diff --git "a/deduped/dedup_0179.jsonl" "b/deduped/dedup_0179.jsonl" new file mode 100644--- /dev/null +++ "b/deduped/dedup_0179.jsonl" @@ -0,0 +1,57 @@ +{"text": "Clinicians require brief outcome measures in their busy daily practice to document global client outcomes. Based on the UK Therapy Outcome Measure, the Australian Therapy Outcome Measures were designed to capture global therapy outcomes of occupational therapy, physiotherapy and speech pathology in the Australian clinical context. The aim of this study was to investigate the construct (convergent) validity of the Australian Therapy Outcome Measures (AusTOMs) by comparing it with the EuroQuol-5D (EQ-5D).The research was a prospective, longitudinal cohort study, with data collected over a seven month time period. The study was conducted at a total of 13 metropolitan and rural health-care sites including acute, sub-acute and community facilities. Two-hundred and five clients were asked to score themselves on the EQ-5D, and the same clients were scored by approximately 115 therapists using the AusTOMs at admission and discharge. Clients were consecutive admissions who agreed to participate in the study. Clients of all diagnoses, aged 18 years and over (a criteria of the EQ-5D), and able to give informed consent were scored on the measures. Spearman rank order correlation coefficients were used to analyze the relationships between scores from the two tools. The clients were scored on the AusTOMs and EQ-5D.There were many health care areas where correlations were expected and found between scores on the AusTOMs and the EQ-5D.In the quest to measure the effectiveness of therapy services, managers, health care founders and clinicians are urgently seeking to undertake the first step by identifying tools that can measure therapy outcome. AusTOMs is one tool that can measure global client outcomes following therapy. In this study, it was found that on the whole, the AusTOMs and the EQ-5D measure similar constructs. Hence, although the validity of a tool is never 'proven', this study offers preliminary support for the construct validity of AusTOMs. The costs of operating public health services in Australia are rapidly rising. Health administrators and practitioners are under pressure to document client outcomes and demonstrate the effectiveness of therapy interventions -3. IncreThe original TOM was developed for use by speech and language therapists in the UK for therapists to measure client outcomes in a clinical setting . Later, The AusTOMs was designed to measure client therapy outcome separately for occupational therapists, speech pathologists and physiotherapists. Similar to TOM, AusTOMs provides a 'snapshot' rating that is determined by the clinical judgment of the therapist, which broadly reflects the client's status. The development of the scales and content validity of AusTOMs has been published , as has The researchers attempted to find a 'gold standard' tool to investigate the concurrent validity of the AusTOMs. Health-related quality of life (HRQoL) tools have increasingly been used to assess multiple aspects of health-related quality of life in clinical trials . Tools sWhile in principle, health professionals support the notion of measuring health status, there is no consensus regarding the method of measurement ,27. WhilThe purpose of this study was to examine the measurement properties of the AusTOMs and to compare them with the EQ-5D in 'real practice'. The main question being; does AusTOMs perform in a similar manner to the EQ-5D? The study sought to investigate the following hypotheses:1. There will be a clear pattern of correlations for the admission, discharge and change scores between the AusTOMs domains and the EQ-5D Health Status and Thermometer. Several scale-specific correlations are expected. For example :a. There will be a moderate negative correlation of the admission, discharge and change scores between the PT AusTOMs Scale 'Pain', Impairment domain and the EQ-5D Health Status Subscale 'Pain'.b. There will be a moderate negative correlation of the admission, discharge and change scores between OT AusTOMs Scale 'Functional Mobility and Walking', Activity Limitation Domain and the EQ-5D Health Status Subscale 'Mobility'.c. There will be a moderate negative correlation of the admission, discharge and change scores between OT AusTOMs Scale 'Self-care', Activity Limitation domain, and the EQ-5D Health Status Subscale 'Self-care'.2. There will be a moderate positive correlation of the admission, discharge and change scores between all the Physiotherapy, Occupational Therapy and Speech Pathology AusTOMs Scales for the Wellbeing /Distress scores and the EQ-5D Thermometer.The research was designed as a prospective, longitudinal cohort study, with data collected over a seven month time period.Thirty-eight occupational therapists, 30 physiotherapists and 47 speech pathologists were trained at 13 participating facilities to collect AusTOMs data, and to present the EQ-5D for clients to complete. However, it is possible that not all these therapists collected data (data collection forms did not require therapists to record their identity). The facilities included acute hospitals, rehabilitation hospitals, and community care facilities. Therapists recorded AusTOMs data and obtained client EQ-5D ratings from 205 clients . These clients were from a larger group of 1007 clients who participated in the study . While some of these participants refused to complete the EQ-5D, or the therapists chose not to burden the client with completing this form, many were children or non-cognizant adults and the EQ-5D is not validated for these groups. Otherwise, the sample was sequential admissions to therapist caseloads over a seven month period.AusTOMs is comprised of three separate sets of scales for Occupational Therapy 12 scales), Speech Pathology and Physiotherapy . The title of each scale is provided in Table 2 scales,Each scale requires a rating for four domains of client function, that is, Impairment, Activity Limitation, Participation Restriction and Wellbeing/Distress. An additional optional rating can be made of a caregiver's level of Wellbeing/Distress if the clinician has had contact with a caregiver, and feels that therapy is directed toward the caregiver in some way. Each of the domains are rated by therapists on an 11-point ordinal scale . Although clinicians are only required to use the 6 defined scale points, clinicians overwhelmingly chose to include the half points in the AusTOM scoring system to increase scale sensitivity. The use of the half points also facilitates international benchmarking of data against the UK TOM. A generic description of each of the domains of client function is presented in Table The EQ-5D consists of two parts; the self -classifier or questionnaire, and the EQ-Vas or Thermometer. The EQ-5D self-classifier is a one-page questionnaire, which captures respondent descriptions of health problems on a 5-dimensional classification of mobility, self-care, usual activities, pain and discomfort and anxiety and depression. Each dimension is rated by respondents on a three-level scale from 1 (no problem) to 3 (unable or extreme problem) . The EQ-Approval from the Human Ethics Committee at La Trobe University and the participating facilities was obtained. Study packs were collated for the collection of data. Each pack contained AusTOMs Scale Manual, AusTOMs and EQ-5D data collection forms, informed consent information and consent forms (if these were required by the facility ethics committee). The packs were sent to a contact person in occupational therapy, speech pathology and physiotherapy departments at each site participating in the project. The role of the contact at each site was to receive the packs, disseminate the packs to therapists, check the packs after completion and return them by postage paid envelope.On admission, the therapists briefed each client about the study and after verbal agreement, clients were given a statement of informed consent to read and sign. Clinicians then recorded relevant demographic information and established with the client a specific goal or set of goals for the first episode of care. The therapist then chose the AusTOMs scale/s that best described the main areas targeted for therapy intervention. An admission rating was made by the therapist for each of the four domains of AusTOMs on a scale from 0 (most severe) to 5 (least severe). A rating for Wellbeing/ distress was also made for the client's carer if this was applicable to the client's situation. Therapists report that the AusTOMs takes approximately 5 minutes to complete. The therapist then asked the client to complete the self -classifier section of the EQ-5D and the EQ-Vas (Thermometer). Clients were instructed to indicate which statements best described their own health state today, by placing a tick in one box for each of the dimension of mobility, personal care, usual activities, pain/discomfort and anxiety depression. Finally, clients completed the EQ-Vas. Information on the form stated, 'to help people say how good or bad a health state is, we have drawn a scale (rather like a thermometer) on which the best state you can imagine is marked 100 and the worst state you can imagine is marked 0. We would like you to indicate on this scale how good or bad your own health is today, in your opinion. Please do this by drawing a line from the box below to whichever point on the scale indicates how good or bad your health state is today' . ClientsThe data were analyzed separately for each profession given the differences in the AusTOMs scales. Correlational analyses were performed to investigate the relationship between AusTOMs and EQ-5D. Given the ordinal nature of the scales, a non-parametric approach was adopted, hence all analyses use Spearman's rank-order correlation coefficients (Spearman's Rho). Given the number of correlations performed, alpha was set at .01, and magnitude of the relationship was considered using the guidelines from Colton where .0Sample sizes were not sufficient to enable individual scale analysis for speech pathology scales. The analyses were conducted using only the first scaled selected by the therapist to rate the client. It is also important to note the directions of relationships reported. The EQ-5D Health Status subscales are 1 = no problem -> 3 = unable or extreme problem and the AusTOMs scores are 5 = Normal -> 0 = unable or extreme problem, hence, we expect to see negative correlations. However, the EQ-5D Thermometer scores 0 as the worst state and 100 as the best state and the overall EQ-5D Health Status self classifier score also indicates a better outcome as the score increases, and the AusTOMs scores are 5 = Normal -> 0 = unable or extreme problem. Hence, we expect to see positive correlations between these scores. In the 'Results' the statement is made that the results are in the 'expected direction'.In line with the research aims and hypotheses, the following analyses were undertaken across each profession's data set. First, a correlation considering all the AusTOMs scales for each domain with EQ-5D Health Status (self classifier score and the 5 dimensions) and Thermometer at admission was performed. Next, AusTOMs scores