On 2017 Nov 21, Samira Vesali commented:

Natural conception and reproductive experiences in cancer survivors who stored reproductive material before their treatment

In the October 2017 issue of human reproduction (vol: 17, Page:1-8), Hammarberg K, 2017, published an opinion piece arguing of 301 respondents who had tried to achieve pregnancy since completing cancer treatment almost all had succeeded, in most cases through natural conception,Hammarberg K, 2017. There are some worthwhile points were not considered in this study, even as limitations or reasons for caution, which are bias influencing their findings. First, relatively response rate. It is not possible to know whether people with better or worse survival were more or less likely to participate. Our thoughts on this issue is that cancer patients undergoing advanced stages likely did not tend to participate in the survey. As well, those with malignancy normally get more extensive chemotherapy, which can damage their reproductive system. Evidence has been shown that different chemotherapy regimens can affect the reproductive system differently, Long JP, 2016. However, cancer patients who were on malignant stages have likely lower life expectancy and less hope childbearing after their treatment. It is possible they are less inclined to look for and benefit from fertility preservation options to store their cryopreserved material. Second, we believe that it is important to view the findings within the context of the cancer type, stage and chemotherapy regimens of the participants, because all the mentioned factors can lead to use or not use the frozen reproductive material and are effective in the participants’ ability to get pregnant naturally (possibly mild chemotherapy which can preserve some of the ovarian reserve). Third, the cancer patients studied were recruited from 1995 to 2014, but as we know Human Fertility and Embryology Authority (HFEA) has given permission to the usage of frozen eggs in United Kingdom (UK) from 2000, Wise J, 2000, and American Society of Reproductive Medicine (ASRM) removed the label of “experimental” from oocyte freezing in 2013,Practice Committees of American Society for Reproductive Medicine., 2013 . So, giving single vision to all frozen materials of participants during this time period maybe is not correct. Earlier, the patients only could enjoy form the cryopreserved embryo and sperm, then ovarian tissue and more recently oocytes. Looking at the table II, the pregnancy achievement is presented as “as a result of ART with stored material” but is not presented separately. It is not clear that all usage of stored material are adequately cryopreserved gametes or embryos or not.<br> Fourth, the essential problem we see is that age can be another confounding factor in this survey. Many of the people who have never tried to get pregnant may be in advanced age, but we do not know the age of those who did not respond or never tried to get pregnant. Reza Omani Samani1, Samira Vesali1* 1 Department of Epidemiology and Reproductive Health, Reproductive Epidemiology Research Center, Royan Institute for Reproductive Biomedicine, ACECR, Tehran, Iran Correspondence address: Department of Epidemiology and Reproductive Health, Royan Institute for Reproductive Biomedicine, Tehran, Iran. E-mail: samiravesali@yahoo.com.

On 2017 Oct 22, Christian J. Wiedermann commented:

Comment on “The dose of hydroxyethyl starch 6% 130/0.4 for fluid therapy and the incidence of acute kidney injury after cardiac surgery: A retrospective matched study”

In a retrospective cohort study (Momeni M, 2017), it was analyzed whether the incidence of acute kidney injury (AKI) in cardiac surgery differed depending on weight-adjusted cumulative doses of 6% hydroxyethyl starch (HES) 130/0.4 for pump priming and/or perioperative fluid therapy. In the absence of any safety study, authors concluded that in cardiac surgery the cumulative dose of modern HES should be kept less than 30 mL/kg.

From a total of 1564 evaluable patients fulfilling the study`s inclusion criteria, 63 subjects were excluded from analyses because cardiac surgery had been performed without administration of HES. Without a control group (patients not receiving HES excluded), the study was performed on 983 subjects who received a low dose of HES and 518 who were in a high dose HES group. Among these HES-receiving patients, a dose-dependent increase of AKI was observed, thus, confirming in cardiac surgery patients previous observations of dose-dependent nephrotoxicity of HES (Mutter TC, 2013).

A safe volume of any HES solution has yet to be determined (Mutter TC, 2013, Wiedermann CJ, 2009). Because AKI in response to 6% HES 130/0.4 may be seen at low doses, the authors' conclusions (Momeni M, 2017) that modern HES should be kept at cumulative doses less than 30 mL/kg ignores the fact that in patients not receiving any HES at all, AKI frequency may be even lower than in their low dose group. Thus, the only conclusion should have been that in cardiac surgery, HES-induced nephrotoxicity is dose dependent. The recommendation of using HES doses less than 30 mL/kg carries the risk of increasing AKI. Unless a safe volume is determined, 6% HES 130/0.4 should be avoided in cardiac surgery.

On 2017 Oct 31, Louis-Etienne Lorenzo commented:

https://www.ncbi.nlm.nih.gov/pubmed/17626281 Differential organization of GABA(A) and glycine receptors in the somatic and dendritic compartments of rat abducens motoneurons.

On 2017 Dec 13, Franz Schelling commented:

"Without a good understanding of the vascular pathophysiologic factors that influence the patency of ballooned IJVs, it is difficult to perform any meaningful work relating any neurologic condition that may or may not be associated with constricted venous outflow." ... ought not this point given in the papers 'Discussion' be given in its 'Conclusion' part.

Three questions asides: (1) Wasn't it observed that the muscular IJV entrapments depend widely on (a) head, (b) shoulder position and (c) jaw bracing? with (a) applying first to the sternal head of the sternocleidomastoid, (a)+(b) to the omohyoid, and (c) to the digastric muscle? (2) What about the often observed efficacy of deep inspiration/chest bracing in terms of flow reversals in the left IJV? (3) MRI findings of a severe hypoplasia of the entire J1 length seem preferentially due to its broad clamping between sternal part of the sternocleidomastoid and anterior scalene muscle - a problem which any good ENT surgeon can solve.

Just some cues which may prove useful for making further advances.

On 2017 Oct 18, FREDERICK DOMANN commented:

Link to Open Access paper: http://www.sciencedirect.com/science/article/pii/S0891584917307864

On 2017 Nov 28, Natalie Clairoux commented:

Free version of this article available after October 10, 2018 at https://papyrus.bib.umontreal.ca/xmlui/handle/1866/19493

On 2017 Oct 17, Joel Nitzkin commented:

I don't think any conclusions can be drawn from this study with regard to softening or hardening without considering the totality of continuing nicotine intake by the various categories of distressed individuals. A new element, not considered by these authors is the development of electronic nicotine delivery systems that can satisfy the urge to smoke for these and other smokers. Pretending that these products do not exist or that these distressed smokers are not utilizing them, or that self-administered nicotine does not provide significant cognitive benefit to these smokers is to blind ourselves to the possibility that these products may offer a new pathway to more substantial reduction in cigarette consumption than has been considered to date.

On 2017 Oct 17, Peter Hajek commented:

The data presented here do not support the 'softening' claim. Objective measures of nicotine intake are needed to see if the reduction in number of cigarettes, which is likely to be a response to increased cost of smoking, generated any reduction in nicotine intake. People may or may not smoke the remaining cigarettes with more puffs and deeper inhalations. Regarding the second finding, a history of more failed quit attempts implies hardening rather than softening.

On 2017 Dec 08, Franz Schelling commented:

Apologies, my dear compatriots: So much has been said and shown on the role which particular vein length play in the emergence of the cerebral lesions of MS - why not risk a glimpse at http://bit.ly/2hu3g9N - wouldn't be so kind as to tell me what your focusing on direct or metabolically mediated arterial risk factors has been motivated be?

On 2017 Nov 18, Kenneth J Smith commented:

The authors agree, of course, that MS lesions predominantly occur around veins, and we make this point in our paper. A purpose of our paper is to provide a deeper understanding of how perivenous lesions can arise due to tissue hypoxia. We make the point that hypoxia in arterial watershed territories will exacerbate the venous influence on lesion genesis.

On 2017 Oct 22, Franz Schelling commented:

The fact that the MS lesion patterns observed in the brain do not reflect arterial border zones, the "last meadows" of arterial perfusion, but an unexplained kind of venous impacts has become more and more evident since 1911. In this year, Alexander Bruce for the first time noted the lesion arrangements along tributaries of the internal cerebral veins. And up to the latest MRI studies, the cerebral MS lesions' vascular relationships have consistently spoken not of central lesion arteries but of central lesion veins.

On 2017 Nov 18, Kenneth J Smith commented:

The authors agree that it is well established that the grey matter has a higher metabolic rate than the white matter, and this is in accord with the higher vascular density in the grey matter. This fact does not address whether oligodendrocytes are particularly susceptible to tissue hypoxia. There is widespread experience that oligodendrocytes are very vulnerable, although the underlying reasons remain unclear. The location of oligodendrocytes in the white matter accentuates their vulnerability, not only due to the relative paucity of the vasculature, but also because of the propensity of the white matter vasculature to contain relatively deoxygenated blood.

On 2017 Oct 22, Franz Schelling commented:

To come closer to the point: Why needs the cerebral grey matter fife to then as much arterial perfusion, oxygen and nutrients than the cerebral white matter? It is the presence of nerve cells as these are present in the grey matter alone. All the other tissue constituents occur in both white and grey matter.

The far higher density of blood vessels in the grey as against the white brain tissues testifies equally to the higher metabolic demands of the nerve cell containing - and not of the oligodendrocyte rich tissue.

On 2017 Nov 18, Kenneth J Smith commented:

The authors do not believe they have deepened any misconceptions. First, we make no claims that Dawson’s fingers are identical to arterial border zones. However, the fact that many MS lesions bear a relationship with arterial border zones has been clearly established, not least in the several detailed studies of thousands of lesions that we cite from other groups. Second, we do not claim that oligodendrocytes’ metabolic demands are generally as high as those of neurons. We do claim that oligodendrocytes are particularly vulnerable to hypoxia, and this is the experience of many investigators. We devote a section to this topic in our manuscript.

On 2017 Oct 17, Franz Schelling commented:

It is a pity this paper deepens two elementary misconceptions: (1) The assumption the MS-specific ventricle-based lesion-formations (Dawson's fingers) were identical with arterial border-zone lesions - as the latter occasionally touch the ventricular border. (2) The opinion, the oligodendrocytes' metabolic demands were generally as high as those of the neurons. Not only the given authors but also the public at large can only be recommended to study the pertinent evidence more carefully so as not to fall prey to easily reiterated mistaken assumptions regarding these pivotal points.

On 2017 Oct 17, Hiroshi Yao commented:

Dear Harald HHW Schmidt, Thank you for your comments on our paper (Int J Mol Sci 2017 Oct 11). I was engaged in our paper (PLoS ONE 2015), when the paper by Kleikers et al. was published. So I could not know this paper at that time, and it was my mistake not to pay attention for this paper during the next 2 years; I am sorry for this. I will comment on this paper in the near future using PubMed Commons. Sincerely yours, Hiroshi Yao, M.D.

On 2017 Oct 12, Harald HHW Schmidt commented:

It is highly surprising that in this review the systematic review and meta-analysis followed by a pre-clinical randomised confirmatory trial which clearly excluded NOX2 as a target in ischemic stroke was overlooked. https://www.nature.com/articles/srep13428

On 2017 Dec 23, Thales Batista commented:

Erratum

In September/October 2017, the Journal of the Brazilian College of Surgeons (Rev Col Bras Cir. 2017;44(5):530-44) published the original article titled “A proposal of Brazilian Society of Surgical Oncology for standardizing cytoreductive surgery plus hypertermic intraperitoneal chemotherapy procedures in Brazil: pseudomixoma peritonei, appendiceal tumors and malignant peritoneal mesothelioma.” (http://dx.doi.org/10.1590/0100-69912017005016), by Thales Paulo Batista; Bruno José Queiroz Sarmento; Janina Ferreira Loureiro; Andrea Petruzziello; Ademar Lopes; Cassio Cortez Santos; Cláudio de Almeida Quadros; Eduardo Hiroshi Akaishi; Eduardo Zanella Cordeiro1; Felipe José Fernández Coimbra; Gustavo Andreazza Laporte; Leonaldson Santos Castro; Ranyell Matheus Spencer Sobreira Batista; Samuel Aguiar Júnior; Wilson Luiz Costa Júnior; Fábio Oliveira Ferreira; Comitê de Neoplasias Peritoneais e Quimioterapia Intraperitoneal Hipertérmica da Sociedade Brasileira de Cirurgia Oncológica. The following errors were identified:

Title:

Reads: “A proposal of Brazilian Society of Surgical Oncology for standardizing cytoreductive surgery plus hypertermic intraperitoneal chemotherapy procedures in Brazil: pseudomixoma peritonei, appendiceal tumors and malignant peritoneal mesothelioma”;

Should read: “A proposal of Brazilian Society of Surgical Oncology (BSSO/SBCO) for standardizing cytoreductive surgery (CRS) plus hyperthermic intraperitoneal chemotherapy (HIPEC) procedures in Brazil: pseudomixoma peritonei, appendiceal tumors and malignant peritoneal mesothelioma.”.

Authors:

Reads: “Thales Paulo Batista; Bruno José Queiroz Sarmento; Janina Ferreira Loureiro; Andrea Petruzziello; Ademar Lopes; Cassio Cortez Santos; Cláudio de Almeida Quadros; Eduardo Hiroshi Akaishi; Eduardo Zanella Cordeiro1; Felipe José Fernández Coimbra; Gustavo Andreazza Laporte; Leonaldson Santos Castro; Ranyell Matheus Spencer Sobreira Batista; Samuel Aguiar Júnior; Wilson Luiz Costa Júnior; Fábio Oliveira Ferreira; Comitê de Neoplasias Peritoneais e Quimioterapia Intraperitoneal Hipertérmica da Sociedade Brasileira de Cirurgia Oncológica”

Should read: “Thales Paulo Batista; Bruno José Queiroz Sarmento; Janina Ferreira Loureiro; Andrea Petruzziello; Ademar Lopes; Cassio Cortez Santos; Cláudio de Almeida Quadros; Eduardo Hiroshi Akaishi; Eduardo Zanella Cordeiro1; Felipe José Fernández Coimbra; Gustavo Andreazza Laporte; Leonaldson Santos Castro; Ranyell Matheus Spencer Sobreira Batista; Samuel Aguiar Júnior; Wilson Luiz Costa Júnior; Fábio Oliveira Ferreira; on behalf of the BSSO/SBCO Committee on Peritoneal Surface Malignancies and HIPEC”

Abstract:

Reads: “hypertermic”

Should read: “hyperthermic”

Rev Col Bras Cir. 2017 Nov-Dec;44(6):665. doi: 10.1590/0100-69912017006016. PMID: 29267565 DOI: 10.1590/0100-69912017006016

On 2017 Oct 13, John Tucker commented:

In this article, Dr. Goldstein et. al raise the pressing issue of drug pricing. They conduct several regression analyses to determine the influence of market changes on oncology drug prices, including labeling changes, off-label use, and the approval of competing drugs on cumulative price increases. Most notably, however, the article serves as a vehicle for the price charts shown in Figures 1 and 2, showing cumulative price increases that are asserted to greatly outstrip the BLS Medical Care Consumer Price Index. The implication of these figures is that drug prices have risen even faster than healthcare prices overall, and thus play a unique role in the rapidly rising cost of care.

Unfortunately, the paper contains several errors that undercut support for this claim. The key figures show a 39% increase in the BLS Medical Care Price Index from 2005 to 2017, but reference to the primary source shows the increase was 49%. The authors appear to have confused the Medical Commodities CPI, which mainly addresses the costs of pharmaceuticals and medical devices, with the more broadly based Medical Care CPI.

Simultaneously, drug price increases are overstated by reliance on Average Sales Price data from CMS uncorrected for 340B discounts. The 340B program mandates discounts of 30 to 50% to hospitals meeting certain criteria related to providing services to low income population, and now includes approximately 1/3 of U.S. hospitals. The program has grown at double digit per annum rates over the time period covered by the Goldstein analysis. Genentech recently disclosed that 17% of its worldwide drug sales were conducted under 340B contracts, which would be approximately 35% of U.S. sales.

Correcting for the effects of the 340B program using publicly available data on the size of the program and hospital/clinic drug expenditures, one finds that the great majority of the price increases discussed in the paper fall below the medical inflation rate described by the BLS Medical Services CPI, and most fall below the general inflation rate as well.

Overall, there is inarguably a pressing need to control healthcare costs in the U.S. To achieve this we need to look at all sectors of spending, and should expect significant sacrifices across the board. Drug prices will be one part of that, but unnecessary and low value care provision, medical salaries, and insurer overhead will surely play an important role as well.

On 2018 Jan 04, Nilesh Banavali commented:

The authors use a few different nucleic acid duplex parameters to understand the extent of B-form RNA structure in the 6S RNA variant structural model reported in this article. A different structural analysis based on Root Mean Square Deviation (RMSD) from canonical A-form and B-form single-strand structures can also address the occurrence and extent of local and global B-form structure. A short description of this analysis on the 6S RNA variant structure is posted on bioRxiv at:

http://biorxiv.org/cgi/content/short/242503v1

Nilesh Banavali, Research Scientist, Wadsworth Center, New York State Department of Health.

