Zerit

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Emilio Bouza, M.D., Ph.D.

• Professor
• Clinical Microbiology
• University Complutense of Madrid
• Chief
• Clinical Microbiology and Infectious Diseases
• Hospital General Universitario Gregorio
• Mara?on (HGUGM)
• Madrid, Spain

Although the breadth of applications remains uncertain treatment irritable bowel syndrome cheap zerit 40 mg online, it is to be hoped that over the next few decades symptoms kidney buy 40 mg zerit mastercard, gene therapy for both monogenic and genetically complex diseases will contribute to the management of many disorders medications safe in pregnancy buy discount zerit 40 mg on-line, both common and rare medications 1 gram 40mg zerit sale. Precision Medicine: the Present and Future of the Treatment of Mendelian Disease the treatment of single-gene diseases embodies the concept of precision medicine tailored to the individual patient as deeply as any other area of medical treatment silicium hair treatment discount zerit 40 mg visa. Knowledge of the specific mutant sequence in an individual is central to many of the targeted therapies described in this chapter medicine bag discount 40mg zerit with visa. The promise of gene therapy for an individual with a mendelian disorder must be based on the identification of the mutant gene in each affected individual and on the design of a vector that will deliver the therapeutic gene to the targeted tissue. Similarly, approaches based on gene editing require knowledge of the specific mutation to be corrected. In many cases, the exact nature of the mutation will define the drug that will bind to a specific regulatory sequence to enhance or reduce the expression of a gene. A compendium of small molecules will gradually become available to suppress particular stop codons, to act as chaperones that will rescue mutant proteins from misfolding and proteosomal degradation, or to potentiate the activity of mutant proteins. Genetic treatment is not only becoming more and more creative, it is becoming more and more precise. The future promises not only a longer life for many patients, but a life of vastly better quality. A 25-year longitudinal analysis of treatment efficacy in inborn errors of metabolism. Lentiviral hematopoietic stem cell gene therapy benefits metachromatic leukodystrophy. Enzyme replacement therapy for lysosomal diseases: lessons from 20 years of experience and remaining challenges. Losartan reduces aortic dilatation rate in adults with Marfan syndrome: a randomized controlled trial. The transthyretin amyloidoses: from delineating the molecular mechanism of aggregation linked to pathology to a regulatory agency approved drug. A cut above the rest: targeted genome editing technologies in human pluripotent stem cells. Gene therapy for primary immunodeficiency disorders: progress, pitfalls and prospects. Novel approaches to the treatment of sickle cell disease: the potential of histone deacetylase inhibitors. Cord blood and bone marrow transplantation in inherited metabolic diseases: scientific basis, current status and future directions. Correction of sickle cell disease in adult mice by interference with fetal hemoglobin silencing. Useful Websites Registry and results database of publicly and privately supported clinical studies of human participants conducted around the world: clinicaltrials. Before treatment, the phagocytes of some less severely affected patients had small but detectable bursts of oxidase activity (unlike those of severely affected patients), suggesting that increased activity in these less severely affected subjects is the result of greater production of cytochrome b from the affected locus. Presumably, the cytochrome b polypeptide of these patients is partially functional, and increased expression of the residual function improved the physiological defect. At the clinic, however, they meet another family with a 5-year-old boy with the same disease. What classes of mutations are likely to be found in homocystinuric patients who are not responsive to the administration of large doses of pyridoxine (vitamin B)? How6 might you explain the fact that Tom is completely responsive, whereas his first cousin Allan has only a partial reduction in plasma homocystine levels when he is given the same amount of vitamin B? Your approach will be to culture cells from the patient, introduce a functional version of the gene into the cells, and reintroduce the cells into the patient. You introduce your version of the gene into fibroblasts cultured from a skin biopsy specimen from the patient. However, when you add H 3 labeled phenylalanine to the cells in culture, no H-labeled tyrosine is formed (in contrast, some cultured liver cells 3 produce a large quantity of H-labeled tyrosine in this situation). Both alleles of an autosomal gene that is mutant in your patient produce a protein that is decreased in abundance but has residual function. Discuss how the location of the nonsense mutation in the predicted reading frame of the protein could account for this differential response. C H A P T E R 1 4 Developmental Genetics and Birth Defects Knowledge of the principles and concepts of developmental genetics, including the mechanisms and pathways responsible for normal human development in utero, is essential for the practitioner who seeks to develop a rational approach to the diagnostic evaluation of a patient with a birth defect. With an accurate diagnostic assessment in hand, the practitioner can make predictions about prognosis, recommend management options, and provide an accurate recurrence risk for the parents and other relatives of the affected child. In this chapter, we provide an overview of the branch of medicine concerned with birth defects and review basic mechanisms of embryological development, with examples of some of these mechanisms and pathways in detail. We present examples of birth defects that result from abnormalities in these processes. And finally, we show how an appreciation of developmental biology is essential for understanding prenatal diagnosis (see Chapter 17) and stem cell therapy as applied to regenerative medicine (see Chapter 13). Developmental Biology in Medicine The Public Health Im pact of Birth Defects the medical impact of birth defects is considerable. In 2013, the most recent year for which final statistics are available, the infant mortality rate in the United States was 5. Another 20% of infant deaths may be attributed to complications of prematurity, which can be considered a failure of maintenance of the maternal-fetal developmental environment. Therefore nearly half of the deaths of infants are caused by derangements of normal development. In addition to mortality, congenital anomalies are a major cause of long-term morbidity, intellectual disability, and other dysfunctions that limit the productivity of affected individuals. Genetic counseling and prenatal diagnosis, with the option to continue or to terminate a pregnancy, are important for helping individuals faced with a risk for serious birth defects in their offspring improve their chances of having healthy children (see Chapter 17). Physicians and other health care professionals must be careful, however, not to limit the public health goal of reducing disease solely to preventing the birth of children with anomalies through voluntary pregnancy termination. For example, recommendations to supplement prenatal folic acid intake, which markedly reduces the incidence of neural tube defects, and public health campaigns that focus on preventing teratogenic effects of alcohol during pregnancy, are successful public health approaches to the prevention of birth defects that do not depend on prenatal diagnosis and elective abortion. In the future, it is hoped that our continued understanding of the developmental processes and pathways that regulate them will lead to therapies that may improve the morbidity and mortality associated with birth defects. Dysmorphology and Mechanisms That Cause Birth Defects Dysmorphology is the study of congenital birth defects that alter the shape or form of one or more parts of the body of a newborn child. Researchers attempt to understand the contribution of both abnormal genes and nongenetic, environmental influences to birth defects, as well as how those genes participate in conserved developmental pathways. The objectives of the medical geneticist who sees a child with birth defects are: to diagnose a child with a birth defect. to suggest further diagnostic evaluations. to give prognostic information about the range of outcomes that could be expected. to develop a plan to manage the expected complications. to provide the family with an understanding of the causation of the malformation, and. to give recurrence risks to the parents and other relatives. To accomplish these diverse and demanding objectives, the clinician must acquire and organize data from the patient, the family history, and published clinical and basic