Background: The existence of socio-economic inequalities in child mortality is well documented. African cities grow faster than cities in most other regions of the world; and inequalities in African cities are thought to be particularly large. Revealing health-related inequalities is essential in order for governments to be able to act against them. This study aimed to systematically compare inequalities in child mortality across 10 major African cities (Cairo, Lagos, Kinshasa, Luanda, Abidjan, Dar es Salaam, Nairobi, Dakar, Addis Ababa, Accra), and to investigate trends in such inequalities over time. Methods: Data from two rounds of demographic and health surveys (DHS) were used for this study (if available): one from around the year 2000 and one from between 2007 and 2011. Child mortality rates within cities were calculated by population wealth quintiles. Inequality in child mortality was assessed by computing two measures of relative inequality (the rate ratio and the concentration index) and two measures of absolute inequality (the difference and the Erreyger's index). Results: Mean child mortality rates ranged from about 39 deaths per 1,000 live births in Cairo (2008) to about 107 deaths per 1,000 live births in Dar es Salaam (2010). Significant inequalities were found in Kinshasa, Luanda, Abidjan, and Addis Ababa in the most recent survey. The difference between the poorest quintile and the richest quintile was as much as 108 deaths per 1,000 live births (95% confidence interval 55 to 166) in Abidjan in 2011-2012. When comparing inequalities across cities or over time, confidence intervals of all measures almost always overlap. Nevertheless, inequalities appear to have increased in Abidjan, while they appear to have decreased in Cairo, Lagos, Dar es Salaam, Nairobi and Dakar. Conclusions: Considerable inequalities exist in almost all cities but the level of inequalities and their development over time appear to differ across cities. This implies that inequalities are amenable to policy interventions and that it is worth investigating why inequalities are higher in one city than in another. However, larger samples are needed in order to improve the certainty of our results. Currently available data samples from DHS are too small to reliably quantify the level of inequalities within cities.

Background: Adequate soft tissue balancing is a key factor for a successful result after total knee arthroplasty (TKA). Posterior cruciate ligament (PCL) is the primary restraint to posterior translation of the tibia after cruciate retaining TKA and is also responsible for the amount of joint compression. However, it is complex to quantify the amount of ligament release with its effects on load bearing and kinematics in TKA and limited both in vivo and in vitro. The goal of this study was to create a dynamic and deformable finite element model of a full leg and analyze a stepwise release of the PCL regarding knee kinematics, pressure distribution and ligament stresses. Methods: A dynamic finite element model was developed in Ansys V14.0 based on boundary conditions of an existing knee rig. A cruciate retraining knee prosthesis was virtually implanted. Ligament and muscle structures were simulated with modified spring elements. Linear elastic materials were defined for femoral component, inlay and patella cartilage. A restart algorithm was developed and implemented into the finite element simulation to hold the ground reaction force constant by adapting quadriceps force. After simulating the unreleased PCL model, two models were developed and calculated with the same boundary conditions with a 50% and 75% release of the PCL stiffness. Results: From the beginning of the simulation to approximately 35 degrees of flexion, tibia moves posterior related to the femur and with higher flexion anteriorly. Anterior translation of the tibia ranged from 5.8 mm for unreleased PCL to 3.7 mm for 75% PCL release (4.9 mm 50% release). A decrease of maximum von Mises equivalent stress on the inlay was given with PCL release, especially in higher flexion angles from 11.1 MPa for unreleased PCL to 8.9 MPa for 50% release of the PCL and 7.8 MPa for 75% release. Conclusions: Our study showed that dynamic FEM is an effective method for simulation of PCL balancing in knee arthroplasty. A tight PCL led in silico to more anterior tibia translation, a higher collateral ligament and inlay stress, while retropatellar pressure remained unchanged. Surgeons may take these results in vivo into account.

