def ask_and_eval(self, func, args=(), gradf=None, number=None, xmean=None, sigma_fac=1,
                     evaluations=1, aggregation=np.median, kappa=1):
        """samples `number` solutions and evaluates them on `func`, where
        each solution `s` is resampled until ``self.is_feasible(s, func(s)) is True``.

        Arguments
        ---------
            `func`
                objective function, ``func(x)`` returns a scalar
            `args`
                additional parameters for `func`
            `gradf`
                gradient of objective function, ``g = gradf(x, *args)``
                must satisfy ``len(g) == len(x)``
            `number`
                number of solutions to be sampled, by default
                population size ``popsize`` (AKA lambda)
            `xmean`
                mean for sampling the solutions, by default ``self.mean``.
            `sigma_fac`
                multiplier for sampling width, standard deviation, for example
                to get a small perturbation of solution `xmean`
            `evaluations`
                number of evaluations for each sampled solution
            `aggregation`
                function that aggregates `evaluations` values to
                as single value.
            `kappa`
                multiplier used for the evaluation of the solutions, in
                that ``func(m + kappa*(x - m))`` is the f-value for x.

        Return
        ------
        ``(X, fit)``, where
            X -- list of solutions
            fit -- list of respective function values

        Details
        -------
        While ``not self.is_feasible(x, func(x))``new solutions are sampled. By
        default ``self.is_feasible == cma.feasible == lambda x, f: f not in (None, np.NaN)``.
        The argument to `func` can be freely modified within `func`.

        Depending on the ``CMA_mirrors`` option, some solutions are not sampled
        independently but as mirrors of other bad solutions. This is a simple
        derandomization that can save 10-30% of the evaluations in particular
        with small populations, for example on the cigar function.

        Example
        -------
        >>> import cma
        >>> x0, sigma0 = 8*[10], 1  # 8-D
        >>> es = cma.CMAEvolutionStrategy(x0, sigma0)
        >>> while not es.stop():
        ...     X, fit = es.ask_and_eval(cma.fcts.elli)  # handles NaN with resampling
        ...     es.tell(X, fit)  # pass on fitness values
        ...     es.disp(20) # print every 20-th iteration
        >>> print('terminated on ' + str(es.stop()))
        <output omitted>

        A single iteration step can be expressed in one line, such that
        an entire optimization after initialization becomes
        ::

            while not es.stop():
                es.tell(*es.ask_and_eval(cma.fcts.elli))

        """
        # initialize
        popsize = self.sp.popsize
        if number is not None:
            popsize = number

        selective_mirroring = self.opts['CMA_mirrormethod'] > 0
        nmirrors = self.sp.lam_mirr
        if popsize != self.sp.popsize:
            nmirrors = Mh.sround(popsize * self.sp.lam_mirr / self.sp.popsize)
            # TODO: now selective mirroring might be impaired
        assert new_injections or self.opts['CMA_mirrormethod'] < 2
        if new_injections and self.opts['CMA_mirrormethod'] != 1: # otherwise mirrors are done elsewhere
            nmirrors = 0
        assert nmirrors <= popsize // 2
        self.mirrors_idx = np.arange(nmirrors)  # might never be used
        self.mirrors_rejected_idx = []  # might never be used
        is_feasible = self.opts['is_feasible']

        # do the work
        fit = []  # or np.NaN * np.empty(number)
        X_first = self.ask(popsize, xmean=xmean, gradf=gradf, args=args)
        if xmean is None:
            xmean = self.mean  # might have changed in self.ask
        X = []
        for k in xrange(int(popsize)):
            x, f = X_first.pop(0), None
            rejected = -1
            while rejected < 0 or not is_feasible(x, f):  # rejection sampling
                rejected += 1
                if rejected:  # resample
                    x = self.ask(1, xmean, sigma_fac)[0]
                elif k >= popsize - nmirrors:  # mirrored sample
                    if k == popsize - nmirrors and selective_mirroring:
                        self.mirrors_idx = np.argsort(fit)[-1:-1 - nmirrors:-1]
                    x = self.get_mirror(X[self.mirrors_idx[popsize - 1 - k]])
                if rejected == 1 and k >= popsize - nmirrors:
                    self.mirrors_rejected_idx.append(k)

                # contraints handling test hardwired ccccccccccc
                length_normalizer = 1
                # zzzzzzzzzzzzzzzzzzzzzzzzz
                f = func(x, *args) if kappa == 1 else \
                    func(xmean + kappa * length_normalizer * (x - xmean),
                         *args)
                if is_feasible(x, f) and evaluations > 1:
                    f = aggregation([f] + [(func(x, *args) if kappa == 1 else
                                            func(xmean + kappa * length_normalizer * (x - xmean), *args))
                                           for _i in xrange(int(evaluations - 1))])
                if rejected + 1 % 1000 == 0:
                    print('  %d solutions rejected (f-value NaN or None) at iteration %d' %
                          (rejected, self.countiter))
            fit.append(f)
            X.append(x)
        self.evaluations_per_f_value = int(evaluations)
        return X, fit


def PreprocessSources(
      self, artifacts_registry_object, source_path_specs,
      resolver_context=None):
    """Preprocesses the sources.

    Args:
      artifacts_registry_object (artifacts.ArtifactDefinitionsRegistry):
          artifact definitions registry.
      source_path_specs (list[dfvfs.PathSpec]): path specifications of
          the sources to process.
      resolver_context (Optional[dfvfs.Context]): resolver context.
    """
    detected_operating_systems = []
    for source_path_spec in source_path_specs:
      try:
        file_system, mount_point = self.GetSourceFileSystem(
            source_path_spec, resolver_context=resolver_context)
      except (RuntimeError, dfvfs_errors.BackEndError) as exception:
        logger.error(exception)
        continue

      try:
        searcher = file_system_searcher.FileSystemSearcher(
            file_system, mount_point)

        operating_system = self._DetermineOperatingSystem(searcher)
        if operating_system != definitions.OPERATING_SYSTEM_FAMILY_UNKNOWN:
          preprocess_manager.PreprocessPluginsManager.RunPlugins(
              artifacts_registry_object, file_system, mount_point,
              self.knowledge_base)

          detected_operating_systems.append(operating_system)

      finally:
        file_system.Close()

    if detected_operating_systems:
      logger.info('Preprocessing detected operating systems: {0:s}'.format(
          ', '.join(detected_operating_systems)))
      self.knowledge_base.SetValue(
          'operating_system', detected_operating_systems[0])


async def update_api(request: web.Request) -> web.Response:
    """
    This handler accepts a POST request with Content-Type: multipart/form-data
    and file fields in the body named "whl", "serverlib", and "fw". The "whl"
    and "serverlib" files should be valid Python wheels to be installed ("whl"
    is expected generally to be the API server wheel, and "serverlib" is
    expected to be the ot2serverlib wheel. The "fw" file is expected to be a
    Smoothie firmware hex file. The Python files are install using pip, and the
    firmware file is flashed to the Smoothie board, then the files are deleted
    and a success code is returned.
    """
    log.debug('Update request received')
    data = await request.post()
    try:
        res0 = await install_py(
            data['whl'], request.loop)
        reslist = [res0]
        if 'serverlib' in data.keys():
            res1 = await install_py(
                data['serverlib'], request.loop)
            reslist.append(res1)
        if 'fw' in data.keys():
            res2 = await install_smoothie_firmware(
                data['fw'], request.loop)
            reslist.append(res2)
        res: Dict[str, Any] = {
            'message': [r['message'] for r in reslist],
            'filename': [r['filename'] for r in reslist]
        }
        status = 200
    except Exception as e:
        res = {'message': 'Exception {} raised by update of {}: {}'.format(
                type(e), data, e.__traceback__)}
        status = 500
    return web.json_response(res, status=status)


def _parsemeta_tmy2(columns, line):
    """Retrieves metadata from the top line of the tmy2 file.

    Parameters
    ----------
    columns : string
        String of column headings in the header

    line : string
        Header string containing DataFrame

    Returns
    -------
    meta : Dict of metadata contained in the header string
    """
    # Remove duplicated spaces, and read in each element
    rawmeta = " ".join(line.split()).split(" ")
    meta = rawmeta[:3]  # take the first string entries
    meta.append(int(rawmeta[3]))
    # Convert to decimal notation with S negative
    longitude = (
        float(rawmeta[5]) + float(rawmeta[6])/60) * (2*(rawmeta[4] == 'N') - 1)
    # Convert to decimal notation with W negative
    latitude = (
        float(rawmeta[8]) + float(rawmeta[9])/60) * (2*(rawmeta[7] == 'E') - 1)
    meta.append(longitude)
    meta.append(latitude)
    meta.append(float(rawmeta[10]))

    # Creates a dictionary of metadata
    meta_dict = dict(zip(columns.split(','), meta))
    return meta_dict


def parse_rec(filename):
    """ Parse a PASCAL VOC xml file """
    tree = ET.parse(filename)
    objects = []
    for obj in tree.findall('object'):
        obj_struct = {}
        obj_struct['name'] = obj.find('name').text
        obj_struct['pose'] = obj.find('pose').text
        obj_struct['truncated'] = int(obj.find('truncated').text)
        obj_struct['difficult'] = int(obj.find('difficult').text)
        bbox = obj.find('bndbox')
        obj_struct['bbox'] = [int(bbox.find('xmin').text) - 1,
                              int(bbox.find('ymin').text) - 1,
                              int(bbox.find('xmax').text) - 1,
                              int(bbox.find('ymax').text) - 1]
        objects.append(obj_struct)

    return objects

def parse_rec ( filename ) : tree = ET . parse ( filename ) objects = [ ] for obj in tree . findall ( 'object' ) : obj_struct = { } obj_struct [ 'name' ] = obj . find ( 'name' ) . text obj_struct [ 'pose' ] = obj . find ( 'pose' ) . text obj_struct [ 'truncated' ] = int ( obj . find ( 'truncated' ) . text ) obj_struct [ 'difficult' ] = int ( obj . find ( 'difficult' ) . text ) bbox = obj . find ( 'bndbox' ) obj_struct [ 'bbox' ] = [ int ( bbox . find ( 'xmin' ) . text ) - 1 , int ( bbox . find ( 'ymin' ) . text ) - 1 , int ( bbox . find ( 'xmax' ) . text ) - 1 , int ( bbox . find ( 'ymax' ) . text ) - 1 ] objects . append ( obj_struct ) return objects


def main(self):
        """The main function containing the loop for communication and process management.

