Introduction From August to more than leading

From August 8 to 10, 2013, more than 120 leading clinicians, researchers, patient advocates, and industry representatives convened in Snowmass Village, Colorado, for the 8th Annual Bladder Cancer Advocacy Network-Think Tank (BCAN-TT). This year׳s meeting engaged participants representing more than 60 institutions from across the United States, Canada, and Europe. Bladder glucose transport proteins cancer is the sixth most common cancer in the United States. In 2013, there were an estimated 72,500 new cases and more than 15,000 deaths from this malignancy [1]. With no major changes in these statistics over the past 30 years, there continues to be a tremendous need for more glucose transport proteins cancer research. Since 2006, the BCAN-TT has focused on creating collaborative opportunities for researchers, practitioners, advocates, and industry partners to move the field forward.

Understanding sex disparities in bladder cancer

Sexual dysfunction in bladder cancer: Expanding the conversation

Targeting novel pathways in bladder cancer

Working Groups

Clinical Trials Working Group

Translational Science Working Group

NMIBC Working Group

Standardization of Care Working Group

Survivorship Working Group

Patient-Centered Outcomes and Policy Working Group (formerly Health Services Research and Health Policy Working Group)

Upper Tract Disease Working Group



Radical cystectomy (RC) and urinary diversion (UD) are the gold-standard treatments for muscle-invasive bladder cancer (BCa) [1]. Despite advances in anesthesia, surgical techniques, and perioperative care, postoperative morbidity within 3 months of surgery is greater than 60% in the contemporary series [2]. Long-term complications related to the UD can also lead to significant morbidity. For example, the incidence of benign ureterointestinal anastomotic (UIA) strictures following RC and UD is reported at 1% to 13% [3–7]. Although most UIA strictures become clinically evident between 7 and 18 months postoperatively [5,7,8], patients occasionally present after more than 10 years from their initial surgery [4]. Patients with UIA strictures can present with nephrolithiasis, recurrent pyelonephritis, asymptomatic worsening hydronephrosis, or even more insidiously with impaired renal function. The pathophysiology of UIA stricture formation is likely secondary to ischemia and inflammation, resulting in fibrosis and ureteral obstruction; however, the exact etiology of UIA strictures remains elusive.
Meticulous surgical technique, preservation of periureteral adventitia and blood supply, avoidance of electrocautery, and excision of the distal or compromised ureter before anastomosis are common strategies employed to mitigate the risks of UIA stricture formation [9]. Additionally, a running end-to-side Bricker UIAs [10], a postoperative urinary tract infection (UTI) [10], and an antirefluxing technique [3,4,11] are potential risk factors for UIA stricture formation. By contrast, Anderson et al. [12] were unable to identify any patient- or disease-specific factor to be associated with UIA stricture formation in a cohort of 478 patients from their institution.

Materials and methods
We obtained approval from our institutional review board before initiating this analysis. A prospective database was reviewed for patients undergoing RC with ileal conduit or ileal orthotopic neobladder UD by 2 surgeons (G.D.S. and N.D.S.) from 2007 to 2012. Both the surgeons have extensive experience in urologic oncology and large practices in BCa resection. An orthotopic neobladder was constructed as a Studer pouch or a modified Hautmann pouch with an isoperistaltic afferent limb. A permanent distal ureteral specimen is routinely sent intraoperatively but frozen sections are not. All UIAs were performed in a similar Bricker end-to-side tension-free technique using 4-0 polyglactin sutures on CV-23 needles. The decision to perform a running vs. interrupted UIA or to excise additional ureter was at the discretion of the surgeon. Our technique for running UIA has been previously described [10]. A single 4-0 monofilament traction suture is placed at the 12-o’clock position to avoid unnecessary manipulation and to ensure correct orientation. The left ureter is tunneled through a wide channel created beneath the sigmoid mesentery by grasping the traction suture with a large right-angled clamp. All anastomoses were stented with either 5-F feeding tubes or 7-F single J stents and tested for water tightness upon completion by irrigating the conduit or the afferent limb with a bulb syringe. Stents were removed following tolerance of oral diet (G.D.S) or approximately 2 weeks postoperatively (N.D.S). The length of the ureter resected was defined as the length of the ureter in the cystectomy specimen plus the length of the distal ureter submitted separately for pathologic analysis. It is a routine practice for our pathologists to quantify the length of the ureter in the specimens and to comment on the presence of dysplasia or neoplasia in the distal ureter on the final pathologic report.

