Altered Glucose Homeostasis and Hepatic Function in Obese Mice Deficient for Both Kinin Receptor Genes

The Kallikrein-Kinin System (KKS) has been implicated in several aspects of metabolism, including the regulation of glucose homeostasis and adiposity. Kinins and des-Arg-kinins are the major effectors of this system and promote their effects by binding to two different receptors, the kinin B2 and B1 receptors, respectively. To understand the influence of the KKS on the pathophysiology of obesity and type 2 diabetes (T2DM), we generated an animal model deficient for both kinin receptor genes and leptin (obB1B2KO). Six-month-old obB1B2KO mice showed increased blood glucose levels. Isolated islets of the transgenic animals were more responsive to glucose stimulation releasing greater amounts of insulin, mainly in 3-month-old mice, which was corroborated by elevated serum C-peptide concentrations. Furthermore, they presented hepatomegaly, pronounced steatosis, and increased levels of circulating transaminases. This mouse also demonstrated exacerbated gluconeogenesis during the pyruvate challenge test. The hepatic abnormalities were accompanied by changes in the gene expression of factors linked to glucose and lipid metabolisms in the liver. Thus, we conclude that kinin receptors are important for modulation of insulin secretion and for the preservation of normal glucose levels and hepatic functions in obese mice, suggesting a protective role of the KKS regarding complications associated with obesity and T2DM.

Long-term leucine supplementation reduces fat mass gain without changing body protein status of aging rats

Objective: Aging is characterized by alterations in body composition such as an increase in body fat and decreases in muscle mass (sarcopenia) and bone density (osteopenia). Leucine supplementation has been shown to acutely stimulate protein synthesis and to decrease body fat. However, the long-term effect of consistent leucine supplementation is not well defined. This study investigated the effect of leucine supplementation during aging. Methods: Six-month-old rats were divided into three groups: an adult group (n = 10) euthanized at 6 mo of age, a leucine group (n = 16) that received a diet supplemented with 4% leucine for 40 wk, and a control group (n = 19) that received the control diet for 40 wk. The following parameters were evaluated: body weight, food intake, chemical carcass composition, indicators of acquired chronic diseases, and indicators of protein nutritional status. Results: Body weight and fat were lower in the leucine group after 40 wk of supplementation compared with the control group but still higher than in the adult group. The lipid and glycemic profiles were equally altered in the control and leucine groups because of aging. In addition, leucine supplementation did not affect the changes in protein status parameters associated with aging, such as decreases in body and muscle protein and total serum protein. Conclusion: The results indicate that leucine supplementation attenuates body fat gain during aging but does not affect risk indicators of acquired chronic diseases. Furthermore, supplemented animals did not show signs of a prevention of the decrease in lean mass associated with aging. (C) 2012 Elsevier Inc. All rights reserved.

Effect of caloric restriction on myenteric neuroplasticity in the rat duodenum during aging

The objective of this study was to evaluate the effects of caloric restriction (CR) on myenteric neurons in the duodenum of Wistar rats during aging. Thirty rats were divided into three groups: the C group (six-month-old animals that were fed a normal diet from weaning until six months of age), the SR group (18-month-old animals that were fed a normal diet from weaning until 18 months of age) and the CR group (18-month-old animals that were fed a 30% CR diet after six months of age). After 12 months, the animals were euthanized. Whole-mount preparations of the duodenums were either stained with Giemsa or underwent NADPH-diaphorase histochemistry to determine the general myenteric neuron population and the nitrergic neuron subpopulation (NADPH-d +), respectively. The NADPH-d-negative (NADPH-d -) neuron population was estimated based on the difference between the Giemsa-stained and NADPH-d + neurons. The neurons were counted, and the cell body areas were measured. Aging was associated with neuronal loss in the SR group, which was minimized by caloric restriction in the CR group. The density (mm(2)) of the Giemsa-stained neurons was higher in the SR group (79.09 +/- 6.25) than in the CR (92.37 +/- 11.6) and C (111.68 +/- 15.26) groups. The density of the NADPH-d + neurons was higher in the SR group (44.90 +/- 5.88) than in the C (35.75 +/- 1.6) and RC (39.14 +/- 7.02) groups. The density of NADPH-d - neurons was higher in the CR (49.73 +/- 12.08) and C (75.64 +/- 17.05) groups than in the SR group (33.82 +/- 4.5). In the C group, 32% and 68% of the Giemsa-stained myenteric neurons were NADPH-d + or NADPH-d -, respectively. With aging (SR group), the percentage of nitrergic neurons (56.77%) increased, whereas the percentage of NADPH-d - neurons (43.22%) decreased. In the CR group, the change in the percentage of nitrergic (42.37%) and NADPH-d - (57.62%) neurons was lower. As NADPH-d - neurons will be mostly cholinergic neurons, CR appears to reduce the loss of cholinergic neurons during aging. The cell body dimensions (mu m(2)) were not altered by aging or CR. Thus. CR had a protective effect on myenteric neurons during aging. (C) 2012 Elsevier B.V. All rights reserved.