Purpose: Re-irradiation has been shown to be a valid option with proven efficacy for recurrent high-grade glioma patients. Overall, up to now it is unclear which patients might be optimal candidates for a second course of irradiation. A recently reported prognostic score developed by Combs et al. may guide treatment decisions and thus, our mono-institutional cohort served as validation set to test its relevance for clinical practice. Patients and methods: The prognostic score is built upon histology, age (< 50 vs. >= 50 years) and the time between initial radiotherapy and re-irradiation (<= 12 vs. > 12 months). This score was initially introduced to distinguish patients with excellent (0 points), good (1 point), moderate (2 points) and poor (3-4 points) post-recurrence survival (PRS) after re-irradiation. Median prescribed radiation dose during re-treatment of recurrent malignant glioma was 36 Gy in 2 Gy single fractions. A substantial part of the patients was additionally treated with bevacizumab (10 mg/kg intravenously at d1 and d15 during re-irradiation). Results: 88 patients (initially 61 WHO IV, 20 WHO III, 7 WHO II) re-irradiated in a single institution were retrospectively analyzed. Median follow-up was 30 months and median PRS of the entire patient cohort 7 months. Seventy-one patients (80.7%) received bevacizumab. PRS was significantly increased in patients receiving bevacizumab (8 vs. 6 months, p = 0.027, log-rank test). KPS, age, MGMT methylation status, sex, WHO grade and the Heidelberg score showed no statistically significant influence on neither PR-PFS nor PRS. Conclusion: In our cohort which was mainly treated with bevacizumab the usefulness of the Heidelberg score could not be confirmed probably due to treatment heterogeneity; it can be speculated that larger multicentric data collections are needed to derive a more reliable score.

Upper gastrointestinal bleeding episodes from variceal structures are severe complications in patients with portal hypertension. Endoscopic sclerotherapy and variceal ligation are the treatment options preferred for upper variceal bleeding owing to extrahepatic portal hypertension due to portal vein thrombosis (PVT). Recurrent duodenal variceal bleeding in non-cirrhotic patients with diffuse porto-splenic vein thrombosis and subsequent portal cavernous transformation represent a clinical challenge if classic shunt surgery is not possible or suitable. In this study, we represent a case of recurrent bleeding of duodenal varices in a non-cirrhotic patient with cavernous transformation of the portal vein that was successfully treated with a collateral caval shunt operation.

Numerous high-throughput sequencing studies have focused on detecting conventionally spliced mRNAs in RNA-seq data. However, non-standard RNAs arising through gene fusion, circularization or trans-splicing are often neglected. We introduce a novel, unbiased algorithm to detect splice junctions from single-end cDNA sequences. In contrast to other methods, our approach accommodates multi-junction structures. Our method compares favorably with competing tools for conventionally spliced mRNAs and, with a gain of up to 40% of recall, systematically outperforms them on reads with multiple splits, trans-splicing and circular products.

Background: Characterizing the nuclear orientation of chromosomes in the three-dimensional (3D) nucleus by multicolor banding (mBANDing) is a new approach towards understanding nuclear organization of chromosome territories. An mBANDing paint is composed of multiple overlapping subchromosomal probes that represent different regions of a single chromosome. In this study, we used it for the analysis of chromosome orientation in 3D interphase nuclei. We determined whether the nuclear orientation of the two chromosome 11 homologs was random or preferential, and if it was conserved between diploid mouse Pre B lymphocytes of BALB/c origin and primary B lymphocytes of congenic [T38HxBALB/c] N wild-type mice. The chromosome orientation was assessed visually and through a semi-automated quantitative analysis of the radial and angular orientation patterns observed in both B cell types. Results: Our data indicate that there are different preferential patterns of chromosome 11 orientation, which are not significantly different between both mouse cell types (p > 0.05). In the most common case for both cell types, both copies of chromosome 11 were oriented in parallel with the nuclear border. The second most common pattern in both types of B lymphocytes was with one homolog of chromosome 11 positioned with its telomeric end towards the nuclear center and with its centromeric end towards the periphery, while the other chromosome 11 was found parallel with the nuclear border. In addition to these two most common orientations present in approximately 50% of nuclei from each cell type, other orientations were observed at lower frequencies. Conclusions: We conclude that there are probabilistic, non-random orientation patterns for mouse chromosome 11 in the mouse B lymphocytes we investigated (p < 0.0001).