for each domain for a subset of the most frequently used OT and PT scales with EQ-5D Health Status (self classifier score and the 5 dimensions) and Thermometer at admission were obtained. Then, considering all the AusTOMs scales for each domain were correlated with EQ-5D Health Status (self classifier score and the 5 dimensions) and Thermometer at discharge. Following this, AusTOMs scores for each domain for a subset of the most frequently used occupational therapy and physiotherapy scales were correlated with EQ-5D Health Status (self classifier score and the 5 dimensions) and the Thermometer at discharge. Finally, correlations were obtained for change from admission to discharge scores for AusTOMs with change from admission to discharge scores for EQ-5D Health Status (self classifier score and the 5 dimensions) and the Thermometer.A brief summary of demographic data from the sample is provided in Table Over all AusTOMs scales for each domain with EQ-5D Health Status (self-classifier score and the 5 dimensions) correlated with the Thermometer at admission .These results are reported in the first 4 rows of Tables AusTOMs scores for each domain for a subset of the most frequently used OT and PT scales with EQ-5D Health Status (self-classifier score and the 5 dimensions) correlated with the Thermometer at admission.Several moderate to strong correlations were found that were expected and these are presented in Table Over all AusTOMs scales for each domain with EQ-5D Health Status (self-classifier score and the 5 dimensions) correlated with the Thermometer at discharge.In relation to this correlation, the results are reported in the first 4 rows of Tables AusTOMs scores for each domain for a subset of the most frequently used OT and PT scales (only) with EQ-5D Health Status (self-classifier score and the 5 dimensions) correlated with the Thermometer at discharge.The correlations expected that were found are presented in Table Change from admission to discharge scores for AusTOMs with change from admission to discharge scores for EQ-5D Health Status (self-classifier score and the 5 dimensions) correlated with the Thermometer.The moderate to good, statistically significant correlations expected between change on the EQ-5D and AusTOMs overall, or in relation to the six AusTOMs scales where sample size permitted are presented as follows: for physiotherapy '. There were several areas where relationships between constructs measured on AusTOMs and EQ-5D were expected (as described below), and it generally appeared that these two tools are measuring similar constructs. This lends some support to the construct (convergent) validity of AusTOMs. However, not all expected correlations were found and while AusTOMs seems to be measuring global change from the therapist's perspective in relation to four distinct domains , EQ-5D (as expected), is measuring client perceptions of how they feel about their health status. Hence, while both assessments attempt to capture global health-related outcomes, the differing perceptions of the raters (clinicians versus clients) does seem to impact on the establishment of construct validity. Suggestions for overcoming this problem are described below.The next sub-hypotheses dealt with specific correlations that were expected in these data. Unfortunately, there were insufficient data to determine if a moderate negative correlation between admission, discharge and change scores between the PT AusTOMs Scale 'Pain', Impairment domain and the EQ-5D Health Status Subscale 'Pain' existed. Similarly, there were insufficient data (n = 13) to explore the hypothesis that '...there will be a moderate negative correlation between admission, discharge and change scores between the OT AusTOMs Scale 'Functional Mobility and Walking', Activity Limitation Domain and the EQ-5D Health Status Subscale Mobility'. The final scale-specific hypothesis predicted a moderate negative correlation between admission, discharge and change scores between the OT AusTOMs Scale 'Self-care', Activity Limitation domain and the EQ-5D Health Status Subscale Self-care. This hypothesis was supported. The results indicate that therapist and client perceptions of client self-care ability status on admission, discharge (and in relation to the change scores) were moderately correlated. Since many occupational therapists spend considerable time working on self-care with clients, and talking about progress in this area, it is reasonable that clients and therapists would rate client status in this area in a similar manner.Finally, it was hypothesised that there would be a moderate positive correlation between admission, discharge and change scores across all the PT, OT and SP AusTOMs Scales for the Wellbeing domains and the EQ-5D Thermometer. There was only limited support for this hypothesis. However, in some cases the sample sizes were on the small side. There were no moderate, statistically significant correlations when analyzing across all combined OT and SP AusTOMs Scales for the Wellbeing domains and the EQ-5D Thermometer. However, there were moderate to good correlations at both admission and at discharge across all PT AusTOMs Scales for the Wellbeing domains and the EQ-5D Thermometer.Given the number of correlations performed for this study, it is important not to over-interpret the relatively small number of moderate and good correlations found. When considering these findings it is also important to note the relatively small sample size since a larger EQ-5D data set may have produced more, significant correlations. The low EQ-5D return rate from speech pathology is not surprising considering that clients seen by speech pathologists often have communication/ cognitive difficulties, and this increases the difficulty in using a self-administered tool such as the EQ-5D. Clinicians also reported that it was difficult to ask quite acutely unwell clients to complete the EQ-5D although they were able to score the client using the AusTOMs.The validity of a tool is never confirmed. Rather, many studies are required over time to demonstrate that a tool is operating in the manner which developers intended. Future validity studies could investigate the ability of AusTOMs to predict client discharge data from admission status, and to determine the capacity of the tool to discriminate between clients with differing severity levels of impairments and activity limitations. This has already been reported for the physiotherapy profession in relation to the UK TOM . In addiThe EQ-5D is used extensively in cost effectiveness analysis . It is bThe use of different tools across different disciplines to measure improvement can lead to different conclusions about benefits. If outcome measures of cost effectiveness are based on client perceptions it could well be the case that therapy interventions which are seen by therapists to lead to statistically significant improvements in outcome may not be so valued by clients. As a result, those interventions may not be found to be cost effective in an economic sense, if such an evaluation is based on measures of client perception, such as EQ-5D. These differences in perceptions may then contribute to conflict between policy makers, therapists and clients. Alternative economic measures of client outcome, such as return to work, may not be suitable in environments where a significant proportion of clients are beyond working age.Although the tools appear to be measuring somewhat similar constructs, the results of this study suggest that therapy outcome measures such as AusTOMs may need to be supplemented by client-based measures. As part of the treatment process, differences between responses should be discussed to improve understanding between client and therapist about expectations and achievable outcomes from therapy. This may in turn assist goal setting for the therapy process.CU and SD have made substantial contributions to conception and design of the study, analysis and interpretation of data and have been involved in drafting the article and revising it critically for important intellectual content. DD has made substantial contributions in the acquisition of data, and has been involved in drafting the article and revising it critically for important intellectual content. APand JS have made substantial contributions to conception and design of the study, acquisition of data, and have been involved in revising the article critically for important intellectual content. NT has made substantial contributions in the acquisition of data and has been involved in revising the article critically for important intellectual content. All authors have given final approval of the version to be published."} +{"text": "Health-related quality of life (HR-QOL) is a relevant and quantifiable outcome of care. We implemented HR-QOL assessment at all primary care visits at UCSD Owen Clinic using EQ-5D. The study aim was to estimate the prognostic value of EQ-5D for survival, hospitalization, and emergency department (ED) utilization after controlling for CD4 and HIV plasma viral load (pVL).We conducted a retrospective analysis of HIV clinic based cohort (1996\u20132000). The EQ-5D includes single item measures of: mobility, self-care, usual activities, pain/discomfort, and anxiety/depression. Each item is coded using 3-levels . The instrument includes a global rating of current health using a visual analog scale (VAS) ranging from 0 (worst imaginable) to 100 (best imaginable). An additional single item measure of health change was included. A predicted VAS (pVAS) was estimated by regressing the 5 EQ-5D health states on VAS using reference cell coding of health states and random effects linear models. Survival models were fit using Cox modelling. Hospitalization and ED rate models were estimated using population-averaged Poisson models.10(pVL) was 4.6. 47 deaths occurred. In two Cox models controlling for CD4 and pVL, the adjusted hazard ratios (aHR) for VAS and pVAS as time-varying covariates were 0.73 (95% CI: 0.63\u20130.83) and 0.66 (95% CI: 0.56\u20130.77) respectively, for every 10 point increase in (p)VAS rating. In Poisson regression models predicting ED visit rates and hospital discharge rates controlling for current CD4 and pVL, each of the EQ-5D health dimensions, VAS, and health change items were significantly (p < 0.05) associated with the outcomes. For ED visit rates, the adjusted incidence rate ratios (aIRR) were 0.86 (0.83\u20130.89) and 0.79 (0.75\u20130.82) for VAS and pVAS, respectively. For hospital discharge rates, the aIRR's were 0.85 (0.82\u20130.88) and 0.79 (0.75\u20130.82) for VAS and pVAS, respectively.965 patients met eligibility criteria. 