Neospora caninum as causative agent of bovine encephalitis in Brazil

For supporting the Brazilian bovine encephalitis surveillance program this study examined the differential diagnosis of Neospora caninum in central nervous system (CNS) by histological analysis (HE staining), immunohistochemistry (IHC), and nested-PCR using a set of primers from the Nc5 region of the genomic DNA and ITS1 region of the ribosomal DNA. A sample of 302 cattle presenting neurological syndrome and negative for rabies, aged 0 to 18 years, from herds in 10 Brazilian states was evaluated for N caninum from January 2007 to April 2010. All specimens tested negative with IHC and nested-PCR using primers from the ITS I region of ribosomal DNA, while two positive cases (0.66%) were found using primers from the Nc5 region of genomic DNA: a 20 month-old male and a 72 month-old female, both from Sao Paulo State. Only the male presented severe multifocal necrotizing encephalitis associated with mononuclear cell infiltration, a pathognomonic lesion caused by parasites of the family Sarcocystidae, and only this case was associated with N caninum thus representing 0.33% positivity. Future studies should explore the association of IHC and nested-PCR with real-time PCR, a quantitative method that could be standardized for improving the detection of N. caninum in bovine CNS specimens.

Inflammatory milieu as an early marker of kidney injury in offspring rats from diabetic mothers

The present study investigated the early presence of inflammatory response in renal tissue of young offspring from diabetic mothers. The effect of L-arginine (L-arg) supplementation was also investigated. The offspring was divided into four groups: group CO (controls); group DO (diabetic offspring); group CA (CO receiving 2% L-arg solution) and group DA (DO receiving the 2% L-arg solution). Glycemia, arterial pressure and renal function were evaluated; gene and protein expression of pro-inflammatory cytokines were also measured. Blood pressure levels were significantly increased in 2 and 6 month-old DO rats, whereas L-arg administration caused a significant decrease in the DA group, at both ages. DO rats showed a significantly blunted glycemic response to exogenous insulin. In 2 month-old DO animals, renal protein expression of pro-inflammatory molecules was significantly increased. At six months of age, we also observed an increase in gene expression of pro-inflammatory molecules, whereas L-arg supplementation prevented this increase at both ages. Our data suggest that activation of inflammatory pathways is present early in the kidney of DO rats, and that L-arg can attenuate the expression of these markers of tissue inflammation. Our results also reinforce the concept that intrauterine environmental factors are a fundamental determinant in the development of metabolic and vascular diseases later in life. (C) 2012 Elsevier B.V. All rights reserved.

Proteomic profiling of the rat hypothalamus

Background: The hypothalamus plays a pivotal role in numerous mechanisms highly relevant to the maintenance of body homeostasis, such as the control of food intake and energy expenditure. Impairment of these mechanisms has been associated with the metabolic disturbances involved in the pathogenesis of obesity. Since rodent species constitute important models for metabolism studies and the rat hypothalamus is poorly characterized by proteomic strategies, we performed experiments aimed at constructing a two-dimensional gel electrophoresis (2-DE) profile of rat hypothalamus proteins. Results: As a first step, we established the best conditions for tissue collection and protein extraction, quantification and separation. The extraction buffer composition selected for proteome characterization of rat hypothalamus was urea 7 M, thiourea 2 M, CHAPS 4%, Triton X-100 0.5%, followed by a precipitation step with chloroform/methanol. Two-dimensional (2-D) gels of hypothalamic extracts from four-month-old rats were analyzed; the protein spots were digested and identified by using tandem mass spectrometry and database query using the protein search engine MASCOT. Eighty-six hypothalamic proteins were identified, the majority of which were classified as participating in metabolic processes, consistent with the finding of a large number of proteins with catalytic activity. Genes encoding proteins identified in this study have been related to obesity development. Conclusion: The present results indicate that the 2-DE technique will be useful for nutritional studies focusing on hypothalamic proteins. The data presented herein will serve as a reference database for studies testing the effects of dietary manipulations on hypothalamic proteome. We trust that these experiments will lead to important knowledge on protein targets of nutritional variables potentially able to affect the complex central nervous system control of energy homeostasis.