        This function is the heart of the daemon.
        It is responsible for:
        - Client communication
        - Executing commands from clients
        - Update the status of processes by polling the ProcessHandler.
        - Logging
        - Cleanup on exit

        """
        try:
            while self.running:
                # Trigger the processing of finished processes by the ProcessHandler.
                # If there are finished processes we write the log to keep it up to date.
                if self.process_handler.check_finished():
                    self.logger.write(self.queue)

                if self.reset and self.process_handler.all_finished():
                    # Rotate log and reset queue
                    self.logger.rotate(self.queue)
                    self.queue.reset()
                    self.reset = False

                # Check if the ProcessHandler has any free slots to spawn a new process
                if not self.paused and not self.reset and self.running:
                    self.process_handler.check_for_new()

                # This is the communication section of the daemon.
                # 1. Receive message from the client
                # 2. Check payload and call respective function with payload as parameter.
                # 3. Execute logic
                # 4. Return payload with response to client

                # Create list for waitable objects
                readable, writable, failed = select.select(self.read_list, [], [], 1)
                for waiting_socket in readable:
                    if waiting_socket is self.socket:
                        # Listening for clients to connect.
                        # Client sockets are added to readlist to be processed.
                        try:
                            client_socket, client_address = self.socket.accept()
                            self.read_list.append(client_socket)
                        except Exception:
                            self.logger.warning('Daemon rejected client')
                    else:
                        # Trying to receive instruction from client socket
                        try:
                            instruction = waiting_socket.recv(1048576)
                        except (EOFError, OSError):
                            self.logger.warning('Client died while sending message, dropping received data.')
                            # Remove client socket
                            self.read_list.remove(waiting_socket)
                            waiting_socket.close()
                            instruction = None

                        # Check for valid instruction
                        if instruction is not None:
                            # Check if received data can be unpickled.
                            try:
                                payload = pickle.loads(instruction)
                            except EOFError:
                                # Instruction is ignored if it can't be unpickled
                                self.logger.error('Received message is incomplete, dropping received data.')
                                self.read_list.remove(waiting_socket)
                                waiting_socket.close()
                                # Set invalid payload
                                payload = {'mode': ''}

                            functions = {
                                'add': self.add,
                                'remove': self.remove,
                                'edit': self.edit_command,
                                'switch': self.switch,
                                'send': self.pipe_to_process,
                                'status': self.send_status,
                                'start': self.start,
                                'pause': self.pause,
                                'stash': self.stash,
                                'enqueue': self.enqueue,
                                'restart': self.restart,
                                'kill': self.kill_process,
                                'reset': self.reset_everything,
                                'clear': self.clear,
                                'config': self.set_config,
                                'STOPDAEMON': self.stop_daemon,
                            }

                            if payload['mode'] in functions.keys():
                                self.logger.debug('Payload received:')
                                self.logger.debug(payload)
                                response = functions[payload['mode']](payload)

                                self.logger.debug('Sending payload:')
                                self.logger.debug(response)
                                try:
                                    self.respond_client(response, waiting_socket)
                                except (BrokenPipeError):
                                    self.logger.warning('Client disconnected during message dispatching. Function successfully executed anyway.')
                                    # Remove client socket
                                    self.read_list.remove(waiting_socket)
                                    waiting_socket.close()
                                    instruction = None
                            else:
                                self.respond_client({'message': 'Unknown Command',
                                                    'status': 'error'}, waiting_socket)
        except Exception:
            self.logger.exception()

        # Wait for killed or stopped processes to finish (cleanup)
        self.process_handler.wait_for_finish()
        # Close socket, clean everything up and exit
        self.socket.close()
        cleanup(self.config_dir)
        sys.exit(0)


def account_info(self):
        """ Certain attributes have a user's account information
        associated with it such as a gifted or crafted item.

        A dict with two keys: 'persona' and 'id64'.
        None if the attribute has no account information attached to it. """
        account_info = self._attribute.get("account_info")
        if account_info:
            return {"persona": account_info.get("personaname", ""),
                    "id64": account_info["steamid"]}
        else:
            return None

def account_info ( self ) : account_info = self . _attribute . get ( "account_info" ) if account_info : return { "persona" : account_info . get ( "personaname" , "" ) , "id64" : account_info [ "steamid" ] } else : return None


def add_route(self, gateway, network):
        """
        Add a route to engine. Specify gateway and network.
        If this is the default gateway, use a network address of
        0.0.0.0/0.

        .. note: This will fail if the gateway provided does not have a
                 corresponding interface on the network.

        :param str gateway: gateway of an existing interface
        :param str network: network address in cidr format
        :raises EngineCommandFailed: invalid route, possibly no network
        :return: None
        """
        self.make_request(
            EngineCommandFailed,
            method='create',
            resource='add_route',
            params={'gateway': gateway,
                    'network': network})

def add_route ( self , gateway , network ) : self . make_request ( EngineCommandFailed , method = 'create' , resource = 'add_route' , params = { 'gateway' : gateway , 'network' : network } )


def connect(provider_id):
    """Starts the provider connection OAuth flow"""
    provider = get_provider_or_404(provider_id)
    callback_url = get_authorize_callback('connect', provider_id)
    allow_view = get_url(config_value('CONNECT_ALLOW_VIEW'))
    pc = request.form.get('next', allow_view)
    session[config_value('POST_OAUTH_CONNECT_SESSION_KEY')] = pc
    return provider.authorize(callback_url)

def connect ( provider_id ) : provider = get_provider_or_404 ( provider_id ) callback_url = get_authorize_callback ( 'connect' , provider_id ) allow_view = get_url ( config_value ( 'CONNECT_ALLOW_VIEW' ) ) pc = request . form . get ( 'next' , allow_view ) session [ config_value ( 'POST_OAUTH_CONNECT_SESSION_KEY' ) ] = pc return provider . authorize ( callback_url )


meta	others	Jitesh Vishwakarma


meta	others	E-mail-Id: - jvishwakarma123@gmail.com


meta	others	Contact Number: - 9960902548


header	experience	PROFESSIONAL SUMMARY:


Context: In the 1960s, a series of discoveries, the most important of which was seafloor spreading, showed that the Earth's lithosphere, which includes the crust and rigid uppermost portion of the upper mantle, is separated into a number of tectonic plates that move across the plastically deforming, solid, upper mantle, which is called the asthenosphere. There is an intimate coupling between the movement of the plates on the surface and the convection of the mantle: oceanic plate motions and mantle convection currents always move in the same direction, because the oceanic lithosphere is the rigid upper thermal boundary layer of the convecting mantle. This coupling between rigid plates moving on the surface of the Earth and the convecting mantle is called plate tectonics.

Question: In what decade was seafloor spreading discovered?


Context: In November 1969, Gemini veteran Charles "Pete" Conrad and rookie Alan L. Bean made a precision landing on Apollo 12 within walking distance of the Surveyor 3 unmanned lunar probe, which had landed in April 1967 on the Ocean of Storms. The Command Module Pilot was Gemini veteran Richard F. Gordon, Jr. Conrad and Bean carried the first lunar surface color television camera, but it was damaged when accidentally pointed into the Sun. They made two EVAs totaling 7 hours and 45 minutes. On one, they walked to the Surveyor, photographed it, and removed some parts which they returned to Earth.

Question: What damaged the color TV camera that Apollo 12 had taken into space?

the Sun
Sun
pointed into the Sun.
the Sun
the Sun


Context: The motion picture, television, and music industry is centered on the Los Angeles in southern California. Hollywood, a district within Los Angeles, is also a name associated with the motion picture industry. Headquartered in southern California are The Walt Disney Company (which also owns ABC), Sony Pictures, Universal, MGM, Paramount Pictures, 20th Century Fox, and Warner Brothers. Universal, Warner Brothers, and Sony also run major record companies as well.

Question: Other than the motion picture and television industry, what other major industry is centered in Los Angeles?


Context: Of the 129 MSPs, 73 are elected to represent first past the post constituencies and are known as "Constituency MSPs". Voters choose one member to represent the constituency, and the member with most votes is returned as a constituency MSP. The 73 Scottish Parliament constituencies shared the same boundaries as the UK Parliament constituencies in Scotland, prior to the 2005 reduction in the number of Scottish MPs, with the exception of Orkney and Shetland which each return their own constituency MSP. Currently, the average Scottish Parliament constituency comprises 55,000 electors. Given the geographical distribution of population in Scotland, this results in constituencies of a smaller area in the Central Lowlands, where the bulk of Scotland's population live, and much larger constituency areas in the north and west of the country, which have a low population density. The island archipelagos of Orkney, Shetland and the Western Isles comprise a much smaller number of electors, due to their dispersed population and distance from the Scottish Parliament in Edinburgh. If a Constituency MSP resigns from Parliament, this triggers a by-election in his or her constituency, where a replacement MSP is returned from one of the parties by the plurality system.

Question: How many members can voters choose to represent the constituency?


Context: Two Block I CSMs were launched from LC-34 on suborbital flights in 1966 with the Saturn IB. The first, AS-201 launched on February 26, reached an altitude of 265.7 nautical miles (492.1 km) and splashed down 4,577 nautical miles (8,477 km) downrange in the Atlantic ocean. The second, AS-202 on August 25, reached 617.1 nautical miles (1,142.9 km) altitude and was recovered 13,900 nautical miles (25,700 km) downrange in the Pacific ocean. These flights validated the Service Module engine and the Command Module heat shield.

Question: How far did the second block, AS-202, travel downrange in km?