12% were female; 42% were non-white. Median time-at-risk was 1.2 years. Median CD4 was 233. Median logEQ-5D is a brief and prognostically useful predictor of mortality, hospitalization, and ED utilization among adults under care for HIV infection, even after adjusting for CD4 and HIV plasma viral load. Self-reported measures of health related quality of life (HR-QOL) and functional status have been widely incorporated in clinical trials and observational cohort studies but are infrequently included among measures routinely administered as part of primary care for patients with HIV infection. In 1996, we implemented routine assessment of HR-QOL using the EuroQol (EQ-5D) instrument at all urgent and routine visits to the UCSD Owen Clinic, a multidisciplinary adult HIV clinic. The EQ-5D is a brief, standardized, generic measure of HR-QOL that provides a profile of patient function and a global health state rating. The 27-We conducted a retrospective analysis of a cohort of adults under care for HIV infection at the UCSD Owen Clinic between 1996\u20132000. Patients were eligible for inclusion if they had confirmed HIV infection and one or more primary care visits at the study clinic during the study period. The principal study measures were longitudinal responses to the EQ-5D and to an additional single item measure of health change. The instrument was administered by medical assistants at the time of clinic check-in following the recording of vital signs. Study covariates were documented in a longitudinal electronic medical record and included socio-demographic characteristics, CD4+ lymphocyte counts, HIV plasma viral load (Roche Amplicor HIV-1 Monitor), hospitalizations, emergency department visits, and mortality verified by search of the Social Security death index. EQ-5D includes single item measures of five health dimensions: mobility, self-care, usual activities, pain/discomfort, and anxiety/depression. Each item has three possible response options that allow the patient to ordinally (no problems/some or moderate problems/extreme problems) rate their current state with respect to each of the 5 domains. In addition, EQ-5D includes a global rating of current health using a visual analog scale (VAS) ranging from 0 (worst imaginable) to 100 (best imaginable). We also included a separate single item measure of health change compared to the prior year.10-transformed HIV plasma viral load were assigned for each patient. The number of hospital admissions and number of emergency department visits for each patient were separately summed by half year. The date of death was assigned according to adjudication by the study clinician (WCM) of death dates from two sources: a clinic registry and the Social Security death index. For analyses pertaining to survival, follow up times end on the death date with censoring of remaining patients on the earlier of the date of the last encounter at the study medical center or the end of the study period (30 June 2000). For analyses pertaining to hospital discharges and emergency department utilization, follow up ended on the date of the last encounter at the study medical center or the end of the study period (30 June 2000). For half years in which no encounters at the study medical center were documented, patients were not considered to be at risk for study outcomes by using discontinuous intervals of risk[For each eligible patient, analysis time began with the first visit to the Owen Clinic or on 1 January 1996 for those with visits prior to that date. Analysis time was divided into six month intervals by calendar year. For each six month period in which a patient had more than one visit, median values of VAS and the five EQ-5D health dimensions were assigned. Similarly, for each six month period, median values of CD4+ lymphocyte count and log2) to the five EQ-5D health dimensions, VAS was regressed on the five reference cell coded [To estimate the percent variance of VAS explained by responses (Rll coded EQ-5D he3) using a Kruskal Wallis test and compared median VAS scores across categories of HIV plasma viral load using a Wilcoxon rank sum test. We also report receiver operating characteristic (ROC) curve area[To estimate the criterion-related validity of EQ-5D VAS when compared with CD4+ lymphocyte count and HIV plasma viral load, we compared, for the first half year measurement, median VAS scores across categories of CD4+ lymphocyte count was estimated in a random effects linear regression model by regre10-HIV plasma viral load were 233 and 4.6, respectively. Median time at risk was 1.2 years. The median number of half years in which at least one EQ-5D score was documented was 3 (range: 1\u20139). Forty seven deaths occurred over the 4.5 year study period. Cumulatively over the study period, the percent of patients with 0, 1, and \u22652 emergency department visits was 60%, 24%, and 16%, respectively. The percent of patients with 0, 1, and \u2265 2 admissions was 61%, 23%, and 16%, respectively.Between January 1996 \u2013 June 2000, 965 patients met eligibility criteria (Table 2) by the five indicator coded EQ-5D health dimensions over the first five half-years of observations was: 39% (n = 915), 47% (n = 735), 48% (n = 511), 56% (n = 348), and 55% (n = 248), respectively. The stability of these estimates with extended follow up suggests that there was no appreciable decay in the meaningfulness of patient responses with repeated administration of the instrument.The variance in VAS scores explained = 28.0, p = 0.001). ROC area for the CD4 criterion was 0.614 (95% CI: 0.566 \u2013 0.662). Median VAS scores were 70 and 75.5 for plasma viral load categories \u2265 1000 and < 1000 copies/mL, respectively .Median EQ-5D VAS scores for the first half year measurement period varied significantly by CD4+ lymphocyte category and those with \"extreme\" anxiety or depression had higher (aIRR 2.0) emergency utilization than those with no reported anxiety or depression. Higher scores on VAS and pVAS, both reflecting better overall health, were associated with lower emergency department visit rates. Finally, those rating their current health as worse than a year previously had nearly twice the rate of ED utilization than those rating their health as better or as unchanged. In two separate models of ED utilization that adjusted simultaneously for CD4+ lymphocyte category, plasma viral load, and either VAS or pVAS, the additional health change item was independently predictive of the outcome .Each of the examined covariates was significantly (p < 0.05) associated with emergency department utilization, but the relationships were more complex than those observed for the survival outcome Table . For mobFor the hospitalization rate outcome Table , each ofThis study has demonstrated that a brief, non-disease specific measure of health related quality of life, when administered routinely to adults under care for HIV infection, captures prognostic information independent of current CD4+ lymphocyte count and HIV plasma viral load. In addition, we confirmed previous observations that theHR-QOL is a multidimensional construct, the components of which have been conceptualized as encompassing physiological factors, symptom status, functional health, general health perceptions, and overall quality of life and thisindex) suitable for use in cost-utility studies. In a cross sectional study of a sample of HIV-infected patients, Delate and Coons demonstrated that EQ-5D health index scores and VAS discriminated between patients with CD4 \u2264 200 cells/mm3 and CD4>200 cells/mm3 and between those with HIV plasma viral load \u2264 30,000 copies/mL and > 30,000 copies/mL[3, Wu et al. demonstrated that both the EQ-5D Index and EuroQol VAS correlated with MOS-HIV mental health and physical health summary scores[3, that scores on five EQ-5D health dimensions explained 46% of the variance in the patients' concomitant VAS ratings. Of the possible 243 possible EQ-5D health states, 83 were observed in the patient sample of 530[Responses to the five EQ-5D health dimensions define 243 possible health states for which general population preference weights have been derived for U.S., European, Japanese, and African samples. The population-specific preference weights for EQ-5D health states can be transformed into summary index scores declare that they have no competing interests.WCM designed the study, performed initial statistical analyses, and drafted the manuscript. SM participated in the analysis plan, performed final statistical analyses, and contributed substantively to the submitted manuscript preparation. Both authors read and approved the final manuscript."} +{"text": "The SF-6D was derived from the SF-36. A single summary score is obtained allegedly preserving the descriptive richness and sensitivity to change of the SF-36 into utility measurement. We compared the SF-6D and EQ-5D on domain content, scoring distribution, pre-treatment and change scores.The SF-6D and the EQ-5D were completed prior to intervention and 1, 3, 6 and 12 months post-intervention in a study enrolling 561 patients with symptomatic coronary stenosis. Patients were randomized to off-pump coronary artery bypass surgery (CABG), standard on-pump CABG, or percutaneous transluminal coronary angioplasty (PTCA). Baseline and change over time scores were compared using parametric and non-parametric tests.The relative contribution of similar domains measuring daily functioning to the utility scores differed substantially. SF-6D focused more on social functioning, while EQ-5D gave more weight to physical functioning. Pain and mental health had similar contributions. The scoring range of the EQ-5D was twice the range of the SF-6D. Before treatment, EQ-5D and SF-6D mean scores appeared similar . Median scores, however, differed substantially (0.69 versus 0.60), a difference exceeding the minimal important difference of both instruments. Agreement was low, with an intra-class correlation of 0.45.Finally, we found large differences in measuring change over time. The SF-6D recorded greater intra-subject change in the PTCA-group. Only the EQ-5D recorded significant change in the CABG-groups. In the latter groups changes in SF-6D domains cancelled each other out.Although both instruments appear to measure similar constructs, the EQ-5D and SF-6D are quite different. The low agreement and the differences in median values, scoring range and sensitivity to change after intervention show that the EQ-5D and SF-6D yield incomparable scores in patients with coronary heart disease. Measurement of health utility is an important part of cost-effectiveness analysis in health care. Health utility can be measured by several preference-based utility measures, of which the EuroQol EQ-5D) ,2 and thD ,2 and We included patients with symptomatic coronary stenosis enrolled in two multicenter randomized controlled trials assessing the efficacy of the Octopus tissue stabiliser for bypass grafting. The first trial (\"OctoPump\") compared standard on-pump coronary artery bypass grafting (CABG) to off-pump CABG using the Octopus device with in 281 patients requiring coronary revascularisation ,13. The The EQ-5D health status instrument comprises 5 questions \u2013 each with 3 levels \u2013 representing 5 health domains: pain, mood, mobility, self care and daily activities ,2. This W test [A qualitative assessment was carried out by comparing (dis-)similarities among domains and theiW test . The ceiW test and by cThe combined study group of 561 patients consisted of mostly males (70.4%); the mean age was 60.2 years (sd 9.3).The EQ-5D and the SF-6D both include pain and mental health (anxiety and depression) with rather similar contributions to the overall utility scores figure . TogetheThe SF-6D had a higher percentage of missing data, both at baseline and post-intervention Table . 