On 2017 Nov 21, Sudheendra Rao commented:

Just an addition since KU955594 was not found in the paper. Literature search suggests that the probable zika strain used to detect seropositivity in India back in 1954 was Zika virus/M.mulatta-tc/UGA/1947/MR-766 (KU955594). Supporting literature is here http://www.jimmunol.org/content/jimmunol/72/4/248.full.pdf http://www.jimmunol.org/content/jimmunol/68/4/461.full.pdf http://www.jimmunol.org/content/jimmunol/68/4/441.full.pdf BLAST results indicate 86-89% identity at nucleotide level of Zika virus/M.mulatta-tc/UGA/1947/MR-766 to Indian strains gb|MF173409, gb|MF173410, gb|MF173411 whereas protein identity is patchy ranging from 81-100% in some regions.

On 2017 Oct 15, Erick H Turner commented:

Beyond the question of whether unpublished data were used, how were they used?

This study asks the important question, what proportion of systematic reviews searched for and made use of unpublished data? However, an important follow-up question remains to be addressed: Among those cases in which unpublished data was used, how was it used? Unpublished data can of course address study publication bias, ie. data from unpublished studies can be simply added to data obtained from the published literature. However, unpublished data can also address outcome reporting bias,[1-3] ie. a trial publication conveys that the intervention is safe and/or effective while unpublished data on the same trial tell a different story. For example, in a study of 74 industry-sponsored antidepressants trials,[4] in addition to 23 (31%) unpublished trials, we found 11 (15%) trials with outcome reporting bias. If we had corrected for the former while ignoring the latter, we would have obtained an effect size estimate that was still inflated. Returning to the current study,[5] an informative follow-up would be to look within the cohort of systematic reviews that made use of unpublished data and determine how many used it to verify the published results.

References:

1 Kirkham JJ, Dwan KM, Altman DG, et al. The impact of outcome reporting bias in randomised controlled trials on a cohort of systematic reviews. BMJ 2010;340:c365.

2 Chan A-W, Altman DG. Identifying outcome reporting bias in randomised trials on PubMed: review of publications and survey of authors. BMJ 2005;330:753. doi:10.1136/bmj.38356.424606.8F

3 Chan A-W, Hróbjartsson A, Haahr MT, et al. Empirical evidence for selective reporting of outcomes in randomized trials: comparison of protocols to published articles. JAMA 2004;291:2457–65. doi:10.1001/jama.291.20.2457

4 Turner EH, Matthews AM, Linardatos E, et al. Selective publication of antidepressant trials and its influence on apparent efficacy. N Engl J Med 2008;358:252–60. doi:10.1056/NEJMsa065779

5 Ziai H, Zhang R, Chan A-W, et al. Search for unpublished data by systematic reviewers: an audit. BMJ Open 2017;7:e017737. doi:10.1136/bmjopen-2017-017737

On 2018 Jan 06, Rima Obeid commented:

Oversampling a high risk group and sampling from a hospital setting where kids were born and later treated for autism (a single Center study) strongly suggest a selection bias. Selection bias limits the external validity and generalizability of results from the Boston cohort. Recent metaanalysis and other large studies do not show an association or show even inverse association (example of links below). Moreover, sensitivity analysis is missing in the study by Raghavan et al.<br> https://www.ncbi.nlm.nih.gov/pubmed/29026508 https://www.ncbi.nlm.nih.gov/pubmed/29299606

On 2017 Dec 12, M Daniele Fallin commented:

True! This is an "enriched risk" ASD cohort in that it was over-sampled for pre-term birth, a consistent risk factor for ASD. In a low-risk or general US population, you would expect somewhere between 1 and 2% based on current CDC estimates of 8 year olds, although the prevalence at younger ages, and in diverse ethnic populations (such as this one) is less clear. This enriched risk design makes the study of ASD possible in this birth cohort (enough ASD events), and is a common design in ASD prospective studies - although typically the risk enrichment is due to family history (baby sibling studies).

On 2017 Dec 06, Aiguo Ren commented:

86 out of 1257 infants (6.8%) had ASD in this cohort! Isn't this incidence too high?

On 2017 Oct 09, Franz Schelling commented:

The paper https://doi.org/10.24019/jtavr.29 addresses only the point of how a one-sided valvular incompetence of the internal jugular veins endangers the brain. It must not be forgotten, though: the blood contained in the jugulars is driven in direction of the brain as often as these veins are impacted upon - but can't empty themselves, quickly enough, in the normal way.

On 2017 Oct 09, Franz Schelling commented:

The hemodynamics of the human brain won't ever be understood ... if the intracranial venous anatomy is not contemplated in its natural context with the extracranial venous and perivenous anatomy and especially its functional changes; the position-dependent strictures and at times tempestuous impacts which the cerebral venous passages located outside the skull are exposed to. Rather than in replacing Newtonian principles with statistical ones, we might make progress in coming to terms with the individually given intricacies of venous hemodynamics. Admittedly a tedious task, showing a humbling underdevelopment of venous computational hemodynamics.

On 2017 Oct 08, Alessandro Rasman commented:

This study is important in relationship to how lymph from the brain is deposited back into the blood stream, as this occurs at the junction where the jugular valve is located. Lymph, CSF and blood all go thru this area, and if there is reflux or slowed flow, the brain is negatively affected.

On 2017 Oct 06, Pete Monk commented:

LHFPL4 is not a member of the tetraspanin family, as defined by HUGO (https://www.genenames.org/cgi-bin/genefamilies/set/768). It is in the LHFPL tetraspan subfamily (https://www.genenames.org/cgi-bin/genefamilies/set/1489) and likely has a very different structure to the tetraspanins. The title is therefore misleading.

On 2017 Dec 01, Randi Pechacek commented:

Kaisa Koskinen, one of the authors of this paper, wrote a blog post on microBEnet describing some background to the research.

On 2017 Oct 10, Oscar Marcelo Lazo commented:

Surname of the first author is misspelled here –it is correct in the pdf though.

On 2018 Jan 15, Hauke Fürstenwerth commented:

Blaustein’s attemps to disqualify Vogeser’s studies started with the false assertion that the analytical protocol did not assess the degree of recovery of the extraction step [1]. Now he presents imaginative speculations about unknown compounds and on a low level of noise in Vogeser’s chromatograms. Blaustein’s defamatory accusations are unfounded. They do not change the fact that Ouabain can not be detected in human serum by using state-of-the-art analytical methods. In the e-pub-first version of his article, Blaustein reports that Clin Chim Acta has refused to retract the Vogeser publication, with good reason. In the assessment of experts in analytical chemistry there is no doubt on the validity of Vogeser’s measurements.

[1] http://hyper.ahajournals.org/content/64/4/680/tab-e-letters

On 2018 Jan 13, Mordecai P Blaustein commented:

Response to Dr. Füerstenwerth:

The case for a ouabain-Na pump endocrine system has been laid out in [1] and my previous response to Dr. Fürstenwerth. All the original reports are cited so that readers can verify my statements.

I must, however, refute Fürstenwerth’s false claim that I made an “unfounded accusation of data manipulation” by stating that Baecher et al. [2] “’edited’ their raw data”. Fürstenwerth apparently has not read Vogeser and Baecher’s Letter to the Editor [3] in which they admit that “In… Fig. 2 of our article ([2])… at a retention time (RT)… of… 5.0 min… the trace signal is broken… This inconsistency was introduced by editing the… (mass spectrum) raw data.” They show (Fig. 2, top, in [3]) that they originally (Fig. 2, top, in [2]) edited out an ion current peak at 4.99 min, and they present a second example (Fig. 1, top, in [3]) in which a similar peak is seen at that same RT (4.98 min) (see [4] Data Supplement). They do not mention the other 28 plasma samples they tested [2]; how many of them exhibited the same peak? Why didn’t they show/describe all their data? (The “broken” trace signal in Fig. 2 of [2] is very difficult to see on the original journal page. Dr. Hamlyn suspected that the spectrum was 'unusually flat'. When he enlarged the image he discovered the discontinuity.) We suggest [4] that the ion current peak at the 5.0 min RT, which has the same mass/charge ratio as ouabain, may correspond to the more polar of two ouabain isomers that have previously been described [5, 6]. Other flaws in the Baecher et al. study [2] are discussed elsewhere [1, 4, 7].

References:

[1] Blaustein MP, 2018

[2] Baecher S, 2014

[3] Vogeser M, 2015

[4] Hamlyn JM, 2016

[5] Jacobs BE, 2012

[6] Hamlyn JM, 2014

[7] Blaustein MP, 2015

On 2018 Jan 12, Hauke Fürstenwerth commented:

Final response to Dr. Blaustein

<p>@ 1: yes, S. kombé contains a mixture of steroids, but contrary to Blaustein’s assertion no ouabain. Kirk discovered the effects of k-strophanthin.</p>

<p>@ 2: yes, inactivating mutation of the mouse alpha-2 Na+ pump ouabain binding site has physiologic consequences. This is no evidence that the endogenous inhibitor of the NaK-pump is ouabain.</p>

<p>@ 3: unfounded accusation of data manipulation (”edited their raw data”, “scientific misconduct”) does not refute the fact that in various laboratories it has not been possible to detect ouabain in human serum with highly specific analytical methods.</p>

<p>@ 4: With the admission that ”ouabain can be expected to have both beneficial and … detrimental effects” Blaustein refutes assertions he has made in his article: “ouabain is a key factor in the pathogenesis of hypertension and heart failure" and “ouabain and its receptor site participate in the pathogenesis of hypertension, cardiac hypertrophy and HF“. Provided ouabain is the endogenous inhibitor of the NaK-pump that at low levels has positive but at elevated levels has detrimental effects, then it remains puzzling why infusion of plant derived ouabain (elevating serum concentration!) in clinical practice lowers blood pressure and is life-saving in acute heart failure. (Oh yes, common sense can be annoying.)</p>

<p>@ 5: With highly specific analytical methods it is not possible to detect “endogenous ouabain”. (Blaustein admits that there is no ”convenient EO assay.”) However, concentrations of plant derived ouabain can be measured even in extreme low concentrations. From such measurements the therapeutic levels of ouabain serum concentrations are known and have been validated by decades of clinical experience. Thus, effective therapeutic dosing of ouabain is a well established procedure.</p>

<p>@ 6: The sophisticated total syntheses of ouabain are high-lights in synthetic chemistry. These masterpieces allow the preparation of a few mg on laboratory scale, but they are not suited for large scale production of ouabain.</p>

Finally, I do agree with Blaustein that in science many notions have landed in the trash bin of history. I dare to predict that ”endogenous ouabain” , too, will suffer that fate.

On 2018 Jan 12, Mordecai P Blaustein commented:

Response to Dr. Fürstenwerth

I thank Dr. Fürstenwerth for his comments about my article. His exuberant advocacy for the clinical use of ouabain is refreshingly entertaining. As he states, however, his views are based largely on “applying common sense”; he appears to ignore the experimental method and actual data. (“Common sense” also led to such ideas as, “the earth is flat,” and “the sun revolves around the earth” – notions that landed in the trash bin of history.)

1. Fürstenwerth correctly asserts that k-strophanthin is the predominant cardenolide extracted from Strophanthus kombé, but this plant produces a mixture of related steroids [1].

2. He states that the “endogenous ouabain-Na+ pump endocrine system… is… wishful thinking.” Data from multiple laboratories, summarized in my article, demonstrate that an inactivating mutation of the mouse alpha-2 Na+ pump ouabain binding site, or infusion of anti-ouabain antibodies to immuno-neutralize endogenous ouabain (EO) in rats, induces a clear phenotype. This loss of EO-Na+ pump interaction is manifested by specific disturbances of (e.g.) behavior and learning, exercise endurance, fetal development and basal blood pressure. In my view, these data trump Fürstenwerth’s “common sense”.

3. He claims that “There is no endogenous ouabain.” Has he read (or understood) the articles listed in Table 2A? Rather than relying on “common sense”, I prefer the mass spectra and NMR spectra published by such distinguished chemists/biochemists as Prof. Wilhelm Schoner [2], Prof. Tadashi Inagami [3], and Prof. Koji Nakanishi [4], a member of the National Academy of Sciences USA and one of the world’s leading natural product chemists. Moreover, the very detailed original mass spectroscopy report included all the original, rigorous purification data [5-7]. In contrast, the few investigators who were unable to detect EO (Table 2C) cut methodological corners (see text and [8]) and even “edited” their raw data [9,10] (and see [8]).

4. Fürstenwerth claims that my review “neglects” the “beneficial” effects of ouabain and “does not discuss (the)... obvious contradictions” that “ouabain lowers blood pressure, (but also) produces hypertension”. His statement is not true. Table 3 shows that mutation (inactivation) of the alpha-2 Na+ pump ouabain binding site elevates basal blood pressure; this implies that EO is normally needed to help keep blood pressure low (i.e., ‘normal’). On the other hand, Yuan et al. [11] were just the first of numerous investigators to show that prolonged, high ouabain levels elevate blood pressure. Like all hormones, ouabain can be expected to have both beneficial and, if greatly elevated for a prolonged period, detrimental effects (see Fig. 4 and pages C14 and C16 of my article).

5. I do not dispute Fürstenwerth’s assertion that the “decisive factor is the (ouabain) serum concentration”. But, in that case, given the aforementioned data, his opposition to my call for “solid information” about plasma EO/ouabain levels before and during ouabain therapy makes no sense. Drug treatment based simply on “common sense” must give way to effective therapeutic dosing that utilizes all the available scientific information to optimize treatment and patient safety.

6. Finally, Fürstenwerth states that “production of Strophanthus glycosides is… restricted to collection of wild plants.” This is not true. The complete chemical synthesis of ouabain was achieved by Deslongchamps [12] and a more concise method has now been developed [13].

In conclusion, as Withering wrote in 1785 [14], “After all, in spite of opinion, prejudice or error, Time will fix the real value upon this discovery, and determine whether I have imposed upon myself and others, or contributed to the benefit of science and mankind”.

References:

[1] Jacobs & Hoffman, J Biol Chem 69: 153-163, 1926.

[2] Schneider R, 1998

[3] Tamura M, 1994

[4] Kawamura A, 1999

[5] Hamlyn JM, 1991

[6] Ludens JH, 1991

[7] Mathews WR, 1991

[8] Hamlyn JM, 2016

[9] Baecher S, 2014

[10] Vogeser M, 2015

[11] Yuan CM, 1993

[12] Reddy MS, 2009

[13] Renata H, 2015

[14] Withering, “An Account of the Foxglove and Some of its Medical Uses”, M. Swinney for G.G.J. and J. Robinson, Birmingham, 1785.

On 2018 Jan 12, Mordecai P Blaustein commented:

None

On 2018 Jan 08, Hauke Fürstenwerth commented:

the mistreated gift from paradise

In the final version of his article Blaustein again reveals his ignorance of the history of Ouabain and Strophanthus glycosides. It is not true that Ouabain is found in Strophanthus kombé. The glycoside occurring in S. kombé is k-strophanthin. Ouabain is found in both Acokanthera ouabaio and Strophanthus gratus. Herman Thoms isolated the pure glycosides from S. kombé and S. gratus in 1904 and has unambiguously assigned them with the names k- and g-strophanthin [1].

Based on the work of Thomas Fraser, Burroughs, Wellcome & Co in 1886 introduced a S. kombé extract called "Tincture of Strophanthus". This was sold at seven shillings per ounce. In America, E.R. Squibb and Sons was one of the first suppliers of Strophanthus preparations. Particularly popular was a chocolate coated tablet of a mixture of Digitalis and Strophanthus extracts, which was sold at 16 cents per one hundred pieces [2]. In 1889, Boehringer Mannheim introduced pure k-strophanthin to the market. In cooperation with Albert Fraenkel Boehringer in 1907 introduced a solution of k-strophanthin for intravenous administration under the brand name “Kombetin”.

In 1904 E. Merck, Darmstadt, commercialized a standardized solution of pure g-strophanthin as "g-Strophanthin crystallisatum after Thoms". In 1906, also Kali-Chemie began marketing a g-strophanthin solution under the trade name “Purostrophan”. In the following years, several suppliers offered Strophanthus glycosides preparations for oral and intravenous use. In contrast to Blaustein's assertion orally administered ouabain products over the decades of their use have been given as standard medication to millions of patients. The database of the German Institute for Medical Documentation and Information records more than 20 orally administered ouabain preparations that were used in Germany after 1950. Decades of clinical experience with dozens of ouabain based preparations (i.e. treatment of millions of patients) can not be disqualified as „anecdotal“.