Context: The role of teacher is often formal and ongoing, carried out at a school or other place of formal education. In many countries, a person who wishes to become a teacher must first obtain specified professional qualifications or credentials from a university or college. These professional qualifications may include the study of pedagogy, the science of teaching. Teachers, like other professionals, may have to continue their education after they qualify, a process known as continuing professional development. Teachers may use a lesson plan to facilitate student learning, providing a course of study which is called the curriculum.

Question: Where do most teachers get their credentials from?

university or college
university
university or college.


reverse shoulder prosthesis is an excellent surgical option for patients with certain shoulder pathologies , of which rotator cuff arthropathy is one .
one area where we are gaining a greater understanding is that of managing acromial pathology .
recent studies are showing that not all acromial pathology is a contraindication to reverse shoulder arthroplasty ; in both pre- and post - operative patients , small lateral fractures of the acromion can be treated non - operatively or fixed surgically with a tension band technique .
overall , results comparable to that of reverse arthroplasty can be achieved with either of these treatment options .
however , fractures at the base of the acromion or of the scapular spine present a different problem . in these types of fractures , a larger length of deltoid muscle is detached , and therefore defunctioned . in reverse shoulder arthroplasty , in order to achieve a stable shoulder , the deltoid must be tensioned a great deal .
this in turn causes a deforming force and distraction at the fracture site , making for a poor healing potential . also , as the reverse shoulder prosthesis relies on the deltoid muscle to move the arm , if the deltoid is detensioned or improperly tensioned , this will lead to poor functional capacity .
we present a case of treatment of a fracture at the base of the acromion using a 90/90 plating construct that healed in a good position .
a 71-year - old right - handed woman presented with a 2-year history of right shoulder pain and dysfunction , which began abruptly when lifting a heavy load . at the initial evaluation ,
her range of motion was limited , particularly in active abduction as she achieved only 45 degrees in this plane . a cuff arthropathy ( hamada grade 3 )
was diagnosed and the decision was taken to proceed with reverse shoulder arthroplasty . to complete the pre - operative assessment ,
a ct scan was performed which confirmed there was no acromial pathology involved . a reverse shoulder prosthesis and a biceps tenodesis
was carried out ( delta xtend , depuy , warsaw , in , usa ) through a deltopecoral approach [ figure 1 ] .
the patient 's right arm was immobilized in a sling and the range of motion exercises were started 6 weeks after arthroplasty [ figure 1a ] .
five months after surgery , she sustained a blow to the right shoulder but sought medical attention 1 month later , at her scheduled follow - up visit .
radiographs showed a displaced fracture at the base of the acromion [ figure 1 ] .
this showed that both the humeral and glenoid components were well fixed and the only pathology was the fracture .
antero - posterior radiographs showing the patient 's right shoulder immediately after reverse shoulder arthroplasty ( a ) and after fracture , 5 months later ( b ) .
the post - operative image shows no pre - existing acromial pathology she was taken to the operating room and her previous incision was extended into a  sabre  incision to better expose the acromion .
two small fragment ( 3.5 mm ) locking plates ( synthes , west chester , pa , usa ) were used in a 90/90 configuration ; one was a fragment specific clavicular plate and the other a reconstruction plate .
the fragment specific clavicular plate was applied on the superior edge of the scapular spine in a compression mode .
a second reconsrtuction plate was applied from the posterior acromion to the posterior cortex of the scapular spine , in the infraspinatus fossa .
fixation was solid , but in order to protect the construct , the patient was placed in an abduction brace for 6 weeks .
eighteen months after fracture fixation , the patient was satisfied with the clinical result [ figure 2 ] .
she was capable of 125 degrees of abduction , 160 degrees of forward flexion , 85 degrees of external rotation in adduction , and 60 degrees of internal rotation .
her quickdash score was 29.5 ( compared to 82.5 pre - op ) and constant score was 69 on the affected side compared to 85 on the left side , for a  good  functional outcome .
a medline search using the key words [ acromion fracture ] , [ scapula fracture ] , [ reverse arthroplasty ] was performed .
we then sought to classify and separate the cases by location ; there were 30 cases of fractures at the base of the acromion , and scapular spine . when our case is added , we have a total of 31 cases .
results are summarized in table 1 . in brief , of the 30 more proximal cases , 21 were treated non - operatively in a sling , 7 were treated with open reduction and open fixation and one with revision of the prosthesis . of those treated non - operatively , and for whom results are published , fourteen had a non - union , four had a malunion and in two cases , it was unclear whether union was achieved . for patients receiving fixation of the fracture , there was one non - union , two repeat fixations , and one patient required removal of the fixation .
the patient who had a revision of the prosthesis had a malunion of the acromion .
results of the literature review . in the fracture location column , the fracture description provided by the authors is presented .
although recent studies have shown that good outcomes may be achieved with non - surgical management of lateral acromial fractures , the same does not hold true for basal acromial fractures .
the likely reason for this is that with fractures at the base of the acromion , a large length of the deltoid is defunctioned and the deltoid muscle is essential to the functioning of the reverse shoulder prosthesis .
previously described techniques , such as tension band fixation achieved poor functional results for fractures at the base of the acromion .
we postulate that this is because the fixation method is insufficient to withstand the forces generated by the deltoid muscle  a tension band can neutralize forces parallel to the axis of the band but in the case of the deltoid , force vectors are generated in different directions .
it also allows for compression along the fracture site and resists motion in all directions .
good screw purchase can be achieved by angling the screws either toward the scapular spine or the coracoid .
the locking option enables good fixation and improves cut - out strength in osteopenic or osteoporotic bone .
in addition to the stable fixation achieved with this technique , we further recommend immobilization of the affected shoulder using a sling and an abduction pillow to detension the deltoid , thus at least partially removing the distractive forces at the fracture site . also essential to achieving a good functional result
we thus also recommend a program of range of motion exercises followed by strengthening exercises to maximize functional capabilities . based on results from previous studies ,
fractures of the tip were those of the most lateral or anterior portion of the acromion .
fractures of the body of the acromion are those medial to the tip of the acromion and lateral to the beginning of the scapular base .
the scapular base is the lateral border of the scapular spine , which is smooth and round . in our nomenclature ,
fractures at the scapular base are termed fractures at the base of the acromion as functionally , this zone connects the acromion to the rest of the scapula and this term avoids confusion with any more medially occurring fractures .
coronal ( a ) and axial ( b ) representations of the proposed classification scheme for acromial fractures associated with revere arthroplasty we propose the above mentioned classification system as it provides a nomenclature for acromial fractures that is descriptive and is based on the anatomy and functionality of the scapula . as the results from the review of the literature indicate , the more medial the fracture , the worse the prognosis with non - operative treatment .
thus , this classification system may be used to predict outcomes and determine treatment offered .
it differs from other classification systems ( crosby ) in that it further subclassifies more medial fractures , which are the more ominous fractures . as more research is carried out in this field

 fractures of the acromion and scapula are known to occur after reverse shoulder arthroplasty .
 we present a case of a fracture at the base of the acromion 5 months after arthroplasty treated successfully with dual plating of the acromion .
 eighteen months after fracture fixation , the patient had 160 degrees of active forward flexion , a quickdash of 29.5 , a constant score of 69 and she was satisfied with the result . a concomitant review of the literature produced , in addition to our patient , 56 cases .
 these were used to produce a classification system , based on bony and functional anatomy as follows .
 tip fractures are of the most lateral or anterior portion of the acromion , those of the body of the acromion are medial to the tip but lateral to the beginning of the scapular base
 . fractures at the scapular base are termed fractures of the base of the acromion and those more medial to that , fractures of the scapular spine .
 the functional results of these case series demonstrated poorer functional outcomes for more medial fractures .
 as future research in this domain increases , clarity on the nomenclature of these fractures will allow for prognostication and treatment based on fracture location as well as comparison between studies .