As life expectancy increases and oncologic

As life expectancy increases and oncologic outcomes are good, functional outcomes such as continence and potency become a more important factor to consider. Yet, only few studies have focused on functional outcomes after RP in elderly patients, and only 2 of them analyzed the effect of age especially on patients aged 75 years or older, with differing results [14–20].

Patients and methods


Despite the large body of literature on outcomes after RP, there are only a few studies focusing on the effect of age≥70 years on outcomes after RP (Table 5) [14,15,17,18,20,24,25].
Kunz et al. [14] stratified patients who underwent RP into age groups of ≥70 (1,225 patients) and<70 years (411 patients) at the time of surgery and did not show a significant difference in 24-month continence (International Continence Society Male Short Form incontinence score) and potency (IIEF-5 score≥17) rates. Contrary to our study, the authors did not find advanced age to be significantly associated with worse continence rates after RP in multivariate analysis. The reason for this purchase Cyclopamine is probably the use of only 2 age groups (≥70 and<70y). Kundu et al. reported continence (no pads) and potency (erection sufficient for intercourse) rates in patients grouped as<50, 50 to 59, 60 to 69, and≥70 years in a single-surgeon series of 3,477 consecutive patients treated with anatomical nerve-sparing radical retropubic prostatectomy from 1983 to 2003. Similar to our results, a significant decrease in both continence (95%, 96%, 93%, and 86%; P<0.001) and potency (92%, 85%, 70%, and 51%; P<0.001) rates over the respective age groups was shown [24]. Patients without nerve sparing were excluded from potency analysis. To our knowledge, there are only 2 studies focusing on patients aged 75 years or older. Shikanov et al. showed a significantly worse outcome for continence (pad free) and potency (erection sufficient for intercourse) in elderly patients 1 year after surgery in a cohort of 1,436 cases who underwent robotic RP. Age was used as a continuous variable. Predicted point estimates were calculated at 65, 70, and 75 years of age. The corresponding values were 66%, 63%, and 59% for continence and 66%, 56%, and 46% for potency, respectively. Only patients who underwent robotic RP were included. The relevant age group with patients aged 70 years or older only consisted of 77 patients. Thus, the predicted point estimates at 70 years of age and especially at 75 years of age might be biased because of the small number of observations in Marker age group [17].
Similar to our study, Labanaris et al. [25] investigated the effect of age on functional outcomes and thereby also focused on patients aged 75 years or older. The records of 2,000 men who underwent robotic-assisted radical prostatectomy from February 2006 to April 2010 were retrospectively reviewed. Patients were stratified into 2 age groups (≥75 and<75y). The authors failed to show a significant difference in 12-month continence rates between both the age groups (92.8% vs. 86.9%, P>0.05). This might have been because of the small sample size (n = 45) of patients aged 75 years or older. Confirming our findings, a significant difference in postoperative potency between age groups (66.2% vs. 39.6%, P<0.001) was reported, whereby only patients with bilateral nerve sparing were included in the potency analysis. No multivariate analyses were performed.
We analyzed the data of nearly 8,300 patients after RP using multivariate regressions and found a clear negative effect of age on both 3- and 12-month rates of postoperative continence and potency. Nevertheless, we showed that the absolute continence and potency rates even in patients older than 70 and 75 years were reasonably high, and hence, age alone is not a contraindication for RP from a functional outcome point of view. Moreover, we provided detailed predicted functional outcome graphs for continence and potency over age groups, allowing guidance for patients before surgery. Interestingly, 12-month continence rates among patients aged 70 to 75 years and 75 years and older were similar and statistically not different (86.0% vs. 86.5%, P = 0.876). Although the size of both the groups is reasonably large to make a conclusion, the influence of nonobserved factors (i.e., selection bias of healthier patients as surgical candidates in older cohorts) on this observation cannot be addressed.