Background: Hepatorenal tyrosinaemia (Tyr 1) is a rare inborn error of tyrosine metabolism. Without treatment, patients are at high risk of developing acute liver failure, renal dysfunction and in the long run hepatocellular carcinoma. The aim of our study was to collect cross-sectional data. Methods: Via questionnaires we collected retrospective data of 168 patients with Tyr 1 from 21 centres (Europe, Turkey and Israel) about diagnosis, treatment, monitoring and outcome. In a subsequent consensus workshop, we discussed data and clinical implications. Results: Early treatment by NTBC accompanied by diet is essential to prevent serious complications such as liver failure, hepatocellular carcinoma and renal disease. As patients may remain initially asymptomatic or develop uncharacteristic clinical symptoms in the first months of life newborn mass screening using succinylacetone (SA) as a screening parameter in dried blood is mandatory for early diagnosis. NTBC-treatment has to be combined with natural protein restriction supplemented with essential amino acids. NTBC dosage should be reduced to the minimal dose allowing metabolic control, once daily dosing may be an option in older children and adults in order to increase compliance. Metabolic control is judged by SA (below detection limit) in dried blood or urine, plasma tyrosine (<400 mu M) and NTBC-levels in the therapeutic range (20-40 mu M). Side effects of NTBC are mild and often transient. Indications for liver transplantation are hepatocellular carcinoma or failure to respond to NTBC. Follow-up procedures should include liver and kidney function tests, tumor markers and imaging, ophthalmological examination, blood count, psychomotor and intelligence testing as well as therapeutic monitoring (SA, tyrosine, NTBC in blood). Conclusion: Based on the data from 21 centres treating 168 patients we were able to characterize current practice and clinical experience in Tyr 1. This information could form the basis for clinical practice recommendations, however further prospective data are required to underpin some of the recommendations.

Background: The absence of horns, called polled phenotype, is the favored trait in modern cattle husbandry. To date, polled cattle are obtained primarily by dehorning calves. Dehorning is a practice that raises animal welfare issues, which can be addressed by selecting for genetically hornless cattle. In the past 20 years, there have been many studies worldwide to identify unique genetic markers in complete association with the polled trait in cattle and recently, two different alleles at the POLLED locus, both resulting in the absence of horns, were reported: (1) the Celtic allele, which is responsible for the polled phenotype in most breeds and for which a single candidate mutation was detected and (2) the Friesian allele, which is responsible for the polled phenotype predominantly in the Holstein-Friesian breed and in a few other breeds, but for which five candidate mutations were identified in a 260-kb haplotype. Further studies based on genome-wide sequencing and high-density SNP (single nucleotide polymorphism) genotyping confirmed the existence of the Celtic and Friesian variants and narrowed down the causal Friesian haplotype to an interval of 145 kb. Results: Almost 6000 animals were genetically tested for the polled trait and we detected a recombinant animal which enabled us to reduce the Friesian POLLED haplotype to a single causal mutation, namely a 80 kb duplication. Moreover, our results clearly disagree with the recently reported perfect co-segregation of the POLLED mutation and a SNP at position 1 390 292 bp on bovine chromosome 1 in the Holstein-Friesian population. Conclusion: We conclude that the 80-kb duplication, as the only remaining variant within the shortened Friesian haplotype, represents the most likely causal mutation for the polled phenotype of Friesian origin.