besides its classical role in calcium and bone homeostasis , vitamin d is considered a potent immunomodulator that can affect the pathogenesis of several autoimmune diseases .
our aim is to evaluate the effect of vitamin d correction to a patient with new onset graves disease ( gd ) with an underlying vitamin d deficiency .
we describe the effect of vitamin d3 on untreated graves disease with vitamin d deficiency .
a healthy saudi woman in her 40s sought consultation with a three - month history of palpitation .
she denied any history of heat intolerance , weight loss , menstrual irregularity or sweating .
. physical examination revealed a mild diffusely enlarged and non - tender thyroid gland with no bruit .
the initial thyroid function test , which was done in an outside hospital , revealed a tsh , 0.01 miu / l ; ft4 , 22.5
vitamin d 25-oh level was done in our hospital and showed a result of 26.0 nmol / l with a tsh , 0.013 miu / l ; ft4 , 16.7
tc-99 m thyroid scintigraphy demonstrated an enlarged thyroid gland with increased radiotracer trapping and heterogeneous distribution .
the patient was given only oral cholecalciferol 4000 iu per day since november 2012 ( prescribed by an outside hospital ) then from may 2013 onwards she was given 50,000 iu per month .
follow - up laboratory exams revealed improved vitamin d levels as well as tsh and ft4 .
vitamin d deficiency may exacerbate the onset and/or development of gd and correction of the deficiency may be able to reverse it .
however , further prospective clinical studies will be needed to define the role of vitamin d treatment in gd .
more recently , vitamin d has been shown to be a modulator in both innate and adaptive immunity.1 there is a well - established link between vitamin d deficiency and various autoimmune diseases , including type 1 diabetes mellitus ( t1 dm ) , systemic lupus erythematosus ( sle ) , rheumatoid arthritis ( ra ) , inflammatory bowel disease ( ibd ) , and multiple sclerosis ( ms ) .
furthermore , it has been found that the supplementation of vitamin d can prevent the onset and/or development of different kinds of autoimmune disorders in human beings and animal models.2 in addition , it has been shown that the prevalence of vitamin d deficiency is common in patients with graves disease ( gd),3 and is associated with higher thyroid volume.4 in our case report , we evaluated the effect of vitamin d correction to a patient with new onset gd with an underlying vitamin d deficiency .
a healthy saudi woman in her 40s sought consultation with a 3 months history of palpitation .
she denied any history of heat intolerance , weight loss , menstrual irregularity , diarrhea , or sweating .
there was no personal or family history of thyroid disease and no specific medication history .
physical examination revealed a mild diffusely enlarged and non - tender thyroid gland with no bruit .
the initial thyroid function test , which was done in an outside hospital , revealed a tsh , 0.01 miu / l ; ft4 , 22.5
vitamin d 25-oh level was done in our hospital and showed a result of 26.0 nmol / l with a tsh , 0.013 miu / l ; ft4 , 16.7
anti - thyroid antibodies showed a tg , 17.1 iu / ml ; tpo , 0.19 iu / ml with a positive tsh receptor antibody .
tc-99 m thyroid scintigraphy demonstrated an enlarged thyroid gland with increased radiotracer trapping and heterogeneous distribution ( fig .
the patient was given only oral cholecalciferol 4000 iu per day since november 2012 ( took it from an outside hospital ) then from may 2013 onwards she was given 50,000 iu per month .
the serial thyroid function tests , vitamin d levels , and titer autoantibodies are summarized in table 1 .
follow - up laboratory exams revealed improved vitamin d levels as well as tsh and ft4 .
written informed consent was obtained from the patient for the publication of this case and accompanying images .
it has become apparent that multiple factors contribute to the etiology of gd , including genetic and environmental factors .
these activated t cells in turn increase the secretion of thyroid - specific autoantibodies from b cells .
the prevalence of vitamin d deficiency was reported to be common in patients with gd.3 whether vitamin d deficiency has a causal relationship with gd remains a controversial issue .
misharin et al.5 observed that vitamin d deficiency was found to modulate graves hyperthyroidism induced in balb / c mice by thyrotropin receptor immunization . in this study ,
balb / c mice on a vitamin d deficient diet were more likely to develop persistent hyperthyroidism than other mice receiving adequate vitamin d supply . in another study ,
combination treatment with methimazole and vitamin d3 ( 1,25 ( oh)2d ) in patients with gd has more rapid euthyroidism achievement compared with patients receiving methimazole alone.6 in addition , vitamin d supplementation has been shown to inhibit inflammatory responses in human thyroid and t cells.7 interestingly , vitamin d deficiency is found to be associated with higher thyroid volume in patients with newly onset gd.4 it has been recently discovered that vitamin d - receptor gene and vitamin d - binding protein gene polymorphisms are associated with gd.8,9
our present case supports the current literature and strongly suggests that vitamin d deficiency may exacerbate the onset and/or development of gd and correction of which may be able to reverse it .
however , further prospective clinical studies will be needed to define the role of vitamin d treatment in gd .

 objectivebesides its classical role in calcium and bone homeostasis , vitamin d is considered a potent immunomodulator that can affect the pathogenesis of several autoimmune diseases .
 our aim is to evaluate the effect of vitamin d correction to a patient with new onset graves disease ( gd ) with an underlying vitamin d deficiency.methodwe describe the effect of vitamin d3 on untreated graves disease with vitamin d deficiency.resultsa healthy saudi woman in her 40s sought consultation with a three - month history of palpitation .
 she denied any history of heat intolerance , weight loss , menstrual irregularity or sweating .
 she has a history of chronic muscle aches and pains . physical examination revealed a mild diffusely enlarged and non - tender thyroid gland with no bruit .
 she had no signs of graves ophthalmopathy . in laboratory examinations ,
 the initial thyroid function test , which was done in an outside hospital , revealed a tsh , 0.01 miu / l ; ft4 , 22.5
 pmol / l and ft3 , 6.5 pmol / l .
 vitamin d 25-oh level was done in our hospital and showed a result of 26.0 nmol / l with a tsh , 0.013 miu / l ; ft4 , 16.7
 pmol / l ; and ft3 , 3.8 pmol / l .
 tsh receptor antibody was positive .
 tc-99 m thyroid scintigraphy demonstrated an enlarged thyroid gland with increased radiotracer trapping and heterogeneous distribution .
 the patient was given only oral cholecalciferol 4000 iu per day since november 2012 ( prescribed by an outside hospital ) then from may 2013 onwards she was given 50,000 iu per month .
 follow - up laboratory exams revealed improved vitamin d levels as well as tsh and ft4 .
 she eventually improved both clinically and biochemically with a satisfactory outcome.conclusionvitamin d deficiency may exacerbate the onset and/or development of gd and correction of the deficiency may be able to reverse it .
 however , further prospective clinical studies will be needed to define the role of vitamin d treatment in gd .