br CYP A and its

CYP17A1 and its role in androgenic steroid production

Rational approach to the development of a specific and potent CYP17A1 inhibitor
Abiraterone is a pregnenolone analogue and a highly specific and irreversible CYP17A1 inhibitor [6,7]. Abiraterone acetate is a 3β-acetoxy prodrug of abiraterone with improved bioavailability compared with abiraterone [8]. After absorption, the 3β-acetoxy prodrug is rapidly hepatically deacetylated to abiraterone. Before the approval of abiraterone, ketoconazole, a nonspecific CYP17 inhibitor, was sometimes used to treat CRPC. Responses were reported in 40% to 60% of patients and associated with reduced levels of testosterone, androstenedione, and DHEA at doses of 400mg 3 times daily. However, as ketoconazole has low specificity for CYP1A1, the dose required for inhibition of CYP17A1 could be associated with significant toxicity. Moreover, loss of CYP17 inhibition with an increase in circulating adrenal androgens often occurred at progression [9]. Abiraterone inhibited both 17α-hydroxylase and C17,20 lyase activities significantly more potently than ketoconazole.
Abiraterone acetate preclinically reduced circulating testosterone levels in male rat and mouse and reduced the weights of androgen-dependent PCI-34051 [8,10]. Important features of abiraterone include the pyridyl ring at C17 (the 2-pyridyl and 4-pyridal analogues are less potent) and the C16, 17 double bond [11]. The ideal agent would inhibit specifically CYP17A1 lyase activity, and not affect cortisol. This to date has been a significant challenge with a number of more specific C17,20 lyase inhibitors currently undergoing evaluation in early clinical trials. The x-ray crystal structures of CYP17A1 bound to abiraterone was also recently reported and confirmed abiraterone binding to cytochrome p450 haem iron [12]. Abiraterone also binds AR weakly and is a weak AR antagonist [13]. The clinical relevance of the latter is uncertain given the clinical activity of abiraterone in patients could be entirely explained by suppression of androgen levels.

Clinical evaluation of abiraterone acetate

Future directions
Given the efficacy and tolerability of abiraterone in CRPC, trials have been designed to assess abiraterone in earlier stages of prostate cancer disease. Abiraterone acetate is being assessed in castrate men in both the neoadjuvant setting before radical radiotherapy (NCT02160353) and after biochemical relapse following radical surgery, in combination with salvage radiotherapy (NCT01780220).
A number of trials have been designed to assess the tolerability and efficacy of combination treatment strategies of abiraterone acetate and prednisone with enzalutamide. A phase I trial from MD Anderson suggests combination treatment strategies will be well tolerated [44]. PLATO is a multicenter trial evaluating the efficacy of adding abiraterone acetate and prednisone vs. placebo and prednisone to enzalutamide at the point of progression ( NCT01995513) to further suppress AR activation, which may be re-emerging on resistance to enzalutamide. Furthermore, given the tolerability of single-agent abiraterone acetate in phase I trials, its administration without concomitant glucocorticoids is being re-evaluated (NCT02025010). Additionally, abiraterone is undergoing evaluation in combination with other approved (e.g., radium-223, NCT02034552) and multiple experimental agents.


Conflict of interest

Since 2000, remarkable headway has been made in our understanding of the biology that underlies development and progression of cancer [1–4]. Particularly important advances have been made in the application of genomics and proteomics to identify and characterize cancer-associated molecular and genetic alterations (e.g., microarray analysis and next-generation sequencing) and in technologies that may be used to measure these characteristics as well as to measure cellular and tissue changes (e.g., quantitative and high-definition imaging, single-cell analysis, and microfluidics). Also important is progress in the design of instruments to measure patient symptoms (e.g., Brief Bone Pain Inventory [5]) and other quality-of-life factors (e.g., patient-reported outcome questionnaires) and to provide systematic assessment of clinical observations and measurements (e.g., bone scan assay and quantitative imaging parameters). Despite these advances, many promising new drugs are failing late in development because they are tested in ill-defined patient cohorts or the gold standard end point of longer overall survival or other efficacy end points are uninterpretable because of confounding factors such as additional therapies during prolonged follow-up or both. Late failures can also arise because of unexpected safety issues from long-term exposure. Drug resistance from preexisting and evolving clones, recognized clonal heterogeneity, and influence of disparate factors outside of the tumor per se are universal challenges [6,7]. All this suggests a high likelihood that the development and clinical application of effective cancer treatments need to address patient-specific, PCI-34051 continuously changing molecular defects in the tumor itself and the tumor microenvironment. To overcome these challenges, the Food and Drug Administration (FDA) has called for the use of analytically and clinically validated biomarkers that have strong evidence of being fit for the purpose (context of use) of identifying patients likely to respond to therapy (prediction) and to evaluate patient response to therapy (response or sensitivity to the treatment), potential toxicity (safety), and understanding mechanisms associated with drug resistance either before or while on treatment [8–11]. In the following sections of this article, we discuss these specific applications of biomarkers for urologic cancers—specifically in cancers of the prostate and urinary bladder.