Background: Stable headache diagnosis classification is a prerequisite for identification of headache type specific risk factors. Does the stability of a headache diagnosis over time vary between migraine and tension-type headache (TTH)? Are there differences in diagnosis stability between a probable and a definite headache diagnosis? Findings: In a sample of 783 students (ages 12 to 18 years) participating in a headache intervention study in greater Munich, the stability of headache classification according to the International Classification of Headache Disorder - third edition (beta version) (ICHD-3 beta) after a follow-up of 7 months was examined. Differences in stability of probable or definite migraine and probable or definite TTH were assessed. The stability of the headache diagnosis was assessed as predictive value of headache diagnosis with regard to confirmation of the headache type using the same diagnostic instrument 7 months later. Predictive values with 95% confidence intervals (CI) are reported. Of students with initial migraine, a diagnosis of migraine was confirmed in 65.71% of students after 7 months (95%-CI {[}59.40-71.64]). A clear distinction between probable (44.71%, 95%-CI {[}33.91-53.89]) and confirmed diagnosis (76.88% 95%-CI {[}69.56-83.17]) of migraine was observed. For TTH the predictive value was 62.66% (95%-CI {[}57.07-68.01]) overall with a lower stability for probable (46.10%, 95%-CI {[}37.68-54.69]) compared to the confirmed diagnosis (69.71%, 95%-CI {[}23.58-37.67]). Conclusion: While confirmed migraine and confirmed TTH diagnoses seem stable over time, stability of a probable diagnosis for either headache type was lower.

Background: We report on the design and implementation of a study protocol entitled Acupuncture randomised trial for post anaesthetic recovery and postoperative pain - a pilot study (ACUARP) designed to investigate the effectiveness of acupuncture therapy performed in the perioperative period on post anaesthetic recovery and postoperative pain. Methods/Design: The study is designed as a randomised controlled pilot trial with three arms and partial double blinding. We will compare (a) press needle acupuncture, (b) no treatment and (c) press plaster acupressure in a standardised anaesthetic setting. Seventy-five patients scheduled for laparoscopic surgery to the uterus or ovaries will be allocated randomly to one of the three trial arms. The total observation period will begin one day before surgery and end on the second postoperative day. Twelve press needles and press plasters are to be administered preoperatively at seven acupuncture points. The primary outcome measure will be time from extubation to `ready for discharge' from the post anaesthesia care unit (in minutes). The `ready for discharge' end point will be assessed using three different scores: the Aldrete score, the Post Anaesthetic Discharge Scoring System and an In-House score. Secondary outcome measures will comprise pre-, intra- and postoperative variables (which are anxiety, pain, nausea and vomiting, concomitant medication). Discussion: The results of this study will provide information on whether acupuncture may improve patient post anaesthetic recovery. Comparing acupuncture with acupressure will provide insight into potential therapeutic differences between invasive and non-invasive acupuncture techniques.

Background: With the help of epigenome-wide association studies (EWAS), increasing knowledge on the role of epigenetic mechanisms such as DNA methylation in disease processes is obtained. In addition, EWAS aid the understanding of behavioral and environmental effects on DNA methylation. In terms of statistical analysis, specific challenges arise from the characteristics of methylation data. First, methylation beta-values represent proportions with skewed and heteroscedastic distributions. Thus, traditional modeling strategies assuming a normally distributed response might not be appropriate. Second, recent evidence suggests that not only mean differences but also variability in site-specific DNA methylation associates with diseases, including cancer. The purpose of this study was to compare different modeling strategies for methylation data in terms of model performance and performance of downstream hypothesis tests. Specifically, we used the generalized additive models for location, scale and shape (GAMLSS) framework to compare beta regression with Gaussian regression on raw, binary logit and arcsine square root transformed methylation data, with and without modeling a covariate effect on the scale parameter. Results: Using simulated and real data from a large population-based study and an independent sample of cancer patients and healthy controls, we show that beta regression does not outperform competing strategies in terms of model performance. In addition, Gaussian models for location and scale showed an improved performance as compared to models for location only. The best performance was observed for the Gaussian model on binary logit transformed beta-values, referred to as M-values. Our results further suggest that models for location and scale are specifically sensitive towards violations of the distribution assumption and towards outliers in the methylation data. Therefore, a resampling procedure is proposed as a mode of inference and shown to diminish type I error rate in practically relevant settings. We apply the proposed method in an EWAS of BMI and age and reveal strong associations of age with methylation variability that are validated in an independent sample. Conclusions: Models for location and scale are promising tools for EWAS that may help to understand the influence of environmental factors and disease-related phenotypes on methylation variability and its role during disease development.