science literature. Medical geneticists work closely with specialists in pediatric surgery, neurology, rehabilitation medicine, and the allied health professions to provide ongoing care for children with serious birth defects. Malformations, Deformations, and Disruptions Medical geneticists divide birth defects into three major categories: malformations, deformations, and disruptions. We will illustrate the difference between these three categories with examples of three distinct birth defects, all involving the limbs. Malformations result from intrinsic abnormalities in one or more genetic programs operating in development. An example of a malformation is the extra fingers in the disorder known as Greig cephalopolysyndactyly (Fig. Because malformations arise from intrinsic defects in genes that specify a series of developmental steps or programs, and because such programs are often used more than once in different parts of the embryo or fetus at different stages of development, a malformation in one part of the body is often but not always associated with malformations elsewhere as well. This patient has heptadactyly with insertion of a digit in the central ray of the hand and a supernumerary postaxial digit. This malformation is typically associated with metacarpal fusion of the third and fourth digits. B, Postaxial polydactyly with severe cutaneous syndactyly of digits two through five. This type of malformation is seen in patients with Greig cephalopolysyndactyly syndrome. In contrast to malformations, deformations are caused by extrinsic factors impinging physically on the fetus during development. They are especially common during the second trimester of development when the fetus is constrained within the amniotic sac and uterus. For example, contractions of the joints of the extremities, known as arthrogryposes, in combination with deformation of the developing skull, occasionally accompany constraint of the fetus due to twin or triplet gestations or prolonged leakage of amniotic fluid (Fig. Most deformations apparent at birth either resolve spontaneously or can be treated by external fixation devices to reverse the effects of the instigating cause. There are multiple, symmetrical joint contractures due to abnormal muscle development caused by severe fetal constraint in a pregnancy complicated by oligohydramnios. Intelligence is generally normal, and orthopedic rehabilitation is often successful. Disruptions, the third category of birth defect, result from destruction of irreplaceable normal fetal tissue. Disruptions are more difficult to treat than deformations because they involve actual loss of normal tissue. One example is amnion disruption, the partial amputation of a fetal limb associated with strands of amniotic tissue. Amnion disruption is often recognized clinically by the presence of partial and irregular digit amputations in conjunction with constriction rings (Fig. This 26-week fetus shows nearly complete disruption of the thumb with only a nubbin remaining. The third and fifth fingers have constriction rings of the middle and distal phalanges, respectively. The fourth digit is amputated distally with a small fragment of amnion attached to the tip. The pathophysiological concepts of malformations, deformations, and disruptions are useful clinical guides to the recognition, diagnosis, and treatment of birth defects, but they sometimes overlap. For example, vascular malformations may lead to disruption of distal structures, and urogenital malformations that cause oligohydramnios can cause fetal deformations. Thus a given constellation of birth defects in an individual may represent combinations of malformations, deformations, and disruptions. Genetic, Genomic, and Environmental Causes of Malformations Malformations have many causes (Fig. Chromosome imbalance accounts for approximately 25%, of which autosomal trisomies for chromosomes 21, 18, and 13 (see Chapter 6) are some of the most common. Some malformations, such as achondroplasia or Waardenburg syndrome, are inherited as autosomal dominant traits. Many heterozygotes with birth defects, however, represent new mutations that are so severe that they are genetic lethals and are therefore often found to be isolated cases within families (see Chapter 7). Other malformation syndromes are inherited in an autosomal or X-linked recessive pattern, such as the Smith-Lemli-Opitz syndrome or the Lowe syndrome, respectively. Another approximately 40% of major birth defects have no identifiable cause but recur in families of affected children with a greater frequency than would be expected on the basis of the population frequency and are thus considered to be multifactorial diseases (see Chapter 8). This category includes well-recognized birth defects such as cleft lip with or without cleft palate, and congenital heart defects. The remaining 5% of birth defects are thought to result from exposure to certain environmental agents—drugs, infections, alcohol, chemicals, or radiation—or from maternal metabolic disorders such as poorly controlled maternal diabetes mellitus or maternal phenylketonuria (see Chapter 12). Such agents are called teratogens (derived, inelegantly, from the Greek word for monster plus -gen, meaning cause) because of their ability to cause malformations (discussed later in this chapter). Pleiotropy: Syndromes and Sequences A birth defect resulting from a single underlying causative agent may result in abnormalities of more than one organ system in different parts of the embryo or in multiple structures that arise at different times during intrauterine life, a phenomenon referred to as pleiotropy. The agent responsible for the malformation could be either a mutant gene or a teratogen. Pleiotropic birth defects come about in two different ways, depending on the mechanism by which the causative agent produces its effect. When the causative agent causes multiple abnormalities in parallel, the collection of abnormalities is referred to as a syndrome. If, however, a mutant gene or teratogen affects only a single organ system at one point in time, and it is the perturbation of that organ system that causes the rest of the constellation of pleiotropic defects to occur as secondary effects, the malformation is referred to as a sequence. The autosomal dominant branchio-oto-renal dysplasia syndrome exemplifies a pleiotropic syndrome. It has long been recognized that patients with branchial arch anomalies affecting development of the ear and neck structures are at high risk for having renal anomalies. The branchio-oto-renal dysplasia syndrome, for example, consists of abnormal cochlear and external ear development, cysts and fistulas in the neck, renal dysplasia, and renal collecting duct malformations. The mechanism of this association is that a conserved set of genes and proteins are used by mammals to form both the ear and the kidney. Similarly, the Rubinstein-Taybi syndrome, caused by loss of function in a transcriptional coactivator, results in abnormalities in the transcription of many genes that depend on this coactivator being present in a transcription complex for normal expression (Fig. In contrast, an example of a sequence is the U-shaped cleft palate and small mandible referred to as the Robin sequence (Fig. This sequence comes about because a restriction of mandibular growth before the ninth week of gestation causes the tongue to lie more posteriorly than is normal, interfering with normal closure of the palatal shelves, thereby causing a cleft palate. The Robin sequence can be an isolated birth defect of unknown cause or can be due to extrinsic impingement on the developing mandible by a twin in utero. The Robin sequence in the Stickler syndrome is a sequence because the mutant collagen gene itself is not responsible for the failure of palatal closure; the cleft palate is secondary to the primary defect in jaw growth. Whatever the cause, a cleft palate due to the Robin sequence must be distinguished from a true primary cleft palate, which has other causes with differing prognoses and implications for the child and family. Knowledge of dysmorphology and developmental genetic principles is thus necessary to properly diagnose each condition and to recognize that different prognoses are associated with the different primary causes. B, Posterior placement of the tongue in the Robin sequence causes a deformation of the palate during development, leading to the constellation of a small chin and a U-shaped cleft palate involving the soft palate and extending into the hard palate. C, In contrast, primary cleft palate resulting from failure of closure of maxillary ridges is a malformation that begins in the anterior region of the maxilla and extends posteriorly to involve first the hard palate and then the soft palate, and it is often V-shaped. D, the delay in jaw development can be observed by serial three-dimensional fetal scans, from as early as 17 weeks (left) to 20 weeks (middle) and 29 weeks (right).