Differences in throughfall and net precipitation between soybean and transitional tropical forest in the southern Amazon, Brazil

The expansion of soybean cultivation into the Amazon in Brazil has potential hydrological effects at local to regional scales. To determine the impacts of soybean agriculture on hydrology, a comparison of net precipitation (throughfall, stemflow) in undisturbed tropical forest and soybean fields on the southern edge of the Amazon Basin in the state of Mato Grosso is needed. This study measured throughfall with troughs and stemflow with collar collectors during two rainy seasons. The results showed that in forest 91.6% of rainfall was collected as throughfall and 0.3% as stemflow, while in soybean fields with two-month old plants, 46.2% of rainfall was collected as throughfall and 9.0% as stemflow. Hence, interception of precipitation in soybean fields was far greater than in intact forests. Differences in throughfall, stemflow and net precipitation were found to be mainly associated with differences in plant structure and stem density in transitional forest and soybean cropland. Because rainfall interception in soybean fields is higher than previously believed and because both the area of cropland and the frequency of crop cycles (double cropping) are increasing rapidly, interception needs to be reconsidered in regional water balance models when consequences of land cover changes are analyzed in the Amazon soybean frontier region. Based on the continued expansion of soybean fields across the landscape and the finding that net precipitation is lower in soy agriculture, a reduction in water availability in the long term can be assumed. (C) 2012 Elsevier B.V. All rights reserved.

A novel DAX1/NR0B1 mutation in a patient with adrenal hypoplasia congenita and hypogonadotropic hypogonadism

We report a case of adrenal hypoplasia congenita (AHC) and hypogonadotropic hypogonadism (HH) due to a novel DAX1 mutation. A 19-month-old boy with hyperpigmentation and failure to thrive came to our service for investigation. Three brothers of the patient had died due to adrenal failure, and a maternal cousin had adrenal insufficiency. Adrenoleukodystrophy was excluded. MRI showed normal pituitary and hypothalamus. Plasma hormone evaluation revealed high ACTH (up to 2,790 pg/mL), and low levels of androstenedione, DHEA-S, 11-deoxycortisol, and cortisol. At 14 years of age the patient was still prepubescent, his weight was 43.6 kg (SDS: -0.87) and his height was 161 cm (SDS: -0.36), with normal body proportions. In the GnRH test, basal and maximum values of LH and FSH were respectively 0.6/2.1 and < 1.0/< 1.0 U/L. Molecular investigation identified a novel mutation that consists of a deletion of codon 372 (AAC; asparagine) in exon 1 of DAX1. This mutation was not found in a study of 200 alleles from normal individuals. Prediction site analysis indicated that this alteration, located in the DAX1 ligand-binding domain, may damage DAX1 protein. We hypothesize that the novel (p.Asp372del) DAX1 mutation might be able to cause a disruption of DAX1 function, and is probably involved in the development of AHC and HH in this patient. Arq Bras Endocrinol Metab. 2012;56(8):496-500

Parathyroid adenoma apoplexy as a temporary solution of primary hyperparathyroidism: a case report