Blaustein's core hypothesis is that “ouabain is a key factor in the pathogenesis of hypertension and heart failure". At the same time he states that ouabain is “equipotent to digoxin” and has been used “for acute iv administration in heart failure emergencies“. By applying common sense, it can be ruled out that a substance that has been used successfully for decades as an emergency drug in the treatment of heart failure will cause heart failure. Equally excluded is that ouabain, which in clinical practice lowers blood pressure, produces hypertension. Already Fraser had pointed out that “strophanthin increases the action of the heart without raising blood pressure.” Blaustein does not discuss these obvious contradictions nor does he suggest an explanation. He as well neglects current reports on cardio protection induced by ouabain as well as conclusions by Lijune Liu and co-workers that ouabain can be beneficial to various stages of heart failure.

Based on all available data it can be ascertained that the mutually exclusive effects of plant derived ouabain and the inhibitor of the Na/K-ATPase observed in mammalian tissues do not support the hypothesis that this inhibitor is identical with ouabain, but favor the interpretation that “endogenous ouabain” is something different. Hence, Blaustein's request to establish "solid information about the normal plasma EO level under a variety of conditions" is unfounded. There is no endogenous ouabain.

African healers have long recognized the medical value of Strophanthus extracts. The medical application relied on alcoholic decotions made by steeping roots in a fermented, alcoholic beverage. The resulting bitter tasting solution would be taken in small sips over a period of days or weeks [2]. The healers knew that the effect of Strophanthus as a potent plant with both healing and highly toxic capabilities, crucially depends on the method of preparation of the drug. In 1971 this observation found a decisive scientific confirmation. Lindenbaum et al published findings that different batches of digoxin from the same manufacturer resulted in different serum concentrations [3]. This publication and subsequent studies lead to the transformation of the art of galenics from a trial-and-error exercise into a scientific discipline. Contrary to Blaustein's assertion, today we know from progress in pharmacology and galenics that absolute bioavailability is not decisive for the therapeutic effect. The only decisive factor is the serum concentration, which enables a sustained therapeutic effect. This is achieved by a correspondingly optimized galenic formulation of the active substance. Different formulations require different dosages to produce the same serum concentration. This is the explanation for the different concentrations of ouabain preparations cited by Blaustein. Contrary to Blaustein's assertion the therapeutic serum concentrations of ouabain are well known: 0.5 ng/ml in steady-state after iv administration and 0.4-0.9 ng/ml on oral administration of suitable galenic preparations.

Blaustein argues on the basis of outdated knowledge that does not take into account the effects of galenics. Today drugs such as Aliskiren, whose absorption rate is about 3%, will not be rejected just because the absorption rate is too low. Aliskiren’s therapeutic effects derive from sufficiently high serum concentrations, not from the total amount absorbed. The same is true for drugs like Nisoldipine (5%), Dabigatranetextilat (6.5%), or Ramipril (15%), which have absorption rates comparable to that of ouabain. For ouabain, absorption rates of up to 10% have been measured.

Blaustein falsely assumes that Ouabain has been withdrawn from the market because there has been a death following intravenous administration. The anecdotal evidence he refers to is a patient with multiple co-morbidities. It is outright medical malpractice to inject 0.75 mg ouabain in such a patient when the standard dose should not exceed 0.25 mg.

Ouabain preparations are no longer available because no company was willing to fund the required clinical trials. The historical preference of Digitalis glycosides over Strophanthus glycosides is due to two factors. 1. Digitalis glycosides can be produced at low cost on an industrial scale from commercial Digitalis plantations. The production of Strophanthus glycosides is and was restricted to collection of wild plants and is correspondingly expensive. 2. Cardiac glycosides were used with the aim of strengthening the contraction force of the heart muscle. Since digitalis glycosides have a stronger inotropic effect than Strophanthus glycosides, the former were preferred. Additionally, false ideas about the importance of galenics have certainly contributed to the uncertainty of clinicians.

For the locals in Africa, Strophanthus was poison and remedy in one. In the mythology of the tribe of the Wilé in Upper Volta, this plant was sent from paradise to the earth to heal or punish people according to their merit [4]. Hence, it is an ethical obligation when studying Strophanthus glycosides to apply generally accepted principles in science. Otherwise hubris and personal vanity will hinder finding the truth. Mordecai P. Blaustein breaks with this generally accepted principles in science. He ignores ideas and data that don’t fit his preconceptions and neglects conflicting results that don’t support his hypotheses. Blaustein’s narrative about the construction of an "endogenous ouabain-Na+ pump endocrine system" lacks a necessary critical perspective. It is guided by wishful thinking and not by facts.

References

[1] https://link.springer.com/chapter/10.1007/978-3-662-40381-5_7

[2] Osseo-Asare AD, Bitter roots: the search for healing plants in Africa, The University of Chicago Press, 2014

[3] Lindenbaum J, 1971

[4] Leuenberger H, Gesund durch Gift, Deutsche Verlagsanstalt Stuttgart, 1972

On 2017 Dec 13, Hauke Fürstenwerth commented:

None

On 2017 Nov 15, Hauke Fürstenwerth commented:

None

On 2017 Nov 14, Mordecai P Blaustein commented:

The topic of "ouabain as a therapeutic agent" is discussed in the print version of this article ("The Pump, the Exchanger and the Holy Spirit..."). The print version will be published in the December 2017 issue of Am J Physiol Cell Physiol.

On 2017 Nov 06, Hauke Fürstenwerth commented:

Are clinical experiences not relevant?<br> In medical research, decisive results are obtained by clinical experiences. Hence, new hypotheses need to be checked for clinical findings and observations. Ouabain and the related Strophanthus glycoside k-strophanthin by default have been used for more than a century to treat heart diseases. Cymarin and convallatoxin have also been used. As early as 1904, a standardized solution of pure ouabain was commercialized by E. Merck, Darmstadt as “g-Strophanthin crystallisatum nach Thoms”. This ouabain solution was used both intravenously [7] and orally administered in the treatment of heart diseases. In 1909, the French physician Henri Vaquez introduced the intravenous application of ouabain (“Ouabain-Arnaud”) in France. In World War I medical personnel in the German army by order of the ambulance corps exclusively used ouabain solutions to treat heart failure [4]. The therapeutic profile and the disease profiles for which the use of Strophanthus glycosides is appropriate are documented in many reports on clinical experiences and have been summarized in numerous reviews, preferably in the German literature [10]. As early as the first half of the 20th century distinguished scientists such as Albert Fraenkel, University of Heidelberg, and Ernst Edens, University of Dusseldorf, have published monographs [8,5] that document in detail the clinical effects of Strophanthus glycosides. In textbooks ouabain has been praised as "the biggest advance in cardiac therapy since Withering in 1785" [6]. Decades of clinical experience with ouabain provide a yardstick by which all research results and hypotheses related to ouabain have to be measured. Observations at the bedside are more meaningful than speculative hypotheses based on experimental research.

In his article Mordecai P. Blaustein gives no reference to the comprehensive literature on clinical experience with ouabain. Although he concludes from his hypotheses that “ouabain and its receptor site participate in the pathogenesis of hypertension, cardiac hypertrophy and HF“ he does not even mention the fact that ouabain has been used successfully in medical therapy of heart failure.

Contrary to well-documented positive clinical experience in the treatment of heart disease with ouabain, Blaustein asserts that ouabain damages the cardio-vascular system. He neglects current reports on cardio protection induced by ouabain [13,15,19] as well as conclusions by Lijune Liu and co-workers that ouabain can be beneficial to various stages of heart failure [14]. Blaustein asserts that ouabain raises blood pressure in humans, but at the same time admits that ouabain increases blood pressure only in selected rodents strains, because the susceptibility to ouabain-induced hypertension is genetically-determined. Thus there is no evidence to suggest that ouabain is hypertensinogenic in humans. In clinical experience a reduction of high blood pressure in patients is observed on treatment with ouabain [9].

Blaustein asserts that in more than two centuries of clinical use of digoxin no hints have been found that digoxin is hypertensinogenic. However, it is common knowledge that Digitalis as well as Strophanthus glycosides in high enough concentration increase blood pressure [1,8]. The effects of cardiac glycosides are very sensitive to the applied dosage. Cardiac glycosides are prototypical examples of hormetic substances [10]. The hormetic nature of ouabain is also observed in the effect on signal transduction. According to the studies quoted by Blaustein in his article, low concentrations of ouabain activate signaling cascades, while high concentrations inhibit them.

Ouabain has been used in clinical application to treat digitalis intoxication in patients. Corresponding reports are documented as early as 1902. Recent in vitro and in vivo studies confirm this well-known clinical observation [16]. So contrary to Blaustein’s hypothesis that digoxin prevents negative effects of ouabain, in clinical practise ouabain has been shown to prevent damage from digoxin. It is a frequently reported observation that Strophanthus glycosides also work in patients in whom digitalis glycosides have no effect, see for example the publication of the renowned cardiologists Franz Groedel and Bruno Kisch [11].

The therapeutic effects of k-and g-strophanthin are largely identical, ouabain being slightly more potent than k-strophanthin [8,17]. In a double blind cross-over study Agostoni compared the effects of k-strophanthin and digoxin in 22 patients with advanced congestive heart failure [2]. K-strophanthin improved functional performance while digoxin failed to provide such results. Norepinephrine plasma level at rest was significantly lowered by k-strophanthin but not by digoxin.

Based on all available data it can be ascertained that the mutually exclusive effects of ouabain and the inhibitor of the Na/K-ATPase observed in mammalian tissues do not support the hypothesis that this inhibitor is identical with ouabain, but favor the interpretation that “endogenous ouabain” is something different.

Blaustein asserts that Hamlyn identified two ouabain isomers in rodent plasma that are absent from commercial (plant) ouabain. This assertion is not backed by the corresponding Hamlyn publication [12]. Therein Hamlyn reports the presence of several substances in plasma of pregnant rats that show immunoreactivity. Two substances are chromatographically slightly different from ouabain and have different mass spectra. Hamlyn does not provide any data for the elucidation of the chemical structure. The chemical structure of these products is unknown. So it is not justified to claim that these substances are isomers of ouabain.

Nor does the existence of these unknown compounds in plasma of rats suggest that endogenous ouabain is of animal origin. A comparison of substances found in unpurified plasma with purified ouabain - ie free from impurities - is meaningless. Provided that these substances will be identified by structural analysis as isomers of ouabain then it still has to be examined whether these substances are also found in Strophanthus or Acokanthera extracts.

References

[1] Abelmann WH, 1973<br> [2] Agostoni PG, 1994<br> [4] https://sites.google.com/a/aryapa.faith/iosifpravin/albert-fraenkel-ein-arztleben-in-licht-und-schatten-1864-1938-reihe-ecomed-biographien-3609162600

[5] Edens E, Die Digitalisbehandlung [Digitalis treatment] , Third edition, Berlin-München, Verlag Urban&Schwarzenberg, 1948

[6] Eichholtz F, Lehrbuch der Pharmakologie [Textbook of Pharmacology], fifth edition, Berlin und Heidelberg, Springer Verlag, 1947.

[7] Fleischmann P, Wjasmensky H. Ü̈ber intravenöse Strophanthintherapie bei Verwendung von gratus-Strophanthinum crystallisatum Thoms. Deutsche Medizinische Wochenschrift 35: 918–921, 1909

[8] https://books.google.de/books?id=iq-kBgAAQBAJ&printsec=frontcover&hl=de&source=gbs_ge_summary_r&cad=0#v=onepage&q&f=false

[9] https://doi.org/10.9734/BJMMR/2015/17042

[10] Fürstenwerth H, 2016

[11] https://doi.org/10.1016/S0025-7125(16)36725-6

[12] Jacobs BE, 2012

[13] Lagerstrom CF, 1988

[14] Liu L, 2016

[15] Morgan EE, 2010

[16] Nesher M, 2010

[17] PFEIFER E, 1960

[19] Wu J, 2015

On 2017 Dec 07, James AM Yeates commented:

The ACTA-PORT score can now be easily accessed as an online calculator (https://qxmd.com/calculate/calculator_436/PORT-score-for-PeriOperative-Risk-of-blood-Transfusion-in-cardiac-surgery-by-ACTA) or can be accessed at the point of care using mobile & web app 'Calculate' by QxMed https://qxmd.com/calculate/calculator_436/PORT-score-for-PeriOperative-Risk-of-blood-Transfusion-in-cardiac-surgery-by-ACTA

On 2017 Dec 06, Stuart RAY commented:

This is a meta-analysis that attempts to correlate mercury exposure with autism spectrum disorders. On page 296 of this report, in the Discussion section, the authors note this first among the limitations of their study: "The major problem with case-control studies is the temporal relationship between exposure and outcome. It is possible, for example, that older children with ASD may exhibit more mouthing behavior than healthy controls, leading to increased levels of mercury (and other pollutants) in their biological tissues." Given this (valid) limitation, the primary conclusion appears to be highly questionable.

On 2017 Oct 05, Zvi Herzig commented:

That current e-cigarette use is also significantly associated with previous asthma in this study, strongly suggests undetected confounding and/or reverse causality.

On 2017 Nov 02, Federico Cabitza commented:

The Limits of Mind: Extended by Computers, or just distanced from sight?

In their Perspective [1] (Obermeyer Z, 2017), Obermeyer and Lee claim that computers, ”far from being the problem [of the increasing complexity of contemporary medicine], are the solution” and suggest that, as the inadequacy of “our inborn sensorium” spurred the development of “stethoscopes, electrocardiograms, and radiographs”, likewise the inadequacy of our “inborn cognition” motivates an analogous augmentation by computers.

However, the mentioned sensorial augmentation amplifies subtle clinical signs offering them at the physicians’ interpretation, while computers would augment cognition in terms of mere textual categories and numerical data, thus often shortcutting intuition, dispelling uncertainty [2] (Simpkin AL, 2016) from clinical reasoning and worse yet potentially biasing interpretation [3] (Goddard K, 2012).

Understating the irreducible gap between the discreteness of data and the continuous (and partly ineffable) experience of illness in physicians regards the “demise of context” we highlighted [4] when physicians overrely on computer outputs (Cabitza F, 2017).

While the computers’ potential for pattern recognition in diagnostic imaging is indisputable, the complexity of more clinical applications has so far been irksome to master [5].

This suggests prudence before entrusting the “future of medicine” to a wider digitization, which can entail unintended bottlenecks.

Federico Cabitza, PhD; Camilla Alderighi, MD; Raffaele Rasoini, MD;

1. Obermeyer Z, Lee TH. Lost in Thought — The Limits of the Human Mind and the Future of Medicine. NEJM 2017; 377:1209-1211

2. Simpkin AL, Schwartzstein RM. Tolerating uncertainty—the next medical revolution? NEJM 2016; 375(18): 1713-1715.

3. Goddard K, Roudsari A, Wyatt JC. Automation bias: a systematic review of frequency, effect mediators, and mitigators. JAMIA. 2011;19(1):121-7.

4. Cabitza F, Rasoini R, Gensini GF. Unintended Consequences of Machine Learning in Medicine. JAMA 2017; 318(6): 517–518

5. Ross C, Swetlitz I. IBM Pitched Its Watson Supercomputer as a Revolution in Cancer Care. It's Nowhere Close. Scientific American, 6 september 2017.

On 2017 Oct 02, Peter Rogan commented:

We would like to alert readers to the fact that information theory-based splicing mutation analysis has been used to analyze a wide range of variants (in/dels and SNVs) that affect splicing in introns and exons in peer reviewed studies. These tools have been used analyze mutations that alter branchpoint recognition and within introns in peer reviewed studies. The Automated Splice Site and Exon Definition Analysis server, ASSEDA (Mucaki EJ, 2013) analyzes mutations at branchpoints, within intronic sequences, at cryptic splice sites, and at splicing regulatory protein binding sites ("enhancer/silencer" sequences). We have also published the Shannon pipeline (Shirley BC, 2013), which carries out mutation analysis affecting splicing (and transcription factor binding sites; Lu R, 2017) on a genome scale. Veridical is software validates splicing mutations found with the Shannon pipeline (or any other program) with RNASeq data from the same individual (Viner C, 2014, Dorman SN, 2014).

Our previous review article extensively describes the use of these tools for splicing mutation analysis by many other research groups, besides ourselves (Caminsky N, 2014).

On 2017 Sep 28, Tanai Cardona commented:

I had a look at my dataset of D1 sequences from Cyanobacteria. You may find interesting that Ala87 is not unique to plants and actually is a trait of early-evolving atypical D1 sequences (rogue and super-rogue) and also of standard D1 forms of early evolving cyanobacteria, like the marine yellowstone Synechococcus (Ja-3-3Ab) or Synechococcus sp. PCC 7336. It is kind of cool because in my 2015 Mol Biol Evol paper, the plant D1 clustered with this early evolving cyanos.