33 patiBaseline and change scores from both measures were not normally distributed . The ceiling effect in the EQ-5D domains and utility score were much larger than in the SF-6D Table . There wAgreement between both measures was poor, with an ICC of 0.45. The Bland-Altman plot showed proportional error, and wide limits of agreement Figure . The corThe EQ-5D and SF-6D both detected change over time in the PTCA group Table . All domWe compared the measurement properties of the EQ-5D and the SF-6D in a group of patients undergoing coronary revascularisation. We found clear differences between these utility measures: conceptual, in baseline scores and in sensitivity to change. First of all, the number of domains differs: 5 versus 6. However, the contribution of the SF-6D vitality domain, which has no counterpart in the EQ-5D, is small. Therefore, one could expect that domains tapping similar areas of health have somewhat equal contributions to the total score. This is the case for the domains pain and mood/mental health. However, the content and weights of the other domains show considerable differences, with the EQ-5D giving more weight to physical functioning and the SF-6D to social functioning. A second difference is that the recall period of both instruments is different: today for EQ-5D, versus the last four weeks (or one week in the acute version of the SF-36) for the SF-6D. The third difference is that the scoring range of the EQ-5D is twice that of the SF-6D. The location of the baseline median scores in the scoring range was quite different: in the top quarter for EQ-5D, halfway for the SF-6D. A fourth difference was that the distributions were significantly different from each other, although the mean values appeared to be similar. The difference between the median values and the limits of agreement in the Bland-Altman plot exceed the minimal clinically important difference of both SF-6D and EQ-5D ,21. The A fifth difference is found in the sensitivity to change. Both measures recorded change in the PTCA group, but differed in the CABG groups: EQ-5D scores improved significantly, but SF-6D scores did not change. The SF-6D recorded greater change than the EQ-5D in the PTCA group, despite its narrower scoring range. In the CABG groups, the change in the EQ-5D was caused by change in anxiety/depression and mobility. There was however no corresponding improvement in the SF-6D physical functioning domain. The significant deterioration in social functioning and role limitations cancelled out the improvement in mental health, resulting in no change in the overall SF-6D score. Another important reason for the difference in amount of change after CABG may lie in the differing recall periods: with a post-intervention assessment at one month, the 4-week recall period of the SF-36 encompasses both the intervention and recovery period, as compared to today's health status in the EQ-5D. However, the difference between SF-6D and EQ-5D remains at the subsequent measurements. This cannot be fully explained by different recall periods, as patients are stable by 6 months, and today's health should not differ that much from that over the last 4 weeks.Both measures display non-normal distributions, both at baseline and in change over time. The EQ-5D is skewed towards good health, which creates a ceiling effect. The SF-6D is highly centred on the middle of the scoring range (see figure A substantial part of the missing SF-6D scores were caused by incompletely filled-in questionnaires. The algorithm of the SF-6D requires that all relevant questions are answered. However, the algorithm of the domain scores of the SF-36 allows a certain amount of missing scores, which are imputed with the mean value of the completed items of that domain . We usedRecently, some studies were done that compared the EQ-5D and the SF-6D, as in our study ,24-29. IThe sensitivity to change of the SF-6D remains unclear: Pickard and colleagues found that the SF-6D was as sensitive as the EQ-5D in stroke patients \u2013 although the SF-6D also changed in patients who reported themselves as unchanged . Other sThese differences at baseline and in change over time imply that changes in utility and/or quality adjusted life years based on different instruments cannot be directly compared. Furthermore, these differences are larger than the minimal clinically important difference, which will influence conclusions of cost-effectiveness analysis and clinical decision-making.In conclusion, the EQ-5D and SF-6D are not equivalent, despite some resemblances. Although the mean utility scores appear to be similar, the differences in median values, scoring range and sensitivity to change after intervention and the low agreement show that the EQ-5D and SF-6D yield incomparable scores. Even within a group of patients with the same diagnosis, the EQ-5D and SF-6D yield different scores, while sensitivity to change seems to be influenced by the type of intervention. The SF-6D has better distributional properties than the EQ-5D, but that did not result in improved sensitivity to change. However, it cannot be said which instrument is correct. Clearly, the SF-6D measures something else than the EQ-5D, and these instruments cannot be used interchangeably.Currently, there is no clear benefit in using the SF-6D in clinical studies instead of the EQ-5D, as the SF-6D is not clearly better. As the EQ-5D presently is generally accepted, it may be preferred, thus obtaining results comparable with previous studies.HFvS participated in the design of the study, performed the statistical analysis and drafted the manuscript. EB conceived of the study and participated in it's design. Both authors read and approved the final manuscript."} +{"text": "The EQ-5D is a reliable tool for measuring Health-Related Quality of Life (HRQoL). However, concern has been expressed that it may ignore elements of HRQoL, particularly cognition. In response to this concern, the EQ-5D has been extended with a cognitive dimension (EQ-5D+C). The aim of this study was to compare the performance of the EQ-5D and the EQ-5D+C in elderly patients with cognitive impairments by assessing their construct validity and responsiveness.Data from the MEDICIE study (n = 196) were used, in which all questionnaires were rated by proxies.Regarding construct validity, we found similar correlations between the EQ-5D and the Mini Mental State Examination (MMSE) and between the EQ-5D+C and the MMSE. Furthermore, both the EQ-5D and the EQ-5D+C were responsive to changes in the MMSE, with the EQ-5D performing slightly better.We conclude that the EQ-5D performs well for evaluating HRQoL in a population with cognitive impairments. Based on the results of this explorative study, it does not seem necessary to adjust the current classification system by adding a cognitive dimension. However, in order to compare both instruments regarding utility values, it is necessary to develop a new scoring algorithm for the EQ-5D+C by conducting a general population study. Considering the explorative nature of this study, it is recommended that more aspects of the validity of both the EQ-5D and the EQ-5D+C are explored in patients with cognitive impairments using a more tailored study design. The increasing number of older adults who are diagnosed with dementia has far-reaching implications for health service delivery and expenditures . EconomiThe EQ-5D is commonly used to measure HRQoL and has been shown to be responsive, internally consistent and reliable in the normal population and other patient groups ,10 as weIn response to the concern that the EQ-5D ignores cognition, the EQ-5D has been extended with a cognitive dimension (EQ-5D+C). In thisThe EQ-5D+C generated different values compared with the EQ-5D. Whereas the content validity of the EQ-5D improved by adding cognition, both versions evoked equally reliable values. Based on these results, the authors emphasized the importance of considering the inclusion of a cognitive dimension. Furthermore, the EQ-5D+C was used to describe the health status of the Dutch population and to investigate sociodemographic differences .In this study, the content validity also improved through the addition of the cognitive dimension, while the reliability remained unaltered. It was concluded by the authors that the EQ-5D+C is an efficient tool for establishing the health status in the community. Another way to examine if the EQ-5D should contain a cognitive dimension is to investigate the performance of the EQ-5D and the EQ-5D+C in a population with cognitive impairments. The aim of this explorative study was to compare the performance of the EQ-5D and the EQ-5D+C by assessing their construct validity and responsiveness in patients aged 55 and older with cognitive impairments.Data were derived from the MEDICIE study. The MEDICIE study is a randomized controlled trial (RCT) comparing the effects of a multidisciplinary diagnostic observation center for psychogeriatric patients (DOC-PG) with care as usual on HRQoL, mental and physical health, and the costs and use of health care facilities by patients with psychogeriatric problems . The DOCIn the MEDICIE study, a total of 234 patients and their caregivers agreed to participate and were included between July 2002 and October 2004. Randomization occurred at the level of general practices. The experimental group visited the new diagnostic facility (DOC-PG), whereas the control group was treated as usual, i.e. the GP made the diagnosis or referred the patient to a specialist facility, namely the Maastricht Memory Clinic (MMC) or the Department of Old Age Psychiatry of the Community Mental Health Service (RIAGG). Patients were followed up after 6 months and 12 months.All outcome measures, except the Mini Mental State Examination (MMSE), were collected through personal interviews with the patient's proxy. After initial assessment by the aforementioned health care professionals, the baseline MMSE scores were gathered from the patient records. The researchers (C.W. and D.W) were trained to assess patients using the MMSE at the 6 and 12 month follow-up. When possible, follow-up scores by the professionals were used. Sociodemographic data of the patients and proxies were collected at baseline. Diagnosis was established by the multidisciplinary teams working at the DOC-PG or the MMC/RIAGG respectively, and was based on the DSM-IV criteria or other regular criteria . In thisThe MMSE is used to detect cognitive impairment, to assess its severity and to monitor cognitive changes over time . The MMS5D) ranging from 0 to 100 .The EQ-5D is a generic instrument to measure HRQoL. The instrument was developed and validated in a number of European countries including the Netherlands ,25,26. T5D.The EQ-5D+C is an extended version of the EQ-5D that includes \"cognitive functioning\" as an additional dimension, with a similar operationalization of three levels (as described above) . The EQ-5D. Subsequently, the proxies were asked to answer the sixth dimension concerning cognitive functioning, whereupon the VAS5D was valued a second time (in this study referred to as the VAS5D+C). Therefore, in this study, the EQ-5D+C refers to the additional cognitive functioning dimension and the VAS5D+C.In this study, the EQ-5D was administered completely