 nigella sativa l. ( ns ) is a vegetal specie of the ranunculaceae family , commonly known as  black cumin seed  ,  neguilla  or  ajemuz  , that is   widely cultivated in the mediterranean region .
its seeds have played an important role over the years in ancient islamic system of herbal medicine and in spain , where they have been traditionally used in folk medicine .
ns seeds have shown several therapeutic effects such as prevention of cancer , antihypertensive effect , anti - inflammatory , analgesic , and antihistaminic   actions .
the volatile oil from this plant presents a relaxant action on different smooth muscles   and tracheal muscles of guinea pigs .
there is evidence of anticonvulsant and antioxidant effects against pentylenetetrazol - induced kindling in mice .
. likewise , aqueous extract of this plant suppresses penicillin - induced epileptic activity in rats .
this anticonvulsant effect is a consequence of selectively altering the monoamine level in different brain regions . in recent works , histopathological changes of neurodegeneration in the frontal cortex and brain stem in neurons after exposition to toluene have been observed [ 15 , 16 ] .
the administration of ns extract and thymoquinone ( major component from ns volatile oil ) causes morphologic improvement over apoptosis and indicates that ns therapy is useful as a potential treatment of neurodegeneration prevention .
ns seeds composition includes nutritional components such as carbohydrates ( glucose , xylose , rhamnose , and arabinose ) , vitamins as thiamine , riboflavin , pyridoxine , niacin and folic acid , mineral elements , and proteins .
the ns seeds are also a source of calcium , iron and potassium , alkaloids ( nigellidine , nigellimine , and nigellicine ) , 36%38% fixed oil and 0.4%2.5% essential oil . the fixed oil is mainly composed of unsaturated and essential fatty acids ( linoleic acid , followed by oleic acid )   whereas the volatile oil has   been shown to contain 18.424% thymoquinone and 46% monoterpenes such as p - cymene and pinene [ 5 , 20 ] .
thimoquinone , as indicated above , is thought to be the main active component of ns seeds    and suppresses itself epileptic seizures in rats , while a monodesmosidic triterpene saponin , -hederin , has also been isolated from the extract of ns seeds and proved to exert antitumoral activity .
three flavonoid glycosides and triterpene saponins were also identified from nigella sativa , together with four phospholipid classes : phosphatidylcholine   phosphatidylethanolamine , phosphatidylserine , and phosphatitdylinositol [ 24 , 25 ] . in previous studies we demonstrated that aqueous and methanolic extracts of ns seeds exert a potent sedative and depressive effect on cns and induce analgesia .
the effect on cns resulted in a significant reduction of spontaneous motility , a decrease in normal body temperature and significant analgesic action against hot - plate and pressure tests .
body temperature reduction can be interpreted as an index of alteration of various central neurotransmitters ; anxiety and sedation are mainly mediated by the gaba - a receptor in the cns . since depressant action was confirmed specially for the methanolic extract , we decided to study whether the addition of this methanolic dry extract in cortical neurons culture could exert any influence on the secretion of the excitatory amino acids aspartate ( asp ) and glutamate ( glu ) , and the inhibitory amino acids gaba and glycine ( gly ) , as well as the presence of these amino acid neurotransmitters in the extract .
we also considered its effect on the amino acids secretion when stimulated by a depolarizing agent and its effect on cultured neurons viability .
the viability of the cultured neurons after exposition to ns extract concentrations 2.5 , 25 , and 250  g / ml during 15 and 60  minutes are shown in figure 1 .
results are expressed as a percentage with respect to control value ( 100% viability ) .
the amino acids gaba , gly , glu , and asp were measured in ns methanolic extract by hplc .
the results are expressed as pmoles / mg of ns extract ( table 1 ) .
the results showed gly as the most abundant , followed by gaba , glu , and asp , respectively .
the amino acids content in the extract was subtracted from the total amino acid content measured in the cellular medium after neuronal stimulation with ns extract so we can state that the final amino acids content in cell culture is a direct consequence of cell release .
the release of the four amino acids after stimulation with the chosen nontoxic concentrations of ns extract ( 2.5 , 25 , and 250  g / ml ) showed a diminished secretion response that was statistically significant ( p < .05 for gly and glu ; p < .01 for gaba ; p < .001 for asp ) after 15  minutes of incubation with respect to control ( neuronal cells stimulated with normal locke medium during the same period of time and considered as 100% secretion ) ( figures 2 , 3 , 4 , and 5 ) .
gly and asp release was reduced in a dose   dependent manner ; glu and gaba showed a tendency to retrieve control values , although their secretion was lower than control .
this fall of aminoacids release is greater for higher extract concentration except for glu and gaba , which showed a tendency to recuperation to control values at the same time    ( figure 2 ) .
the hplc analysis revealed the same behavior for all the amino acids , with the exception of gaba , after treatment with ns extract during 60  minutes .
the increased presence of this amino acid was statistically significant for 25 and 250  g / ml ns extract . in order to know the response to a depolarizing agent ,
cortical neurons were stimulated with ns extract at the indicated concentrations , during 15 and 60  minutes previous to depolarization with 60 mm kcl ( figures 6 and 7 ) .
the neurons treated with ns extract during 15  minutes and subsequently stimulated with kcl showed a dose - dependent decrease in amino acids secretion with respect to control value ( neuronal cells stimulated with locke medium ) , which was considered as 100% . the observed behaviour was more relevant for glu and asp at 25 and 250   g / ml than for gaba and gly under the same conditions ( figure 6 ) .
measurement of secretion mediated by kcl during 60  minutes revealed an inhibition of the liberation of these neurotransmitters .
in this case , only gaba and glu were released in a dose - dependent manner ( figure 7 ) .
the aim of the study was to determine the effects of ns methanolic extract on the release of neurotransmitter amino acids by measuring their concentrations in the culture media using hplc precolumn derivatization technique .
three concentrations of ns extract ( 2.5 , 25 , and 250  g / ml ) and two time points ( 15 and 60  min ) for the determination of the effects were used .
this is a preliminary study which shows that exposure of the cultured neurons have a modulatory effect on the release and contents of these aminoacids .
the 3-(4,5-dimethylthiazol-2-yl)-2,5diphenyltetrazolium bromide ( mtt ) assay was employed to estimate the cells viability when neurons were treated with ns extract .
the three concentrations of dry methanolic extract used in our study did not affect cellular respiratory capacity at any of the two periods of time considered .
these results allowed us to consider the adequate approach to the study of amino acid secretion in the conditions selected and to confirm the innocuous characteristics of the chosen extract concentrations .
our previous in vitro findings support the hypothesis that the sedative and depressive effects of nigella sativa ( ns ) observed in vivo , could be based on changes of inhibitory / excitatory amino acids levels .
several authors attribute the sedative effects of different plant extracts ( valeriana officinalis l. , scutellaria lateriflora l. ) [ 27 , 28 ] to its endogenous gaba concentration , although they also hypothesize that there exist other components of the vegetal extracts with benzodiazepine - like effects that may account for their in vivo effects .
the aim of our research was to determine whether these substances that are present in the ns extract could mediate the specific effects previously observed in vivo through the secretion of asp , glu , gaba , and gly .
first of all , the presence and content of the four amino acids in the extract was analyzed by hplc , showing a major presence of inhibitory amino acids ( gly and gaba ) ( table 1 ) .
then , the cell amino acids release was assayed after addition of several concentrations of ns extract to cultured neurons during two different periods of time ( 15 and 60  minutes ) .
the aim of this approach was to observe whether neuronal secretion could be modified depending on the exposition time .
high secretion of gaba was observed after 60  minutes ' contact with ns extract at 25 and 250  g / ml . this time is close to the one that allowed the maximum effect in our in vivo study , close to 40  minutes . under these conditions ,
similar results have been observed when high gaba concentrations are present in an aqueous extract of valeriana officinalis root which induced in vitro liberation of [ h]gaba in rat synaptosomes by reversal of the gaba carrier and inhibition of its reuptake .
both plants are widely prescribed as sedative / anxiolytic ones . as the gaba presence in the methanolic extract of ns
was confirmed with our results , it is possible to assume that a high level of gaba in the medium during cellular incubation and a longer period of exposition at this one could exert the same effect above described .
recent findings suggest that ns protects from induced generalized epilepsy in rats by selectively altering the monoamine level in different brain regions .
this study pointed that ns possibly facilitates the inhibitory activity of the gabaergic system through a competitive agonist action in the benzodiazepine ( bzd ) site of the gaba receptor as well as the involvement of dopaminergic and noradrenergic system .