Our finding that EZH expression is greater in

Our finding that EZH2 expression is greater in flat CIS than invasive carcinoma contrasts with the findings of Wang et al. [10], which showed invasive carcinoma to have higher EZH2 expression than flat CIS. The reason for this discrepancy is unclear. Scoring systems used in both the studies were different, possibly accounting for the discrepancy. Much of this discrepancy may be a result of TMA design. The study by Wang et al. utilized material from 81 cystectomy specimens, from which 235 spots of invasive carcinoma and 49 spots of CIS were taken. In contrast, the TMA for the present study utilized material from 260 patients, from which 230 spots of invasive carcinoma and 120 spots of flat CIS were taken. The present study was thus larger in terms of patient number and CIS cores, which may have allowed for more accurate determination of EZH2 status. It is also possible that biases were introduced in taking multiple tissue cores of invasive carcinoma from single cystectomy specimens.

In summary, the present study shows that CIS is more commonly EZH2 positive than invasive carcinoma and noninvasive papillary UC. Benign urothelium was EZH2 negative more frequently than all cancer groups. Our data also uniquely show that EZH2 status of invasive and noninvasive Senexin B cancers present in the same bladder are correlated, suggesting that EZH2 may be a marker of lineage rather than a direct marker of stage progression. The present study showed no association between EZH2 expression and oncologic outcomes in bladder cancer, corroborating a prior study by Wang et al. [10].


Despite the introduction of drugs targeting vascular endothelial growth factor or the mammalian target of rapamycin, metastatic renal cell cancer (mRCC) is still the tenth cancer-related death in developed countries [1]. Patients respond heterogeneously to targeted therapy [2], and outcomes can differ substantially between individuals with similar clinical and pathological characteristics [3].
Prognostic models like the Memorial Sloan-Kettering Cancer Center (MSKCC) and International Metastatic Renal Cell Carcinoma Database Consortium (IMDC) risk assessment have been validated to stratify the patient risk of cancer progression and overall survival (OS) in the era of targeted therapy [4]. However, patients assigned to identical risk groups still have a broad range of survival expectancy. For example, intermediate-risk patients have a median survival of 27 months [4,5], but 25% do not survive the first year and 25% live 4 years and longer [5].
In a recent IMDC retrospective study consisting of exclusively synchronous mRCC, only those patients who underwent cytoreductive nephrectomy (CN) had a prognosis comparable to the survival expectancy reported for intermediate risk in the literature [6]. Survival for patients without a CN was 10 months shorter despite sharing the same risk group. The survival difference became nonsignificant with ≥4 IMDC factors present. Although next generation sequencing is underway to unravel predictive and prognostic gene signatures, no molecular biomarkers have been identified to augment the existing risk models. Several clinical parameters have been suggested to improve prediction of survival expectancy in mRCC. A recurrent and consistent feature is sexual reproduction the extent of disease at the time of diagnosis may determine the heterogeneous outcomes observed within identical risk groups. The definition of disease extent varies in literature, using number of metastatic sites, baseline tumor burden (TB) according to Response Evaluation Criteria in Solid Tumors (RECIST) or volume of disease [7–9].
Baseline TB according to RECIST is easy to measure on diagnostic computed tomography (CT) scans. However, the correlation between longest diameter and tumor volume (TV) is not perfect [10]. A study revealed significant variability of lung tumor measurements by RECIST on CT scans taken within 15 minutes [11].