Abstract Introduction The natural history of patients with spontaneous parathyroid necrosis is unknown. In this case report we describe the clinical course, laboratory, radiographic, bone densitometry tests, parathyroid ultrasonography and scintigraphy examinations of a patient performed over a period of eight years after she first presented with a sudden episode of spontaneous resolution of primary hyperparathyroidism (PHPT). Case presentation A 24-year-old woman with a clinical history and laboratory and radiographic tests compatible with PHPT suffered a sudden episode of cervical pain and presented with clinical evidence of hypocalcemia. Biopsy of a cervical nodule revealed necrotic material compatible with ischemia of the parathyroid. The follow-up of the patient presented four distinct phases: the first, which lasted two years, was compatible with a period of bone hunger during which it was necessary to introduce calcitriol and calcium carbonate. During this period, the patient showed bone mass gain. The second phase was characterized by normalization of calcium and parathyroid hormone levels and its end was difficult to define. During the third phase there was a recurrence of hypercalcemia associated with elevated parathyroid hormone (PTH) levels and loss of bone mass. The last phase corresponded to the interval after parathyroidectomy, which was characterized by normalization of serum levels of calcium and PTH, as well as bone mass gain. Conclusion This case report indicates that spontaneous resolution of PHPT by adenoma necrosis is potentially temporary. Thus, in cases in which a conservative approach is chosen, clinical and laboratory follow-up is indispensable. Bone mass measurement is a useful tool in the follow-up of these cases. However, this option exposes the patient to a potential roller-coaster ride of bone mass gain and loss, whose long term consequences are still unknown.

Clinical, radiographic and histologic analysis of the effects of pulp capping materials used in pulpotomies of human primary teeth

Aim: To compare the clinical, radiographic and histological responses of the pulp to mineral trioxide aggregate (MTA), calcium hydroxide (CH) and Portland cement (PC) when used as a pulpotomy agent in human primary teeth. Study design: Forty-five mandibular primary molar teeth were randomly assigned to CH, MTA or PC groups and treated by pulpotomy technique. Methods: The teeth were treated by conventional pulpotomy technique, differing only in the capping material for each group. Clinical and radiographic evaluations were recorded at 6-, 12- and 24-month follow-up. Teeth in the regular exfoliation period were further processed for histologic analysis. Statistics: The teeth were treated by conventional pulpotomy technique, differing only in the capping material for each group. Clinical and radiographic evaluations were recorded at 6-, 12- and 24-month follow-up. Teeth in the regular exfoliation period were further processed for histologic analysis. Statistics: Clinically and radiographically, the MTA and PC groups showed 100 % success rates at 6, 12 and 24 months. In CH group, several teeth presented clinical and radiographic failures detected throughout the follow-up period, and internal resorption was a frequent radiographic finding. Histologic analysis revealed the presence of dentine-like mineralised material deposition obliterating the root canal in the PC and MTA groups. CH group presented, in most of the sections, necrotic areas in the root canals. Conclusions: MTA and PC may serve as effective materials for pulpotomies of primary teeth as compared to CH. Although our results are very encouraging, further studies and longer follow-up assessments are needed in order to determine the safe clinical indication of Portland cement.

Impairment of the hematological response and interleukin-1β production in protein-energy malnourished mice after endotoxemia with lipopolysaccharide

The objectives of this study were to determine if protein-energy malnutrition (PEM) could affect the hematologic response to lipopolysaccharide (LPS), the interleukin-1β (IL-1β) production, leukocyte migration, and blood leukocyte expression of CD11a/CD18. Two-month-old male Swiss mice were submitted to PEM (N = 30) with a low-protein diet (14 days) containing 4% protein, compared to 20% protein in the control group (N = 30). The total cellularity of blood, bone marrow, spleen, and bronchoalveolar lavage evaluated after the LPS stimulus indicated reduced number of total cells in all compartments studied and different kinetics of migration in malnourished animals. The in vitro migration assay showed reduced capacity of migration after the LPS stimulus in malnourished animals (45.7 ± 17.2 x 10(4) cells/mL) compared to control (69.6 ± 7.1 x 10(4) cells/mL, P ≤ 0.05), but there was no difference in CD11a/CD18 expression on the surface of blood leukocytes. In addition, the production of IL-1β in vivo after the LPS stimulus (180.7 pg·h-1·mL-1), and in vitro by bone marrow and spleen cells (41.6 ± 15.0 and 8.3 ± 4.0 pg/mL) was significantly lower in malnourished animals compared to control (591.1 pg·h-1·mL-1, 67.0 ± 23.0 and 17.5 ± 8.0 pg/mL, respectively, P ≤ 0.05). The reduced expression of IL-1β, together with the lower number of leukocytes in the central and peripheral compartments, different leukocyte kinetics, and reduced leukocyte migration capacity are factors that interfere with the capacity to mount an adequate immune response, being partly responsible for the immunodeficiency observed in PEM.