On 2017 Oct 03, Kartik Gupta commented:

The title contains the word "tree oil" and not "tea tree oil". The authors want to convey that this cocktail of commonly used tree-derived oils (tea tree, neem and pine) and kerosene can cause methemoglobinemia.

On 2017 Sep 25, Tony Larkman commented:

The title of this report 'Case of methaemoglobinaemia caused by tree oils and kerosene' is misleading because it appears to blame tea tree oil and/or kerosene for the symptoms reported. Apart from the 15% tea tree oil and 20% kerosene in the rat poison the product also contained 40% Neem (azadirachtin) oil and 25% pine oil. These products, which were not mentioned in the title, both contain terpenes and other potentially poisonous compounds when ingested.

On 2017 Nov 28, Natalie Clairoux commented:

Free version of this article available after Sept. 21, 2018 at https://papyrus.bib.umontreal.ca/xmlui/handle/1866/19535

On 2017 Nov 12, Jonathan Eisen commented:

I believe the claims regarding "beneficial" organisms in this paper are inaccurate and misleading. For example, consider statement in the abstract:

"While the vast majority of microbial species classified were beneficial"

No evidence is presented anywhere in the paper that the microbes they identify via sequence analysis are beneficial in any way. I engaged in a Twitter discussion with the senior author of this paper, Chris Mason, about this topic where we discussed my concerns. Details of this discussion are here: https://phylogenomics.blogspot.com/2017/11/flaws-in-prediction-of-presence-of.html

As far as I can tell from this discussion and from the paper, the authors considered all organisms that were not specifically assigned to be a putative pathogen to be beneficial.

This is simply a flawed approach.

First, just because they are not assigned to be putative pathogenic does not mean that they are not pathogenic.

Second, this ignores the possibility that microbes could have no effect. That is, some could be parasitic, some could be beneficial, and some could have no effect - what was the no effect category ignored?

Third, the DNA could be coming from dead organisms that presumably would not have any significant effects.

Overall, I believe this paper's claims regarding "beneficial" microbes are inappropriate and misleading.

On 2017 Oct 15, Nevit Dilmen commented:

Let's clarify the hypothesis about the potential use of AI in mammography:

Some cancers which are present in the patient's breast have a footprint on mammography but the human radiologists are unable to detect the sign in some cases.

AI might help in improving above category.

AI can NOT help if a cancer has no footprint on a mammogram. Indeed mammograms do not show cancers in some cases and we should not expect any benefit of using AI in those cases. Examples are any tumor that is too small, any tumor outside of the imaged area, dense breasts.

Much of the effort to improve screening is focused on reading. AI might also help to clarify how much we should expect from mammography itself as a modality. How much human readers are actually missing.

On 2017 Oct 08, Clive Bates commented:

A further point to add to Rodu's and Sweanor's excellent critique above. The original authors inexplicably avoid exposing the quantified results in the abstract. Why? These are:

When asked whether some smokeless tobacco products “are less harmful to a person’s health than cigarettes,”the majority of respondents 66.8%, (95% CI=63.9, 69.6) said “no,” 22.2% (95% CI=20.0, 24.7) said “don’t know,” and 10.9% (95% CI=9.4, 12.8) said “yes.

So only 10.9% have the answer right - an astonishing misalignment of public perception and reality for which several federal agencies bear contributory responsibility. Given switching from smoking to smokeless radically reduces health risks, this is a very disturbing finding.

Yet the position is even more troubling than these data suggest. The most appropriate answer is that smokeless tobacco products "are much less harmful" than smoking. American smokeless tobacco is likely in the range 98-100% less harmful than smoking - but merely "less harmful" could mean 10%, 30%, 70% or 98% less harmful, and only the last of these is approximately correct.

The answer "much less harmful" is not allowed in the HINTS survey for smokeless. However, this response is allowed in the HINTS survey for e-cigarettes. In this survey, only 5.3% correctly say e-cigarettes are "much less harmful" and a further 20.6% say "less harmful" - indicating extensive misperceptions of the magnitude of the risk differential even among those who are not literally wrong in believing these products are less harmful than smoking.

On 2017 Oct 04, Brad Rodu commented:

The study by Feirman et al. (Feirman SP, 2018) described in detail the results from one question in the 2012, 2014, and 2015 Health Information National Trends Surveys: “Do you believe that some smokeless tobacco products, such as chewing tobacco and snuff, are less harmful than cigarettes?” The possible answers were “Yes,” “No,” and “Don’t Know.”

The article highlighted these findings:

• “A majority of adults do not think smokeless tobacco is less harmful than cigarettes.” (i.e., didn’t answer “yes.”) • “Believing smokeless tobacco is not less harmful than cigarettes declined from 2012–2015.” • “Perceptions about the harm of smokeless tobacco differed by demographic subgroup.”

The authors, from the U.S. FDA and National Cancer Institute, commented: “…our findings may help inform public health communications aimed at reducing tobacco-related harms. Additionally, understanding consumer perceptions of tobacco products plays an important role in FDA's regulatory work.”

This claim is not valid because of one glaring omission throughout the article, which contained 3,800 words, 3 large tables of numbers and 58 references. The article failed to specify that the correct answer is: “Yes, smokeless tobacco products are less harmful than cigarettes.” In fact, it focused almost entirely on the majority of participants who inaccurately answered “No” or “Don’t Know,” which reflects misperception fostered by an effective “quarantine” of truthful risk information by federal agencies (Kozlowski LT, 2016).

Decades of epidemiologic studies have documented that the health risks of smokeless tobacco use are, at most, 2% those of smoking (Rodu B, 2006; Rodu B, 2011; Fisher M 2017; Royal College of Physicians, 2002; Lee PN, 2009). Unlike cigarettes, smokeless tobacco does not cause lung cancer, heart and circulatory diseases or emphysema. In 2002 the Royal College of Physicians concluded: “As a way of using nicotine, the consumption of non-combustible [smokeless] tobacco is on the order of 10–1,000 times less hazardous than smoking, depending on the product.” (Royal College of Physicians, 2002)

The low risks from smokeless tobacco use even include mouth cancer. A 2002 review documented that men in the U.S. who use moist snuff and chewing tobacco have minimal to no risk for mouth cancer (Rodu B, 2002), and a recent federal study found no excess deaths from the disease among American men who use moist snuff or chewing tobacco (Wyss AB, 2016).

As one of us recently wrote, “Deception or evasion about major differences in product risks is not supported by public health ethics, health communication or consumer practices. Public health agencies have an obligation to correct the current dramatic level of consumer misinformation on relative risks that they have fostered.” (Kozlowski LT, 2018)

Brad Rodu Professor of Medicine University of Louisville

David Sweanor Adjunct Professor of Law Centre for Health Law, Policy and Ethics University of Ottawa

Brad Rodu is supported by unrestricted grants from tobacco manufacturers to the University of Louisville, and by the Kentucky Research Challenge Trust Fund.

On 2018 Feb 04, Sin Hang Lee commented:

The medical profession, including medical schools and hospitals, is now a part of the health care industry, and implementation of editorial policies of medical journals is commonly biased in favor of business interests. PubMed Commons has offered the only, albeit constrained, open forum to air dissenting research and opinions in science-based language. Discontinuation of PubMed Commons will silence any questioning of the industry-sponsored promotional publications indexed in PubMed.

On 2017 Sep 25, Sin Hang Lee commented:

The research paper by Lager and colleagues [1] reported the first attempt to compare the sensitivity and specificity of any direct nucleic acid-based test protocols used by different laboratories in detecting the DNA of various borrelial species. Such efforts, if continued, may eventually lead to development of a useful direct test for reliable diagnosis of Lyme borreliosis (LB) and should be encouraged worldwide.

The authors’ statement “PCR is not suitable as a primary diagnostic tool for Lyme borreliosis (LB)” may be too dogmatic. If a PCR test can be proven to be sensitive and specific for reliable diagnosis of LB, there is no reason to reject it as a primary diagnostic tool since several co-authors of this article have stated in a recent position paper that clinicians are advised to avoid serological testing whenever the clinical symptoms are not indicative of LB according to the case definitions because the current serology tests are of little diagnostic value. [2]

It is no surprise that the authors found that the16S rRNA PCR protocols have a higher analytical sensitivity than the non-16S rRNA PCR protocols and the concordance between the 16S rRNA PCR protocols is high. The bacterial 16S rRNA gene is species-specific, is essential for protein synthesis and does not mutate in our lifetime. Non-16S rRNA genes in a borrelia strain may mutate or be deleted, and may be shared by other species of bacteria.

However, using real-time PCR to detect a signature segment of borrelial 16S rRNA gene for the diagnosis of Lyme borreliosis is bound to encounter technical difficulties. For clinical diagnostic real-time PCR, the optimal amplicon length is usually less than 150 bp [3], often below 80 bp [4], as illustrated in this article. [1] Since all bacterial species have a 16S rRNA gene consisting of about 1500 bp of DNA with interspecies highly conserved segments and hypervariable segments of sequence intercalated between themselves, PCR primer selections are crucial. The false positive B. hermsii and B. miyamotoi detection in protocols 3, 7 and 8 illustrates the inevitable errors of depending on probe hybridization to distinguish closely related DNA sequences. The authors have finally reached a correct conclusion that “In practice, all 16S PCR-based tests without DNA sequencing of the PCR amplicon for validation are prone to generate this kind of error”. In order to detect Borrelia spielmanii, Borrelia lusitaniae and Borrelia japonica, a pair of more inclusive genus-specific PCR primers [5] may be needed.

The recommendation “to complement the real-time PCR results with sequencing results” is not practical for the diagnosis of Lyme borreliosis. The amplicon generated by real-time PCR primers cannot be used for automated Sanger sequencing because the fragments are too short. If the real-time PCR technology were used to screen patient materials like the blood samples which contain human genomic DNA, there would be many questionable positive results which need to be re-tested by conventional PCR to prepare suitable templates for Sanger reaction.

In their research as reported [1], the authors distributed cDNA and extracted DNA in water or buffer solution from pure borrelial cultures and normal cerebrospinal fluid spiked with pure borrelial cultures as the testing materials which do not contain human genomic DNA as interfering substances. These experimental designs do not reflect the real conditions the diagnostic laboratories are facing.

It is recommended that a similar comparative research be conducted by sending out blind-coded EDTA blood samples spiked with different concentrations of various borrelial cultures to different laboratories for a proficiency test survey. There may be more appropriate direct tests out there which are better than real-time PCR for a reliable diagnosis of Lyme borreliosis.

References

[1] Lager M, Faller M, Wilhelmsson P, Kjelland V, Andreassen Å, Dargis R, Quarsten H, Dessau R, Fingerle V, Margos G, Noraas S, Ornstein K, Petersson AC, Matussek A, Lindgren PE, Henningsson AJ. Molecular detection of Borrelia burgdorferi sensu lato - An analytical comparison of real-time PCR protocols from five different Scandinavian laboratories. PLoS One. 2017 Sep 22;12(9):e0185434.

[2] Dessau RB, van Dam AP, Fingerle V, Gray J, Hovius J, Hunfeld KP, Jaulhac B, Kahl O, Kristoferitsch W, Lindgren PE, Markowicz M, Mavin S, Ornstein K, Rupprecht T, Stanek G, Strle F. To test or not to test? Laboratory support for the diagnosis of Lyme borreliosis. Clin Microbiol Infect. 2017 Sep 5. pii: S1198-743X(17)30488-3.

[3] Ornstein K, Barbour AG. A reverse transcriptase-polymerase chain reaction assay of Borrelia burgdorferi 16S rRNA for highly sensitive quantification of pathogen load in a vector. Vector borne and zoonotic diseases. 2006; 6:103-12.

[4] Tsao JI, et al. An ecological approach to preventing human infection: vaccinating wild mouse reservoirs intervenes in the Lyme disease cycle. Proc Natl Acad Sci U S A. 2004 ;101:18159-64.

[5] Lee SH, et al. DNA sequencing diagnosis of off-season spirochetemia with low bacterial density in Borrelia burgdorferi and Borrelia miyamotoi infections. Int J Mol Sci. 2014;15:11364-86.

Conflicts of Interest: Sin Hang Lee, MD is the director of Milford Molecular Diagnostics Laboratory specialized in developing DNA sequencing-based diagnostic tests.

On 2017 Sep 26, Clive Bates commented:

So again, we have a study that ignores the central feature of vaping: namely, that it is a human behaviour in which the human user regulates variables like the choice of device and hence coil and wicking configuration, voltage and power settings during operation, and the rate of liquid consumption according to their preferences.

The formation of volatile aldehydes (VAs) is largely temperature dependent (they are products of thermal decomposition), and increasingly vaping devices include temperature control. But the ultimate control is with the user. A high volume of liquid consumption combined with greater coil surface area can still allow for operation at a moderate temperature even at high power, as the liquid transfers heat away from the coil surface.

Users will operate the equipment in a way that does not lead to harsh dry puff conditions, with associated high VA formation. This is a key human control feedback that does not exist in laboratory equipment. So experiments that just standardise power settings or volume consumption must take care to validate these are realistic proxies for human use for a particular device. In this paper, many of the coil, power and volume settings combinations were not realistic. That could have been avoided through engaging with people with real practical expertise.

On 2017 Sep 26, Clive Bates commented:

I would like to recommend that the authors (and anyone attempting similar experiments) consult experienced users about the way these products are used in practice in order to ensure their work is relevant and realistic. I am posting a critical review of this paper by an experienced vaper, Paul Barnes, a trustee of the New Nicotine Alliance.

Paul Barnes' review starts here

An emerging category of electronic cigarettes (ECIGs) are sub-Ohm devices (SODs) that operate at ten or more times the power of conventional ECIGs

Sub-Ohming has been a feature of vaping for many years with advanced, or hobbyist, users utilising knowledge of Ohms Law and unregulated mechanical mods (“mech-mods”), along with user-made coils to provide an experience customised to suit the individual user.

As technology has improved, the need for mechanical mods has waned, bringing forth the era of the regulated devices. These contain a chipset to regulate power output (wattage), include safety cut-off (to prevent over-use), and control thermal safety (to prevent cell failures), among other features. These devices can produce similar, or greater, power output compared with the mechanical device.

Pre-made coils are now the norm for most users. The coils mentioned in this paper - Smok TF-Q4 (1), Smok V8-Q4 (2), Smok V8-T8 (3) and the Smok V8-T10 (4) - present a unique problem for researchers lacking in an understanding of both the technology and the consumer.

In this paper, all the chosen coils were used at a constant power of 50W, with the Smok V8-T8 coil head being used at varying power levels (50, 75, and 100 Watts).

Fundamentally, the design of the coil head is suitable for higher power usage, not low power.

One of the key problems with this approach is the misunderstanding of a) how these devices are used in the real world, and b) the particular user characteristics.

For example, the Smok TF-Q4 states (screen printed on the coil head itself) that the “best” range (determined by user experience, the resistance of the coil, and knowledge of consumer preferences) for power (in Watts) is between 80-120W - between the medium and the upper end of the coil-head maximum capability of 140 Watts.

The power ranges for the other coils are as follows (according to manufacturer specifications):

Smok V8-Q4: 50-180W and "best between" 90-150W

Smok V8-T8: 50-260W and "best between" 125-180W

Smok V8-T10: 50-300W and "best between" 130-190W

Considering that the coil head chosen for the variable power test (Smok V8-T8) has a “best” operating range of 125-180 W, testing at 100 demonstrates an imbalance between the cooling effects of the e-liquid, aerosol generation and airflow - a factor not directly considered in the paper.

At a measured resistance of 0.15 Ohms - the culmination of eight physical coils arranged in parallel - (assuming the Joyetech Cuboid used measured the resistance accurately), and a power setting of 100W, the voltage applied to the coil head is 5.33V (35.59A).

Finding a decrease in VA emissions is obvious, given the coil heads fundamental design and operating parameters. In comparison, the Vapor Fi (5) device used demonstrated high levels of VA emissions when used at 11 W (approximately 6.2V), far and above the power that would generate the "dry puff" phenomenon (6); as commonly seen in the older CE4/CE5 clearomisers favoured by some researchers (7).

The key difference between the VF coil and the Smok coil-heads is in the construction. The Smok coil-heads utilise multiple physical coils inside a single unit, conversely, the VF coil is a single coil unit. Therefore, the entirety of the 6.2V (at 11W) is being applied to a single resistance material. The unique construction of the Smok coil-heads negates this fundamental problem by providing up to 10 distinct coils within the head. The total effect is the same, 5.33V is being applied to the entirety of the head, but distributed across 4, 8 or 10 distinct paths.

Coupled with the larger surface area and substantially more wicking material, heat dissipation through the wick, aerosolisation and air inhalation, the Smok coil heads are capable of handling much higher voltage, while using substantially more e-liquid, without generating the dry-puff.