first, that is the five dimensions followed by the VASConstruct validity, the extent to which an instrument correlates with other measures which it should be related to , was estIn this study, responsiveness was defined as the correlation of the changes in an instrument to changes in other measures which it should be related to, using an anchor-based approach ,32. We eThe software used for the analyses was SPSS version 12.0.1 and STATA version 8.2. Background characteristics of the participants (both the patients and their proxies) were summarized using descriptive statistics. Response distributions of the instruments are given. Missing data of the participants were imputed using multiple imputation (MI). MI provides a useful strategy for dealing with data sets with missing values. Instead of filling in a single value for each missing value, Rubin's multipleKolmogorov-Smirnov tests were used to test for normality. Non-parametric tests for comparisons were selected. Associations between the instruments were analyzed with Spearman rank correlations.Table After six months, 16 patients (6.8%) had died and 11 patients (4.7%) and their caregivers had dropped out of the study. Four patients (1.7%) did not attend the six month follow-up because of personal reasons. After 12 months another 11 patients (4.7%) had died and two more patients (0.9%) and their caregivers had dropped out of the study. The 27 patients (11.5%) who had died were excluded from the analyses as well as the 11 study dropouts (4.7%) who completed only 1 measurement. Missing data of the remaining 196 patients were imputed using MI. To make sure the imputations did not influence our results, separate analyses were performed on the 5 imputed datasets. The results were highly comparable (data not shown). Therefore, the first imputed dataset was used for analysis.5D+C scores were significantly lower than the mean VAS5D scores at all measurements .The responses in the EQ-5D and the EQ-5D+C at baseline and follow-up measurements are summarized in table The responses in the MMSE at baseline and follow-up measurements are summarized in table 5D of the EQ-5D. Correlations were also found between the MMSE and the cognitive dimension and the VAS5D+C of the EQ-5D+C. At the six month follow-up, correlations were found between the MMSE and the utility score, and more specifically all five dimensions, and the VAS5D of the EQ-5D. Correlations were also found between the MMSE and the cognitive dimension and the VAS5D+C of the EQ-5D+C. At the 12 month follow-up, correlations were found between the MMSE and the utility score, and more specifically all dimensions except for the pain/discomfort dimension, and the VAS5D of the EQ-5D. Correlations were also found between the MMSE and the cognitive dimension and the VAS5D+C of the EQ-5D+C.Table 5D of the EQ-5D and the change scores of the MMSE. Correlations were also found between changes in the cognitive dimension and the VAS5D+C of the EQ-5D+C and the change scores of the MMSE.Table The aim of this explorative study was to compare the performance of the EQ-5D and the EQ-5D+C by assessing their construct validity and responsiveness in patients aged 55 and older with cognitive impairments.5D. Results regarding construct validity of the EQ-5D are in line with the recent findings of J\u00f6nssen et al. [Based on our results it can be concluded that the construct validity of the EQ-5D and the EQ-5D+C is comparable in our study population, except for the VASn et al. . Contrarn et al. , in patin et al. and in pn et al. . Anothern et al. failed tWith regard to responsiveness, the EQ-5D performed slightly better than the EQ-5D+C, which is also in line with the findings of J\u00f6nssen . An impoHowever, no judgments were made about the strength of the correlations, which would provide us with a stricter criterion regarding the performance of the EQ-5D and EQ-5D+C. In the literature, different classifications were found -41 a cleThe majority of authors ,41,42 anRegarding responsiveness, fair correlations were found between changes in the EQ-5D and EQ-5D+C and changes in the MMSE. The relatively low responsiveness of the EQ-5D in this study could be due to the, on average, small changes in cognition in a year, or to a ceiling effect because there are only three levels for each dimension of the EQ-5D. Patients' health may improve or decline but not enough to go up or down one level. Instruments that have a greater number of possible responses may be more responsive. Furthermore, it is possible that adaptation to illness on the part of the proxy leads to a lack of responsiveness, especially with a chronic condition such as dementia . It shou5D. Subsequently, the proxies were asked to answer the sixth dimension concerning cognitive functioning, whereupon the VAS5D+C was valued. It would have been better to administer the EQ-5D+C completely as well in order to make valid comparisons between the 2 versions. However, considering the explorative nature of this study, we did not want to burden the participants of the MEDICIE trial by administering a similar questionnaire twice.There are several limitations to this study that need to be recognized. An important limitation of this study concerns our study design. The origin of this study, the MEDICIE trial, was designed to compare the effects of a multidisciplinary diagnostic observation centre for psychogeriatric patients (DOC-PG) with care as usual on HRQoL, mental and physical health, and the costs and use of health care facilities by patients with psychogeriatric problems. Therefore, studying the usefulness of the EQ-5D+C in this patient population was framed in this RCT. The EQ-5D was administered first, that is the five dimensions followed by the VAS5D+C, even though they had been instructed to rate the VAS5D+C again based on the overall health. This effect is called a framing effect, which suggests that how something is presented (the 'frame') influences the choices people make [5D+C with the MMSE are due to a framing effect. However, according to Parkin et al. [5D are affected by end-state descriptors (last named dimensions).Second, regarding the assessment of the EQ-5D+C, the proxies may have focused their attention on the cognitive dimension when scoring the VASple make . Hence, n et al. , the fraAnother possible limitation is the use of proxies to complete the questionnaires. Previous research indicated that there is generally fairly good proxy-patient agreement for observable items such as mobility, self care and usual activities, but poor agreement for non-observable items such as pain and affect . Others A final limitation also concerns the design of our study. Comparisons between the EQ-5D and the EQ-5D+C were merely based on the dimensions and VAS-scores of both versions and not on the utility scores since these are not available for the EQ-5D+C. It should be noted that an algorithm has been developed for EQ-5D+C health states, based on Dutch disability weights ,52. In tIn this explorative study, the construct validity and responsiveness of the EQ-5D and the EQ-5D+C were assessed and compared in patients aged 55 and older with cognitive impairments. We conclude that the EQ-5D performs well for evaluating HRQoL in our population with cognitive impairments using proxy ratings. Therefore, based on the results of this study and given its (serious) limitations, it does not seem necessary to adjust the current classification system by adding a cognitive dimension. However, in the absence of a gold standard for measuring HRQoL, a general population study to obtain valuations for the EQ-5D+C health states could provide a better insight into whether cognition has a separate and significant effect on utility values, and would enable us to compare the utility values deduced from both versions in a correct manner.The author(s) declare that they have no competing interests.FV was the principal investigator of the larger trial and is guarantor. FV, AK, CD, and JS designed this trial. CW and DW carried out the outcome measures. AK and CW were responsible for statistical analysis and interpretation of the study, and all authors contributed to interpretation. CW drafted the manuscript, and all authors critically revised it for scientific content and approved the final version."} +{"text": "The one leg hop for distance is one of the most commonly employed functional tests utilized in the evaluation of the ACL deficient and reconstructed patient. While the reliability of the hop test scores has been well established, validity studies have revealed low sensitivity rates in detecting functional limitations using the hop index (the ratio or percentage of limb performance). However, the impact of the inherent limitations associated with the hop index have not been investigated to date. One specific limitation relates to the impact of the differences in the underlying hop distance scores. Therefore, this pilot study set out to determine: 1) the impact that between limb differences in hop distance has on the sensitivity of the hop index in detecting functional limitations and; 2) whether a logarithmic transformation of the underlying hop distance scores improves the sensitivity of the hop index.A cross sectional design involving the evaluation of one leg hop for distance performance in a consecutive sample of 10 ACL deficient males with an isolated ACL tear awaiting reconstructive surgery and nine gender, age-matched controls.In the ACL deficient, the hop index was associated with the distance hopped on the non-injured limb but not on the injured limb. Transformation (logarithmic) of the hop distance scores and re-calculation of the hop index using the transformed scores increased the sensitivity of the hop index in the detection of functional limitations from 20 to 60% and 50 to 70% using the normal limb symmetry reference norms of \u2265 85% and 90% respectively.The distance hopped on the non-injured limb is a critical factor in detecting functional limitations using the hop index in patients with an ACL deficient knee. Logarithmic transformation of the hop distance scores minimizes the effect of the arithmetic differences between limbs however; the sensitivity of the hop index in detecting abnormal limb symmetry remains low. The one-leg hop for distance (OLHD) has become one of the most commonly employed functional tests utilized in the evaluation of the ACL deficient (ACLD) or reconstructed patient, especially since its inclusion in the International Knee Documentation Committee (IKDC) standard knee ligament evaluation -10. It iThe OLHD scores include the hop distance and hop index, which is the ratio or percentage of hop distance achieved on one limb relative to the other. Hop index reference norms are used widely as clinical benchmarks for establishing normal versus abnormal OLHD performance. A normal hop index has been shown to be \u2265 85% by Barber et al and \u2265 90While the reliability of the OLHD has been well established in terms of the consistency of patient scores,18,21,22Distance hopped on the non-injured leg may vary widely according to natural differences in athletic ability and muscle strength however; variation in the distance hopped on the ACL injured leg is likely constrained due to impairment. Consequently, the