Background: In the last few decades, health systems research (HSR) has garnered much attention with a rapid increase in the related literature. This study aims to review and evaluate the global progress in HSR and assess the current quantitative trends. Methods: Based on data from the Web of Science database, scientometric methods and knowledge visualization techniques were applied to evaluate global scientific production and develop trends of HSR from 1900 to 2012. Results: HSR has increased rapidly over the past 20 years. Currently, there are 28,787 research articles published in 3,674 journals that are listed in 140 Web of Science subject categories. The research in this field has mainly focused on public, environmental and occupational health (6,178, 21.46%), health care sciences and services (5,840, 20.29%), and general and internal medicine (3,783, 13.14%). The top 10 journals had published 2,969 (10.31%) articles and received 5,229 local citations and 40,271 global citations. The top 20 authors together contributed 628 papers, which accounted for a 2.18% share in the cumulative worldwide publications. The most productive author was McKee, from the London School of Hygiene \& Tropical Medicine, with 48 articles. In addition, USA and American institutions ranked the first in health system research productivity, with high citation times, followed by the UK and Canada. Conclusions: HSR is an interdisciplinary area. Organization for Economic Co-operation and Development countries showed they are the leading nations in HSR. Meanwhile, American and Canadian institutions and the World Health Organization play a dominant role in the production, collaboration, and citation of high quality articles. Moreover, health policy and analysis research, health systems and sub-systems research, healthcare and services research, health, epidemiology and economics of communicable and non-communicable diseases, primary care research, health economics and health costs, and pharmacy of hospital have been identified as the mainstream topics in HSR fields. These findings will provide evidence of the current status and trends in HSR all over the world, as well as clues to the impact of this popular topic; thus, helping scientific researchers and policy makers understand the panorama of HSR and predict the dynamic directions of research.

Background: Although the number of child laborers in Latin America is generally high, data on occupational hazards and injuries is insufficient. The objective of this study was therefore to determine the lifetime prevalence of and risk factors for occupational injuries among working students (10-17 years old) in Cusco Province. Methods: A cross-sectional study was conducted at five public night schools. 375 students (response 91.5%) completed an interview-based questionnaire on socio-demographics, work-related factors, and lifetime prevalence of occupational injuries. Multiple logistic regression analyses were performed to estimate risk factors for different types and causes of occupational injuries. Results: Falls (11%), car accidents (9%) and physical violence (3%) were common causes of injuries in this population. Severe injuries (fractures, luxation or amputations) were reported by 3% of the population. A high daily income (>= 20 PEN, similar to 15 USD) was a statistically significant predictor for injuries caused by falls [OR 2.8; 95% CI 1.2-6.5] and physical violence at work [12.1; 1.3-115.9] whereas children born in Cusco and those working in the service sector were at higher risk of injuries caused by car accidents [3.7; 1.5-9.3 and 4.2; 1.2-15.3]. Conclusions: Occupational accidents among child workers attending public night schools are common in Cusco with a lifetime prevalence of 3% for severe injuries. High income seems to convince child laborers to accept poor working conditions.

Background: Recurrent respiratory papillomatosis (RRP) is a rare disease, which is characterised by the growth of papillomavirus-induced papillomas within the respiratory tract. Malignant transformation occurs in less than 1\% of the cases. Case presentation: We report a case of human papillomavirus (HPV) type 11-associated juvenile-onset RRP (JORRP) initially diagnosed at the age of two years. Remarkably high copy numbers of HPV11 DNA and antibody titres targeting the capsid protein L1 were detected in the patient's serum. The patient developed squamous cell carcinomas in both lungs and extraordinarily an HPV11 DNA-positive papillary endocardial lesion in the left atrium of the heart, which caused thromboembolic events leading to the patient's death at 19 years old. Conclusion: We here report a severe case of JORRP hallmarked by HPV11 DNAemia and very high antibody titres directed against the major viral capsid protein L1. Furthermore, the extent of malignant transformation and the discovery of a very rare fatal endocardial lesion highlight the unpredictability of JORRP and the complexity of its clinical management.