Prior research (8) on the various types of e-cig coil, including a common Sub-Ohm tank and coil, has previously been performed with a focus on nicotine aerosolisation, suggesting that the liquid consumed through vaping is not proportional to nicotine content.

In summary

The central point of this paper is to examine the relationship between increasing power applied to a coil or coil-head and increasing VA emissions. Fundamentally, with a coil-head containing multiple physical coils, the total heating area, relative to a single (or even a dual) coil is substantially greater. The amount of wicking material which, when soaked with e-liquid (with or without nicotine) provides a significant cooling effect, is also substantially greater. With more physical coils in the coil-head, the time taken for a coil-head to reach a temperature that is both a) satisfying for the user, and b) includes the possibility of inducing a dry-puff, is much longer. Further, the material used for the coil alters the overall heat capacity; as demonstrated by the "Coil Wrapping" calculator (9).

In reality, as power to the coil increases, liquid consumption also increases. In real-world scenarios, human users regulate both power and liquid flow to minimise the risk of dry-puff conditions and therefore avoiding increases in VA emissions.

References

(1) Smok TF-V4 Coil - UK ECIG Store: [link]

(2) Smok Tech Store V8-Q4 core: [link]

(3) Smok Tech Store V8-T8 core: [link]

(4) Smok Tech Store V8-T10 core: [link]

(5) VaporFi Platinum II Tank: [link]

(6) Farsalinos K, Voudris V, Poulas K - E-cigarettes generate high levels of aldehydes only in 'dry puff' conditions [link] Farsalinos KE, 2015

(7) CE5 Clearomizer Tank - VapeClub: [link]

(8) Farsalinos K et al - Protocol proposal for, and evaluation of, consistency in nicotine delivery from the liquid to aerosol of electronic cigarette atomizers: [link] Farsalinos KE, 2016

(9) For example, see Steam Engine Coil Wrapping Calculator [link]

On 2017 Sep 30, Alessandro Rasman commented:

Very interesting study. It is important now to test it on humans because there are doubts about the utility of the EAE model in the MS (1). References: 1. Behan, Peter O., and Abhijit Chaudhuri. "EAE is not a useful model for demyelinating disease." Multiple Sclerosis and Related Disorders 3.5 (2014): 565-574.

On 2017 Sep 21, David Mage commented:

The NEUROKININ 1 RECEPTOR, a.k.a NK1R SUBSTANCE P RECEPTOR and TACR1, has a cytogenetic location on autosome 2 (2p12). The authors report in Table 1 that their 55 "SIDS" cases were 33 male and 22 female, apparently not noticing that the male fraction of 0.60 they do not report, is virtually identical to the SIDS male fraction of almost all SIDS cohorts pooled together. It has been claimed (PMID 5129451) that such consistency must be related to a recessive X-linkage that doesn't exist for this NK1R receptor.

On 2017 Sep 21, Margaret Hammerschlag commented:

The data reviewed here is not really new. The CDC's recommendations for screening and treating pregnant women in 1993 have resulted in a dramatic drop in perinatal chlamydia infection. We have seen only one case of chlamydial ophthalmia at my institution over the past 20 years and no cases of chlamydial pneumonia. We used to see 30-40 cases/year before screening. We have confirmed this by seroepidemiologc studies, one recently published online in Sex Transm Dis (Banniettis N, Thumu S, Weedon J, Szigeti A, Chotikanatis K, Hammerschlag MR, Kohlhoff SA. Seroprevalence of Chlamydia trachomatis in inner-city children and adolescents – implications for vaccine development. Sex Transm Dis, in press, 2017.). This is also confirmed by the observation that chlamydial ophthalmia is still very common in countries, like the Netherlands, that do not screen and treat pregnant women (Rours GIJG, Hammerschlag MR, De Faber JTHN, de Groot R, Verkooyen RP. Chlamydia trachomatis as a cause of neonatal conjunctivitis in Dutch infants. Pediatrics 121:e321-326, 2008.) Canada has discontinued neonatal ocular prophylaxis and will focus on expanded screening. Neonatal ocular prophylaxis in ineffective for prevention of perinatal chlamydial infection as we demonstrated in 1989 (Hammerschlag MR, Cummings CC, Roblin PM, Williams TH, Delke I. Efficacy of neonatal ocular prophylaxis for the prevention of chlamydial and gonococcal conjunctivitis. New Engl J Med 320:769-72, 1989.). At this point there is so little neonatal chlamydial infection in the US that treatment trials are not really possible.

On 2017 Sep 21, Daniel Corcos commented:

The reason why the reduction in breast cancer mortality is overestimated is because the reason for the lack of efficiency of mammography screening in terms of mortality reduction has not been understood. As cancers are detected by mammography more than one year before physical examination, this must translate in a strong decrease in mortality. The fact that this strong decrease is not observed is due to the fact that mammography leads to a strong increase in cancer incidence (mistakenly considered as overdiagnosis). The barrier I see relates to information about the actual risks of low-dose irradiation.

On 2017 Sep 21, Thomas Jové commented:

I would like to warn anyone who could be concerned by the appealing title of this paper. There is no serious evidence of an integron integrase activity in this paper. First, there is no description of the used recombination activity assays (authors refer to previous papers) which turns the paper very difficult to follow. For instance, there is no description of the plasmid content. There is a critical absence of control since Table 4 display "excision efficacy" for every assays (no control in absence of integron, absence of integrase, etc). Then, the efficacy of excision (actually, frequency of excision) is determined as being the ratio of negative or positive PCR (this is also unclear) after transformation of several unexplained plasmid in a Streptococcus strain. Therefore the resulting % most probably reflect the efficiency of PCR rather than the % of excision/integration of GC. A very important point not investigated here (no control) is that is remains unsilved whether the recombination of GC is due to the IntI1 activity or IntI-independant recombination. It is noteworthy to mention that authors did not sequence any PCR product to check the specificty of amplifications. Lastly, there are some very significant signs this paper has not been properly reviewed: (i) The paper contains spelling mistakes in the name of bacteria. (ii) The paper has many wrong claims like the Figure 1 (Structure of integron) in which attC are separated from gene cassette of being part of them. Anyone in the integron field knowns that contrariliy to what is written in the Table 1 the G/TTRRRY does not suffice to determine an attC site. Class 1 integron are not associated to Tn7 but Tn21 transposons (L71), a basic in the integron field. (iii) It is very surprising to have not a single quote of any of the numerous papers from D. Mazel team that is the team leading the field of integron recombinations (iv) The paper was received the 7/09, revised (after reviewing?) the 13/09 and accepted the 14/09 which is far to fast to be honest.

I would really appreciate Pubmed to reconsider the indexation of such papers, and maybe of this journal in which such papers are regular (at least in my fields).

On 2017 Oct 17, Stuart RAY commented:

According to a story on Retraction Watch, the journal's publisher says that they are in the process of retracting this manuscript. Also noted is that the senior author (Christopher A. Shaw) was an author on a prior publication Inbar R, 2016 that made related claims (harm to mice from aluminum in vaccine) and was also retracted; that paper was subsequently republished in Immunology Research Inbar R, 2017.

On 2017 Sep 20, David Mage commented:

See Scand J Forensic Sci 2016; 22 (1): Editorial, for an alternative interpretation of these data.

On 2017 Sep 21, Stuart RAY commented:

Not apparent from the record above, this is a substantial shift (in terms of the conclusions) from an earlier version of the same analysis, here: Jakobsen JC, 2017

On 2017 Nov 03, Frank Lippert commented:

It is good to see that more basic, fundamental research on SDF, in particular on enamel caries, is being conducted. The strength of this study is undoubtedly the use of a bacterial caries model. However, the inclusion of appropriate controls, such as silver- and fluoride-only interventions at equimolar concentrations to SDF, would have been advantageous. The observed remineralization effect of SDF could have been simply a fluoride effect, similarly to those observed after a fluoride varnish application. The present study did not allow for the determination of the impact of silver on remineralization, and further, more controlled studies will be required.

On 2017 Sep 18, Clive Bates commented:

I may have misunderstood the study, but the findings and conclusions seem banal...

The authors were comparing products that actually exist with products that don't, given all e-cigs are flavoured in some way and flavours are integral to the product. Obviously, the producers don't set out to produce unappealing products, and 'appeal' is central to the role these products play in harm reduction - as low-risk alternatives to smoking. ​The authors discover that unflavoured, low-nicotine vaping products are less popular than those with flavours. Of course, they are... but only in the same way people prefer orange juice that tastes of oranges rather than water, and sausages that taste of meat rather than sawdust.

On 2017 Dec 14, Denise N Slenter commented:

The pathway model outlined in Figure 1, including all studied drugs, is available as free machine readable data in WP4189 in WikiPathways: https://www.wikipathways.org/index.php/Pathway:WP4189

On 2017 Nov 27, Steven Watterson commented:

This paper follows on from work developing comprehensive models of cholesterol biosynthesis (https://www.ncbi.nlm.nih.gov/pubmed/23583456) using systems biology file formats and standards.

On 2017 Sep 24, Mohammed AlJasser commented:

The abstract does not match the title. I think the abstract belongs to another article.

On 2017 Nov 24, Ryszard Grenda commented:

Thank you; the comment is valid; apologies from the authors for mistake in the review.

On 2017 Nov 18, Mark Milton commented:

This article states that "Eculizumab is a humanized monoclonal antibody directed against the C5a component of the complement system, and this binding leads to blockade of the C5b-9 membrane attack complex while the other functions of the complement are maintained."

This is incorrect. Eculizumab, specifically binds to the C5, thereby inhibiting its cleavage to C5a and C5b and preventing the generation of the terminal complement complex C5b-9

On 2017 Sep 20, Valerie Matarese commented:

Editors' competencies and editing terminology: a call for improved dialog between two worlds of editors

Moher et al. offer a detailed list of competencies for “scientific editors,” by which they mean editors of scientific (particularly biomedical) journals. As they explain (with difficulty) in the first sentence, these are editors who set journal policy, oversee the peer review process, and choose manuscripts for publication. In common parlance, these are editors-in-chief, associate editors, and managing editors.

The authors acknowledge that their list of competencies may also be “useful to other types of editors at biomedical journals, such as technical editors (i.e., those responsible for substantial editing of manuscripts, including re-writing for clarity and language)”. Editors who work “at ... journals” are (or were—few remain today) usually called copyeditors or manuscript editors (as opposed to journal editors). Those few who are still employed by prestigious or well-funded journals may choose to call themselves technical editors, but technical editing and technical writing are terms used (especially in the US) to mean the preparation of reports for technical companies.

Moher et al. do not acknowledge another type of increasingly important editor, namely the authors' editor—one who edits manuscripts before they are submitted to journals and, often, between peer review and acceptance. These editors, who do not work at journals, also advise researcher-authors on journal policy, peer review practices and publishing ethics (as does the newly proposed publications officer). Unlike the publications officer, though, authors' editors have a half-century of quiet experience during which they have matured an approach to working with researcher-authors, documented in a large body of (albeit difficult to find) literature. How they edit depends on many factors, but there exists a broadly agreed nomenclature to describe the spectrum of possible activities—called “levels of edit.” These levels range from the superficial proofreading and copyediting, to language editing, substantive editing (not “substantial” editing), and developmental editing (two other pertinent language services are translation and medical writing). Many levels of edit involve the handling of scientific and technical content. Thus authors' editors are scientific editors, too.

Just as it is essential for authors' editors to know about journals' publication policies, it would be useful for journal editors to be familiar with the spectrum of editorial support that researcher-authors use to prepare fit-for-publication manuscripts. This familiarity should begin with an understanding of the editing services offered for sale by journals' very own publishers. It should also include basic knowledge of the levels of edit terminology, an awareness of the settings in which this type of editing is done (e.g. in-house institutional services, freelance professional services, online e-commerce firms), and an appreciation that editing scope and depth (hence, the quality of the edited text) vary greatly depending on the authors' needs and desires, the editors' abilities, the budget and time, and so on. Because authors' editors provide valuable services to researchers worldwide and, consequently, to journal editors, improved dialog between these two worlds of scientific editors will positively impact research publishing.

Disclosure: I have published two books on editorial support for researchers including Editing Research, a book that investigates and documents the work of authors' editors.

On 2017 Sep 18, Clive Bates commented:

No actual evidence is presented that this 'prescribe NRT' intervention works or works better than alternative interventions to reduce child secondhand smoke exposure, such as suggesting parents have a voluntary home smoking policy or take some other sort of action like switching to vaping. Both may be easier for parents to do than quitting completely.

On 2017 Sep 30, Alessandro Rasman commented:

Very interesting study. It is important now to test it on humans because there are doubts about the utility of the EAE model in the MS (1). References: 1. Behan, Peter O., and Abhijit Chaudhuri. "EAE is not a useful model for demyelinating disease." Multiple Sclerosis and Related Disorders 3.5 (2014): 565-574.

On 2017 Sep 18, Clive Bates commented:

A couple of great quotes from this report:

[Linda] Bauld commented “In the UK, regulators endeavour to balance the benefits of e-cigarettes (to help adults quit tobacco smoking) with any potential risks (protecting young people). Our evidence from a number of surveys is reassuring. Although some young people who do not smoke tobacco cigarettes are experimenting with e-cigarettes, this is not leading to regular e-cigarette use. Most experimentation and regular use of e-cigarettes is by young people who already smoke tobacco cigarettes. Importantly, smoking among adolescents is continuing to decline.”

...

John Britton (Nottingham University, Nottingham, UK) added “This study demonstrates again that experimentation with e-cigarettes among young people in the UK rarely leads to uptake of smoking. The findings should therefore help to reassure those who worry that the availability of e-cigarettes is increasing uptake of smoking. Combined with overwhelming evidence that e-cigarettes are helping thousands of UK smokers to quit smoking each year, this is excellent news for public health.”

On 2017 Sep 18, Clive Bates commented:

The Portland State University researchers display little awareness of the deep flaws in their 2015 attention-grabbing "Hidden Formaldehyde" NEJM paper - see Jensen RP, 2015 for the study and comments. Nowhere in the present paper do they check whether their operating conditions are a realistic proxy for user experience and therefore whether their findings have any real-world relevance. They dismiss the controversy over their previous paper as just differences in standardisation.

However, a major challenge is the lack of standardized analytical protocols. This issue has led to wide variations in interlaboratory results and has contributed to the dichotomy in the literature about electronic cigarettes and their potential health effects.

No, this diagnosis is incorrect. The wide variation is between researchers who use the products in unrealistic conditions and researchers who recognise the human use control feedback created by dry-puff conditions and so measure the products in realistic conditions. These authors are in the former category.

Creating a realistic proxy for human use does not appear to have influenced their choice of equiment settings. This was determined by:

Wattage settings of the battery unit used were 10 W and 15 W. These conditions were chosen to produce amounts total HCHO that could enable them to be conveniently distinguished, with the intent to produce a comparison between various sampling and analytical methods.

There are no human use considerations at all, as far as I can see. If they don't check for conditions that breach plausible human use, the whole work is unreliable as any sort of guide to e-cigarette health risks or for regulatory policy - just like the last one.

On 2018 Feb 04, Sin Hang Lee commented:

The medical profession, including medical schools and hospitals, is now a part of the health care industry, and implementation of editorial policies of medical journals is commonly biased in favor of business interests. PubMed Commons has offered the only, albeit constrained, open forum to air dissenting research and opinions in science-based language. Discontinuation of PubMed Commons will silence any questioning of the industry-sponsored promotional publications indexed in PubMed.

On 2017 Sep 21, Sin Hang Lee commented:

The narrative review titled “To test or not to test? Laboratory support for the diagnosis of Lyme borreliosis” by Dessau and colleagues[1] is a position paper of the authors. It is not a systematic review. A systemic review typically involves a detailed and comprehensive plan and search strategy derived a priori, with the goal of reducing bias by identifying, appraising, and synthesizing all relevant studies on a particular topic.[2] The gross biases in this position paper are:

1.Dessau and colleagues recognized “Lyme borreliosis (LB) is a tick-borne infection caused by Borrelia burgdorferi sensu lato.”, namely a bacterial infectious disease. However, the authors proposed using objective signs of clinical presentations to diagnose borreliosis[1], but failed to mention that the European Centre for Disease Prevention and Control requires detection of the pathogen’s nucleic acid in a clinical specimen and confirmation by DNA sequencing for diagnosis of any emerging infectious diseases, such as Ebola.[3] According to an official publication of the United States Centers for Disease Control and Prevention, the state of the art in diagnosing infectious diseases is by molecular approaches[4], in particular by 16S rRNA gene analysis for bacterial infectious diseases, such as anthrax.[5]

2.Dessau and colleagues stated that “clinicians are advised to avoid serological testing whenever the clinical symptoms are not indicative of LB according to the case definitions”. However, the case definitions which were written by some of the authors of the current position paper are “for reliable epidemiological studies and are of great value in clinical management[6]”, not for reliable diagnosis of Lyme borreliosis. In fact, in another recet review, two of the co-authors (Strle and Hovius) of the current narrative review stated on record that “Demonstration of borrelial infection by laboratory testing is required for reliable diagnosis of Lyme borreliosis, with the exception of erythema migrans.” [7] Therefore, at least two of the co-authors of this position paper[1] are advancing an agenda of managing clinical patients of Lyme borreliosis, an infectious disease, without a reliable diagnosis against their own beliefs.