sensitivity of the hop index in detecting functional limitations in the ACLD would increase incrementally with the distance hopped on the non-injured leg. A logarithmic transformation of the hop distance scores could improve the sensitivity of the hop index by making it more sensitive to the proportional variation in the scores relative to arithmetic differences for those ACLD patients who do not hop as far on the non-injured limb.In view of the above, the objectives of this pilot study were twofold:1. To assess the impact that between limb differences in hop distance has on the sensitivity of the hop index in detecting functional limitations in the ACLD patient requiring reconstructive surgery and;2. To assess whether a logarithmic transformation of the hop distance scores increases the sensitivity of the hop index within this population.Ten consecutive males on a waiting list for ACL reconstructive surgery were recruited. The inclusion of the ACL deficient patient was dependent upon them having a grade 2 or 3 ACL ligamentous laxity on manual testing, being at least 6 weeks post injury and the absence of other ligamentous involvement. Ten gender and age-matched healthy Controls were recruited from the community through the use of flyers and word-of-mouth.The ACLD patients were tested 5.3 to 60 months post injury and were similar in mean (+/- SEM) age in comparison to Controls (28.4 (+/- 2.74) and 28.4 (+/- 1.11) years respectively). All ACLD patients demonstrated normal extension range of motion on the injured limb (less than 3-degree difference between limbs), seven had normal flexion (between 0 to 5-degree difference between limbs) and three had nearly normal flexion (between 6 to 15 degree difference between limbs). None of the ACLD patients had evidence of swelling at the time of testing.Self-report activity levels were evaluated using the Tegner Activity Scale . The ACLD patients engaged in significantly less demanding work/sport related activities after their ACL injury pre-injury: 7.5 and post-injury 4.5 ; p = 0.004). However, the difference between the ACLD patients and Controls at the time of testing was not significantly different versus 6.5 respectively; p = 0.082).OLHD performance was evaluated with the subject's hands behind their back, to minimize the effect of arm swing and subjects were instructed to stand on one limb and hop as far forward as possible. Placement of the other foot upon landing was not permitted however; subjects were not required to hold their landing position. A total of three hop trials on each limb were performed. Practice trials were not permitted and the order of limb testing was randomly determined. Subjects warmed up for five minutes on a stationary bike prior to testing.The hop distance was calculated by measuring the distance traveled from heel to heel from the beginning to final standing position. The longest distance of the three trials for each leg (as opposed to the average) was used to calculate the hop index for ease in computing as it has been shown that the different analysis strategies have no effect on the hop index . Leg domInformed consent was obtained prior to testing, subjects were tested on one occasion only and all testing was performed by the same physical therapist. The research ethics committee of the hospital and its affiliated academic institution granted approval of the study protocol.10) transformation, although logarithms to any base would have had the same effect [The validity of the OLHD in depicting functional limitations in an ACLD knee was determined through an interpretation of the diagnostic indices . The impact of limb differences in distance hopped on the hop index was explored by analyzing scatterplots of the hop distance scores, examining the association between limb hop distance scores and investigating the relationships between the hop distance scores and hop index. In order to minimize the arithmetic variation between limb performance of the ACLD and Controls, the hop distance scores were transformed using a logarithmic . For comparisons involving parametric data, independent and paired t-tests were employed and for non-parametric data, the Mann-Whitney Rank Sum and Wilcoxon-Signed Rank tests were used. Linear regression analyses were conducted using the Pearson Product Correlation Coefficient. All differences were deemed significant at the p < 0.05 level.Within group comparisons revealed a significant difference in distance hopped between limbs within the ACLD group but not within the Controls . Also, between group comparisons demonstrated a significant difference in the distance hopped on the ACLD limb relative to the average limb performance (dominant + non-dominant / 2) of the Controls but not between the non-injured limb of the ACLD patients and Controls .The percentage of ACLD patients with an abnormal hop index using the hop index reference norm \u2265 85% was 20% and \u2265 90%, 50%. Whereas, 100% of the Controls demonstrated a normal hop index irrespective of the reference norm employed compared to Controls however, on the non-injured limb, the correlation between the hop index and hop distance was significant Figure . The ConThe percentage of ACLD patients with an abnormal hop index of < 85% increased from 20 to 60% when the hop index scores were recalculated using the transformed hop distance scores. In a like manner, the percentage with an abnormal hop index of < 90%, increased from 50 to 70%. The percentage of Controls who demonstrated a normal hop index basically remained unchanged declare that they have no competing interests.SO'D conceived and designed the study, acquired the data, conducted the data analysis and drafted the manuscript. ST contributed to the conception and the design of the study, assisted with the interpretation of the analysis and reviewed the manuscript critically for intellectual content. PM assisted in the recruitment of subjects and contributed to the overall coordination of the study. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:"} +{"text": "Information on health related quality of life (HR-QOL) can be integrated with other classical health status indicators and be used to assist policy makers in resource allocation decisions. For this reason instruments such as the SF-12 and EQ-5D have been widely proposed as assessment tools to monitor changes in HR-QOL in general populations and very recently in general practice settings as wellThe primary goal of our study was to assess the construct validity of the Italian version of the EQ-5D in a general population of North Italy using socio-demographic factors and diagnostic sub-groups. Our secondary goal was to assess the concurrent validity of the EQ-5D and SF-12.The SF-12, the EQ-5D plus an additional questionnaire on socio-demographic characteristics, clinical conditions and symptoms were completed by 1,622 adults, randomly selected from the Registry of the Health Authorities of the city of Bologna, Italy. The primary care physician of each subject was contacted to report on the subject's health status.Our findings indicate that the Italian version of the EQ-5D is well accepted by the general population (91% response rate), has good reliability , and shows evidence of construct validity.Our data provide a basis for further research to be conducted to assess the validity of the EQ-5D in Italy. In particular future studies should focus on assessing its ability to detect a clinically important change in health related quality of life over time (responsiveness). Improving the health of local populations requires specific knowledge of the current levels of health status, which can be compared over time. However commissioning health care services carries with it the need to prioritize resources. For this reason policy makers have always expressed the necessity to identify variations within the communities they are serving, compare local data with normative population levels and eventually monitor changes in health status by diagnostic and socio-demographic sub-groups. Information on health related quality of life (HR-QOL) can be integrated with other classical health status indicators and be used to assist policy makers in resource allocation decisions -3. For tThe SF-12 is a generic short form health survey, originally developed in the USA to provide a short alternative to the SF-36 . It prodThe EQ-5D is an internationally developed health related quality of life measure that has been used throughout the world. The mainThe primary goal of our study was to assess the applicability, internal consistency, and construct validity of the Italian version of the EQ-5D in a random sample of the citizens of Bologna . Our secondary goal was to test its concurrent validity with the SF-12.th, 14th and the 21st day from the inception of the survey. Delinquency after the third phone call resulted in dropping out the subject from the study and replacing her with a subject (same age and gender) randomly selected from the original sample. No reimbursement was offered to the study participants.A sample of 1,622 adults, aged 18\u201393, was randomly selected (simple random sample) from the Registry of the North and South Health Authorities of the city of Bologna, Italy. The adopted exclusion criteria were: people aged < 18 years, non residents of the two Health Authorities geographical areas, institutionalized subjects, and people not able to reason or understand and make decisions on their own. The study was performed in 2002 and the sample was expected to be representative of the residents of the geographical area covered by the two Health Authorities. A package with the SF-12 and the EQ-5D questionnaires plus an additional questionnaire on socio-demographic characteristics, clinical conditions and symptoms was sent home to the 1,622 subjects. The primary care physician of each subject was contacted by mail to report on the enrolled subject's health status by filling out a questionnaire to be returned to the Health Authority. In order to maximize the response rate each subject was contacted by telephone three times after the 7Two instruments were used to measure health related quality of life: the SF-12 v.1 and the EQ-5D. The SF-12 is a generic instrument that contains 12 items from the SF-36 Health Survey. The SF-12 estimates scale scores for four of the SF-36 eight health concepts using two items each; the remaining four health concepts are each represented by a single item. We calculated the summary scores PCS-12 and MCS-12 using the scoring program described by Apolone .The EQ-5D is a generic instrument, consisting of five three-level items, representing various aspects of health: mobility, self-care, usual activities, pain/discomfort and anxiety/depression (mood). Respondents can value their health in each domain by reporting whether they are experiencing none (score 1), some (score 2) or extreme (score 3) problems. These scores result in a health profile, e.g. a patient with profile 12113 has no problem with mobility, usual activities and pain/discomfort, some problems with self-care and extreme problems with anxiety/depression. Data of a visual analogue scale are also included in the EQ-5D and used by subjects to rate their health status between worst imaginable health state (score 0) to best imaginable health state (score 100). A utility index score was calculated for each subject's EQ-5D health status by applying the time trade-off-based valuations from a general UK population sample to the observed EQ-5D profile, as data from an Italian norm are not available at the present time. Using the data at hand self-rated index were also calculated using the EQ-VAS score method.In the package shipped to the subjects we also included an additional questionnaire to gather data on socio-demographic characteristics and to investigate clinical conditions and/or symptoms that based on a literature search we hypothesized could affect everyday life (i.e. headache) and do not necessary require a medical consult or that are known to be reliable when self reported . -21The self-reported questionnaire focused on the following symptoms or clinical conditions: visual impairment, hearing impairment, anxiety/depression, headache, diabetes, and dialysis. In addition a final open question was created asking the subject to report on other clinical conditions affecting her health status.We used the level of education as proxy indicator of socio-economic status because information on income was not available. The level of education was described according to the Italian school system into 5 categories: less than elementary school degree, elementary school degree, middle school degree, high school degree, and college degree equivalent to less than 5 years of school, between 5 and 8, between 8 and 13 and more than 13 respectively.We grouped the variable occupation into 7 categories: 1) managers, professionals, directors, businessmen, 2) public or private companies' employees, 3) labors, 4) house-keeping, 5) retirees, 6) students and 7) unemployed.The primary care physician of each subject was invited to give a clinical assessment on the enrolled subject. In order to gather such information in a structured and reliable way we designed a questionnaire including the definition of each investigated condition based on a review of the most recent clinical guidelines. References to the adopted guidelines were included and the questionnaire piloted tested before implementation. The clinical conditions included in the questionnaire were: hypertension, heart failure, angina, COPD, asthma, back-pain, cancer (diagnosed in the past 5 years), stroke, cirrhosis, arthritis (proved by X-ray documentation), myocardial infarction (occurred in the past 5 years), and stomach ulcer (proved by endoscopy).Construct validity refers to the evaluation of hypotheses about the expected performance of an instrument. A construct can be thought as a mini-theory to explain the relationships among attitudes, behaviors, and perceptions as well. Construct validation is an ongoing process of learning more about the construct, making new predictions and then testing them. It is a process where the theory and the measure are assessed at the same time Our approach in evaluating the EQ-5D construct validity was based on comparisons of mean value scores and ORs (for the EQ-5D items) across categories such as diagnostic or socio-demographic groups known or hypothesized to score differently \"known group validity\". For example we hypothesized that subjects of older age, with a lower educational attainment, female and unemployed scored lower compared to younger, more educated, male and employed subjects.We also hypothesized that for the 14 identified diagnostic sub-groups scores would have been lower compared to healthy subjects.The SF-12 was used to compare whether conceptually similar domains had higher correlations than conceptually unrelated domains.Internal consistency of the multi-item EQ-5D scale was calculated by means of Cronbach's \u03b1 . AverageThe concurrent validity of the EQ-5D and SF-12 in this respondent sample was tested examining the relationship between the self-reported EQ-5D and the SF-12 component scores. The relationships between comparable dimensions and component scores, such as anxiety/depression with the MCS-12 and mobility, self-care, usual activities and pain/discomfort with the PCS-12 were hypothesized to be stronger than between less comparable dimensions and component scores, for example mobility and the MCS-12. In contrast the EQ-VAS score was expected to correlate reasonably well with both the MCS-12 and PCS-12. The correlation between the EQ-index and the EQ-self rated index was also computed. The strength of the correlation was determined by Cohen's (1992) criteria where large correlations are described as being >0.50, medium correlations range between 0.30\u20130.49 and small correlations range between 0.10\u20130.29.The compare the \"discriminant\" validity of the two questionnaires we used the magnitude of ratio of the F-test from multivariable analyses of variance. We hypothesized the ratio to be greater for comparable dimensions such as PCS-12 and the 4 EQ-functional dimensions compared to non-comparable dimensions such as PCS-12 and the anxiety dimension.Data were analyzed using Statistical Package for the Social Sciences (SPSS) version 11.5.Completed questionnaires were collected from 1,555 subjects, 96% response rate. Of the 1,555 subjects 1,421 (91%) completed the EQ-5D, 1,326 (85%) the EQ-VAS, and 1,364 (88%) the SF-12.Considering the original sample 16.4% of non-respondents were replaced. Thirty-six percent (524) of respondents that completed all items of the EQ-5D reported no problems (i.e. 11111) on all five dimensions. Of the 243 possible health states described by the EQ-5D, respondents reported 47 different health states. Therefore the ceiling effect of the EQ-5D was modest compared to other studies .The subject socio-demographic information is presented in Table Cronbach's coefficient \u03b1 was 0.73 showing good reliability of the instrument.F-test (p < 0.001) after adjusting for age and gender. Among occupations, retirees reported the lowest scores.The mean EQ-5D index score (SD) was 0.81 0.22) and the mean EQ-VAS score (SD) was 77.0 (17.4). The EQ-VAS sample mean score of 77.0 (17.4) was lower than the general population norm of 82.5 (17) from the U.K. sample. [24]The Pearson correlation coefficient between the EQ index and EQ-VAS was 0.65 (p < 0.001) and between the EQ index and EQ-self rated index was 0.89 (p < 0.001). With the exception of the age category 25\u201334, mean scores on both the EQ index and EQ-VAS decreased with increasing category of age Diabetes was associated to all 5 dimensions with ORs ranging from 4.8 (95% C.I. 2.7\u20138.7) in the mobility domain to 1.7 (95% C.I. 1.0\u20133.0) in the anxiety and depression domain.With respect to the clinical conditions referred by the subject's primary care physician all were significantly associated with increased odds of reporting impairment in all 5 EQ dimensions. Table All clinical conditions showed a negative impact on HR-QOL when the EQ-5D index, EQ-self rated index and the EQ-VAS scores were taken into considerations. Applying a linear regression model, adjusting for age and gender, regression coefficients ranged from \u2013 0.08 (p < 0.005) for obesity and stomach ulcer impacting the EQ-5D index and EQ-5D VAS score respectively and -0.35 (p < 0.001) for arthritis impacting the EQ-VAS score, results are shown on Table As expected the relationships were stronger between the EQ-5D functional dimensions and the PCS-12, and between the MCS-12 and the anxiety/depression dimension. As a matter of fact the correlation coefficients between PCS-12 and the functional dimensions ranged from 0.65 for the usual activities domain to 0.43 for the self-care domain. As expected the MCS-12 score well correlated with the anxiety and depression domain r = 0.59. The relationships between the less comparable dimensions and the component scores were not as strong. In fact the correlation coefficients between the MCS-12 and the physical items ranged from 0.34 for the usual activities domain to 0.25 for the self-care and mobility domains. While the PCS-12 score correlated with the anxiety and depression domain with a coefficient as low as of 0.29. The EQ-VAS scores were positively correlated with both component scores; r = 0.46 for MCS-12 and r = 0.66 for PCS-12. All correlations were significant with p-value < 0.001.In addition corresponding dimensions and summary scores were more strongly related than dissimilar dimensions .In this study we investigated the construct validity of the Italian version of the EQ-5D administering the instrument to a sample of citizens living in Bologna . We provided evidence supporting the construct validity and reliability of the instrument supported by data on socio-demographic characteristics and diagnostic sub-groups of the participants. Strength of our study was the achieved high response rate and the primary care physicians' support in assessing each subject's health status.The instrument resulted to be consistent with the hypothesized construct and showed good reliability. The convergent and discriminant validity of the EQ-5D were also supported by the relationship with the SF-12 component scores observed in the data, with stronger relationships observed between the PCS-12 scores and the functional dimensions than with the anxiety/depression dimension. Likewise the MCS-12 scores differentiated the level of anxiety/depression dimension more strongly than for the levels of the functional dimensions of mobility, self-care, usual activities and pain/discomfort.We consider our results as a preliminary step towards the empirical validation process of the EQ-5D in Italy. However some limits of our research should be taken into consideration.Our sample was representative of two health district areas of the city of Bologna, the Italian territory is extremely heterogeneous in terms of population characteristics such as age, socio-economic status, health status and life-style. In particular differences are present in most health indicators between the North and South of the country. Therefore any inference on the Italian population should be cautious. The utility value calculated for the EQ-5D was based on the U.K. population norm data, debate on the cross adaptability of such scores has not been solved yet. The absence of values based on the Italian population affects the most important characteristic of the instrument, which is its use in cost-effectiveness analysis. However EQ-self rated index scores were derived and showed a high correlation with the UK EQ-index scores.A known limit of the EQ-5D is to have a 3 responses format, as a consequence subject to a considerable ceiling effect. However in our sample it appeared that the dimensions were discriminative enough to distinguish between respondents with and without specific clinical conditions.An other limit of our study was not being able to assess the instrument's responsiveness, which is extremely important for its use in monitoring a population's health status.Our data provide evidence on the construct validity of the Italian version of the EQ-5D in a general population of a large city in North Italy. The measurements of the EQ-5D behaved in patterns that were consistent with recognized socio-demographic differences in health status.Future studies should focus on assessing the instrument's ability to detect a clinically important change in health related quality of life over time (responsiveness) in order to be able to adopt the tool to monitor a population's health status. However in addition to a psychometric approach measurement/metric equivalence of the Italian version of the EQ-5D should also be investigated. In particular the clinically minimal important difference (MCID), which is defined as the smallest difference between the scores in a questionnaire that the patient perceives to be beneficial should be assessed in an Italian sample should be assessed. A national effort in designing a study with a representative sample of the Italian population will be a necessary step to increase evidence on the EQ-5D applicability in Italy.The author(s) declare no competing interest in the conduction of the study.Dr. Pandolfi designed and led the study, Dr. Collina led the implementation of the study in the health district under her authority, Dr. Fantini offered methodological support in designing the study and for the data management plan, Dr. Dallolio coordinated data entry and data analysis, Dr. Savoia provided assistance with data analysis and the narrative of the manuscript. All authors revised the text and provided information and comments to its final version."