Understanding the links between genetic, epigenetic and non-genetic factors throughout the lifespan and across generations and their role in disease susceptibility and disease progression offer entirely new avenues and solutions to major problems in our society. To overcome the numerous challenges, we have come up with nine major conclusions to set the vision for future policies and research agendas at the European level.

Background: Conventional cardiac pacemakers are still often regarded as a contraindication to magnetic resonance imaging (MRI). We conducted this study to support the hypothesis that it is safe to scan patients with cardiac pacemakers in a 1.5 Tesla MRI, if close supervision and monitoring as well as adequate pre- and postscan programming is provided. Methods: We followed up 356 patients (age 61.3 +/- 9.1 yrs., 229 men) with single (n = 132) or dual chamber (n = 224) cardiac pacemakers and urgent indication for a cranial MRI for 12 months. The scans were performed at 1.5T. During the scan patients were monitored with a 3-lead ECG and pulse oximetry. Prior to the scan pacemakers were programmed according to our own protocol. Results: All 356 scans were completed without complications. No arrhythmias were induced, programmed parameters remained unchanged. No pacemaker dysfunction was identified. Follow-up examinations were performed immediately, 2 weeks, 2, 6, and 12 months after the scan. There was no significant change of pacing capture threshold (ventricular 0.9 +/- 0.4 V@0.4 ms, atrial 0.9 +/- 0.3 V@0.4 ms) immediately (ventricular 1.0 +/- 0.3 V@0.4 ms, atrial 0.9 +/- 0.4 V@0.4 ms) or at 12 months follow-up examinations (ventricular 0.9 +/- 0.2 V@0.4 ms, atrial 0.9 +/- 0.3 V@0.4 ms). There was no significant change in sensing threshold (8.0 +/- 4.0 mV vs. 8.1 +/- 4.2 mV ventricular lead, 2.0 +/- 0.9 mV vs. 2.1 +/- 1.0 mV atrial lead) or lead impedance (ventricular 584 +/- 179 O vs. 578 +/- 188 O, atrial 534 +/- 176 O vs. 532 +/- 169 O) after 12 months. Conclusions: This supports the evidence that patients with conventional pacemakers can safely undergo cranial MRI in a 1.5T system with suitable preparation, supervision and precautions. Long term follow-up did not reveal significant changes in pacing capture nor sensing threshold.

Evidence suggests that research protocols often lack important information on study design, which hinders external review. The study protocol should provide an adequate explanation for why the proposed study methodology is appropriate for the question posed, why the study design is likely to answer the research question, and why it is the best approach. It is especially important that researchers explain why the treatment difference sought is worthwhile to patients, and they should reference consultations with the public and patient groups and existing literature. Moreover, the study design should be underpinned by a systematic review of the existing evidence, which should be included in the research protocol. The Health Research Authority in collaboration with partners has published guidance entitled `Specific questions that need answering when considering the design of clinical trials'. The guidance will help those designing research and those reviewing it to address key issues.

Background: The receptor for activated C-kinase 1 (RACK1) is a conserved protein belonging to the WD40 repeat family of proteins. It folds into a beta propeller with seven blades which allow interactions with many proteins. Thus it can serve as a scaffolding protein and have roles in several cellular processes. Results: We identified the product of the Dictyostelium discoideum gpbB gene as the Dictyostelium RACK1 homolog. The protein is mainly cytosolic but can also associate with cellular membranes. DdRACK1 binds to phosphoinositides (PIPs) in protein-lipid overlay and liposome-binding assays. The basis of this activity resides in a basic region located in the extended loop between blades 6 and 7 as revealed by mutational analysis. Similar to RACK1 proteins from other organisms DdRACK1 interacts with G protein subunits alpha, beta and gamma as shown by yeast two-hybrid, pull-down, and immunoprecipitation assays. Unlike the Saccharomyces cerevisiae and Cryptococcus neoformans RACK1 proteins it does not appear to take over G beta function in D. discoideum as developmental and other defects were not rescued in G beta null mutants overexpressing GFP-DdRACK1. Overexpression of GFP-tagged DdRACK1 and a mutant version (DdRACK1mut) which carried a charge-reversal mutation in the basic region in wild type cells led to changes during growth and development. Conclusion: DdRACK1 interacts with heterotrimeric G proteins and can through these interactions impact on processes specifically regulated by these proteins.