Mutagenicity is dis these systems vary in their ability to identify specific teratogenic cussed in detail in Chap treatment conjunctivitis cheap zerit 40mg online. In general medications 222 cheap zerit 40mg free shipping, With the advent of techniques that readily allow manipula the available assays cannot identify functional or behavioral terato tion of the mouse genome symptoms xeroderma pigmentosum generic zerit 40mg, transgenic animals have been developed gens (Faustman symptoms ketoacidosis purchase zerit discount, 1988) medicine klonopin discount zerit 40mg with amex. For example treatment for strep throat discount zerit 40mg with visa, 2 commercially available mouse strains, the “MutaMouse” and “Big Blue,” contain the lac operon of E. Stable, homozy genetic material in the nucleus of cells in ways that allow the gous strains of these transgenic animals (both mice and rats have changes to be transmitted during cell division. Mutations can occur been engineered) can be exposed to potential mutagenic agents. If mutations are present at the time of fertilization in either the egg or the sperm, the resulting combination of genetic material may not be viable, and Oncogenicity Bioassays the death may occur in the early stages of embryonic cell division. Oncogenicity studies are both time consuming and expensive, Alternatively, the mutation in the genetic material may not affect and are usually only done when there is reason to suspect that a early embryogenesis but may result in the death of the fetus at a chemical may be carcinogenic, or when there may be wide spread, later developmental period, resulting in abortion. Congenital abnor long-term exposures to humans (eg, widely used food additives, malities may also result from mutations. Somatic mutations refer drinking water contaminants, or pharmaceuticals that are likely to to mutations in all other cell types and are not heritable but may be administered repeatedly for long periods of time). Chemicals result in cell death or transmission of a genetic defect to other cells that test positive in several mutagenicity assays are likely to be in the same tissue through mitotic division. Because the initiating carcinogenic, and thus are frequent candidates for oncogenicity event of chemical carcinogenesis is thought to be a mutagenic one, bioassay assessment. In the United States, the National Toxicology mutagenic tests are often used to screen for potential carcinogens. In this case, cyto as part of the preclinical assessment, depending on the intended genetic analysis of bone marrow smears is used after the animals use of the drug, and the results of mutagenicity assays and other have been exposed to the test agent. Most regulatory guidelines require that both benign and 200 400 600 800 1000 malignant tumors be reported in oncogenicity bioassays. Statistical Number of animals in test group increases above the control incidence of tumors (either all tumors Figure 2-14. Statistical limitations in the power of experimental animal or specific tumor types) in the treatment groups are considered studies to detect tumorigenic effects. Thus, the conclusion as to the average lifetime of the species (18 months to 2 years for mice, whether a given chronic bioassay is positive or negative for carcino 2–2. To ensure that 30 rats per dose survive the genic potential of the test substance requires careful consideration 2-year study, 60 rats per group per sex are often started in the study. Properly designed chronic onco Both gross and microscopic pathological examinations are made genicity studies require that a concurrent control group matched not only on animals that survive the chronic exposure but also on for variables such as age, diet, and housing conditions be used. Adrenal gland pheochromocytoma However, identifying with statistical confidence a 0. Liver adenoma/carcinoma this curve shows that in a chronic bioassay with 50 animals per test Lung adenoma/carcinoma group, a tumor incidence of about 8% could exist even though no Mesothelioma Skin papilloma/carcinoma animals in the test group had tumors. These statistical consider 00 2525 5050 7575 100100 ations illustrate why animals are tested at doses higher than those % with tumors that occur in human exposure. Because it is impractical to use the large number of animals that would be required to test the poten Female F344 rats tial carcinogenicity of a chemical at the doses usually encountered Pituitary gland adenoma/carcinoma by people, the alternative is to assume that there is a relationship Mammary gland neoplasms between the administered dose and the tumorigenic response and Mononuclear cell leukemia give animals doses of the chemical that are high enough to produce Uterus stromal polyp a measurable tumor response in a reasonable size test group, such Thyroid c-cell adenoma/carcinoma as 40 to 50 animals per dose. The limitations of this approach are Clitoral gland adenoma/carcinoma discussed in Chap. The values were obtained broadly on the properties of the agent and the suitability of the ani from 27 different studies involving a combined total of between 1319 and mal (4) and permit data interpretation in the context of clinical use. For example, the range in liver adenoma/ 39 carcinoma incidence in 30 different groups of unexposed Liver adenoma/carcinoma (control) male B6C3F1 mice went from a low of 10% to a Lung adenoma/carcinoma high of 68%. Pituitary gland adenomas/carcinomas ranged Subcutaneous tissue neoplasms from 12% to 60% and 30% to 76% in unexposed male and Malignant lymphoma female F344 rats, respectively, and from 0% to 36% in unex Hemangioma/hemangiosarcoma posed female B6C3F1 mice. Harderian gland adenoma/carcinoma Adrenal cortical tumors Taken together, these data demonstrate the importance of 00 2525 5050 7575 100100 including concurrent control animals in such studies. In addition, % with tumors comparisons of the concurrent control results to “historic” con trols accumulated over years of study may be important in iden Female B6C3F1 mice tifying potentially spurious “false-positive” results. The relatively high variability in background tumor incidence among groups of Malignant lymphoma healthy, highly inbred strains of animals maintained on nutrition Liver adenoma/carcinoma ally balanced and consistent diets in rather sterile environments Pituitary gland adenoma/carcinoma highlights the dilemma in interpreting the significance of both Lung adenoma/carcinoma positive and negative results in regard to the human population, Hemangioma/hemangiocarcinoma which is genetically diverse, has tremendous variability in diet, Harderian gland adenoma/carcinoma nutritional status, and overall health, and lives in an environ Uterus stromal polyps ment full of potentially carcinogenic substances, both natural and Thyroid gland follicular cell tumors human-made. The values were obtained from 30 different studies involving a total of between 1447 and 1474 ani genistein because its mammary tumors are responsive to estrogenic mals per tumor type. The data shown represent the per cent of animals in control (nonexposed) groups that developed the Neurotoxicity or a neurotoxic effect is defined as an adverse change specified tumor type by the end of the 2-year study. These studies in the chemistry, structure, or function of the nervous system fol involved more than 1300 rats of each sex. There are several key points that the potential neurological effects of a compound, effects may be can be derived from these summary data: on the central or peripheral nervous system or related to exposure that occurred during development or as an adult. Tumors, both benign and malignant, are not uncommon events nervous system is particularly sensitive to chemical exposures in animals even in the absence of exposure to any known (see Chap. There are numerous different tumor types that develop “spon idly developing area of neurotoxicity assessment. Specific cell taneously” in both sexes of both rats and mice, but at different lines are available to examine effects on neuron or glial cells such rates. In vitro assays have a number of potential advantages uncommon in another (eg, testicular interstitial cell adenomas including minimizing the use of animal, lower costs, and adaptable are very common in male rats but rare in male mice; liver ade to high-throughput screening. It is also possible to use an in vitro nomas/carcinomas are about 10 times more prevalent in male model to examine the interaction of chemicals, such as food addi mice than in male rats). Even within the same species and strain, large gender differ lenges of in vitro neurotoxicity testing are well described (Claudio, ences in background tumor incidence are sometimes observed 1992; Tiffany-Castiglioni, 2004). Even when the general protocols, diets, environment, strain are commonly used to evaluate the neurotoxic properties of chemi and source of animals, and other variables are relatively con cals. A wide range of adult and developmental animal tests are used stant, background tumor incidence can vary widely, as shown to access neurobehavioral function. These protocols include tests of neurobehav lying such individual susceptibility. In the case of chronic beryl ioral function, such as auditory startle, learning and memory func lium disease, a genetic polymorphism in a gene involved in antigen tion, changes in motor activity, and neuropathological examination recognition may be associated with increased susceptibility (see and morphometric analysis. Although our ability to predict immunogenic evaluation are well established (Claudio et al. For example, the increasing incidence of tiple chemical exposures in animals (Moser et al. Nonhuman dust mites, molds, and animal dander), genetic factors, and other primates have been invaluable