the confirmed presence of gaba in the methanolic extract could be directly related to its conduct over the gaba receptor and this could explain the potent sedative and depressive effect on cns as previously reported . moreover , the important presence of gly in the extract could be also related to its inhibitory action .
the binding of both neurotransmitters to their receptors on the neuronal membrane induces hyperpolarization that could be responsible for a significantly lower secretion of amino acids with respect to control values .
in addition to this , our results showed a decrease in neuronal excitatory activity derived from a diminished asp and glu secretion , specially the second one .
our results show the behavior of the cortical neurons and confirm what we expected from the previous study performed in vivo .
likewise the methanolic extract composition is able to mediate in the neuronal amino acids release . in this case , the ns extract had an influence on neuronal transmission because it modifies the neurotransmitter amino acids release .
depolarization of neuronal cells by application of high k+ concentration ( 60  mm kcl ) induced a diminished amino acid release in both periods of time assayed .
this diminished release was similar to nondepolarizing secretion except for gaba which also diminished its secretion .
although multiple mechanisms of neurotransmitter release evoked by elevated extracellular k+ may be involved [ 29 , 30 ] , we consider that the effect of ns extract over neuronal cells produces a drop in the transmission and is responsible for of the inhibitory effect indicated above .
a possible action of ns extract over l - type calcium channels or an opening on potassium channels had been suggested by others authors [ 3135 ] , and it could contribute to the relaxant activities of this plant .
furthermore , its possible effect over these channels could persist even after the extract was eliminated from the medium before depolarization .
with respect to gaba secretion , the only amino acid which differs in its behavior with respect to nondepolarizing liberation , the diminished secretion may derivate from the membrane transporter - reversal for gaba above suggested . in our study , we have considered the possibility that the gaba carrier had been previously affected by the presence of ns extract during 15 or 60  minutes , inhibiting gaba reuptake and favouring its liberation from neurons .
other authors   have concluded that extracellular k+ ( 50  mm kcl ) provokes gaba release by reversal transporter of gaba . in our case
, we observed a diminished liberation that could be justified by the previous loss of cellular gaba content as the neurons had been treated with the ns extract . in conclusion , this study suggests a sedative effect of ns methanolic extract by modification of neurotransmitter amino acids release , because the ns extract may induce an important release of gaba and gly in the cultured neurons medium and therefore , exert an increase in the agonist action over their receptors .
the results explain the sedative and depressive effects observed in vivo by an increase in inhibitory amino acids at the synaptic terminals .
even more , this effect is complemented with a possible decrease of excitatory transmission , as it has been demonstrated in vitro and could contribute to inhibitory response .
minimum essential eagle 's medium ( emem ) was obtained from bio - whittaker , and foetal bovine serum ( fbs ) and horse serum ( hs ) were procured from sera - lab ( sussex , england )
. standards of glutamate , aspartate , gaba and glycine were purchased from sigma ( st . louis , mo , usa ) .
reagents and solvents for hplc were triethylamine from sigma ( st . louis , mo , usa ) , acetic acid and methanol ultra gradient grade from merck ( darmstadt , germany ) .
distilled water used for the preparation of buffers and standards was deionized with milli - q purification system .
syringe filters millex - gv were obtained from millipore ( milford , ma , usa ) .
membrane filters ( 0.45  m pore size ) from tecknochroma ( barcelona , spain ) were used for filtration of the mobile phase and samples .
cell proliferation kit ii ( xtt ) , colorimetric determination , was purchased from roche diagnostics gmbh ( mannheim , germany ) .
, usa ) coupled with a photodiode array detector shimadzu spd-10a ( izasa , madrid , spain ) was used for the amino acids isolation and quantification . the analytical system consisted of a waters ods spherisorb 150  4.6  mm i.d . ; 5  m packed column ( teknokroma , barcelona , spain ) as stationary phase , preceded by a guard column spherisorb rp-18 , 5  m , 4  mm  4 mm .
a microplate fluorescence reader fl600-biotek spectrofluorimeter was used for the quantification of cell viability at 492  nm .
seeds of nigella sativa l. were supplied by the medicinal and aromatic plants research institute of egypt ( el cairo , egypt ) .
herbarium samples were authenticated by a taxonomist and a voucher specimen was deposited in the herbarium of the faculty of pharmacy , universidad complutense de madrid , with voucher number maf 161043 .
the methanolic extract of the plant was prepared according to ( science and technology program for development ) cyted protocol for vegetal species from countries that are included in this program .
brain neurons were obtained from foetal rat brains of 19 days of gestation as previously described   with minor modifications .
isolated neurons were suspended in eagle 's minimum essential medium ( emem ) containing 0.3  g / l glutamine , 0.6% glucose , 5% phosphate buffered saline ( pbs ) , 5% horse serum ( hs ) , 100  u / ml penicillin and 100  g / ml streptomycin .
cells , at a density of 1  10 cells / well , were placed on plastic petri dishes of 24 wells , treated with 10  g / ml poly - l - lysine to aid attachment .
the plates were incubated in a humidified incubator in an atmosphere of 5% co2/95% air at 37c . after 72  hours ,
nonneuronal cells ( contaminating glial cells ) were mitotically inhibited by exposure to cytosine arabinoside .
the incubation medium was replaced by fresh medium to which cytosine arabinoside was added to a final concentration of 10  m .
after 3 days , this medium was replaced by fresh medium and experiments were carried out using cultures ranging from 1015 days .
cell purity was checked by both cells staining with cresyl violet to identify neurons and with the specific antiglial fibrillary acidic protein ( gfap ) antibody to identify glial cells .
cortical neurons , after 7 days in culture , were detached from the culture plates with trypsin solution ( 0.25% trypsin and 0.02% edta in dulbecco 's buffered saline without calcium and magnesium ) and then the cells were fixed ( during 30  min ) with 2% p - formaldehyde .
after two washes with 1  ml of pbs , the cells were treated ( during 1  h ) with anti - gfap antirabbit ( at dilution of 1/500 ) .
subsequently , the cells were washed with pbs and treated with antirabbit conjugated igg fitc , at 1/100 , for 30  min .
the glial cells in the cultures were 8.3  3.6% of the total ( neural + glial cells ) .
this assay is used as an index of cell survival or cellular respiratory capacity - based on method of mossmann   and improved by weislow et al .   and roehm et al . .
the tetrazolium assay is based on the mitochondrial dehydrogenases ( md ) activity and their inactivation after cell death . in live cells ,
mtt is reduced to a highly water - soluble orange colored product , formazan dye .
neuronal cells were seeded in 96-multiwell plates at a density of 36  10 cells / well ( in 200  l medium ) and kept in the incubator until 8090% confluence .
after this , the medium was removed and the cells were washed twice with pbs and the ns extract previously dissolved in pbs was added to the wells and incubated for 15  minutes or 1  hour .
after each one of the treatment periods ( 15 or 60  min ) , the medium was removed and incubated with mtt solution ( final concentration 0.3  mg / ml ) , according to the kit specifications .
after 2  h incubation at 37c in a humidified atmosphere , orange dye solution was spectrophotometrically quantified using an elisa plate reader at 492  nm .
the amount of orange formazan formed , as monitored by the absorbance , directly correlates to the number of living cells .
hplc analysis of amino acids was performed by a previously described method   with minor modifications and with the equipment and conditions that were previously developed for the amino acids determination .
prior to hplc amino acid secretion analysis cells were washed twice , at 10  min intervals , with 1  ml of locke medium . after removing the medium ,
cells were stimulated for 15  min or 1  hour at 37c with 250  l fresh locke medium ( control cells ) or with 250  l of locke medium containing the dry methanolic extract of ns seeds at different concentrations ( 2.5 , 25 and 250  g / ml ) .
after stimulation , the wells medium ( supernatant s1 ) was taken for amino acid valuation and cells were then stimulated with 250  l of 60  mm kcl for 15  min .
after this , the cells secretion ( supernatant s2 ) was removed for their valuation and cells were lysated with 250  l of distilled water for total intracellular amino acids content determination .
the different supernatants obtained , s1 and s2 , as well as the cell lysated , were lyophilized for their dansylation .
the content of the four amino acids present in the methanolic extract was also determined by hplc analysis under the same conditions and these results were subtracted from the total amino acids content in cellular medium in presence of ns extract ( s1 ) in order to obtain cellular secretion value itself .
the results were calculated as the amino acid release into the incubation medium with respect to the total amino acid content .
these results were expressed as a percentage of secretion with respect to control experiments that were considered as 100% .
data are presented as means  sem of four separated experiments from different cell cultures , each one performed in triplicate with different batches of neuronal cells .