br Discussion Urban planners and other policy makers should be

Urban planners and other policy makers should be interested in the questions examined in this study, especially as urban agricultural uses—including daunorubicin gardens—become an “object of planning” (Thibert, 2012). Thibert (2012) argues that food provision and urban agriculture need to be better theorized as a planning strategy and integrated into comprehensive plans and frameworks. But before this integration occurs, it would be helpful to know more about community gardens as a land use, particularly in terms of attractiveness, so that the benefits of the use can be maximized.
Further investigation into the maintenance question is warranted because maintenance was loosely defined in this study and the level of maintenance required for a community garden in Ohio varies greatly by season. While not exhaustive, the following list provides some idea of the maintenance tasks typically required per season:
Study limitations: It is possible that the study participants differ demographically from the people who typically live near urban green spaces. Demographic information was not collected because a frequently cited meta-analysis by Stamps (1999) found that demographic groups (including cultural and ethnic groups) do not differ in how they rate the attractiveness of environments. According to Stamps (1999), the degree of consensus is so strong that it would take a study of 100,000 stimuli that generated a correlation of 0.0 to overturn his findings. Notably, one issue that Stamps (1999) did not examine in detail is whether exposure to green spaces or gardening influences responses. Therefore, since the study is based on the observations of participants interested in community gardening, the author checked for biases within this group and found that responses varied little according to frequency of gardening at home, frequency of community gardening, or gender. While the sample did not differ internally, it is still possible that the responses differ from those of the general population.
Given the number of photos in the survey and the lack of incentives provided to people to participate, an effort was made to keep the survey as brief as possible to improve the response rate. Therefore, no open-ended response options were included in the study. For example, participants were not asked to indicate why they rated the spaces as attractive or unattractive. This information would have been helpful to contextualize the results. If participants had based their ratings on summertime attractiveness and greenery, then they would have rated winter scenes as less attractive. If they had based their ratings on a standard of wintertime attractiveness, then they may have considered certain winter landscapes attractive. In this study, a given participant\’s frame of reference or standard of attractiveness is not known. In retrospect, it would have been useful to ask participants an open-ended question about what characteristics make an open space and/or community garden attractive before showing them the photographs. Similarly, participants were not directly asked whether they prefer gardens over vacant lots or how vacant lots should be reused, since these questions were not the focus of the study. If participants had been asked these types of questions, perhaps the study\’s results would be interpreted differently. Some people may prefer vacant lots in general—not necessarily esthetically—because of the increased possibilities for active recreation.

With forethought and care, urban green spaces can serve many functions, including increasing the attractiveness of a neighborhood. This study has shown that, regardless of season, the level of maintenance of a green space has the largest influence on perceived attractiveness. Properly maintained green spaces are vital to resident morale and overall health (Hale et al., 2011; Litt et al., 2011; Pleasant et al., 2013)—especially in legacy cities where neighborhoods are often plagued by blight (e.g., abandoned homes and vacant lots).

dihydrofolate reductase The HEC emerges as a place of calm sanctuary

The HEC emerges as a place of calm, sanctuary, and rejuvenation for research participants. The words “quiet”, “calming”, and “peaceful” are frequently used to describe the courtyard forest. Student participants speak of it dihydrofolate reductase as a place where they can get away from computers, deadlines, academic pressures, and other stressful situations (Fig. 4).

Restorative contributions
It is noteworthy that the calming effects and other personal contributions of the courtyard forest reflect certain qualities of restorative environments identified by leading theorists Stephen Kaplan and Roger Ulrich. In early seminal publications (Kaplan, 1991, 1995; Ulrich, 1992, 1999), they offer distinct lists (with some overlapping elements) of requirements which must be met if places – including healthcare environments, places of learning, and general everyday surroundings – are to help restore peoples’ capacities to recover from stress and to process information more effectively. These capacities are particularly relevant to work at a university campus, as reflected in research participant statements that time spent in the HEC helps to reduce tension, rest the mind, and restore motivation to return to work.
Kaplan (1991, 1995) describes a restorative environment as physically or conceptually different from one\’s everyday environment, a setting which offers distance from day-to-day routine work pressures and other negative situations. Ulrich (1992, 1999) stipulates that a restorative environment must also offer privacy from everyday environments and tensions.
Both Kaplan and Ulrich stress that such restorative environments must also offer a high level of interest to people needing to recover from stress and/or recharge their mental energies. The place must be fascinating enough to distract from stressful activities and situations, to maintain associated attention without effort (Kaplan, 1991, 1995), and to provide positive stimulation which can block or reduce negative thoughts (Ulrich, 1992, 1999). Nature, Ulrich (1992, 1999) points out, offers particularly effective positive distractions and stimuli.
Reciprocity, interestingly, suggests a certain agency on the part of the wildlife and plants in the courtyard forest. While agency has typically been emphasized as a human accomplishment growing out of human consciousness, intent and capacity for transformative action, it can also be understood more generally as the capacity to act, produce an effect, or exert power (OED, n.d.). This more basic conception of agency is manifested by both human and nonhuman entities in the HEC, where members of the natural community are, in a sense, responding to both intentional and unintended human activities. Flora and fauna act, for example, by simply appearing (seeds germinating), growing, and thriving. Various species acting together could be perceived as producing an effect of wildness and privacy, thereby exerting a certain power of fascination, stimulation, distraction and refuge – which combine to benefit human courtyard visitors. The dynamic uniqueness and significance of the HEC could, in fact, be cast in terms of human and nonhuman agency interacting and reciprocating.