Facial lesions caused by renal osteodystrophy in a patient with chronic renal insufficiency: a case report

PURPOSE: Chronic renal insufficiency (CRI) is the last stage of a chronic renal condition in which the kidney loses its filtration and endocrine functions. Chronic endocrine hypofunction causes generalized damage to the body known as Uremic Syndrome, which affects the central nervous system as well as the cardiovascular, hematologic, dermatologic, ophthalmic, endocrine, respiratory, gastrointestinal and skeletal systems. The present study reports the case of a female patient with CRI who presented facial osteodystrophy of the osteitis fibrosa type, and highlights the main features of this condition. CASE DESCRIPTION: A 24-year old, female, Caucasian patient presented chronic glomerulonephritis recurrence and lost the transplanted kidney five years before, undergoing arteriovenous fistula hemodialysis three times a week. She presented swelling of the left masseter area with a hard consistency on palpation, covered by intact skin, swelling at the bottom of the left atrium, with a hard consistency on palpation, a mucosa-like color and absence of inflammation signs, suggesting expansive bone lesions on the face. These features were compatible with hyperparathyroidism brown tumor and/or osteodystrophy. The CT scan showed expansive bone lesions of heterogeneous appearance on the left jaw, maxilla/nasal floor, and right frontotemporal suture areas. The clinical and histopathological characteristics of the lesion, in association with PHT hormone high serum levels led to renal osteodystrophy diagnosis. The patient was referred to the nephrology services. CONCLUSION: Osteodystrophic bone alterations have a high prevalence in renal disease patients, and the dentist must take these alterations into consideration in bone lesion diagnosis for this specific group of patients.

Cytology of tracheobronchial and bronchoalveolar lavage in healthy Holteins calves during the first month of life

Benesi F.J., Wachholz L., Bertagnon H.G., Leal M.L.R., Mori E. & Fernandes W.R. 2012. [Cytology of tracheobronchial and bronchoalveolar lavage in healthy Holteins calves during the first month of life.] Citologia dos lavados traqueobronquico (LTB) e broncoalveolar (LBA) de bezerros holandeses sadios durante o primeiro mes de vida. Pesquisa Veterinaria Brasileira 32(3):267-270. Departamento de Clinica Medica, Faculdade de Medicina Veterinaria e Zootecnia, Universidade de Sao Paulo, Av. Prof. Dr. Orlando Marques de Paiva 87, Sao Paulo, SP 05508-270, Brazil. E-mail: febencli@usp.br The neonatal calf is a critical moment for adaptation of the newborn to extra uterine life. The respiratory tract is functionally very demanded and often affected by disease, resulting in direct loss of their function and causing serious economic losses in livestock. The basic point to reduce these losses is appropriate clinical evaluation of neonates; but the diagnosis based solely in physical examination is very difficult to establish. The use of complementary analysis such cytology of the respiratory tract becomes an important diagnostic tool; however their findings must be standardized in the face of different techniques employed. This research studied the dynamics of the cellularity of the bronchoalveolar and tracheobronchial region obtained through lung lavage harvested by nasotracheal catheterization technique and tracheocenthesis respectively, during the first month of life of healthy calves. The tracheobronchial cytology was influenced by the time, showing decreased number of alveolar macrophages and greater number of neutrophils, possibly increased by local irritation caused by the technique, which was repeated sequentially, and/or through greater stimulation of inhaled microorganisms deposited in this region. In the bronchoalveolar region no variation in the cellular constituents in function of time was found. The results allowed the conclusion the cell population of the tracheobronchial region has changed over the week-old calves, possibly due to the technique used and/or to the normal region physiology, represented by higher magnitudes of neutrophils. Otherwise, the cells of the broncholaveolar region showed a stable behavior during the first month of life of newborn calves, presenting numerical predominance of alveolar macrophages. O período neonatal dos bezerros é um momento crítico para adaptação do recém-nascido à vida extra uterina e o sistema respiratório, um dos mais exigidos funcionalmente, é frequentemente afetado por enfermidades, redundando no prejuízo direto da sua função e acarretando perdas econômicas importantes na pecuária. O ponto básico para reduzir estas perdas, é representado pela adequada avaliação clínica dos neonatos, todavia o diagnóstico baseado exclusivamente no exame ísico é muito di ícil de ser estabelecido. O uso de exames complementares como a citologia do trato respiratório torna-se uma ferramenta diagnóstica importante nestes casos, porém faz-se necessário, padronizar seus achados frente às diferentes técnicas empregadas para a sua obtenção. Assim, o presente estudo propôs-se acompanhar as variações dos constituintes celulares da região traqueobrônquica e broncoalveolar obtidos por lavados respiratórios pelos métodos de traqueocentese e por colheita nasotraqueal respectivamente, durante o primeiro mês de vida de bezerros sadios. Observou-se alteração no quadro citológico ao longo do tempo, quando a região traqueobrônquica foi lavada, expresso por diminuição da porcentagem de macrófagos alveolares, com aumento de neutró ilos, possivelmente, por maior irritação local provocada pela técnica, que se repetiu sequencialmente e/ou por maior estimulo de microorganismos inalados depositados nesta região. Na região broncoalveolar, não encontraram- -se variações nos constituintes celulares em função do tempo. Os resultados permitiram a conclusão que a população celular da região traqueobrônquica modi icou-se ao longo das semanas de vida dos bezerros, possivelmente pela técnica empregada e/ou isiologia normal da região, sendo representadas por maiores magnitudes de neutró ilos. De modo diverso, na região broncolaveolar, as células evidenciaram um comportamento estável durante o primeiro mês de vida dos bezerros neonatos, apresentando predomínio numérico dos macrófagos alveolares.

