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VAG COM V311.2.zip Full Version
A complementary approach to read recruitment is to assemble the full metagenome with the goal of recovering not only single genes, but also operons. This approach could shed some more light on the metabolic potential of the community, as could be the case for DHA production. Assembly of the metagenomic sequences resulted in a total of 19,431 contigs (Table S2), representing 23.1% of the reads and 22.1% of the total bases in the metagenome data set. The N50 for the assembly was 1,529, and the majority of the assembled and annotated contigs contain a single gene (Figure S2). For the operon encoding proteins involved in the synthesis of DHA, no contigs representing the complete operon were found.
We also looked at the distribution and abundance of genes involved in sulfur cycling dynamics. Dissimilatory sulfur-based energy conversion is a process that occurs almost exclusively among Bacteria and Archaea [48], where this metabolism is linked to energy transformation via photosynthesis or respiratory processes. Several mechanisms have been described for the conversion of various reduced inorganic sulfur compounds [49]. Reconstruction of the metabolic pathway for sulfur reactions (Figure S7) shows the potential of the community for carrying out the reduction of sulfur compounds, where the dominant members of the community associated with this processes are the Gammaproteobacteria and Flavobacteria (Figure 6). No proteins involved in sulfur oxidation reactions, such as the Sox system [49], were found in the metagenome, suggesting that the microbial community is not carrying out these set of reactions.
The clinical course of CPP can be for a number of years. In the British prevalence study, described above, one-third of women reported pain that started more than 5 years before (Zondervan et al. 2001). In a follow-up study of 72 women with CPP the cumulative proportion of women who had not reached full recovery after 6 years was 70 % (Weijenborg et al. 2007).
Next the abdominal wall is carefully examined using single digit palpation seeking painful foci that may indicate trigger points or neuroma sites. This is to avoid excessive manual pressure as is used for assessment of abdomino-pelvic organs. Other authors have emphasised the importance of the single digit examination of the abdominal wall (Gunter 2003; Howard 2003; Perry 2003). For somatic sites pain foci are easy to examine but much less accessible in visceral structures.
An early comprehensive evaluation in primary or secondary care should fully assess biological and psychosocial factors to find pointers towards referral to a multidisciplinary team environment. This assessment should include altered mood and anxiety states, marital and family counselling, eating and behavioral disorders and sleep disturbances. A multidisciplinary team approach aiming to strengthen coping and cognitive strategies is of proven value (Turk and Okifuji 2002). Sudden spontaneous pain events often produce much fear, avoidance and disability. Reassurance that hurt does not equate with harm nor life threatening pathologies is often relieving in its own right.
Clinically used opioids for any pain include morphine, methadone, oxycodone, hydromorphone, fentanyl, pethidine, dihydrocodeine and buprenorphine. In some European countries ketobemidone is available. Codeine is a pro-drug for morphine and requires hepatic metabolism by cytochrome P450 enzyme CYP2D6 for this conversion. A proportion (about a third) of the population lack the enzymes to do this (Williams et al. 2002), and SSRIs inhibit this transformation. Tramadol can be effective treatment for neuropathic pain (Dworkin et al. 2010) but only in some people. Its efficacy is similar to that reported for tricyclics and anticonvulsants but adequate direct comparisons are not available. Its use is often limited by side effects of nausea, dizziness, drowsiness, tiredness, fatigue, constipation and sweating (Dworkin et al. 2007). Seizures are possible in dose excess (Dworkin et al. 2007, 2010). 2ff7e9595c
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