Looking back, looking forward
The HEC is essentially an experiment, an attempt to establish a piece of boreal forest – actually “Laurentian boreal/mixed hardwood transition forest” according to a plaque at the courtyard entrance – in an urban, downtown location. The experiment has not been successful in establishing a true boreal ecosystem because of the growing conditions at the location; the confines of the enclosed space also limit the forest\’s capacity to transition. Yet the courtyard forest has succeeded in growing into a unique and vibrant little ecosystem which plays important roles on campus – roles which could develop and expand to enrich the student experience and improve workplace wellness, while at the same time enhancing biodiversity and campus ecology in dynamic reciprocity. The same potential exists for similar spaces at other places of research and learning, as already noted on other North American university campuses (Bardekjian et al., 2012; Barlett, 2002).

Introduction Today high school students face unprecedented levels of school

Today, high school students face unprecedented levels of school-related stress and mental health issues (Marin and Brown, 2008). The buy KN-93 hydrochloride that students have to deal with in university entrance exams, for example, has increased to significant levels in recent years in Turkey (Student Selection and Placement Center, 2014). According to the Student Selection and Placement Center, known as ÖSYM, more than 1.9 million students took the university entrance exam in 2014 and only 38% of those students could attain universities and two year colleges in Turkey (Student Selection and Placement Center, 2014). Researchers have demonstrated that the university entrance exam is the leading source of stress and mental health issues among high school students (Özbaş et al., 2012; Sonay, 2012). In addition, many researches have shown that in this age group school-related issues are the main reasons for stress and mental health problems (Kaiser Family Foundation, 2005; Stuart, 2006; Marin and Brown, 2008). Furthermore, while stress and anxiety levels are increasing among young people (Twenge et al., 2010; Collishaw et al., 2010; Murphy and Fonagy, 2012), young people are at high risk for mental disorders and other health co-morbidities due to high levels of stress and anxiety (McNamara, 2000; Murphy and Fonagy, 2012).
A growing body of research has investigated the restorative effects of green space on human health (Kaplan and Kaplan, 1989; Hartig et al., 1991; Laumann et al., 2003; Hartig and Staats, 2006; Berman et al., 2008; Roe and Aspinall, 2011a; Wells and Rollings, 2012). A restorative environment is a place that “promotes, and not merely permits, restoration” (Hartig, 2004, p. 273). Two main theories explain the restorative effects of green space: The Psycho-evolutionary Theory (Ulrich, 1983) and the Attention Restoration Theory (ART; Kaplan and Kaplan, 1989). According to the Psycho-evolutionary Theory, humans are biologically linked to safe, natural settings possessing trees, water, and other vegetation for immediate positive responses. The Psycho-evolutionary Theory posits that natural settings possess a calming and stress-reducing effect on humans. Therefore, in natural settings not only a sense of restoration is experienced on purpose with the emotions, but involuntary physiological reactions are triggered that provide rapid short-term recovery from stress (Ulrich, 1983; Ulrich et al., 1991). According to the ART, many activities require effortful attention and when the capacity to focus or concentrate is decreased by overuse, people experience mental fatigue. The ART posits that contact with nature has the potential to restore an individual\’s directed attention capabilities. Therefore, an individual\’s capacity for attention is recovered in natural environments, which provide qualities of “fascination,” “being away,” “extent,” and “compatibility” (Kaplan and Kaplan, 1989; Kaplan, 1995). These constructs are self-reported measures and have been described as measures of perceived restorativeness (Hartig, 2011).
Numerous studies have demonstrated that green space is associated with providing restorative effects (Laumann et al., 2001; Herzog et al., 2003; Korpela et al., 2008; Berman et al., 2008). Studies reported that green space is related to positive physiological effects (Herzog and Strevey, 2008; Park et al., 2010), reductions in the risk of psychosocial and psychological stress-related diseases (Grahn and Stigsdotter, 2003; Morita et al., 2007; Francis et al., 2012) and quicker recovery from stress (Nielsen and Hansen, 2007; Lafortezza et al., 2009; van den Berg et al., 2010; Ward Thompson et al., 2012). In addition, researchers found green space positively related to health, quality of life, and well-being (van Dillen et al., 2011; McFarland et al., 2008; de Vries et al., 2003; Mitchell and Popham, 2008; Ward Thompson et al., 2012).
Studies demonstrated that green space in a schoolyard has a higher positive effect on children\’s perceived restoration (Bagot, 2004; Corraliza et al., 2012; Bagot et al., 2015) and that greening of the schoolyard significantly improves students’ physiological well-being and reduces physiological stress (Kelz et al., 2015). In addition, studies show that adolescent students who spent a day in a forest school versus a day inside a classroom reported less anger and stress, and a greater sense of happiness and energy (Roe and Aspinall, 2011b). Likewise, research indicates that contact with nature could improve academic achievement (Williams and Dixon, 2013; Smith and Sobel, 2010) reported that higher test scores are associated with nature based restoration (Heschong, 2003). For instance, Matsuoka (2010) found that high school students who have views of trees and shrubbery versus built features or large empty lawns from windows have more merit awards, higher graduation rates, more plans to attend college, and less criminal behavior. Similarly, Tennessen and Cimprich (1995) revealed that university students with more natural views from their windows score higher than those with less natural views on tests of directed attention.