 nigella sativa l. ( ns ) has been used for medicinal purposes since ancient times . this
 study aimed to investigate the cytotoxicity of ns dry methanolic extract on cultured
 cortical neurons and its influence on neurotransmitter release , as well as the presence of
 excitatory ( glutamate and aspartate ) and inhibitory amino acids ( gamma - aminobutyric
 acid  gaba  and glycine ) in ns extract .
 cultured rat cortical neurons were exposed to
 different times and concentrations of ns dry methanolic extract and cell viability was
 then determined by a quantitative colorimetric method .
 ns did not induce any toxicity .

 the secretion of different amino acids was studied in primary cultured cortical neurons
 by high - performance liquid chromatography ( hplc ) using a derivation before injection
 with dansyl chloride .
 ns modulated amino acid release in cultured neurons ; gaba was
 significantly increased whereas secretion of glutamate , aspartate , and glycine were
 decreased .
 the in vitro findings support the hypothesis that the sedative and depressive
 effects of ns observed in vivo could be based on changes of inhibitory / excitatory amino
 acids levels .


pheochromocytomas are rare catecholamine producing tumors arising from chromaffine cells in the sympatho adrenal system .
its prevalence is estimated at 0.1% to 0.6% . they secrete various catecholamines , predominantly norepinephrine , and epinephrine to small extent .
these catecholamines are responsible for the manifestations with sustained or paroxysmal symptoms . diagnosis is established by measuring metanephrines in the urine or blood .
localization of the tumor is done using computed tomography ( ct ) or magnetic resonance imaging ( mri ) scans .
thrombosis of the inferior vena cava ( ivc ) has comparable etiological factors to lower limb deep venous thrombosis .
hypercoagulability related to hematological or neoplastic abnormalities , venous stasis secondary to extraluminal pressure from tumors or inflammatory processes , and vessel injury due to trauma have all been implicated as primary mechanism in the pathophysiology of ivc thrombosis .
however , its association with pheochromocytoma in indian subjects has not been reported till date .
a 48-year - old man was admitted to our hospital with complaints of headache , sweating , anxiety , dizziness , nausea and vomiting .
the patient was 164 cm tall and weighed 57 kg . on physical examination , there were no caf au lait spots or neurofibromas .
hematological analysis confirmed normocytic anemia with hemoglobin 11.3 gm / dl , a raised erythrocyte sedimentation rate ( esr ) ( 130 mm fall in the first hour ) , while the total and differential leukocyte counts were normal .
biochemical parameters such as liver and kidney functions , and serum electrolytes , calcium , phosphorous , alkaline phosphatase and d - dimer were within normal limits .
the endocrinological evaluation revealed increased urine catecholamines and urinary vanillyl mandelic acid ( vma ) [ table 1 ] .
baseline biochemical parameters of the patient abdominal ct revealed a well defined , heterogenous mass lesion of size 7.6  5.3  4.8 cms with attenuation score of 35 hu at the upper pole of right kidney without any calcifications [ figure 1 ] .
there was no involvement of renal vein , hepatic veins and veins of lower limbs demonstrated by doppler ultrasound .
magnetic resonance imaging ( mri ) revealed intraluminal thrombus extending proximally up to the confluence of hepatic veins immediately inferior to the right atrium without distal extension to femoral veins bilaterally [ figure 2 ] .
an ivc venogram via the right jugular vein demonstrated multiple filling defects indicating occlusion of the ivc inferior to the right atrium [ figure 3 ] .
there was simultaneous enlargement of distal part of ivc . computed tomography of the abdomen- showing a well defined , heterogeneously enhancing mass lesion of size 7.6  5.3  4.8 cm at the upper pole of right kidney without any calcifications .
the left adrenal gland appeared to be normal t2-weighted axial magnetic resonance imaging demonstrating the mass ( predominantly high signal ) between the inferior vena cava and right kidney ( black arrow ) compressing the overlying inferior vena cava ( white arrow ) ivc venogram showing multiple filling defects indicating occlusion of the inferior vena cava inferior to the right atrium .
there is distal enlargement of inferior vena cava a diagnosis of ivc thrombosis with pheochromocytoma was established , and surgical treatment was planned .
alpha receptor blocking therapy with prazosin was instituted , followed by  blocker , after testing for adequacy of  blockade .
the patient was treated conservatively with subcutaneous low molecular weight heparin followed by oral warfarin .
after 2 weeks , hypertension was well controlled and the remaining symptoms disappeared . with adequate blood pressure control ,
biopsy of the specimen revealed a typical organoid or zellballen pattern with no cytoplasmatic inclusion , pleomorphism , cytological alterations or necrosis ; and , the mitotic index was low [ figure 4 ] . during the postoperative period ,
the patient 's blood pressure remained normal . a 24-hour urine specimen collected for metanephrine and vma , revealed levels within normal limits . at present , the patient is asymptomatic , requires no medications , and is employed as an engineer .
mri imaging demonstrated resolution of the thrombosis and return of patency of the ivc at 4 months [ figure 5 ] . the typical growth pattern of nests of tumor cells ( zellballen ) surrounded by a discontinuous layer of sustentacular cells and fibrovascular stroma in the biopsy specimen of the patient in the study .
blood vessels surrounding tumor nests are composed of round to oval cells t2-weighted axial magnetic resonance imaging comparable in position and image acquisition to figure 2 demonstrating complete resolution of inferior vena cava thrombosis ( white arrow ) after 4-months of oral anticoagulation therapy
two aspects render our case unusual : 1 ) the coexistence of pheochromocytoma with ivc thrombosis 2 ) though there are case reports citing the association between malignant pheochromocytoma and ivc thrombus , to our sincere belief ; this is the first such report citing this uncommon association from india .
although the lifetime incidence of venous thrombosis is 0.1% , it still remains a rare condition especially in patients below 30 years of age .
predisposing factors include alterations in blood flow [ stasis ] , injury to the vascular endothelium and abnormalities in the constitution of blood hypercoagulability ( virchow 's triad ) .
endothelial damage is invariably an acquired phenomenon , whereas hypercoagulability may result from both congenital and acquired risk factors ( especially in the peri - operative period ) .
the classical presentation of ivc thrombus varies according to the level of the thrombosis with up to 50% of patients presenting with bilateral lower extremity swelling and dilatation of superficial abdominal vessels . whilst some patients remain asymptomatic ,
lower back pain , nephrotic syndrome , hepatic engorgement , cardiac failure and pulmonary embolus have also been described .
tsuji et al . reported a series of 10 patients where 40% were pyrexic at presentation , with an associated elevation in d - dimer levels and inflammatory markers ( white cell count , c - reactive protein ) .
our patient had no lower limb , liver or kidney involvement , and this might be ascribed to the partial occlusion of ivc .
we could not explain normal d - dimer levels in the backdrop of such a large thrombus in our patient .
ct scan with contrast enhanced images and mri scan are used to localize adrenal pheochromocytoma .
meta - iodobenzylguanidine ( mibg ) and positron emission tomography ( pet ) scanning ( gallium- dota - toc / noc and dopa - pet perform better than fdg- pet ) are largely reserved for extraadrenal paraganglioma , or very large tumors to rule out metastasis .
heterogeneity , high hounsfield density on ct ( > hu ) , marked enhancement with intravenous contrast and delayed contrast washout ( < 60 % at 10 minutes ) , high signal intensity on t2 weighted mri , cystic and hemorrhagic changes point to pheochromocytoma , adrenocortical carcinoma or metastasis .
however , pheochromocytoma with lipid degeneration can result in low attenuation scores ( < 10 hu ) and > 60% washout at delayed ct scanning .
benign adrenal incidentalomas are characterized by size < 5 cm , sharp margins , smooth contours , lack of demonstrable growth on serial examinations , attenuation scores < 10 hu , and > 60% washout at delayed ct scanning . in our patient , ct scan revealed nonhomogenous mass of hu 35 without any calcification .
histologically , pheochromocytomas are capsulated and are composed of round or polygonal epithelioid / chief cells arranged in characteristic compact cell nests ( zellballen ) or trabecular patterns .
the chief cells have centrally located nuclei with finely clumped chromatin , and a moderate amount of eosinophilic , granular cytoplasm .
tumors of higher grade are characterized by a progressive loss in the relationship between chief cells and sustentacular cells , and a decrease in the number of sustentacular cells . in our patient , typical zellballen pattern was found .
presence of markers like chromogranin a ( cga ) , neuron specific enloase , synaptophsyin serve as additional tools to confirm the neuroendocrine nature of the chief cells .
the only reliable clue to the presence of a malignant pheochromocytoma is local invasion or distant metastases , which may occur as long as 20 years after resection .
benign  on pathologic examination , long term follow - up is indicated in all patients to confirm that impression .
other markers for malignancy are absent or weak expression of inhibin / activin- beta b subunit , and presence of succinate dehydrogenase b ( sdh b ) subunit is seen . in absence of any invasion , we considered the mass in our patient to be benign . the simultaneous occurrence of pheochromocytoma and ivc thrombosis is reported sporadically .
ivc thrombosis in this case could be because of : 1 ) local compression leading to alteration in blood flow and stasis 2 ) sustained hypertension leading to vascular endothelial injury and hypercoagulability , 3 ) association of pheochromocytoma with systemic lupus erythematous and behcet 's disease might explain the triggering of an autoimmune phenomenon leading to a hypercoagulable state , and 4 ) an underlying anatomic abnormality or coagulation disorder .
it also could be a chance association between these 2 conditions . in our case ,
recent advances in the utilization of ultrasound , ct and mri imaging as well as endovascular procedures have resulted in an increase in detection rates of ivc anomalies , as well as an increase in the incidental discovery of such abnormalities during unrelated investigations , therapeutic endovascular or surgical procedures .
contrast venography remains the standard for diagnosis of ivc thrombosis with a low false - positive rate , and the advantage of access for immediate treatment if required .
however , it is an invasive procedure associated with a 2%-10% incidence of post - procedural deep venous thrombosis ( dvt ) .
duplex ultrasound scanning has become an accurate non - invasive method of diagnosing ivc thrombosis and is often the first - line investigative modality .
however , duplex usg is operator dependant and can be limited by body habitus or the presence of bowel gas and may occasionally fail to identify any ivc anomaly .
ct imaging is a rapid non - invasive method which can accurately diagnose and assess the extent of thrombus as well as delineate any associated abdominal or pelvic abnormality .
mri imaging is now replacing ct as the optimal investigative tool avoiding radiation and giving more accurate delineation of thrombus as well as any ivc anomaly .
mri is also used to follow - up patients to determine morphological changes in the thrombus following therapy .
management of patients with coexisting pheochromocytoma and ivc thrombosis needs operative resection of the adrenal mass and medical / interventional management of ivc thrombosis .
the goals of operation include 1 ) removal of the tumor with postoperative normotension , and 2 ) ivc luminal restoration and anticoagulation .
minimally invasive techniques are being increasingly used for resection of adrenal tumors and to treat renal artery lesions .
our patient was subjected to laparoscopic adrenalectomy after adequate preoperative blood pressure control by  blockers , followed by  blockers .
treatment options in the case of ivc thrombus without anatomical variance include anticoagulation , mechanical thrombectomy , systemic thrombolytic therapy , transcatheter regional thrombolysis , pulse - spray pharmacomechanical thrombolysis and angioplasty .
there is no specific literature describing the ideal duration of anticoagulation in these instances ; however , case evidence identifies a trend toward treatment for a minimum of one year with the interplay of hypercoagulability disorders needing to be factored into any decision .
surgical reconstruction of the ivc and bypass of an aberrant section are both recognized modalities reserved for the most severe cases and are associated with morbidity and mortality risk .
endovascular stent placement in combination with angioplasty is recommended in the cases of residual stenosis and chronic ivc occlusion . in the case of ivc thrombus
associated with an aberrant ivc , with no other predisposing factors , treatment involves anti - coagulation .
the duration of this treatment is widely debated with no extensive literature to provide an evidence based approach .
dean et al . took a view , which is quite similar to that of ours , that a caval anomaly is a permanent risk factor for venous stasis and thrombosis and that anticoagulant treatment should be lifelong . since our patient had no anatomic abnormality or any other predisposing factors , we decided to give the treatment for 4 months only and stopped it then after documenting radiologic luminal restoration .
though cases of renal artery stenosis , renal artery aneurysm and inferior vena cava thrombosis have been described , we found the uncommon association with ivc thrombosis in an indian patient .
ct or preferably mri imaging are required to delineate ivc anatomy and ascertain proximal extent of the thrombus .
although invasive therapeutic modalities exist , long - term and commonly life - long anticoagulation is often required .
pheochromocytoma does not seem to have any effect on the outcome of the coexisting ivc thrombosis .