3.The statement “Laboratory testing for antibodies to B. burgdorferi in serum is necessary for diagnosing suspected manifestations of LB such as Lyme carditis, borrelial lymphocytoma, Lyme arthritis, acrodermatitis chronica atrophicans and possibly other rare LB manifestations” while omitting direct DNA testing of blood for the diagnosis of spirochetemia is biased. At least two of the co-authors of this position paper knew and stated that the early stage of Lyme borreliosis infections “can be treated successfully with a 10–14 day course of antibiotics”, “serodiagnostic tests are insensitive during the first several weeks of infection” and if untreated “within days to weeks, the strains of B. burgdorferi in the United States commonly disseminate from the site of the tick bite to other regions of the body.”[7] Sensitive 16S rRNA gene analysis for the detection of Lyme borreliae in blood samples has been known since 1992.[8-12] Continued suppression of using direct DNA testing for the diagnosis of early Lyme borreliosis infections is no longer acceptable.

4.The authors of this position paper emphasized “an immune response with clinical findings, such as skin lesions, neurological signs, cardiac involvement (e.g. AV block), or arthritis involving the large joints”, but avoided mentioning that cardiac involvements may be due to myocarditis caused by spirochetes invading the myocardium.[13] The authors focused on management of the immune response in the cases of chronic Lyme neuroborreliosis because “there is no convincing evidence that B. burgdorferi produces any toxin.” It is well known that Treponema pallidum, the spirochetes causing neurosyphilis, also lacks a lipopolysaccharide endotoxin. However, it possesses abundant lipoproteins which induce inflammatory processes.[14] Would these authors recommend not to treat patients suffering from neurosyphilis with antibiotics?

In summary, this narrative review by Dessau and colleagues contains serious scientific biases and should not be used as materials to influence public health policy decisions or as guidelines to direct clinical practice.

References

[1] Dessau RB, van Dam AP, Fingerle V, Gray J, Hovius J, Hunfeld KP, Jaulhac B, Kahl O, Kristoferitsch W, Lindgren PE, Markowicz M, Mavin S, Ornstein K, Rupprecht T, Stanek G, Strle F. To test or not to test? Laboratory support for the diagnosis of Lyme borreliosis. Clin Microbiol Infect. 2017 Sep 5. pii: S1198-743X(17)30488-3.

[2] Uman LS. Systematic reviews and meta-analyses. J Can Acad Child Adolesc Psychiatry. 2011;20:57-9.

[3] http://ecdc.europa.eu/en/healthtopics/ebola_marburg_fevers/EVDcasedefinition/Pages/default.aspx

[4] CDC. State of the Art. Molecular Approaches to Diagnosing and Managing Infectious Diseases: Practicality and Costs https://wwwnc.cdc.gov/eid/article/7/2/70-0312_article

[5] Sacchi CT, et al. Sequencing of 16S rRNA gene: a rapid tool for identification of Bacillus anthracis. Emerg Infect Dis. 2002 Oct;8(10):1117-23.

[6] Stanek G, Fingerle V, Hunfeld KP, Jaulhac B, Kaiser R, Krause A, Kristoferitsch W, O'Connell S, Ornstein K, Strle F, Gray J. Lyme borreliosis: clinical case definitions for diagnosis and management in Europe. Clin Microbiol Infect. 2011;17:69-79.

[7] Steere AC, Strle F, Wormser GP, Hu LT, Branda JA, Hovius JW, Li X, Mead PS. Lyme borreliosis. Nat Rev Dis Primers. 2016 Dec 15;2:16090.

[8] Marconi RT Garon CF . Development of polymerase chain reaction primer sets for diagnosis of Lyme disease and for species-specific identification of Lyme disease isolates by 16S rRNA signature nucleotide analysis. J Clin Microbiol . 1992;30:2830–2834.

[9] Cyr TL, et al Improving the specificity of 16S rDNA–based polymerase chain reaction for detecting Borrelia burgdorferi sensu lato–causative agents of human Lyme disease. J Appl Microbiol . 2005;98:962–970.

[10] Santino I, et al. Detection of Borrelia burgdorferi sensu lato DNA by PCR in serum of patients with clinical symptoms of Lyme borreliosis. FEMS Microbiol Lett . 2008;283:30–35.

[11] Lee SH, et al. Early Lyme disease with spirochetemia - diagnosed by DNA sequencing. BMC Res Notes. 2010 Nov 1;3:273. doi: 10.1186/1756-0500-3-273.

[12] Lee SH, et al. DNA sequencing diagnosis of off-season spirochetemia with low bacterial density in Borrelia burgdorferi and Borrelia miyamotoi infections. Int J Mol Sci. 2014 Jun 25;15(7):11364-86.

[13] Muehlenbachs A, et al. Cardiac Tropism of Borrelia burgdorferi: An Autopsy Study of Sudden Cardiac Death Associated with Lyme Carditis. Am J Pathol. 2016;186:1195-205.

[14] https://www.ncbi.nlm.nih.gov/books/NBK7716/

Conflicts of Interest: Sin Hang Lee, MD is the director of Milford Molecular Diagnostics Laboratory specialized in developing DNA sequencing-based diagnostic tests.

On 2018 Feb 04, Sin Hang Lee commented:

The medical profession, including medical schools and hospitals, is now a part of the health care industry, and implementation of editorial policies of medical journals is commonly biased in favor of business interests. PubMed Commons has offered the only, albeit constrained, open forum to air dissenting research and opinions in science-based language. Discontinuation of PubMed Commons will silence any questioning of the industry-sponsored promotional publications indexed in PubMed.

On 2018 Jan 14, Sin Hang Lee commented:

The review by Mohsen and colleagues, titled “Major findings and recent advances in virus-like particle (VLP)-based vaccines”, correctly pointed out that bacterial or viral nucleic acids are probably the real active adjuvants through activation of various toll like receptors (TLRs) in the antigen-presenting cells (APCs) to boost innate immune responses in VLP-based vaccinations, as illustrated in Fig. 5 of the review article. However, in Section “HPV VLP-based vaccines” the authors merely mentioned the facts that Gardasil® is adjuvanted with amorphous aluminum hydroxyphosphate sulfate (AAHS) and that Cervarix® contains an aluminum hydroxide-based AS04 adjuvant which carries TLR4 agonist 3-0-descyl-4'-monophosphoryl lipid A (MPL)- a moiety of the cell wall lipopolysaccharide of Salmonella Minnesota. Since HPV vaccination is now being carried out in large scale, additional discussion on these two VLP-based vaccines is warranted.

In spite of the fact that VLPs are more immunogenic than the same epitopes displayed repetitively on a flexible polymer, both aforementioned VLP-based HPV vaccines still need special proprietary aluminum salt adjuvants to boost the immune responses of the host to reach sustained high levels of genotype-specific anti-HPV L1 antibodies for protective efficacy. Immunization with HPV L1 VLPs formulated with AAHS elicited a significantly stronger immune response with higher peak antibody titers both at four weeks post vaccination (12.7 to 41.9-fold higher) as well as in the persistent phase at week 52 (4.3 to 26.7-fold higher) than that with HPV L1 VLPs alone. [1] The AS04 formulation Cervarix® elicited an increased frequency (2.2-5.2-fold) of HPV L1 VLP specific memory B cells when compared with the aluminum salt only formulations. [2]

However, aluminum salts do not activate TLRs. They simply bind and carry the TLR agonists into the APCs. The addition of TLR agonists as adjuvant to a vaccine product is a logical choice to enhance innate immune response needed for effective vaccination. The TLR4 agonist MPL bound to aluminum hydroxide (AS04) is used in licensed vaccines against hepatitis B and human papilloma virus (Cervarix®). The effect of other TLR agonists, including TLR9 agonist CpG ODN which is known to enhance the antibody response in mice to hepatitis B antigen formulated with aluminum hydroxide, on the immune response to aluminum-adjuvanted vaccines has been investigated, but this has not yet led to licensed products. [3]

To function as an effective adjuvant in vaccination, a TLR agonist molecule either in the form of MPL or in the form of a nucleic acid must bind the cationic aluminum salt loosely or partially so that part of its linear molecule can make contact with the TLR [4]. If a bacterial or viral nucleic acid is used as the TLR9 agonist, the agonist molecule must be rendered resistant to nuclease attack, thus increasing its in vivo half-life [5].

Although both AS04 and AAHS are commonly labeled as special proprietary “vaccine adjuvants” and both prepared by partial ligand exchange of a phosphate group for a hydroxyl group on aluminum hydroxide, there is a big difference between these two “adjuvants” in that for AS04 the phosphate group is TLR4 agonist MPL while for AAHS the phosphate group is an inorganic anionic phosphate which is immunologically inert. When AAHS is used as an adjuvant in formulation of recombinant hepatitis B vaccine (Merck), some of the hydroxyl groups on the AAHS are exchanged for the phosphate groups of the phospholipid-containing hepatitis B surface antigen [6] that the phospholipid moiety of the viral surface antigen actually serves as TLR4 agonist [7]. However, for Gardasil® formulation with AAHS there is no disclosed TLR agonist.

In compliance with good manufacturing practice for vaccine production, the HPV VLPs have been rendered free of packaged DNA [8, 9]. However, Gardasil® does contain recombinant HPV L1-specific DNA fragments [10, 11], and at least some of these viral DNA fragments bound to the AAHS particles have assumed non-B topological conformations [12], thus rendered resistant to nuclease degradation after being transfected into APCs. These viral DNA fragments bound to AAHS in non-B conformations can serve as potent long-acting TLR9 agonist.

In theory, the major difference between Cervarix® and Gardasil® in the mechanism of stimulating immune response seems to be that Cervarix® depends on using an MPL bound to cationic aluminum to activate the TLR4 located on the surface of innate immune cells [13] while Gardasil® uses HPV L1 gene DNA fragments also bound to cationic aluminum to activate the TLR9 located in the endosome of the immune cells [13]. In general, TLR4 activation by MPL (AS04) induces cytokine cascades of both Th1 and Th2 type responses with a probably preferential bias toward induction of a Th2 phenotype while TLR9 activation favors induction of pro-inflammatory and Th1 cytokines (for example, IL-6, IL-1, TNFα, IFNγ and IL-12). [14] However, Cervarix® may contain HPV L1 DNA fragments as well, and both the DNA and MPL molecules may attach side-by-side to the same cationic aluminum; the juxtaposition of these two linear molecules may change the shape of the DNA and interfere with conventional PCR amplification for DNA detection. In addition, TLR9 activation may be effected by more than one category of agonists. Therefore, additional research on TLR activation is needed for further improvement of safety and efficacy in HPV vaccination.

References

[1] Ruiz W, et al. Kinetics and isotype profile of antibody responses in rhesus macaques induced following vaccination with HPV 6, 11, 16 and 18 L1-virus-like particles formulated with or without Merck aluminum adjuvant. J Immune Based Ther Vaccines. 2005;3:2.

[2] Giannini SL, et al. Enhanced humoral and memory B cellular immunity using HPV16/18 L1 VLP vaccine formulated with the MPL/aluminium salt combination (AS04) compared to aluminium salt only. Vaccine. 2006;24:5937-49.

[3] Hogenesch H. Mechanism of immunopotentiation and safety of aluminum adjuvants. Front Immunol. 2013;3:406.

[4] Tagliabue A, Rappuoli R. Vaccine adjuvants: the dream becomes real. Hum Vaccin. 2008;4:347-9.

[5] Aebig JA, et al. Formulation of vaccines containing CpG oligonucleotides and alum. J Immunol Methods. 2007;323:139-46.

[6] Egan PM, et al. Relationship between tightness of binding and immunogenicity in an aluminum-containing adjuvant-adsorbed hepatitis B vaccine. Vaccine. 2009;27:3175-80.

[7] Wong-Baeza C, et al. Nonbilayer Phospholipid Arrangements Are Toll-Like Receptor-2/6 and TLR-4 Agonists and Trigger Inflammation in a Mouse Model Resembling Human Lupus. J Immunol Res. 2015;2015:369462.

[8] Frazer IH. Eradicating HPV-Associated Cancer Through Immunization: A Glass Half Full…. Viral Immunol. 2018 Jan 3. doi: 10.1089/vim.2017.0119.

[9] Mach H, et al. Disassembly and reassembly of yeast-derived recombinant human papillomavirus virus-like particles (HPV VLPs). J Pharm Sci. 2006 Oct;95(10):2195-206.

[10] Lee SH. Detection of human papillomavirus (HPV) L1 gene DNA possibly bound to particulate aluminum adjuvant in the HPV vaccine Gardasil. J Inorg Biochem. 2012;117:85-92.

[11] FDA Information on Gardasil – Presence of DNA Fragments Expected, No Safety Risk. http://www.fda.gov/BiologicsBloodVaccines/Vaccines/ApprovedProducts/ucm276859.htm

[12] Lee SH. Melting profiles may affect detection of residual HPV L1 gene DNA fragments in Gardasil®. Curr Med Chem. 2014;21:932-40.

[13] O'Neill LA, et al. The history of Toll-like receptors - redefining innate immunity. Nat Rev Immunol. 2013;13:453-60.

[14] Dowling JK, Mansell A. Toll-like receptors: the swiss army knife of immunity and vaccine development. Clin Transl Immunology. 2016;5(5):e85.

Conflicts of Interest: Sin Hang Lee, MD is the director of Milford Molecular Diagnostics Laboratory specialized in developing DNA sequencing-based diagnostic tests.

On 2018 Jan 13, Sin Hang Lee commented:

None

On 2017 Sep 18, Clive Bates commented:

The paper provides a very unsatisfactory contribution to the literature on e-cigarettes and harm reduction, from which no useful policy conclusions can be drawn.

CONCLUSIONS: E-cigarette use, which is common in adults with or at risk for COPD, was associated with worse pulmonary-related health outcomes, but not with cessation of smoking conventional cigarettes. ​

But it turns out that e-cigarette use was associated with more intensive smoking in the past.

E-cigarette users had a heavier conventional cigarette smoking history and worse respiratory health, were less likely to reduce or quit conventional cigarette smoking, had higher nicotine dependence, and were more likely to report chronic bronchitis and exacerbations.

This likely explains the difference in respiratory health and why more heavily dependent users may find it harder to quit. In other words, it is nothing to do with e-cigarettes, the use of which is probably just a marker of more intensive smoking, higher dependency and greater difficulty quitting - not caused by e-cigarette use. It is the smoking history that matters.

From this the authors add to their conclusion:

Although this was an observational study, we find no evidence supporting the use of e-cigarettes as a harm reduction strategy among current smokers with or at risk for COPD.

​It is literally true that they "find no evidence...", but that is because this study is completely ill-suited to drawing any policy conclusions about e-cigarettes and COPD. Despite hinting at the limitations of cross-sectional data, the authors draw a negative-sounding conclusion without addressing the key question of how respiratory health changes for a given smoker who uses e-cigarettes to quit or cut down once they are ill from smoking or as a way of preventing COPD.

For respiratory physicians wondering what to do in the interest of their patients, Polosa R, 2016 Evidence for harm reduction in COPD smokers who switch to electronic cigarettes might be more useful.

A whole new level of over-interpretation is achieved in the press statements that accompany this paper.

"The data further suggest that there's no clear benefit of e-cigarettes as a harm-reduction strategy in this population of smokers with or at-risk for COPD."

This effortlessly moves from a no-evidence-of-effect (the paper) to evidence-of-no-effect (the press statement). I'm sure the authors will be embarrassed by that.

On 2017 Nov 04, Arnaud Chiolero MD PhD commented:

I fear that we will not survive. But this is not new - evidence has never matched public health and clinical practice.

On 2017 Sep 13, Francesco Brigo commented:

Very nice study. Congratulations! This has reminded me about the recent exhumation of the body of Salvador Dalì. According to forensic experts, his moustache was still inact, pointing to 10-past-10, just as he wanted. Francesco Brigo, University of Verona, Italy

On 2017 Oct 02, Donald Forsdyke commented:

VIRAL REPRODUCTIVE ISOLATION WITHIN A COMMON HOST CELL

This otherwise admirable article (Hunter P, 2017) begins with the curious assertion that, "since they depend on their host for replication," then viruses cannot "be categorized as species on the basis of reproductive isolation." The latter prevents recombination between organisms and so forms the most generally accepted definition of species. Virus species whose members share a common host cell, and depend on that cell for their replication, are still able to retain their species individuality. Their members do not mutually destroy each other by recombinational blending of their genomes. They are reproductively isolated from each other.