Many published results have already reported the expression of specific

Many published results have already reported the expression of specific markers within tumors in pre-clinical animal models using ultrasound molecular imaging (Deshpande et al. 2011; Willmann et al. 2008). In our study, we evaluated the expression levels of three tumor angiogenesis biomarkers (endoglin, integrin and VEGFR2) in a murine melanoma model xenografted in nude mice. According to previous studies with this tumor model, changes in the vascular network appear within a short period (as early as 2 d after treatment initiation) (Leguerney et al. 2012). We thus proposed multidrug resistant to assess the expression levels during tumor growth and under therapy between 11 and 14 d after inoculation of the cells. Expression of the three proteins was evaluated by ultrasound molecular imaging on a small animal imaging platform using functionalized microbubbles with specific multidrug resistant attached to their surface shells.


Thirty-two mice, control or treated with sorafenib, were examined over 3 d using the Vevo 2100 system to evaluate tumor volume in three dimensions and the expression of three types of endothelial biomarkers using specific targeted microbubbles. At both baseline and D3, tumor samples were taken to evaluate the microvessel density and expression of the different biomarkers with or without therapeutic administration. A total of 7 mice (4 control, and 3 sorafenib) did not reach the end of the protocol at D3, because of excessive tumor volumes and ulceration of tumors (n = 4) or death of the animals during the protocol (n = 3). The number of evaluations for each parameter considered in this study is given in Table 1.
Mean tumor volume (Fig. 1) did not significantly differ between the two groups at D0 (p = 0.51). Between D0 and D3, tumor volume increased about 58.3% for the control group (p = 0.11, 787.1 ± 650.8 mm3 at D0 and 1246.2 ± 835.4 mm3 at D3) and decreased about 15% for the sorafenib group (p = 1, 821.3 ± 610.4 mm3 at D0 and 698.1 ± 635.6 mm3 at D3). For the sorafenib group at D3 (n = 10), one should note that the tumor volumes increase for 5 mice and decrease for 5 mice, indicating potential therapeutic resistance. These tumor volume changes were not statistically significant, due certainly to the large variation in tumor volumes from one animal to another, especially in the control group at D3.
Three bolus injections of MicroMarker contrast agents were performed to quantify the expression of functionalized microbubbles specifically targeted to endoglin, VEGFR2 and αv integrin. For each type of microbubble, the semiquantitative perfusion parameters could be extracted directly from the fitted time–intensity curves. PE (Table 2) was analyzed and compared between mice and between groups to verify that the signal intensity after the bolus injection did not significantly differ. Indeed, we hypothesized that the US backscatter signal intensity could not be affected by the different antibodies attached to the microbubble surface shells. In vivo targeted contrast-enhanced US revealed that the PE for the three bolus injections of biomarkers (endoglin, VEGFR2 and αv integrin) did not significantly differ at D0 and at D3 for the control group (p = 0.89 for D0, p = 0.66 for D3) or for the sorafenib group (p = 0.74 for D0, p = 0.95 for D3). The control group exhibited slightly higher PE values at D3 than at D0, but without a significant difference. At D3, the sorafenib group exhibited PE values lower than those at D0 for both endoglin and integrin biomarkers (p = 0.04), because of local modifications in tumor vasculature. Indeed, tumor vessels explored by anti-CD31 staining looked thinner and rarefied for the sorafenib group compared with the control group. Nevertheless, these observations were not quantified, and local modifications could not be directly related to PE changes.
Differential targeted enhancement is an indicator of the amount of fixed targeted microbubbles and, thus, of expression of biomarkers within the tumor vasculature. An example of the fixation of different MicroMarker contrast agents with the corresponding time–intensity curves is illustrated in Figure 2. The ultrasound signal intensities were recorded as a function of time for about 100 s (Fig. 2a). Ten minutes after the bolus injection, the signal intensity before and after microbubble destruction within the selected ROI is shown for IgG (Fig. 2b), endoglin (Fig. 2c), VEGFR2 (Fig. 2d) and integrin (Fig. 2e) antibodies. As expected, the signal from IgG microbubbles, which do not bind any specific receptor, did not change, whereas a significant decrease was observed for the bound microbubbles after burst destruction.