in evaluating the effects of neuro factors in the in utero and postnatal environment (see Donovan and toxicants and the risk assessment process (Burbacher and Grant, Finn, 1999; Armstrong et al. Sophisticated assessment of operant behavior, and learning Immunosuppression is another form of immune system toxic and memory assessment of rodents, has been used to evaluate the ity, which can result in a failure to respond to pathogenic infection, effects of lead (Cory-Slechta, 1995, 1996, 2003). Monkeys can a prolonged infection period, or expression of a latent infection also be used to evaluate the low-level effects of neurotoxicants or cancer. Various chemicals have been associated with immuno such as mercury on vision, auditory function, and vibration sensi suppression. These Autoimmunity is a specific immune system disorder in which methods have also been applied to Hispanic workers (Rohlman components of the immune system attack normal (self) tissues. As with other forms of immune system toxicity, autoimmu ioral test batteries for assessing children (Rohlman et al. Evaluation of the childhood neurological effects of lead (Lanphear Finally, new forms of immunotoxicity are appearing based et al. Such cases are stark reminders of the challenges we face in understanding how the immune system is regulated, developing reliable test systems Immunotoxicity Assessment for identifying such risks prior to human use, and developing safe Under normal conditions, the immune system is responsible for means for testing these agents in humans. This tiered approach is generally accepted worldwide a pathology in most any organ or tissue (see Chap. Tiered testing relies on the concept that standard toxicity stud “nutrigenomics”) are being devised to look broadly at the biologi 41 ies can provide good evidence for immunotoxicity when considered cal response of an organism to change. The integration of all of with known biological properties of the chemical, including struc these levels of molecular function (genomics, transcriptomics, pro tural similarities to known immunomodulators, disposition, and teomics, metabonomics, etc) to the understanding of how a living other clinical information, such as increased occurrence of infec organism functions at the cellular level is sometimes referred to as tions or tumors. Evaluation of hematological changes, including dif “systems biology” (Weston and Hood, 2004). Because each level ferential effects on white blood cells and immunoglobulin changes, of analysis generates a very large quantity of data, the collection, and alterations in lymphoid organ weights or histology, can provide organization, evaluation, and statistical analysis is in itself an enor strong evidence of potential effects to the immune system. The field of “bioinformatics” has been devel such evaluations indicate a potential effect on immune system oped to address the many computational and statistical challenges function, more detailed evaluations may be considered, including of “omics” data. In the field of toxicology, the term “toxicogenom the evaluation of functional effects (eg, T-cell-dependent antibody ics” is used to define the area of research that “combines transcript, response or natural killer cell activity), flow cytometric immuno protein and metabolite profiling with conventional toxicology to phenotyping, or host resistance studies. Thus, as with other areas investigate the interaction between genes and environmental stress of toxicology, the evaluation of immune system toxicity requires in disease causation” (Waters and Fostel, 2004). A conceptual the toxicologist to be vigilant in observing early indications from a model for how the various new “omics” technologies can be incor variety of sources in developing a weight-of-evidence assessment porated into toxicological evaluation is shown in Fig. Thus, each cell of an organism has the same toxicity testing protocol because they are required by the various genome, characterized by the nucleotide sequences inherited from regulatory agencies. The human genome consists of approximately 3 billion in the protocol to provide information relating a special route of base pairs of deoxyribonucleotides. The duration of exposure for inha differences in susceptibility to chemicals or other environmental lation toxicity tests can be acute, subchronic, or chronic, but acute factors discussed previously, represents a relatively new and grow studies are more common with inhalation toxicology. Other special ing area of study that aims to understand the complex interac types of animal toxicity tests include toxicokinetics (absorption, tions between the human genome and the environment (Costa and distribution, biotransformation, and excretion), the development of Eaton, 2006). It is the differential expression of genes In the past decade, numerous new genome-based technologies have in a given cell that is largely responsible for the diverse function become available that allow for the large-scale analysis of biologi of the thousands of different cells, tissues, and organs that consti cal responses to external stimuli. Thus, understanding which genes are to elucidate the biochemical and molecular effects of toxic sub expressed in a given tissue, at what level, and how toxicants perturb stances focused largely on examining biochemical pathways that the “transcriptome” is of great relevance to toxicology. However, technologies now available allow one to examine the entire “universe” of biological responses to a toxic substance (Fig. These new “hypothesis-generating” Epigenetics/Epigenomics technologies include genomics (characterization of much or all of the expanding research into the relatively new field of epigenomics the genome of an organism), transcriptomics (characterization of will have important implications for public health and toxicology. Conrad Hal Waddington first cules in a cell or tissue, including substrates, products, and cofactors postulated in the 1930s that it was not just the genes that shaped of enzyme reactions). Other “omics” approaches (eg, “lipidomics,” development but also the environment that shapes the genes 42 0100 010110 10101001 Omics database(s) Genome database(s) 0101011010 101001010110 Treatment 10101110111001 001010010010100 Gene, protein, or “Sequence anchoring” Literature metabolite-expression of molecular expression mining profiles Histopathology Computational analysis Identify gene/protein Multi domain functional groups, multi genome Clinical chemistry pathways, and networks knowledge base “Phenotypic anchoring” Weight, physiology of molecular expression Iterative biological modeling Integrated Absorbtion, distribution, systems metabolism, excretion toxicology O O N Toxicology database(s) Figure 2-17. Conceptual approach for incorporating “omics” technologies and resulting large databases into toxicological evaluation. Data from experiments that evaluate the effects of a chemical on global patterns of gene expression (transcriptomics), protein content (proteomics), and small molecules/metabolites (metabonomics/metabolomics), combined with genomic information from both the test species (eg, rats, mice) and the target species of interest (eg, humans), are analyzed by computational tools (bioinformatics) for unique or potentially predictive patterns of toxicity. Essential to the use of omics data for predictive toxicology/safety assessment is the ability to reliably tie observed omics patterns to traditional measures of toxicity, such as histopathology and clinical chem istry (phenotypic anchoring). Understanding a possible mechanism had to wait thus may have important toxicological implications. Epigenetic changes can potentially be transgenera cancer, neurodevelopment disorders, autoimmune diseases, dia tional, as suggested in some animal models, which has impor betes and metabolic disorders, asthma, behavioral disorders, and tant implications for toxicological assessment (Rosenfeld, 2010; endocrine disorders (Godfrey et al. Given the growing recognition of epigenetics 2009; Zhang and Ho, 2011; Attig et al. Process and consequence of epigenetic regulation of gene expression (National Institute of Health). However, 1 of the major chal Transcriptomics lenges in toxicogenomics is the recognition that transcriptional Among the first changes that a cell will exhibit following exposure regulation is highly dynamic, and that gene expression profiles can to a toxic substance is a change in gene expression. Although changes in gene expression often contribute sis to assess the level of expression of individual genes in cells or to , or are reflective of, phenotypic changes that occur in response to tissues for decades. Thus, large amounts of material for analysis complement of proteins that are present in a cell or tissue at a given can be obtained from a relatively small number of cells. Both have their advantages and possible to “amplify” the number of copies of proteins in a cell. Because of size limita One feature in common among all of the various “omics” technolo tions for accurate mass spectrometry, protein mixtures are usually gies is the ability to generate very large volumes of data (literally digested to smaller peptide fragments. Both the data ments is resolved into individual components, and the identity of management and statistical evaluation of toxicogenomics stud the specific peptides is determined based on high-resolution mass ies represent an enormous challenge. The emerging field of bio analysis and sequential degradation (sequential loss of single amino informatics has developed to address these challenges. Numerous acids) of the peptides by various means (Aebersold and Mann, commercial platforms for conducting microarray analysis of the 2003). The large and complex set of peptide mass fragments