When we compare two viral species that have a common host cell, with two viral species that, even within a common host, do not share a common cell, we would expect to observe a fundamental difference related to their reproductive isolation mechanisms. If that difference is found to apply to other viral pairs that occupy a common host cell, then a fundamental isolation mechanism has been identified.

Such a difference was first related to the base compositions of insect viruses (1), a then to the base compositions of herpes viruses (2). A more extreme example arose from studies of retroviruses that share a T-lymphocyte host. The AIDS virus (HIV1) and human T cell leukaemia virus (HTLV1), can be assumed to have evolved from a common ancestor. Differentiation of members of that ancestral species within a common host cell into two independent populations would have required some mechanism to prevent their blending. Thus, we see today a wide divergence in base compositions. HIV1 is one of the highest AT-rich species know. HTLV1 is one of the highest GC-rich species known (3). There is high differentiation of chromosomal nucleic acids.

In these viruses there has been no opportunity for other reproductive isolation mechanisms to supersede chromosomal mechanisms. Diffusible cytoplasmic products make the subsequent evolution of genic incompatibilities less likely, and being in a common host cell there is no equivalent of prezygotic isolation as conventionally understood (4).

1. Wyatt GR (1952) The nucleic acids of some insect viruses. J Gen Physiol 36:201-205. WYATT GR, 1952
2. Schachtel GA et al. (1991) Evidence for selective evolution of codon usage in conserved amino acid segments of human alphaherpesvirus proteins. J Mol Evol 33:483-494. Schachtel GA, 1991
3. Bronson EC, Anderson JN (1994) Nucleotide composition as a driving force in the evolution of retroviruses. J Mol Evol 38:506-532. Bronson EC, 1994
4. Forsdyke DR (1996) Different biological species broadcast their DNAs at different (G+C)% wavelengths. J Theoret Biol 178:405-417. Forsdyke DR, 1996% "wavelengths".")

On 2018 Feb 01, Joe G. Gitchell commented:

Readers may find this correspondence responding to the Kostygnia et al paper (https://www.ncbi.nlm.nih.gov/pubmed/27077338) of interest, too:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5105003/

On 2017 Sep 27, Donald Forsdyke commented:

"CLOSE TO SELF" AND "NEAR SELF"

A major conclusion of this elegant modeling study is that "TCR selection against self-peptides has a minimal influence on the recognition of peptides which are 'close' to self." Thus, "TCR negative selection by host peptides has only a weak suppressive effect on detecting peptides which closely resemble self." This agrees with a somewhat less elegant modeling study that invoked lymphocyte clones selected for anti-"near-self" immune reactivity. These would normally have escaped negative selection (i.e. would have been positively selected; 1). The "near-self" viewpoint contrasted with the then prevailing "altered self" viewpoint (2). However, whereas George et al. (2017) regard their study as "empirical," the earlier study (1) arose from consideration of alloreactive phenomena and recognized implications for cancer immunotherapy in keeping with an "overall objective of optimizing CRL therapy" (3, 4). Full historical reviews are available (5, 6).

1. 1.Forsdyke DR (1975) Further implications of a theory of immunity. J Theor Biol 52: l87-l98.Forsdyke DR, 1975

2. 2.Forsdyke DR (2005) "Altered-self" or "near-self" in the positive selection of lymphocyte repertoires? Immunol Lett 100: 103-106.Forsdyke DR, 2005

3. 3.Forsdyke (1977) Grant application

4. 4.Forsdyke DR (1999) Heat shock proteins as mediators of aggregation-induced "danger" signals: implications of the slow evolutionary fine-tuning of sequences for the antigenicity of cancer cel1s. Cell Stress Chaperone 4: 205-210.Forsdyke DR, 1999

5. 5.Forsdyke DR (2012) Immunology (1955-1975): The natural selection theory, the two signal hypothesis and positive repertoire selection. J Hist Biol 45: 139-161.Forsdyke DR, 2012

6. 6.Forsdyke DR (2015) Lymphocyte repertoire selection and intracellular self/not-self discrimination: historical overview. Immun Cell Biol 93: 297-304.Forsdyke DR, 2015

On 2017 Sep 13, Haibao Tang commented:

No major flaws in "Identification of individuals by trait prediction using whole-genome sequencing data"

For a complete discussion, please also read authors' response to Erlich's critique:

http://www.biorxiv.org/content/early/2017/09/11/187542

Abstract

In a recently published PNAS article, we studied the identifiability of genomic samples using machine learning methods [Lippert et al., 2017]. In a response, Erlich [2017] argued that our work contained major flaws. The main technical critique of Erlich [2017] builds on a simulation experiment that shows that our proposed algorithm, which uses only a genomic sample for identification, performed no better than a strategy that uses demographic variables. Below, we show why this comparison is misleading and provide a detailed discussion of the key critical points in our analysis that have been brought up in Erlich [2017] and in the media. We also want to point out that it is not only faces that may be derived from DNA, but a wide range of phenotypes and demographic variables. In this light, the main contribution of Lippert et al. [2017] is an algorithm that identifies genomes of individuals by combining DNA-based predictive models for multiple traits.

On 2017 Sep 08, Yaniv Erlich commented:

Major flaws in "Identification of individuals by trait prediction using whole-genome"

Check the following bioRxiv link for a full explanation on the methodological problems in this paper: http://www.biorxiv.org/content/early/2017/09/06/185330

Abstract

Genetic privacy is an area of active research. While it is important to identify new risks, it is equally crucial to supply policymakers with accurate information based on scientific evidence. Recently, Lippert et al. (PNAS, 2017) investigated the status of genetic privacy using trait-predictions from whole genome sequencing. The authors sequenced a cohort of about 1000 individuals and collected a range of demographic, visible, and digital traits such as age, sex, height, face morphology, and a voice signature. They attempted to use the genetic features in order to predict those traits and re-identify the individuals from small pool using the trait predictions. Here, I report major flaws in the Lippert et al. manuscript. In short, the authors' technique performs similarly to a simple baseline procedure, does not utilize the power of whole genome markers, uses technically wrong metrics, and finally does not really identify anyone.

On 2017 Sep 19, Helmi BEN SAAD commented:

The exact names of authors are: Ben Khelifa M, Ben Salem H, Sfaxi R, Chatti S, Rouatbi S, Ben Saad H"

On 2017 Sep 22, Ryan Jajosky commented:

After asking the FDA for clarification, I was directed to the FDA's Blood Products Advisory Committee Transcript... which states the following "Babesia microti is among the most frequently transfusion transmitted infections reported to FDA, with associated fatalities, for which no donor testing is available."

https://www.fda.gov/downloads/AdvisoryCommittees/CommitteesMeetingMaterials/BloodVaccinesandOtherBiologics/BloodProductsAdvisoryCommittee/UCM449523.pdf

The FDA has labelled the page number 9 (which corresponds to digital page number 11).

So, this statement may have been misinterpreted to mean that "Babesia is the most common transfusion transmitted infection in the United States".

On 2017 Sep 09, Clive Bates commented:

The authors of the original study Jensen RP, 2015 should now correct or retract their findings. The key weakness in their work was an attention-grabbing calculation of formaldehyde-related excess cancer risk. It was this that gained the authors world wide media coverage.

The problem for the authors is that cancer is a human condition and their calculation is based exposures measured by a lab machine in conditions that no humans would be able to tolerate.

It is thus a wholly flawed and misleading paper. Yet it has been cited 141 times as of - 9 Sept 2017, and continues to mislead and contaminate the literature with its baseless assertions about formaldehyde exposure and cancer risk.

On 2017 Oct 27, Thomas Jové commented:

I would like to point out that the right citation for the localisation of the Pc promoter from the IntIA Vibrio cholerae integron is PMID24614503 (Krin et al., 2014) and not PMID22287520 (Baharoglu et al., 2012) as stated in the discussion section of our paper. Our apologies for the inconvenience.

On 2017 Sep 25, Franz Schelling commented:

What appears rather strange is, besides, this fact: The massive changes found to affect the MS lesions' central veins themselves as well as their perivascular spaces are hardly anywhere taken into account

On 2017 Sep 25, Franz Schelling commented:

It is a pity this study offers no explanation for the following: (a) the prominent involvement of the inner cerebral veins (Zeng ea 2013); (b) the abrupt respectively gradual destruction of large subependymal collecting veins (Adams 1989); (c) the extension of these changes on certain segments of mainly the cerebral hemispheres' periventricular veins, first shown by Charcot in 1866, explicitly pointed out by Bruce in 1911, traced in 3D reconstructions by Putnam Adler in 1937 and the most thoroughly and comprehensively by Fog in 1964/5; (d) the absence of any evidence regarding a vein-dependent development of the lesions affecting the spinal cord in MS; and, above all, (e) the lesion dynamics revealed at http://www.msdiscovery.org/news/news_synthesis/322-more-meets-eye. References on request.

On 2017 Sep 18, David Hubbard commented:

Reposted from ResearchGate A new model of MS pathogenesis is reviewed in which the primary mechanism is not immunopathology but instead blood-brain barrier disruption and hypoperfusion: “The focus on the peripheral immune system alone may be limiting our understanding of the disease and the success of developing therapies.” The authors note that all current immunomodulatory therapies act on downstream immune-mediated pathology and provide no treatment for progressive disease or cure. A review of research demonstrates that BBB disruption is present at the earliest stages of disease, preceding symptoms, enhancing lesions, or other MRI changes. Global hypoperfusion is present before any grey matter volume loss and is out of proportion to reduced metabolic demand associated with axonal loss. They propose that oxidative stress secondary to chronic hypoxia causes oligodendrocyte degeneration and selective myelin loss which then leads to immune cell infiltration secondarily.

Finally, the diagnosis and treatment of MS shifts from suppressing T-cells and to perfusing oligodendrocytes.

On 2017 Sep 14, Alessandro Rasman commented:

Giampiero Avruscio MD and Alessandro Rasman

We read with interest the paper from Spencer et al. titled "Vascular pathology in multiple sclerosis: reframing pathogenesis around the blood-brain barrier" (1). Nice review but no mention of pressure, flow, gradient, G-lymphatics. And we find it really curious that the authors are now acting as though it's a surprise there is a vascular pathogenesis in MS. We know the blood brain barrier breaksdown occurs before demyelination. There’s a paper on this from 1990 (2). This ain't new.

References: 1. Spencer, Jonathan I., Jack S. Bell, and Gabriele C. DeLuca. "Vascular pathology in multiple sclerosis: reframing pathogenesis around the blood-brain barrier." J Neurol Neurosurg Psychiatry (2017): jnnp-2017. 2. Kermode, A. G., et al. "Breakdown of the blood-brain barrier precedes symptoms and other MRI signs of new lesions in multiple sclerosis: pathogenetic and clinical implications." Brain 113.5 (1990): 1477-1489.

On 2017 Sep 08, Harald HHW Schmidt commented:

This is a poorly reviewed paper. I cannot detect any evidence that this peptide is specific for sGC nor that it would act via sGC-alpha1 to induce apoptosis.

On 2017 Sep 01, Daniel Corcos commented:

Maybe women who did not find believable the statements about overdiagnosis showed good judgement. Overdiagnosis only accounts for a small part of excess cancers observed after mammography screening.

On 2017 Sep 30, Alessandro Rasman commented:

Very interesting study. It is important now to test it on humans because there are doubts about the utility of the EAE model in the MS (1). References: 1. Behan, Peter O., and Abhijit Chaudhuri. "EAE is not a useful model for demyelinating disease." Multiple Sclerosis and Related Disorders 3.5 (2014): 565-574.

On 2017 Sep 20, christian lino cardenas commented:

Hdac9 gene encode different isoforms. it would be interesting to know which isoform miR-182 is targeting and whether such interaction occurs in humans.

On 2017 Aug 31, Varshil Mehta commented:

Great work team!

On 2017 Nov 28, Natalie Clairoux commented:

Free version of this article available at https://papyrus.bib.umontreal.ca/xmlui/handle/1866/19536

On 2017 Sep 15, Anna Selva commented:

Thank you. We are glad this strategy have been added to ISSG Search Filters Resource. It will help its diffusion to potential users.

On 2017 Sep 05, Kath Wright commented:

I agree this is a useful addition to the literature. It's been added to the issg Search Filter Resource at https://sites.google.com/a/york.ac.uk/issg-search-filters-resource/filters-to-identify-studies-of-public-views-and-patient-issues

On 2017 Sep 15, Anna Selva commented:

Thank you. The copy-paste version is available under request. Please, contact the corresponding author and we will provide it to you.

On 2017 Sep 03, Hilda Bastian commented:

This is a useful addition on an important topic, and is a good resource for other similar search strategies. Given it is such a long search strategy, it would be useful if the authors could provide a cut and paste version. Small point: the KiMS search strategy cited with reference number 27 in the article is actually at reference number 28 (Wessels M, 2016).

On 2017 Sep 03, Honglin Jia commented:

A recent report about RON4 in T.gondii should be refered. Wang et al., The moving junction protein RON4, although not critical, facilitates host cell invasion and stabilizes MJ members.Parasitology.

On 2017 Oct 06, Susan Altfeld commented:

We thank Dr. Mages for his interest in our work; however, we do not agree with his assessment. While it would have been more precise to talk about “non-Hispanic Black mothers” and “Hispanic mothers”, the authors of the paper we were citing (Colson, Willinger, Rybin et al., 2013) themselves refer to “non-Hispanic Black infants” and “Hispanic infants” in their study (most likely adhering to the NCHS standard of attributing mother’s race-ethnicity to the infant.) We are aware of the difference between race and ethnicity, but are not sure what point Mages was trying to make, as combining the two in demographic categories (e.g. “non-Hispanic black”) is standard practice in reporting epidemiological data (hence the common use of the term “race/ethnicity”.) The focus of our commentary was not racial/ethnic differences in SUID rates, but on the need for a more nuanced, harm reduction approach to safe sleep messaging. Many caregivers, of diverse backgrounds, have failed to adhere to abstinence messages regarding infant sleep and new approaches are needed to impact caregiver knowledge and behavior.

On 2017 Oct 01, David Mage commented:

Altfeld et al., PMID: 28838726, made an excellent study of the recent efforts to reduce sleep-related infant deaths in the U.S. However, they made both an explicit error and an implicit error that needs to be called to the readers’ attention:

Explicit Error: On page 2, they refer to “mothers of non-Hispanic Black infants” and “mothers of Hispanic infants.” [NB: Hispanic is an ethnicity and not a race] Apparently, the authors did not read carefully their references [1, 2, 21] and the Technical Notes cited therein. The CDC and NCHS both explicitly state that their cited racial data are either the mother’s self-identified race if monoracial, or “To provide uniformity and comparability of these data [to census data, per OMB requirement], multiple race [of mother] is imputed to a single race.” (see NCHS Technical Notes). The authors of reference 21 conducted an evening at-the-door survey of parents of recently born infants, and “Participants were asked: ‘Which of the following best describes [your, or] the mother's race or ethnic background?’ They were then read a list but also given the option to name one that was not listed.” The mother answered 84% of the time and 16% of the time another adult person responded for her;

Implicit Error: The authors seem to have forgotten that the father of an infant often plays a role in the determination of the race of the infant. I used the word “often” instead of always because “Tis a wise child that knows its own father.” [Puddn’head Wilson, Mark Twain] {Old Burlesque joke: Enter little redhaired boy. Clown: What lovely red hair you have. Do mommy and daddy have red hair too? Little Boy: No --- But we do have a milkman with red hair. (audience laughs) Exit boy.} Therefore, implicitly, the self-identified race of the mother is the same race as the infant if, and only if, the mother is monoracial, and the father (either known or unknown) is the identical race as the mother.

On 2017 Dec 03, Donald Forsdyke commented:

REDESIGNATING SELF AS NOT-SELF MARKERS

A cell's altruistic service to the population of cells that comprise its host organism may be compromised by a foreign pathogen or by a mutated driver cancer gene (both deemed "non-self"). Such intracellular compromising agents can first be addressed by internal sensing and auto-destructive mechanisms. Should one of these fail, then external sensing and destructive mechanisms, involving reactions with specific predatory T cells, may come into play. A compromised cell has the option of displaying peptides as pMHC complexes to see if they are recognized by members of T cell populations that, following thymic surveillance and deletion of nascent strongly self-reacting T cells, are programed to eliminate cells displaying non-self markers.

While such markers may arise from foreign proteins or mutated self proteins, Mishto and Liepe note that the scope of markers ("the antigenic landscape") can be greatly increased by redesignating potential self markers (unspliced peptides in pMHC complexes) as non-self (1). This creation of foreign from self is achieved by splicing and trimming non-contiguous peptides to create novel peptides that would not have passed thymic filters and so would be seen as non-self. Two corollaries of this are that such peptide splicing must not occur in the thymus and that, to militate against autoimmunity, extra-thymic specific splicing of separate protein segments would not occur randomly in uncompromised cells.