Leukograms of healthy Holstein calves within the first month of life

To establish reference values and to assess the influence of age on the leukograms of healthy Holstein calves, blood samples were obtained from 300 animals. These samples were distributed equally (n=20) among 15 experimental groups according to age: birth to 8 hours, 9 to 16 hours, 17 to 24 hours, 2 days, 3 days, 4 days, 5 days, 6 to 7 days, 8 to 9 days, 10 to 11 days, 12 to 13 days, 14 to 15 days, 16 to 20 days, 21 to 25 days and 26 to 30 days of age. The maximum numbers of leukocytes (9,305.0/mL), segmented neutrophils (6,551.2/mL) and total neutrophils (6,678.3/mL) were noted within the first 8 hours of life, while band neutrophils peaked in number (133.3/mL) between 9 and 16 hours after birth. Meanwhile, the maximum total lymphocyte (4,992.1/µL) and typical lymphocyte (4,686.1/µL) counts occurred between 21 and 25 days, whereas atypical lymphocytes (388.5/µL) reached their maximum number between 26 and 30 days, demonstrating an inversion of the neutrophil:lymphocyte ratio over time. Thus, the influence of age on the leukocyte count of the evaluated calves was verified. The release of endogenous corticosteroids during labor or at birth may contribute to this variation in leukograms with age.

Breast Milk and Glucose for Pain Relief in Preterm Infants: A Noninferiority Randomized Controlled Trial

OBJECTIVE: The study goal was to compare the efficacy of expressed breast milk (EBM) versus 25% glucose on pain responses of late preterm infants during heel lancing. METHODS: In a noninferiority randomized controlled trial, a total of 113 newborns were randomized to receive EBM (experimental group [EG]) or 25% glucose (control group [CG]) before undergoing heel lancing. The primary outcome was pain intensity (Premature Infant Pain Profile [PIPP]) and a 10% noninferiority margin was established. Secondary outcomes were incidence of cry and percentage of time spent crying and adverse events. Intention-to-treat (ITT) analysis was used. RESULTS: Groups were similar regarding demographics and clinical characteristics, except for birth weight and weight at data collection day. There were lower pain scores in the CG over 3 minutes after lancing (P<.001). A higher number of infants in the CG had PIPP scores indicative of minimal pain or absence of pain (P = .002 and P = .003 on ITT analysis) at 30 seconds after lancing, and the mean difference in PIPP scores was 3 (95% confidence interval: 1.507-4.483). Lower incidence of cry (P = .001) and shorter duration of crying (P = .014) were observed for CG. Adverse events were benign and self-limited, and there was no significant difference between groups (P = .736 and P = .637 on ITT analysis). CONCLUSIONS: Results based on PIPP scores and crying time indicate poorer effects of EBM compared with 25% glucose during heel lancing. Additional studies exploring the vol and administration of EBM and its combination with other strategies such as skin-to-skin contact and sucking are necessary. Pediatrics 2012;129:664-670