 pheochromocytomas have been described in association with vascular abnormalities like renal artery stenosis .
 a 48-year - old man was admitted to our hospital with the complaints of headache , sweating , anxiety , dizziness , nausea , vomiting and hypertension . for last several days , he was having a dull aching abdominal pain .
 abdominal computed tomography ( ct ) revealed the presence of a left adrenal pheochromocytoma .
 an inferior vena cava ( ivc ) venogram via the right jugular vein demonstrated occlusion of the ivc inferior to the right atrium .
 surgical removal of pheochromocytoma was done , followed by anticoagulant treatment for ivc thrombosis , initially with subcutaneous low molecular weight heparin , and then with oral warfarin , resulting in restoration of patency . to the best of our knowledge ,
 the occurrence of pheochromocytoma in ivc thrombosis has not been reported so far from india .
 possible mechanisms of such an involvement are discussed .


 acute mountain sickness ( ams ) occurs during exposure to high altitude ( ha ) and is a clinical syndrome characterised by headache , insomnia , malaise , and gastrointestinal symptoms .
it is common , developing in 1030% at 25003000 meters   and in up to 60% of those ascending to around 4500 meters .
it causes significant morbidity and is a challenging clinical condition in remote environments . a biochemical marker of ams , particularly one available as a point - of - care test ( poc ) , could have widespread clinical utility .
the pathophysiology of ams is not clearly understood but involves alterations in fluid balance , endothelial function , vascular permeability , inflammation , and oxidative stress .
the renal response to ha is an important factor in acclimatization , and ha exposure leads to renal arteriole constriction and relative hypoxia [ 3 , 4 ] . despite the relative renal hypoxia ,
ngal ( neutrophil gelatinase - associated lipocalin ) is a 25  kda peptide , part of the lipocalin family of small soluble proteins .
it is produced in a number of human tissues , notably the distal nephron but also in the lung   ngal rises rapidly in the nephron in response to a renal insult and an ngal 150  ng / ml following acute kidney injury ( aki ) is predictive of acute renal failure ( arf ) well before creatinine has risen .
ngal is also an acute - phase protein , has a role in inflammation [ 8 , 9 ] , and is upregulated in the lung during inflammation [ 5 , 10 , 11 ] .
ngal is also known to rise in conditions associated with oxidative stress [ 12 , 13 ] , and oxidative stress has been implicated in ams [ 14 , 15 ] .
we therefore hypothesised that ngal would increase at ha secondary to these various stimuli and that the magnitude of any increase might relate to the presence of ams .
we therefore studied a combined cohort of trekkers from 2 expeditions to ha . in order to clarify the relative contribution of ams , hypoxia or exercise to ngal levels
, we also studied a cohort pre- and postexercise at near sea level , and a further cohort exposed to acute normobaric hypoxia .
the potential role of inflammation in stimulating ngal was assessed by the measurement of highly sensitive c - reactive protein ( hscrp ) in a subset of participants .
all study protocols were approved by the ministry of defence research ethics committee , whitehall , uk , and satisfied the requirements of the declaration of helsinki . in all studies informed ,
thirty - two subjects participating in a defence medical services ( dms ) trekking expedition ( trek 1 ) in the khumbu region of nepal were studied .
blood samples were taken from the antecubital fossa at 3 study altitudes : on day 2 at 3400  m , day 6 at 4270  m , and day 10 at 5150  m ( following ascent to everest base camp at 5364  m ) . all samples in this study
were collected immediately following a day trekking (  posttrek  ) to the study altitude .
twenty subjects from a further dms expedition ( trek 2 ) to nepal were also studied .
blood samples were again taken at 3 study altitudes : on day 2 ( 3400  m ) , day 6 ( 4270  m ) , and day 10 ( 5150  m ) ( following ascent to kala patthar ( kp ) , 5643  m ) .
samples in this study were again collected immediately following a day trekking (  posttrek  ) .
additional samples were taken at rest in kathmandu ( kat ) at 1300  m and at rest the next morning at the 3 study altitudes .
as serving members of the military , all subjects were able to fulfil the fitness criteria of their relevant service .
this broadly includes an age - adjusted ability to run 1.5 miles in under approximately 11 minutes and to perform an age - adjusted number of sits - ups and push - ups within two blocks of 2 minutes .
fourteen subjects underwent a 3-hour exposure to normobaric hypoxia ( fio2 11.6% , equivalent to 4800  m altitude ) in a hypoxic chamber .
this exposure included a 5-minute step test ( step height of 25  cm , 1 complete step every 2 seconds ) at 95 minutes .
a group of 22 subjects had ngal assayed at rest and after exercise at sl in the uk following ascent from sea level to 1085  m over 6 hours ( an equivalent gain in altitude and duration of exercise similar to that experienced on a trekking day in nepal ) .
two subjects from trek 2 were part of the sl exercise group , but data collection occurred several months apart .
ngal was analysed in the field on a biosite triage point of care monitor ( alere ltd , stockport , uk ) using a triage ngal test kit .
the triage ngal test is a point - of - care , fluorescence - based immunoassay used which gives a rapid ( 15 minutes ) quantitative measurement of ngal in a range from 60 to 1,300  ng / ml .
oxygen saturation ( digitally on warm hands at rest ) was measured using a nellcor np-20 pulse oximeter ( covidian , ma , usa ) during trek 1 + 2 and in the hypoxic chamber study at the same time as blood samples were taken . during trek 1 + 2 ,
twice - daily ams scores were assessed using the lake louise score ( lls ) questionnaire .
the lls allocates a score of 0 to 3 ( symptom not present to severe ) for symptoms of ams ( headache , gastrointestinal symptoms , fatigue / weakness , dizzy / light - headedness , and difficulty sleeping ) .
a score of 3 or more in the presence of headache is consistent with ams , a score of 6 or more with severe ams .
the commercially available , highly sensitive , immunoturbidimetric assay ( roche diagnostics ) was used to measure crp in trek 2 at the same time points as ngal .
mg / l and a between - run coefficient of variation between 2.5 and 5.7% . for statistical calculations ,
the software package spss 14.0 was used . for subjects with a ngal below the limit of detection of the assay ( 60  ng / ml ) ,
a value of 60  ng / ml was assigned for the purposes of statistical analysis .
all data were tested for gaussian distribution using the kolmogorov - smirnov test and shapiro wilks statistic .   for the analysis of dependent variables that were normally distributed , changes were tested by student 's paired t - test . for independent variables that were normally distributed ,
a within - subjects anova was performed to investigate any serial changes in ngal with ascent at rest and post - trek . a two - way mixed anova with either resting or after trek ngal at each study altitude as the within - subjects factor and the presence of ams ( according to the ll score at multiple altitudes ) as the between - subjects factor
if the mauchly sphericity test was significant , then p values were expressed after multiplication by the greenhouse - geisser epsilon .
correlation analyses for normally distributed data were performed by calculating the pearson coefficient of correlation .
a p value < 0.05 ( two - sided ) was considered significant . as the ascent profile and route were closely matched in trek 1 and trek 2 , data were combined and analysed as a whole . taking medication ( acetazolamide , dexamethasone )
had no apparent effect on ngal values , and therefore these subjects ( n = 11 ) were not excluded from the analysis .
demographic data for the field study ( trek 1 + 2 ) , the controls , and the hypoxic chamber study are shown in table 1 . in the 22 subjects ascending to 1085  m in the uk
, there was no significant ( p = 0.084 ) rise in ngal following exercise : resting sl ngal was 64  11 ( ng / ml , mean  sd , range 60104 ) and postexercise ngal was 71  14 ( ng / ml , mean  sd , range 60100 ) . of the 52 subjects ,
spo2 ( % , mean  sem ) dropped from 97  2 at kat ( 1300  m ) to 84  5 and 79  7 at 4270 and 5150  m , respectively ( p < 0.001 ) .
there was a moderate inverse correlation between ngal and spo2 at 5150  m ( r = 0.477 , p = 0.001 ) ( figure 1 ) with a weaker inverse correlation between ngal and spo2 at 4270  m ( r = 0.340 , p = 0.019 ) .
within the subjects , anova demonstrated a significant change in ngal with ascent both at rest ( p = 0.007 ) and after trek ( p = 0.001 ) ( figure 2 ) .
spo2 ( % , mean  sem ) dropped from 99  0.4 at baseline to a nadir of 79  5 ( p < 0.001 ) . despite an equivalent drop in spo2 to
that seen in trek 1 + 2 , ngal ( ng / ml , mean  sd , range ) showed no change between baseline and 180 minutes : 63  26 ( 2980 ) versus 67  25 ( 2784 ) , p = 0.538 . in trek 2 , serum creatinine { mol / l , mean  sem , ( range ) , ( p value versus baseline at kat ) } was 78  2 ( 6395 ) at baseline ; at 3400 , 4270 and 5150  m it was 87  3 ( 72120 ) ( p = 0.001 ) ; 84  2 ( 72104 ) ( p < 0.001 ) ; and 94  5 ( 76142 ) ( p < 0.001 ) .
according to their ll scores at the highest study altitude ( 5150  m ) , there were 23 subjects with no ams , 16 subjects with mild ams , and 7 subjects with severe ams .
there was a significant difference between ngal depending on the presence or absence of ams at 5150  m ( figure 3 ) with higher values in those with ams and severe ams . a two - way mixed anova revealed a significant change ( p = 0.003 ) in resting ngal with ascent and an interaction with ams at 4270  m ( p = 0.017 ) and 4910  m ( p = 0.002 for change in ngal , p = 0.027 for interaction with ams ) .
hscrp was ( mean  sem , range ) : 1.6  0.4 ( 0.337.53 ) at baseline ; at 3400  m , 4270  m , and 5150  m post - trek : 7  2.9 ( 0.7847.93 ) ( p = 0.002 versus baseline ) ; 25.7  8.1 ( 0.58104 ) ( p < 0.001 versus baseline ) ; 9  3.2 ( 0.5644.62 ) ( p = 0.003 versus baseline ) . at 3400  m , 4270  m , and 5150  m at rest : 6.2  2.9 ( 1.8725.1 ) ( p = 0.001 versus baseline ) ; 21.6  5.7 ( 0.4983.9 ) ( p < 0.001 versus baseline ) ; and 5.8  2.1 ( 0.5426.59 ) ( p = 0.012 versus baseline ) .
ngal at 5150  m , after trek was moderately correlated with hscrp at 5100  m after exercise ( rho 0.526 , p = 0.036 ) .
this is the first report to describe an association between ngal and both the presence and severity of ams at ha .
the significant novel findings are that ngal rises in response to sustained hypobaric hypoxia but not acute normobaric hypoxia or near sl exercise and that this rise is related to ams at 5150  m.   the rise in ngal following trekking ( by day 2 at 3400  m ) was to the levels normally associated with the subsequent development of arf ( > 150  ng / ml ) , but this did not occur .
although creatinine rose significantly with altitude , the rise was very modest , and we suspect that a combination of factors other than a simple renal insult is responsible for the increase in ngal at ha .
our data suggest an inverse correlation between spo2 and ngal at 5150  m ( and to a lesser extent at 4270  m ) . although no such correlation was found at 3400  m , this may still suggest that prolonged renal hypoxia could be a significant drive to ngal release .
in addition to renal hypoxia , we suspect that other factors may also contribute to the rise in ngal at ha .   the significantly greater ngal in those with severe or mild ams versus those without at 5150
indeed , ngal is an acute - phase protein   with a role in inflammation [ 8 , 10 , 11 ] .
exercise stimulates an immune response , and hypoxia is also known to cause a response in immune and endothelial cells with inflammatory markers such as hscrp increasing with ha [ 1922 ] .
consistent with this , we saw a significantly higher hscrp at all altitudes compared to baseline .
limited data have suggested hscrp may be associated with ams   but we did not demonstrate any evidence to support this .
there was a weak correlation between hscrp and ngal at 5150  m but this can not explain the rise in ngal as a whole .
ngal also rises with oxidative stress [ 9 , 12 ] which is increased by exercise , and ha - induced oxidative stress   has been implicated in ams . as such , it is interesting to note that we found a higher ngal following trekking and in those with ams at the highest altitude .   in an attempt to clarify the relative influence of exercise and hypoxia on ngal , we measured ngal before and after exercise of a similar duration ( 6  hrs ) and similar incremental altitude ( 1085  m ) as that experienced daily in nepal and also in a hypoxic chamber . in neither scenario did ngal rise .
this may reflect inadequate duration or severity of stimulus but may also reflect that the ngal response is not due to exercise or hypoxia alone but is multifactorial involving hypoxia , oxidative stress , an inflammatory response , and other , as yet unidentified , stimuli .
we also acknowledge limitations such as a lack of serum markers of oxidative stress and a lack of resting ngal data in trek 1 .
in addition , we did not measure ngal at sl before departure to nepal , although the ngal recorded as a baseline at kat ( 1300  m ) ( 68  ng / ml ) was no different to those recorded at sl in the uk ( 63 and 64  ng / ml ) .
we also acknowledge the fact that although we measured creatinine in trek 2 , we did not continue to monitor it after the cessation of trekking . as a consequence of creatinine rising more slowly in response to a renal insult than ngal ,
in conclusion , there are several interesting and novel findings that are worthy of further exploration .
ngal rises in response to prolonged hypobaric hypoxia ; marked increases in ngal may occur without concomitant arf and the degree of ngal rise at ha is associated with the presence or absence of ams .
the fact that ngal does not appear to rise secondary to acute normobaric hypoxia or exercise in isolation suggests that the rise at ha and relation with ams may have common pathways , perhaps related to prolonged hypoxia and an inflammatory response . with the huge and increasing popularity of recreational sports undertaken at both moderate and high altitude
assessment of ngal takes a matter of minutes using poc testing , and its use in identifying ams requires further evaluation .

 acute mountain sickness ( ams ) is a common clinical challenge at high altitude ( ha ) . a point - of - care biochemical marker for ams could have widespread utility .
 neutrophil gelatinase - associated lipocalin ( ngal ) rises in response to renal injury , inflammation and oxidative stress .
 we investigated whether ngal rises with ha and if this rise was related to ams , hypoxia or exercise .
 ngal was assayed in a cohort ( n = 22 ) undertaking 6 hours exercise at near sea - level ( sl ) ; a cohort ( n = 14 ) during 3 hours of normobaric hypoxia ( fio2 11.6% ) and on two trekking expeditions ( n = 52 ) to over 5000  m. ngal did not change with exercise at sl or following normobaric hypoxia . during the trekking expeditions ngal levels ( ng / ml , mean  sd , range ) rose significantly ( p < 0.001 ) from 68  14 ( 60102 ) at 1300  m to 183  107 ( 65519 ) ; 143  66 ( 60315 ) and 150  71 ( 60357 ) at 3400  m , 4270  m and 5150  m respectively .
 at 5150  m there was a significant difference in ngal between those with severe ams ( n = 7 ) , mild ams ( n = 16 ) or no ams ( n = 23 ) : 201  34 versus 171  19 versus 124  12 respectively ( p = 0.009 for severe versus no ams ; p = 0.026 for mild versus no ams ) . in summary ,
 ngal rises in response to prolonged hypobaric hypoxia and demonstrates a relationship to the presence and severity of ams .