is then transcriptome are available, and sophisticated software is available analyzed by computers and compared with a large database of mass for both data management and analysis. Because as few as 5 amino lenges in statistical analysis of large data sets is the large number acid sequences may provide unique identification of a specific pro of “false positives” that will result from multiple comparisons. In a tein, the presence and relative abundance of specific proteins in a typical gene array experiment, it is not uncommon for an investiga sample can then be reconstructed through bioinformatic analyses. At the typical “95%” As with transcriptomics, it is hoped that changes in protein expres statistical confidence limit, one would expect more than 1000 of sion can be used as specific biomarkers for particular types of toxic the noted differences to occur just by chance alone. Of course, such conceptual approaches have been used rigorous statistical methods have been developed to reduce the so for years, for example, use of serum transaminase proteins as indi called false discovery rate in such experiments (Storey et al. The potential power of proteomics lies in the Challenges in Using “Omics” ability to identify unique patterns of protein expression, or identi fication of unique proteins or peptides, that are predictive of early Technologies for Predictive toxic response or later development of disease. Toxicology and Risk Assessment A conceptual framework for incorporating these new technologies into toxicology, sometimes referred to as “systems toxicology,” is Metabonomics/Metabolomics shown in Fig. Metabonomics has been defined as “the comprehensive information from the species of interest, (3) computational tools and simultaneous systematic profiling of metabolite levels and that extract information from these and other databases and the their systematic and temporal change through such effects on diet, published literature to identify critical pathways and networks that lifestyle, environment, genetic and pharmaceuticals, both benefi are altered by the toxicant treatment, and (4) comparison with tra cial and adverse, in whole organisms” (Lindon et al. Regardless iology in the animal (histopathology, clinical chemistry, etc)—a of the specific term used (metabonomics will be used here), the process called “phenotypic anchoring” (Waters and Fostel, 2004). However, the incorporation of such approaches into rou nomics, because the changes in these small molecules must rep tine toxicity assessment presents numerous challenges. Numerous resent a biologically relevant integration of all of the molecular, working group reports and publications have addressed the chal biochemical, and cellular perturbations that lead to the develop lenges of incorporating toxicogenomics data into predictive toxi ment of toxicity (Fig. Traditional measure of tually superior to either transcriptomics or proteomics for predic toxicity, such as histopathological changes in a tissue, tends to be tive toxicology, metabonomics lags significantly in technological stable or even irreversible, whereas the myriad of molecular, bio development of readily accessible tools for thorough analysis of chemical, and cellular changes that give rise to the toxic response(s) the metabonome.

Thus treatment 6th feb order zerit 40mg with amex, it can now be investigated on a genome-wide scale medicine song zerit 40mg mastercard, whether particular branching points are found repeatedly in numerous multigene families and whether these nodes correlate with important branching events in the underlying vertebrate species tree gas treatment cheap zerit 40mg with mastercard. Based on this information it is possible to analyze the interplay of divergence between paralogs or entire paranomes (the ensemble of duplicated genes) and phenotypic evolution treatment solutions buy zerit toronto. Therefore symptoms your dog has worms cheap zerit 40 mg free shipping, today – one hundred fifty years after the publication of the Origin of Species – it is for the first time possible to investigate in-depth the impact of gene and genome duplications on the evolution of the vertebrate branch in the Tree of Life symptoms you are pregnant cheap zerit 40 mg with mastercard. This transition was accompanied with fundamental changes in both anatomy and genome structure. At the morphological level, neural crest cells, placodes, a complex brain and the endoskeleton are key innovations of the vertebrate bauplan (Gans and Northcutt 1983; Hall 1999; Shimeld and Holland 2000). At the genomic level, an increase in genome size from invertebrate chordates to vertebrates has occurred (Ohno 1970) that was accompanied by substantial expansion of numerous gene families (Spring 1997). Genome duplication (polyploidization) may occur within a species (autopolyploidization) or through the hybridization of two different species (allopolyploidization). The timing of 2R is controversial and might have taken place before or after the divergence of agnathans. While there is only one Hox cluster in vertebrates’ nearest invertebrate relatives, the cephalochordates and the urochrodates (Fig. The fourfold paralogy of vertebrate Hox clusters is due to the twofold duplication of the single invertebrate Hox cluster. Fourfold paralogy is also found for other vertebrate genomic clusters such as the ParaHox clusters (Ferrier et al. Examples for fourfold paralogy of chromosomal blocks consisting of unrelated genes are the major histocompatibility complex regions (Kasahara 2007), the neuropeptide Y receptor paralogons (Larsson et al. Paralogons have also been used to reconstruct the ancestral vertebrate, pre-1R/2R karyotype (Nakatani et al. The timing of the second round (2R), in contrast, remains controversial and might have occurred in a common ancestor of agnathans (lamprey and hagfish) and gnathostomes (Kuraku, Meyer, and Kuratani 2008) or later in the gnathostome lineage after the split from agnathans (Panopoulou and Poustka 2005). Subsequently, further evidence came through the identification of many additional duplicated genes in 1 Own contributions are underlined. These gene duplicates showed the phylogenetic topology, genome-wide chromosomal distribution and evolutionary age indicative of a large-scale genomic duplication event in a common ancestor (Wittbrodt et al. In some fish lineages, further polyploidizations have occurred (reviewed in Le Comber and Smith 2004; Leggatt and Iwama 2004), for example the autotetraploidization in salmonids around 100 million years ago (Fig. Ray-finned fishes therefore offer a unique opportunity to study genome duplications of different ages. In the short term, this increase in gene dosage may be compensated by gene-copy silencing (Adams and Wendel 2005; Pala et al. In the long term, the most likely fate of a pair of duplicates is nonfunctionalization, i. Consequently, most gene duplicates have a rather short lifetime of a few million years only (Lynch and Conery 2000). However, many gene duplicates survive much longer periods and there are several models explaining how both duplicates can be retained and persist in the genome over long evolutionary periods. According to the classical neofunctionalization model (Ohno 1970), one of the two paralogs might acquire a new, positively selected function, while the other fulfils the ancestral gene functions (Fig. Sub and neofunctionalization are not mutually exclusive and might occur successively during paralog evolution (Fig. Sub-neofunctionalization might be particularly observed in ancient duplicates (He and Zhang 2005). Nevertheless, many duplicates retain at least some functional overlap, thereby providing robustness to the system to withstand detrimental mutations (Wagner 2008). In addition, there are many more possible mechanisms for the retention of gene duplicates (see. For example, a backup circuit between the duplicates may be establish after duplication to buffer against inactivation of one of the paralogs (Klüver et al. Figure 2 – Evolutionary fates of duplicated genes An ancestral gene (black box) has two functions (green box, blue circle). As long as redundancy persists at least partially, the duplication may provide genetic robustness, i. Under certain conditions, functional redundancy is evolutionary stable (Nowak et al. Further evolution of duplicate gene pairs may involve the three following fates: one of the two genes fulfils the ancestral functions, while the other gets lost (nonfunctionalization) or evolves a new function (neofunctionalization), represented by a triangle, or both genes partition the ancestral functions (subfunctionalization). Duplicate gene pairs might pass through subfunctionalization accompanied by neofunctionalization (sub-neofunctionalization). An important question is, which classes of genes are preferentially retained in duplicate. The retention of such genes is rather uncommon for paralogs generated through small-scale duplications (Maere et al. For example, it has been proposed that 1R and 2R were genomic prerequisites for the evolution of the vertebrate endoskeleton (Zhang and Cohn 2008), the neural crest (Shimeld and Holland 2000; Wada 2001; Wada and Makabe 2006), jaws (Ohno 1970), or the adaptive immune system (Kasahara 2007; Okada and Asai 2008). However, detailed studies supporting these hypotheses are sparse and mostly restricted to few gene families. With around 23,500 species, teleosts represent approximately one half of all extant vertebrate species (Nelson 2006). The duplication-diversification hypothesis predicts that gen(om)e duplication and subsequent reciprocal gene loss or differential paralog evolution in divergent populations can lead to genomic incompatibilities between isolated populations and ultimately to speciation (Werth and Windham 