Thus, some elements of an internal sensing mechanism within a compromised cell would be needed to foster an extension of the antigenic landscape. The growing evidence for such a mechanism in the antigen presentation pathway (intracellular self/non-self discrimination) is presented elsewhere (2). I agree that "the unexpectedly large frequency and amount of … spliced peptides may … have profound implications for the concept of self/nonself peptide presentation" (3).

1.Mishto M, Liepe J. (2017) Post-translational peptide splicing and T cell responses. Trends in Immunology 38:904-915 Mishto M, 2017

2.Forsdyke DR (2015) Lymphocyte repertoire selection and intracellular self/not-self discrimination: historical overview. Immunology and Cell Biology 93:297-304. Forsdyke DR, 2015

3.Liepe J et al. (2016) A large fraction of HLA class I ligands are proteasome-generated spliced peptides. Science 354:354-358.Liepe J, 2016

On 2017 Oct 28, Daniel Weiss commented:

Karter et. al describe a tool to predict the risk of hypoglycemia in persons with Type 2 Diabetes. This tool confirms obvious, well-established clinical observations: sulfonylureas and insulin are associated with an increased risk of hypoglycemia. Three points are worth clarifying.

First, this tool was developed in the Kaiser Permanente of Northern California health care system where practitioners have a very limited choice of agents for Type 2 Diabetes. In that system and the Veterans Health Administration, the usage of drugs that do not tend to cause hypoglycemia is restricted due to cost. Yet, glucagon-like peptide-1 (GLP-1) receptor agonists have been available since 2005 and the first sodium-glucose cotransporter-2 (SGLT2) inhibitor was approved in 2013. Although less effective, dipeptidyl peptidase-4 (DPP-4) inhibitors have been around since 2007. All these drug classes cost more than sulfonylureas but none put patients at risk for hypoglycemia.

In large part, because of that risk of hypoglycemia, the American Association of Clinical Endocrinologists algorithm (1) for pharmacotherapy of Type 2 Diabetes judges sulfonylureas as the worst option. Indeed, the annual rate of hypoglycemia was lowest in the Group Health Cooperative patients where sulfonylureas were used less frequently.

Second, the authors fail to account for the type of insulin prescribed. They lump all insulins together. And they discuss skipping meals as a cause of hypoglycemia. All insulins are not the same. For example, NPH insulin is associated with a greater risk of hypoglycemia than is insulin glargine in head to head trials (2). And the pharmacokinetics of NPH insulin are such that insulin levels often peak when the patient is not eating. Well-designed insulin regimens allow patients to skip meals with no problem.

Third, in their lengthy discussion on steps to reduce the risk of hypoglycemia, the authors fail to even mention choosing effective agents that do not cause hypoglycemia such as GLP-1 receptor agonists or SGLT-2 inhibitors. And some of these newer agents have now been demonstrated to reduce cardiovascular events and mortality.

The authors focus on population approaches, not the best care for the individual patient in the exam room.

Conflict of Interest Disclosures: This commenter receives clinical research funding and speaker honoraria from multiple pharmaceutical companies that market medication for diabetes.

1. Garber AJ, Abrahamson MJ, Barzilay JI, et al. Consensus Statement by the American Association of Clinical Endocrinologists and American College of Endocrinology on the Comprehensive Type 2 Diabetes Management Algorithm - 2017 Executive Summary. Endocr Pract. 2017;23(2):207-238.
2. Riddle MC, Rosenstock J, Gerich J, Insulin Glargine Study I. The treat-to-target trial: randomized addition of glargine or human NPH insulin to oral therapy of type 2 diabetic patients. Diabetes Care. 2003;26(11):3080-3086.

On 2017 Sep 02, David Keller commented:

More evidence that light-to-moderate ethanol consumption reduces all-cause mortality, primarily by reductions in cardiovascular events. Now, we need randomized controlled trials of ethanol

This large study paid careful attention to the drinking history and pattern of ethanol consumption of its subjects, eliminating many of the objections raised to prior studies which have reached the same conclusions. I, for one, am as convinced as can be, given the observational nature of all such studies, that light-to-moderate consumption of ethanol is probably beneficial, especially in persons at higher than average risk of cardiovascular (CV) events. The time has come to conduct interventional trials, with subjects randomized to receive capsules of ethanol at bedtime or placebo, to compare outcomes when ethanol is prescribed to patients with evidence of atherosclerotic vascular disease (ASVD), or at high risk thereof. If these most-likely-to-benefit patients do benefit, the next trial could expand to include subjects at average CV risk. Ethanol remains the agent most likely to benefit those with ASVD which cannot be prescribed, because it has never been studied as a medicine, rather than an addiction.

On 2017 Aug 23, Mick Watson commented:

Quite remarkable that this review fails to cite our prior review on exactly the same subject:

http://journal.frontiersin.org/article/10.3389/fgene.2017.00023/full

On 2017 Aug 29, Marcus de Jong commented:

With great interest, but also with significant apprehension, we read the article by Yamanaka et al. recently published on-line ahead of print in Neurosurgical Review, entitled "Trilateral retinoblastoma: A systematic review of 211 cases."

We have had a long-time interest in retinoblastoma, including trilateral retinoblastoma, and we became worried about the fact that the authors allegedly have included 211 patients with trilateral retinoblastoma in their statistical analysis. We have reason to believe that this number, and consequently, the presented results may not be correct. In 2014, we published a systematic review and meta-analysis on trilateral retinoblastoma in Lancet Oncology, based on strict adherence to the PRISMA Statement (de Jong et al. [1]). We also contacted authors to resolve any equivocal issues. In particular, we meticulously matched patients between reports to prevent including any patients twice in our analysis. Many patients with trilateral retinoblastoma appear in the literature two or more times over the years; in the extreme case, one patient features in five different reports over 12 years. Resolving duplications and consolidating the sequential reports by each patient, we ended up with 174 unique individuals with trilateral retinoblastoma (see the attached table from the online supplement of our article).

Naturally, a number of trilateral retinoblastoma cases included in Yamanaka et al.'s paper have been published after acceptance of our paper. These are Andrade et al. [2] with 1 case, De Ioris et al. [3] with 2 new cases, and Pham et al. [4] with 3 cases, amounting to a total difference of 6 unique patients.

However, we included several articles that Yamanaka et al. have not ascertained during their research: De Jong et al. [5], Duncan et al. [6], Dunst et al. [7], Gururangan et al. [8], Jin et al. [9], Lim et al. [10], Mauger et al. [11], Onadim et al. [12], Popovic et al. [13], White et al. [14], and Zimmerman et al. [15]. These amount to a total of 18 unique cases.

We became very concerned after noting that, correcting for new cases and articles not included by Yamanaka et al., the difference in the number of patients between the two articles is no less than 49 (our 174 - 18 not included by Yamanaka et al. = 156 in De Jong et al. [1] versus their 211 - 6 newly reported = 205 in Yamanaka et al. [16]). Because Yamanaka et al. have not provided a patient-by-patient table of their cases unlike we did, we are limited to this numerical comparison and cannot verify case by case their unique cases.

In summary, we have reason to believe that Yamanaka et al. have not accounted for the fact that trilateral retinoblastoma patients have often been published in more than one paper. Although the results of the meta-analysis by Yamanaka et al., in general, show results that appear largely similar to those that what we published, the unexplained and large difference in the number of patients suggests to us that most, if not all, percentages and p-values from the meta-analysis by Yamanaka et al. do not reflect reality. There is also no way of knowing whether a particular statistic is correct or not.

To solve this issue, we ask Yamanaka et al. to clarify this crucial aspect of their meta-analysis, ideally by providing a patient-by-patient list of the 211 cases to verify their uniqueness to be attached to their paper. Hopefully the authors can provide a valid explanation that completely resolves our concerns. Otherwise, we are afraid that the statistical results of this paper will be misleading and cannot be trusted, and then perhaps the paper in the present form should be retracted in order to correct the literature and to avoid wrong interpretations in clinical practice of managing children with trilateral retinoblastoma.

Marcus de Jong,

on behalf of the authors of de Jong et al. [1]

References

1.de Jong MC, Kors WA, de Graaf P, et al (2014) Trilateral retinoblastoma: A systematic review and meta-analysis. Lancet Oncol 15:1157–1167. doi: 10.1016/S1470-2045(14)70336-5

2.Andrade GC de, Pinto NP de C, Motono M, et al (2015) Trilateral retinoblastoma with unilateral eye involvement. Rev Assoc Med Bras 61:308–10. doi: 10.1590/1806-9282.61.04.308

3.De Ioris MA, Valente P, Randisi F, et al (2014) Baseline central nervous system magnetic resonance imaging in early detection of trilateral retinoblastoma: pitfalls in the diagnosis of pineal gland lesions. Anticancer Res 34:7449–54.

4.Pham TTH, Siebert E, Asbach P, et al (2015) Magnetic resonance imaging based morphologic evaluation of the pineal gland for suspected pineoblastoma in retinoblastoma patients and age-matched controls. J Neurol Sci 359:185–192. doi: 10.1016/j.jns.2015.10.046

5.de Jong MC, Moll AC, Göricke S, et al (2016) From a Suspicious Cystic Pineal Gland to Pineoblastoma in a Patient with Familial Unilateral Retinoblastoma. Ophthalmic Genet 37:116–8. doi: 10.3109/13816810.2014.929717

6.Duncan JL, Scott IU, Murray TG, et al (2001) Routine neuroimaging in retinoblastoma for the detection of intracranial tumors. Arch Ophthalmol 119:450–2. 7.Dunst J, Fellner E, Erhardt J (1990) Trilaterales Retinoblastom mit spinalen Metastasen. Rofo 153:343–4. doi: 10.1055/s-2008-1033391

8.Gururangan S, McLaughlin C, Quinn J, et al (2003) High-dose chemotherapy with autologous stem-cell rescue in children and adults with newly diagnosed pineoblastomas. J Clin Oncol 21:2187–91. doi: 10.1200/JCO.2003.10.096

9.Jin J, Tang H-F, Zhou Y-B (2006) Trilateral retinoblastoma: a case report. World J Pediatr 2:151–153.

10.Lim FPM, Soh SY, Iyer JV, et al (2013) Clinical profile, management, and outcome of retinoblastoma in Singapore. J Pediatr Ophthalmol Strabismus 50:106–12.

11.Mauger TF, Makley TA, Davidorf FH, Rogers GL (1992) Retinoblastoma, microphthalmia, coloboma, and neuroepithelioma of the pineal body. Ann Ophthalmol 24:290–4.

12.Onadim Z, Woolford AJ, Kingston JE, Hungerford JL (1997) The RB1 gene mutation in a child with ectopic intracranial retinoblastoma. Br J Cancer 76:1405–9.

13.Popovic MB, Balmer A, Maeder P, et al (2006) Benign pineal cysts in children with bilateral retinoblastoma: a new variant of trilateral retinoblastoma? Pediatr Blood Cancer 46:755–61.

14.White L, Johnston H, Jones R, et al (1993) Postoperative chemotherapy without radiation in young children with malignant non-astrocytic brain tumours. A report from the Australia and New Zealand Childhood Cancer Study Group (ANZCCSG). Cancer Chemother Pharmacol 32:403–6.

15.Zimmerman L (1985) Trilateral retinoblastoma. In: Blodi F (ed) Retinoblastoma. Churchill Livingstone, New York, pp 185–210

16.Yamanaka R, Hayano A, Takashima Y (2017) Trilateral retinoblastoma: A systematic review of 211 cases. Neurosurg Rev. doi: 10.1007/s10143-017-0890-4

Also posted here: https://pubpeer.com/publications/50D5D3EFEA81DCD2421841D84FDA8D#

On 2018 Feb 04, Sin Hang Lee commented:

The medical profession, including medical schools and hospitals, is now a part of the health care industry, and implementation of editorial policies of medical journals is commonly biased in favor of business interests. PubMed Commons has offered the only, albeit constrained, open forum to air dissenting research and opinions in science-based language. Discontinuation of PubMed Commons will silence any questioning of the industry-sponsored promotional publications indexed in PubMed.

On 2017 Aug 20, Sin Hang Lee commented:

Since the lead author and several co-authors of this report are officers of the Centers of Disease Control and Prevention (CDC), the CDC should clarify if this metabolomics-driven technology is now officially recommended for clinical laboratory tests for the diagnosis of emerging infectious diseases in general, or it is created in competition against the well-established 16S rRNA sequence analysis in bacterial infections [1,2] which should be used for molecular diagnosis of Lyme borreliosis. To rely on finding metabolic biosignature consisting of molecular features in patient body fluids to diagnose or to distinguish between emerging infectious diseases is an unproven technology and may have untoward consequences. Would these authors propose using metabolic biosignature in the blood of patients to diagnose Ebola or to distinguish between Ebola and malaria? Of course not!

The authors cited two articles published by other investigators [3,4] to support their novel approach. However, in one of these articles [3] metabolomics were reported to be used as a tool in precision medicine for disease risk assessment and customized drug therapy in clinics. In the other [4], metabolomics were used as a tool to identify the chemical differences that contribute to health and disease, such as chronic fatigue syndrome. Neither concerned diagnosis of or distinguishing between infectious diseases.

The authors claimed to have “previously demonstrated that metabolic profiling of sera provided a high level of accuracy in differentiating early Lyme disease patients from healthy individuals …” [5]. However, in the latter cited article the same lead author [5] stated that it was only a study of “proof-of-concept for a novel diagnostic approach” and that “the early LD biosignature correctly diagnosed 77%–95% of 2-tier negative early LD patients”. That means there was an up to 23% failure in detecting early Lyme disease. Even this statistical model is highly questionable since the very case definition of early Lyme disease is still open to question. According to the CDC's answer to the question: “Is PCR useful for the diagnosis of Lyme disease? In general, the answer is no.” [6].

The claim to have discovered an objective, diagnostically useful “metabolic biosignature” of Lyme disease or STARI which are both emerging infectious diseases, by analysis of a set of metabolites in tissue fluids of the patients must be supported by undisputed evidence with proven scientific principles. The authors’ novel approach in fact has deviated from the classic teachings of diagnostic microbiology. The findings of metabolic differences between patients with Lyme disease and patients with STARI do not automatically yield a test that can be used to diagnose or to distinguish between Lyme disease and STARI.

Conflicts of Interest: Sin Hang Lee, MD is the director of Milford Molecular Diagnostics Laboratory specialized in developing DNA sequencing-based diagnostic tests. References: [1] https://www.cdc.gov/labtraining/docs/588-100_103-17_16S_rRNA_Sequence_Based_Bacterial_Identification.pdf [2] https://www.cdc.gov/microbenet/about.html [3] Guo L, Milburn MV, Ryals JA, et al. Plasma metabolomic profiles enhance precision medicine for volunteers of normal health. Proc Natl Acad Sci U S A. 2015 Sep 1;112(35):E4901-10. [4] Naviaux RK, Naviaux JC, Li K, et al. Metabolic features of chronic fatigue syndrome. Proc Natl Acad Sci U S A. 2016 Sep 13;113(37):E5472-80. [5] Molins CR, Ashton LV, Wormser GP, et al. Development of a metabolic biosignature for detection of early Lyme disease. Clin Infect Dis. 2015 Jun 15;60(12):1767-75. [6] Christina A. Nelson, MD, MPH, Medical Officer in the Bacterial Diseases Branch of CDC's Division of Vector-Borne Disease. http://www.medscape.com/viewarticle/764501?src=par_cdc_stm_mscpedt&faf=1 Last accessed August 19, 2017.

On 2017 Sep 10, Susanne Bejerot commented:

Intriguingly we published a parallel study with the same methodology using the equipment provided by the company Sensodetect Inc, but we found that the method had a very low ability to identify patients with psychotic disorders, adhd and autism, as well as identifying the healthy controls in a blinded study, see Manouilenko I, Humble MB, Georgieva J, Bejerot S. Brainstem Auditory Evoked Potentials for diagnosing Autism Spectrum Disorder, ADHD and Schizophrenia Spectrum Disorders in adults. A blinded study. Psychiatry Res. 2017 Jul 6;257:21-26. Manouilenko I, 2017. Consequently, I contacted the first author of the Acta Neuropsychiatrica paper, Eva Juselius Baghdassarian, to discuss our conflicting findings. Her explanation was their use of an old stationary auditory brainstem response apparatus, whereas we used the company’s mobile modern machine. Our machine was transported back and fourth between Stockholm and the south of Sweden in a large cabin bag. This is of course highly problematic, as the company currently markets the method that we used. I suggest that the interested reader carefully reads the method section of both papers.