1.0 mm), were performed on each subject. T2-, T1-weighted images were examined for any gross brain pathology, such as cysts, tumors, or any other mass lesions, and presence of such anomaly was used as an exclusion criteria. We used high-resolution T1-weighted structural images for measuring regional gray matter changes and construction of structural network. Brain imaging data were processed using the statistical parametric mapping package (SPM8, http://www.fil.ion.ucl.ac.uk/spm/), MRIcroN, and MATLAB-based (The Math Works Inc, Natick, MA) custom software. High-resolution T1-weighted images from all subjects were visually examined for the presence of tumors and cysts. High-resolution T1-weighted images corrected for any bias and inhomogeneity-corrected images were partitioned into gray, white, and cerebrospinal fluid tissue types using a unified segmentation approach9,10. Gray matter tissues maps were normalized to the Montreal Neurological Institute (MNI) space and were modulated and smoothed using a Gaussian filter (FWHM, 10 mm). For the strctural networks construction we used graph theory based analysis using GAT software by using gray matter maps as described in details elsewhere11. In brief we generated 90 cortical and subcortical regions of interest (ROIs), excluding the cerebellum, from the Automated Anatomical Labeling (AAL) atlas using the WFU PickAtlas Toolbox. The extracted residual volumes of all 90 anatomical ROIs were used for construction of structural correlation networks.

Statistical analysis

All statistical computations were performed using the Statistical Package for Social Sciences (SPSS) version 16.0 (SPSS Inc., Chicago, USA). The normalized and smoothed gray matter tissue probability maps were compared between groups using analysis of covariance (ANCOVA; uncorrected threshold, p =  0.01; extended threshold, 100 voxels), with age and gender included as covariates. A p value of less than 0.05 was considered to be statistically significant.

Results

Glass brain images in Fig. 1 are showing significantly lower gray matter volumes (GMV) in multiple brain sites with few brain areas showing significantly higher GMV in pediatric cirrhotic compared to those of controls (Fig. 1). The correlation matrix of the cirrhotic group showed overall lower correlation strength than the control group (Fig. 2). In pediatric cirrhotic reduced brain network characteristic across a range of network densities was observed compared to control (Fig. 3). Pediatric cirrhotic also showed altered structural connectivity networks and hubs (Fig. 4).

Discussion

Cirrhotic patients showed altered gray matter volumes suggesting the brain tissue injury and decreased regional connectivity (clustering coefficient), while reduced global network organization (small worldness) and integration (hubs) suggesting decreased robustness and efficiency of the brain network. These results contribute to novel insights regarding the neurobiological mechanisms underlying cognitive deficits in these patients. The pathophysiological mechanism of brain tissue injury may include hyper ammonia secondary to inflammation resulting neuronal tissue injury2. This structural analysis using voxel based and graph theory might provide a more appropriate paradigm for understanding complicated neurobiological mechanism of cirrhotic patients, and may help to improve the clinical managements of these patients 12.

References

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2. Butterworth RF. Pathogenesis of hepatic encephalopathy in cirrhosis: the concept of synergism revisited. Metab Brain Dis. 2015.

3. Lai PH, Chen C, Liang HL, et al. Hyperintense basal ganglia on T1-weighted MR imaging. AJR Am J Roentgenol 1999;172:1109–15.

4. Geissler A, Lock G, Fründ R, et al. Cerebral abnormalities in patients with cirrhosis detected by proton magnetic resonance spectroscopy and magnetic resonance imaging. Hepatology 1997;25:48–54.

5. Rovira A, Grivé E, Pedraza S, et al. Magnetization transfer ratio values and proton MR spectroscopy of normal-appearing cerebral white matter in patients with liver cirrhosis. AJNR Am J Neuroradiol 2001;22:1137–42.

6. Laubenberger J, Häussinger D, Bayer S, et al. Proton magnetic resonance spectroscopy of the brain in symptomatic and asymptomatic patients with liver cirrhosis. Gastroenterology 1997;112:1610–16.

7. Miese F, Kircheis G, Wittsack HJ, et al. 1H-MR spectroscopy, magnetization transfer, and diffusion-weighted imaging in alcoholic and nonalcoholic patients with cirrhosis with hepatic encephalopathy. AJNR Am J Neuroradiol 2006;27:1019–26.

8. Kale RA, Gupta RK, Saraswat VA, et al. Demonstration of interstitial cerebral edema with diffusion tensor MR imaging in type C hepatic encephalopathy. Hepatology 2006;43:698–706.

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Critically ill patients in the intensive care units (ICUs) are often in acutely disturbed state of mind characterized by restlessness, illusions, and nervousness. Such patients, for instance, those who are mechanically ventilated may incur difficulties during treatment procedures such as endotracheal tube intubation/extubation. Apart from critical illness, treatment induced delirium may cause them to dislodge themselves from life-saving equipment and thus hinder cooperative and safe treatment in the ICU. Hence, it is often recommended to moderately sedate such patients for several days to reduce patient anxiety, facilitate sleep, aid treatment and thus endure patient safety. However, most anesthetics affect cardiac and respiratory functions. Hence, it is important to monitor and control the infusion of anesthetics to meet sedation requirements while keeping patient vital parameters within safe limits. The critical task of anesthesia administration also necessitates that drug dosing be optimal, patient specific, and robust.

Towards this end, we propose to use a reinforcement learning based approach to develop a closed-loop anesthesia controller that accounts for hemodynamic parameter variations. Main advantage of the proposed approach is that it does not require a model, it involves optimization, and is robust to interpatient variabilities. We formulate the problem of deriving control laws that track a desired trajectory as a sequential decision making problem represented by a finite Markov decision process (MDP) and then use reinforcement learning-based approach to solve the MDPs for goal oriented decision making. Specifically, we use reinforcement learning approaches, such as Q-learning, to develop a closed-loop anesthesia controller using the bispectral index (BIS) as a control variable while concurrently accounting for the mean arterial pressure (MAP). Moreover, the proposed method monitors and controls the infusion of anesthetics by minimizing a weighted combination of the error of the BIS and MAP signals. Account for two variables by considering the error reduces the computational complexity of the reinforcement learning algorithm and consequently the controller processing time.

We present simulation results and statistical results using the 30 simulated patients. For our simulations, the pharmacokinetic and the pharmacodynamic values of the simulated patients are chosen randomly from a predefined range. To quantify the performance of the trained agent in the closed-loop anesthesia control, we use the median performance error (MDPE), median absolute performance error (MDAPE), root mean square error (RMSE), and interquartile range (IQ). In order to further investigate the effect of simultaneous regulation of the BIS and MAP parameters on the sedation level (BIS) of a patient, we also conducted three different in silico case studies. In the first case study, a hemodynamic disturbance is considered in which the MAP is altered by d units. This case study considers the effect of other factors such as hemorrhage on MAP as an exogenous disturbance. In the second case study, the MAP is set to a constant value irrespective of propofol infusion, which corresponds to patients that remain intubated in the ICU with post-aortic aneurysm repair or septic patients with respiratory failure. In the third case study, a disturbance due to administration of a synergetic drug such as remifentanil is considered during the administration of propofol. This case study considers the effect of drug interaction on the closed-loop control of hypnotic agent administration.