Background: Genome wide association studies (GWAS) are applied to identify genetic loci, which are associated with complex traits and human diseases. Analogous to the evolution of gene expression analyses, pathway analyses have emerged as important tools to uncover functional networks of genome-wide association data. Usually, pathway analyses combine statistical methods with a priori available biological knowledge. To determine significance thresholds for associated pathways, correction for multiple testing and over-representation permutation testing is applied. Results: We systematically investigated the impact of three different permutation test approaches for over-representation analysis to detect false positive pathway candidates and evaluate them on genome-wide association data of Dilated Cardiomyopathy (DCM) and Ulcerative Colitis (UC). Our results provide evidence that the gold standard - permuting the case-control status - effectively improves specificity of GWAS pathway analysis. Although permutation of SNPs does not maintain linkage disequilibrium (LD), these permutations represent an alternative for GWAS data when case-control permutations are not possible. Gene permutations, however, did not add significantly to the specificity. Finally, we provide estimates on the required number of permutations for the investigated approaches. Conclusions: To discover potential false positive functional pathway candidates and to support the results from standard statistical tests such as the Hypergeometric test, permutation tests of case control data should be carried out. The most reasonable alternative was case-control permutation, if this is not possible, SNP permutations may be carried out. Our study also demonstrates that significance values converge rapidly with an increasing number of permutations. By applying the described statistical framework we were able to discover axon guidance, focal adhesion and calcium signaling as important DCM-related pathways and Intestinal immune network for IgA production as most significant UC pathway.

Background: Musculus gastrocnemius tightness (MGT) can be diagnosed by comparing ankle dorsiflexion (ADF) with the knee extended and flexed. Although various measurement techniques exist, the degree of knee flexion needed to eliminate the effect of the gastrocnemius on ADF is still unknown. The aim of this study was to identify the minimal degree of knee flexion required to eliminate the restricting effect of the musculus gastrocnemius on ADF. Methods: Bilateral ADF of 20 asymptomatic volunteers aged 18-40 years (50% female) was assessed prospectively at six different degrees of knee flexion (0 degrees, 20 degrees, 30 degrees, 45 degrees, 60 degrees, 75 degrees, Lunge). Tests were performed following a standardized protocol, non weightbearing and weightbearing, by two observers. Statistics comprised of descriptive statistics, t-tests, repeated measurement ANOVA and ICC. Results: 20 individuals with a mean age of 27 +/- 4 years were tested. No significant side to side differences were observed. The average ADF [95% confidence interval] for non weightbearing was 4 degrees{[}1 degrees-8 degrees] with the knee extended and 20 degrees [16 degrees-24 degrees] for the knee 75 flexed. Mean weightbearing ADF was 25 degrees[22 degrees-28 degrees] for the knee extended and 39 degrees[36 degrees-42 degrees] for the knee 75 degrees flexed. The mean differences between 20 degrees knee flexion and full extension were 15 degrees[12 degrees-18 degrees] non weightbearing and 13 degrees[11 degrees-16 degrees] weightbearing. Significant differences of ADF were only found between full extension and 20 degrees of knee flexion. Further knee flexion did not increase ADF. Conclusion: Knee flexion of 20 degrees fully eliminates the ADF restraining effect of the gastrocnemius. This knowledge is essential to design a standardized clinical examination assessing MGT.