1991; Lynch and Force 2000). To these belong, for example, the complexity and diversity of their body pigmentation and color patterning (Braasch et al. Despite the possible correlation between genome duplications and increases in morphological complexity and/or biodiversity in vertebrates and other organisms, several authors disagree that gene and genome duplications are important mechanisms for morphological evolution. After closure of the neural tube, neural crest cells delaminate and migrate to diverse regions of the embryo. Neural crest development involves a progressive series of fate restrictions such as the distinction into ectomesenchymal and non-ectomesenchymal neural crest (Fig. It is due to the diversity of its derivatives that the neural crest is considered to constitute a “fourth germ layer” (Hall 2000). The acquisition of the neural crest has been of major importance for the evolutionary success of the vertebrate lineage (Gans and Northcutt 1983; Hall 1999; Donoghue et al. Neural crest-derived structures are involved in the evolution of vertebrate-specific features, such as the transition from a sessile filter feeder to an active, jawed predator (“new head hypothesis”, Gans and Northcutt 1983). The neural crest is absent from the most basal living group of chordates, the cephalochordates (Bourlat et al. In contrast, migratory ‘neural crest-like’ cells that develop into pigment cells have been found recently in urochordates, the sister clade of vertebrates (Jeffery et al. A bona fide neural crest, however, is a synapomorphy of vertebrates including lampreys (Fig. However, this is not the only model proposed to explain the origin and subsequent evolution of the neural crest (reviewed in Donoghue, Graham, and Kelsh 2008). According to the “gene regulatory co-option model”, the origin of the neural crest is based on the recruitment of neural crest specifier genes into a pre-existing gene regulatory network at the neural plate border (Meulemans and Bronner-Fraser 2005; Sauka-Spengler and Bronner-Fraser 2008a; Yu et al. The “new genes model” proposes that the evolution of the neural crest has been relying on the emergence of genes de novo, particularly signaling molecules, in the vertebrate lineage (Martinez-Morales et al. Importantly, the three models are not mutually exclusive but put emphasis on different aspects of neural crest evolution at the molecular level. Therefore, to further dissect the molecular basis of neural crest evolution, to differentiate between ancestral states and evolutionary novelties, and to evaluate the three models of neural crest evolution, it is necessary to reconstruct the emergence and evolution of key components in the neural crest regulatory network. In the present study, I have reconstructed the evolutionary history of such a key component, the endothelin system (Braasch et al. The endothelin system consists of G protein-coupled endothelin receptors (Ednr) that are activated by endothelin (Edn) signaling peptides (Fig. Besides its importance for blood pressure regulation, the endothelin system plays a major role in the determination, migration, proliferation, survival and differentiation of neural crest cells and their derivatives (reviewed in Pla and Larue 2003). Disruption of endothelin signaling leads to malformations of neural crest derivatives like the craniofacial cartilage, enteric neurons and pigment cells. However, despite its important functions in vertebrate physiology and development relatively little is known so far about the evolution of the endothelin system in chordates. The different vertebrate groups are equipped with varying sets of pigment cell types derived from the neural crest (Fig. Common to all vertebrates are the dark melanophores (termed melanocytes in mammals and birds). The yellow to red xantho-/erythrophores and the silvery-reflecting iridophores are found in teleost fishes, amphibians and reptiles, but not in the dermis of mammals or birds (Fig. This suggests that the fish-like last common ancestor of bony vertebrates possessed melanophores, xantho-/erythrophores and iridophores. The latter two pigment cell types have been lost secondarily in the lineages leading to mammals and to birds, respectively, probably due to the evolution of an outer coat of hair or feather (Oliphant et al. Afterwards, cells become further fate-restricted, finally leading to the differentiation into around 50 different cell types. B) Three different types of pigment cells, melanophores, iridophores and xanthophores, build the stripe pattern on the tail of an adult zebrafish. In birds, iridophores and xanthophore/erythrophore-like cells are found in the iris (brackets), but not in the dermis. Figure 4 – the endothelin system the big endothelin (Edn) peptide is cleaved from preproendothelin protein by the furin peptidase and further processed by the endothelin-converting enzyme (Ece) into the endothelin ligand peptide. Endothelins bind to the G protein-coupled endothelin receptors (Ednr) and regulate blood pressure as well as neural crest development. In teleosts, several of the major pigment cell types are even further partitioned into distinct sublineages that are under different genetic controls (Kallman 1975; Johnson et al. Each chromatophore has its characteristic pigments that reside in specialized pigmentary organelles (Tab. The relationships between the different chromatophore types remain largely unknown, but the occurrence of more than one type of pigmentary organelle or pigment in mosaic pigment cells suggests a common developmental origin of chromatophores from a stem cell population (Bagnara et al. Table 1 – Vertebrate pigment cell characteristics (after Bagnara and Matsumoto 2006) chromatophore pigmentary organelle pigment (chromophore) coloration 1. Taken together, with the innovation of new pigment cell types (leucophores, cyanophores) and pigment cell sublineages the teleost pigmentary system has evolved a higher level of complexity than any other vertebrate group (Braasch et al. For example, sexual selection on male nuptial colors is a major mechanism in the adaptive radiations of cichlids in the East African Great Lakes (Salzburger et al. Poeciliids (guppies, platyfishes, swordtails) as well as coral-reef fish communities are further examples for particularly colorful fish assemblages. Pigment cell regression in the blind cave forms of the Mexican tetra is a fascinating example for the evolution in extreme environments (Protas et al. The Tomita collection includes more than 40 medaka pigmentation mutants (Tomita 1975; Kelsh et al. In mouse, in comparison, over 60 coat color genes involved in melanocyte development have been cloned so far (Silvers 1979; Bennett and Lamoreux 2003; The identification of pigmentation genes in different vertebrates revealed that the genetic basis of melanophore development and differentiation is largely conserved between mammals and teleosts (Fig. For instance, the function of the Sox10 transcription factor gene to specify the non-ectomesenchymal neural crest including chromatophores is conserved between zebrafish and mouse (Dutton et al. Sox10 regulates the expression of the Mitf gene, which is the master regulator of melanophore/melanocyte differentiation in teleosts and mammals (Lister et al. The involvement of the Kit and Ednrb transmembrane receptors in melanophore development is also conserved between fish and mammals (Parichy et al. Thus, ‘vertebrate pigmentation genes’ are defined here as those genes that were shown in at least one vertebrate species to be involved in the development and differentiation of neural crest-derived pigment cells. Only very few genes involved in the development and differentiation of non-melanophore pigment cell types have been identified so far. For example, the csf1r receptor tyrosine kinase gene is essential for xanthophore development (Parichy et al. Iridophore fate specification requires the expression of the leukocyte tyrosine kinase (ltk) gene (Lopes et al. The teleost mitf duplicates encode two different Mitf isoforms, which are produced by a single gene in mammals. The yellow to reddish pteridine pigments of xanthophores are synthesized in the pteridine synthesis pathway (reviewed in Ziegler 2003). H4biopterin is a cofactor for neurotransmitter synthesis and tyrosinase activity in melanophores. The third pathway shares several steps with the first one and leads to the formation of the yellow pigments, sepiapterin and its derivatives, as well as probably to the reddish drosopterin, which is also found in teleost fishes (Henze et al. GchI expression is an initial step for melanophore and xanthophore differentiation due to its involvement in the different component pathways (Ziegler 2003). During initial shotgun sequencing of the sex chromosomes of the platyfish (Xiphophorus maculatus) by our group, partial coding sequences of a gchI gene were found on the Y chromosome closely linked to the sex-determining locus (Froschauer 2003; Schultheis et al. The platyfish sex chromosomes are hot spots for segmental duplications and carry several genes in multiple copies (Schultheis et al. For teleosts, there is so far no evidence for the presence of the lighter pheomelanin, which is found in mammalian and avian melanosomes (Fujii 1993b). Melanogenesis mainly involves the members of the tyrosinase gene family: tyrosinase (tyr), tyrosinase-related protein 1 (tyrp1) and dopachrome tautomerase (dct; also known as tyrosinase related protein 2) (Hearing and Tsukamoto 1991; del Marmol and Beermann 1996). The latter was subsequently duplicated in the vertebrate lineage giving rise to tyrp1 and dct (Sato et al. Figure 5 – Pigmentation mutants in mouse and zebrafish Mutations in orthologous genes lead to similar melanocyte/-phore defects in mouse and zebrafish.