For most scattering tissues the BSC

For most scattering tissues, the BSC presents an intrinsic stochastic behavior as it depends on the random position of scatterers (Insana and Brown 1993; Insana et al. 1990; Teisseire et al. 2010) or, for spatially correlated scatterers, on the pair-correlation function describing the relative position of their structures, which is also a random process (Fontaine et al. 1999; Franceschini and Cloutier 2013; Saha and Kolios 2011; Savéry and Cloutier 2001). Likewise, the measurement of BSC is affected by electronic noise, which is also stochastic by nature. Thus, to obtain a robust estimate of the BSC, coherent image compounding was implemented by averaging decorrelated spectra from multiple locations of the investigated tissue (Chen et al. 2005) or from the same location in multiple frames with different angles of observation (Gerig et al. 2004). Another approach consisted of deforming the tissue by applying an external pressure to obtain different signatures (Herd et al. 2011). Alternatively, several decorrelated temporal frames taken over the same region of interest (ROI) can be averaged to obtain a good BSC estimate in the case of fast-moving tissues (e.g., heart, vessel walls and flowing blood). However, with conventional focusing imaging, this usually requires gating and averaging over several cardiac cycles because of the limited frame rate.
The reduction of the stochastic nature of the BSC and the availability of a high frame rate to improve spectral tissue characterization can be addressed using ultrafast imaging (UI) techniques. Recent hardware improvements, such as graphic processing units, have enabled their use for real-time applications (Tanter and Fink 2014). Theoretically, UI techniques can offer thousands of frames per second (Montaldo et al. 2009). Moreover, these techniques can improve the image quality in terms of lateral resolution and contrast-to-noise ratio in the full field of view (Garcia et al. 2013). These latter studies indicated that the image quality is comparable to that of multi-focus techniques, but with an increase in effective frame rate.
One of the most common techniques for UI is plane wave imaging (PWI). In calcium channel blockers to the traditional line-by-line formation of B-mode images using conventional focused beams, PWI uses all elements of an array transducer to emit a series of plane waves (Fig. 1a, b) and receive resulting echoes. Plane wave imaging results in diffraction hyperbolas (Fig. 1a), which must be collapsed in a process called migration, or beamforming (Fig. 1b), to generate an image. Several migration techniques have been proposed, including delay-and-sum reconstruction (Montaldo et al. 2009) and spectral domain signal interpolations (Garcia et al. 2013; Lu 1997). To produce a B-mode image, migrated frames steered at different angles are averaged to improve the lateral resolution with compounding (Fig. 1c).
Backscatter coefficient estimation using PWI has recently been validated in vitro for isotropic media (i.e., a tissue producing similar echoes independent of the angle of insonification) (Garcia-Duitama et al. 2014; Salles et al. 2014). However, several biological tissues present anisotropic characteristics. In such cases, compounding of images from different angles could induce a biased BSC estimation as different information is averaged. We therefore expected, in this study, to evidence a bias in the characterization of anisotropic media, caused by the directivity of scatterers.
This study thus aimed to validate experimentally the possibility of using PWI to estimate BSCs in isotropic and anisotropic media. We specifically intended verifying the effect on BSC of single-angle insonifications (Fig. 1b) and compounded images (Fig. 1c). The validity of the results was confirmed by comparing BSCs with those obtained with single-element transducers and conventional focusing imaging (FI).



In this study, we estimated the BSC of two isotropic tissue-mimicking phantoms and anisotropic aggregating erythrocyte structures using two PWI strategies: compounded and single-angle insonifications. In isotropic media, both PWI approaches provided accurate BSC estimations compared with benchmark measures. For flowing blood, even if mean deviations from benchmark BSC values were higher than with the phantom data sets (1.1–2.2 dB vs. 0.15–0.26 dB), it can be concluded that PWI gave satisfying estimations of the backscatter coefficient. Indeed, observed mean differences below 2.2 dB between PWI and FI BSCs are smaller than the inter-subject variability for porcine blood (approximately 3 dB) (Shung et al. 1992) and well below changes in BSC attributed to the kinetics of red blood cell aggregation (approximately 12 dB) (Yuan and Shung 1988b).