Syndromes

• About any allergies your child may have to medicine, latex, tape, or skin cleaner
• DO NOT eat soft cheeses (such as queso blanco fresco)
• Teeth clenching
• Nervousness
• Audiology/audiometry to test hearing loss
• About 10 days before surgery, your child may be asked to stop taking aspirin, ibuprofen (Advil, Motrin), naproxen (Aleve, Naprosyn), warfarin (Coumadin), and any other drugs that make it hard for blood to clot.
• Do you walk or stand for long periods of time?

According to this standard medications jokes purchase zerit 40 mg visa, activities in environmental protection are continuously recorded and optimized as part of an improvement process medications lexapro purchase zerit overnight delivery. Here treatment brown recluse spider bite purchase genuine zerit line, an internationally valid group certificate applicable to all sites will supersede the previous individual certificates treatment goals for ptsd purchase zerit 40mg online. This requires particularly responsible collaboration among the sites since the certificate will only be granted if all sites in an audit sampling fulfill the certification criteria medicine 44175 buy generic zerit 40 mg on-line. We thus successfully introduced the group certificate for the production sites and will in future incorporate additional sites in accordance with developments of the Merck Group treatment thesaurus purchase 40 mg zerit. In order to accomplish this, we are focusing on 15 sites, which together account for more than 80% of our total global emissions. We reached our previous goal, which was to lower direct emissions by 10% by 2010, compared to 2002 levels, ahead of schedule. In 2009, we already submitted a large number of registration dossiers to the new European Chemicals Agency in Helsinki. In addition to training sessions with regulatory specialists, advanced e-learning courses were also held and customers were given detailed information material. We can use our expertise in regulatory affairs and in product docu mentation to provide our customers with support. This rate consists of the number of workplace accidents with one or more missed days of work relative to the number of hours worked. At Merck, the global value is less than four, which means that we exceeded our own targets. Its goal is to promote legally compliant behavior and social standards along the supply chain. This code has created an international minimum standard that applies across different industries. It covers rules to fight corruption and child labor as well as minimum requirements regarding antitrust rulings and environmental protec tion by suppliers. Through this initiative, pharmaceuticals such as antimalaria medicines or antibiotics can be tested quickly, thus closing gaps in monitoring. Children’s aid program to fight a serious tropical disease Merck donated 200 million the fight against the tropical disease schistosomiasis, an insidious life-threatening worm disease, tablets containing the active is showing results. Africa the preconditions for the widespread treatment of infected school children. We have expanded our aid program to Nigeria, Malawi, Mauritania, Tanzania, Mozambique, Zambia, the Central African Republic, Angola, Senegal, Benin, and Cameroon. In 2009, 25 million tablets of Cesol 600 were shipped to these countries, thus nearly doubling the amount shipped in 2008. Worldwide, around 200 million people suffer from schistosomiasis, 200,000 of whom die each year. In total, Merck donated 200 million tablets of Cesol 600, which contains the active ingredient praziquantel. Improvement in the capital market arena the year 2009 was marked by very dynamic developments in the international capital markets. Following a tailspin that lasted until around the end of the first quarter, the sentiment improved considerably as of April. Following a good start to the year, negative news weighed on the share price several times. From a full-year perspective, Merck shares represented a stable investment in a highly dynamic market environment in 2009. The risk-balanced business model consisting of Pharmaceuticals and Chemicals modu lated the fluctuations. Our share price proved to be considerably more robust than the benchmark indices in the crisis-ridden first quarter. The news that cladribine tablets could represent the first marketed oral treatment for multiple sclerosis supported the share price. Like the German indices, the Merck share price declined in the course of the first quarter and marked its low on March 6, 2009, closing at 57. This was attributable to a letter from the scientific committee of the European Medicines Agency issuing a negative opinion on the use of our oncology drug Erbitux in the treatment of lung cancer. In September and October, Merck shares caught up with the indices and rose to 70. In response to Merck’s request for re-examination of the negative opinion on the use of Erbitux in lung cancer, a negative opinion was again issued on November 19, 2009. Food and Drug Adminis tration on the new drug application for cladribine tablets led to a 4. Merck is working intensively to resubmit the application in the world’s largest pharmaceutical market. For instance, the Liquid Crystals business recovered significantly in the course of the year, a development that was viewed positively by financial analysts. On July 24, the first trading day after the negative opinion on Erbitux in the lung cancer indication in Europe, nearly 4. We want to ensure at all times that our shares are freely tradable on the stock exchanges. Analysts’ estimates A total of 31 banks and equity analysts reported regularly on and assessed Merck shares in 2009. As of the end of 2009, Merck shares were given buy recommendations by more than half of the 31 analysts who cover us. Details of the individual analysts and their estimates can be found on our website at We therefore reported not only on our quarterly and annual financial results, but also on the latest developments in the company. In 2009, the Executive Board and the Investor Relations team held road shows for existing and potential institutional investors at the major financial centers in Europe, North America and Asia, and reported on the latest company developments. In addition, Merck held presentations at ten investor conferences in Frankfurt, London, Luxembourg, Munich, New York, and Paris. At our Investor Relations stand at the 2009 Annual General Meeting, we addressed questions, most of which were posed by private investors. At 59%, the share capital represented at this Annual General Meeting was the highest recorded to date. Identified investors by region in % 6 8 53 9 13 11 source: thomson Reuters (status as of september 2009) United States United Kingdom Rest of Europe Germany France Rest of the world 32 Merck Annual Report 2009 Increase in the number of investors based in the United States Within the scope of the shareholder identification survey conducted in September 2009, we identified around 87% of the bearer shares in free float held by institutional investors. The survey provides information about the regional distribution of the institutional inves tors as well as the classification of the respective institutional investor types. Thus, the United States still ranks well ahead of the United Kingdom and Germany, where 11% and 9% of our shares are held, respectively. In the breakdown by investor type, the share of value investors grew from 23% in 2008 to 30%. Our efforts in these areas are continually analyzed and assessed by independent capital market institutes. If the holder of the registered share is a general partner, he or she has no such right of appointment. The approval is granted at the sole discretion of the personally liable general partner with an equity interest, namely E. As of December 31, 2009, one holding in the company’s share capital (Sun Life Financial Inc. According to the Articles of Association of the company, the general partners not holding an equity interest, who form the Executive Board, are admitted by E. A person may only be a general partner not holding an equity interest if he or she is also a general partner of E. The Articles of Association of the company can be amended by a resolution by the General Meeting that requires the approval of the general partners. The resolutions of the General Meeting are, notwithstanding any statutory provisions to the contrary, adopted by a simple majority of the votes cast. Where the law requires a capital majority in addition to the voting majority, resolutions are adopted by a simple majority of the share capital represented in the vote. The Executive Board is authorized, with the approval of the Supervisory Board and of E. The company has not entered into any material agreements subject to a change of control pursuant to a takeover offer nor has it concluded any compensation agreements with the members of the Executive Board or employees in the event of a takeover offer. It markets innovative prescription drugs of chemical and biotechnological origin, including monoclonal antibodies and other therapeutic proteins, and offers its leading brands in around 150 countries. With annual R&D spending of more than 1 billion, Merck Serono focuses on highly specialized therapeutic areas such as Neurodegenerative Diseases, Oncology, Fertility, Endocrinology as well as Autoimmune and Inflammatory Diseases. This growth was mainly attributable to the good performance of biopharmaceuticals such as Rebif and Erbitux as well as classic products such as the medicines of the Glucophage family. We generated 60% of our sales, or 2,980 million, with our five top-selling biopharmaceuticals. Rebif, a treatment for relapsing-remitting multiple sclerosis, was once again the top-selling product. Global sales of this product increased in 2009 to 1,537 million, representing growth of 15%. The targeted cancer therapy Erbitux again saw double-digit growth in 2009, with sales increasing by 23% to 697 million. Our recombinant hormone Gonal-f was approved for the treatment of infertile women in the key Japanese market in July. Top five medicines by sales in 2009 million 395 291 8 % 6 % 486 1,588 10 % 31 % 697 1,537 14 % 31 % Other products Rebif Erbitux Gonal-f Concor family Glucophage family Royalty and commission income declined by 3. Research and development spending rose by 10% to 1,184 million owing to the high costs of many trials in the final stage of clinical development. Moreover, impairment losses of 28 million relating mainly to intangible assets were recorded for the termination of research projects. As a result of altered estimates of the future amount of royalty income for certain partner products, we partly wrote down the corresponding rights by 72 million. Owing to the growing and clearly emerging currency risk in Venezuela, we recorded currency losses of 59 million in the operating result of the Merck Serono division. These were partly offset by exchange rate gains from currency hedging transactions. Sales there fell by 15%, due in part to generic competition faced by our CardioMetabolic Care products. Merck Serono | Sales by region million 779 2,557 16 % 51 % 711 14 % 947 19 % Europe North America Latin America Asia, Africa, Australasia In North America, we expanded our market position, with a 21% increase in sales to 947 million, primarily attributable to the strong growth of Rebif. Argentina and Colombia performed well, with sales growth of 21% and 36%, respectively, while sales in Mexico declined by 2. Focusing on the markets of Asia: In Asia, Africa and Australasia, sales increased sharply by 24%, rising to 779 million. Thanks We achieved good growth rates in to the success of Erbitux, we more than quadrupled our sales in Japan to 127 million. Over the next four years, we plan to invest 150 million in the establishment of a global center for research and develop ment in Beijing. Erbitux is currently approved for use in colorectal cancer in 78 countries and in head and neck cancer in 73 countries. In 2009, sales of Erbitux continued on a growth course, increasing by 23% to 697 million. This development underscores our strong position in the field of personalized medicine. A recommendation of this kind is a prerequisite in the United Kingdom for funding of a medical treatment by the National Health Service. In 2009, Rebif recorded double-digit growth of 15%, with sales increasing to 1,537 million. The new formulation, which offers improved injection tolerability, has meanwhile been introduced in all countries of the European Union and in Switzerland. Germany and the United Kingdom, two important markets, registered strong above-average growth of 7. With sales of 676 million, North America is our second-largest market for Rebif. Food and Drug Administration concerning the approval of the new formulation of Rebif continue. While sales in Latin America increased by 13%, mainly because of strong growth in Argentina, we recorded an increase of 5. Electronic injection device Rebismart™ to improve patient compliance Rebismart™ for the In June, we launched Rebismart™, an electronic injection device for the self-administration self-administration of Rebif is of Rebif. It is intended to increase compliance so that patients can fully benefit from their treatment. The majority of patients found the injection device “suitable” or “very suitable” for self-injection and rated the device function as “easy” or “very easy” to use. They were observed as adverse events in patients treated with Raptiva, our drug for the treatment of moderate-to-severe psoriasis. As a result of the sales termination and product recalls, sales of Raptiva dropped from 93 million in 2008 to 4. We recorded an exceptional item of 40 million for all costs associated with the suspension of the marketing authorization. Merck Serono intends to continue to focus on Autoimmune and Inflammatory Diseases, a commitment that is underscored by the development projects in our pipeline in conditions as diverse as systemic lupus erythematosus and osteoarthritis. We are the only company that offers physicians and patients recombinant versions of the three main reproductive hormones that are important for the treatment of infertility. In 2009, we generated half of our sales, which were slightly higher than in 2008, in this region.

Purchase zerit online from canada. Montel Williams on Multiple Sclerosis.

References

• Vongpatanasin W, Brickner E, Hills D. Eisenmenger syndrome in adults. Ann of Int Med. 1998;138:745-56.
• Brott TG, Halperin JL, Abbara S, et al: 2011 ASA/ACCF/AHA/AANN/AANS /ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS guideline on the management of patients with extracranial carotid and vertebral artery disease: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, and the American Stroke Association, American Association of Neuroscience Nurses, American Association of Neurological Surgeons, American College of Radiology, American Society of Neuroradiology, Congress of Neurological Surgeons, Society of Atherosclerosis Imaging and Prevention, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of NeuroInterventional Surgery, Society for Vascular Medicine, and Society for Vascular Surgery, Stroke 42:e420-e463, 2011.
• Wiesmann M, Yousry I, Seelos KC, et al. Identification and anatomic description of the anterior choroidal artery by use of 3D-TOF source and 3D-CISS MR imaging. AJNR Am J Neuroradiol 2001;22(2):305-10.
• Frustaci A. Cytopathic pathways of enteroviral myocardial infection. Eur Heart J 2010;31:637.
• Terai, A., Ichioka, K., Kohe, N., Ueda, N., Utsunomiya, N., Inoue, K. Antimicrobial prophylaxis in radical prostatectomy: 1-day versus 4-day treatments. Int J Urol 2006;13:1488-1493.
• Kasturi S, Sehgal SS, Christman MS, et al: Prospective long-term analysis of nerve-sparing extravesical robotic-assisted laparoscopic ureteral reimplantation, Urology 79(3):680n683, 2012.