} +{"text": "Diabetes has a high burden of illness both in life years lost and in disability through related co-morbidities. Accurate assessment of the non-mortality burden requires appropriate health-related quality of life and summary utility measures of which there are several contenders. The study aimed to measure the impact of diabetes on various health-related quality of life domains, and compare several summary utility measures.In the ADVANCE study, 978 Australian patients with Type 2 diabetes completed two health-related quality of life questionnaires at baseline: the EQ-5D and the SF-36v2, from which nine summary utility measures were calculated, and compared. The algorithms were grouped into four classes: (i) based on the EQ-5D; (ii) using fewer items than those in the SF-12 (iii) using the items in the SF-12; and (iv) using all items of the SF-36.Overall health-related quality of life of the subjects was good (mean utility ranged from 0.68 (\u00b10.08) to 0.85(\u00b10.14) over the nine utility measures) and comparable to patients without diabetes. Summary indices were well correlated with each other (r = 0.76 to 0.99), and showed lower health-related quality of life in patients with major diabetes-related events such as stroke or myocardial infarction. Despite the smaller number of items used in the scoring of the EQ-5D, it generally performed at least as well as SF-36 based methods. However, all utility measures had some limitation such as limited range or ceiling effects.The summary utility measures showed good agreement, and showed good discrimination between major and minor health state changes. However, EQ-5D based measures performed as well and are generally simpler to use. Many randomized control trials of therapies for Type 2 Diabetes now routinely include a generic health-related quality of life instrument administered to patients at baseline and during follow-up. The two most commonly used generic instruments are the EQ-5D and the While the generic instruments provide information that enables comparison of the health status of the study participants with other populations , they are primarily used in the valuation of outcomes in economic evaluation. This typically involves use of predefined algorithms to convert item survey responses into a utility scale where 1.0 implies the patient is in perfect health and 0.0 is a health state equivalent to death. This is the most commonly used approach to estimate quality adjusted life years (QALYs) and provides a composite measure that aims to incorporate survival and health-related quality of life into a single index. QALYs are a particularly important outcome measure in the evaluation of therapies for a disease such as diabetes where complications, such as amputation, can have a considerable impact on overall health-related quality of life.While many trials in diabetes now routinely include one or more generic health-related quality of life instrument there is no consensus as to either which instrument should be used, or which algorithm should be applied, to convert patient responses into utilities. In the case of the EQ-5D, traditionally the most commonly used algorithm was derived from a study involving individuals from the UK population . HoweverThere are at least seven published algorithms ,12-17 foThe purpose of this study is to compare summary statistics of the estimated utility values produced by different algorithms for common complications of diabetes. In particular we are interested to see if there are systematic differences in both the absolute mean utility values and the deviations associated with each type of diabetes-related complication.All patients included in this study were participating in the ADVANCE study. ADVANCE is a randomised 2 \u00d7 2 factorial trial in 11,140 normotensive patients with Type 2 diabetes comparing (i) intensive, gliclazide-based therapy or regular, guideline-based glucose control therapy in patients with Type 2 diabetes, and (ii) intensive blood pressure lowering based on a perindopril-indapamide combination or matching placebo .Two health-related quality of life questionnaires are being used in the ADVANCE trial: the EQ-5D (EuroQol 5-Dimensions) and the SF-36v2 (Short Form 36 version 2). The EQ-5D has five questions \u2013 on mobility, personal care, usual activities, pain/discomfort, and anxiety/depression \u2013 each encompassing the range of values 1 (= no problems), 2 (= some problems), 3 (= severe problems).The SF-36v2 is a multipurpose short-form survey with 36 questions that measure eight health attributes using multi-item scales containing 2 to 10 items each. These attributes are: (1) physical functioning, (2) role limitations due to physical health problems, (3) bodily pain, (4) general health, (5) vitality (energy/fatigue), (6) social functioning, (7) role limitations due to emotional problems, and (8) mental health . The SF-12 and SF-6D are health-related quality of life instruments that use a subset of these items.The EQ-5D was administered to all patients in the ADVANCE trial, from the 20 participating countries. The SF-36v2 questionnaire was administered to the subgroup of Australian patients only. Both questionnaires were administered at baseline and 2 years after randomization to the study. As the analysis involves a comparison of the EQ-5D with the SF-36 we have restricted the analysis to the Australian patients.We undertook a literature search to identify studies that reported algorithms to convert generic health-related quality of life instruments into utility values which could potentially be used in valuing outcomes in economic evaluations. We identified seven studies ,12-17 thWe report summary statistics for patients with a history of any of seven diabetes-related complications: stroke or transient ischemic attack (TIA), peripheral revascularization and/or amputation, hospital admission for unstable angina, myocardial infarction, coronary artery bypass graft, and currently treated for hypertension. This history was reported on the baseline form. The mean (sd) utility for those with the complication, without the complication, and without any of the complications, was calculated for all nine algorithms. Confidence intervals were calculated for differences in the mean level of utility of those experiencing each type of complication with those not experiencing that complication in the Australian ADVANCE population, and displayed graphically. To compare how the mean difference in utility varied between algorithms we ranked the severity of the seven complications of diabetes for each utility measure, then used Spearman's rank correlation coefficient to assess the degree of consistency in ranking. We also graphed the average difference in mean utility for these complications by the four classes of algorithm.To estimate the within-person variability, we used the measures in the subgroup of patients who had had no major adverse event between the baseline and two-year qol measurements. This was used to define a signal-to-noise ratio as the difference in mean utility between those who had a major event and those who did not, divided by the standard deviation of the utility measure in those who did not have a major event. Furthermore, linear regression models were used to assess the statistical significance of the presence of a major event on change in 2-year utility score, adjusted for baseline score.Characteristics of the ADVANCE study population have been published , and incTable Table Table The two health-related quality of life instruments (SF-36 and EQ-5D) were administered to all patients again at approximately two year after baseline. During this time, details of any serious adverse events (SAEs) experienced by the patients were also collected and then used in conjunction with the 2-year qol information to examine changes in health status since baseline. In the ADVANCE study, serious adverse events are defined as events that: (1) result in death, (2) are life threatening in the opinion of the responsible investigator,(3) require inpatient hospitalisation or prolongation of existing hospitalization, 4) result in persistent or significant disability or incapacity, (5) result in congenital anomaly or birth defect (unlikely since participants must be aged 55 years or over at entry to study), and (6) are important medical events in the opinion of the responsible investigator. The presence or absence of an SAE was then used in conjunction with the difference in utility measure between baseline and two-year values to calculate regression coefficients and signal/noise ratios algorithm, but only 0.05 for the Brazier SF-6D (SF-36) algorithm , and also demonstrating minimal day-to-day fluctuation when no major changes have occurred. That is, a good \"signal-to-noise\" ratio. Those instruments based on direct valuation of health states (i.e. EQ-5D and SF-36) tend to have lower signal to noise ratios (indicating greater variation in the utility measures) than those using some form of mapping, however this is due to differences in methods of derivation. In particular, the latter is generally based on predictions of mean utilities derived from regression equations that tend to reduce the degree of variation across health states. In regard to the instruments based on direct valuation, the EQ-5D generally seemed to perform as well as the SF-36 based methods. This is somewhat surprising given the smaller number of items assessed and used in the scoring of the EQ-5D.A third criterion for choosing a utility instrument is the generation of an appropriate range for the utility values. In this regard, the Brazier algorithm, which is now the standard summary score for the SF-36, has a much narrower range as it cannot achieve scores lower than 0.296. This limits the degree to which it can characterize the utility associated with extremely poor health states, such as disabling stroke. The Lundberg score was highly correlated with the Brazier score and showed similar problems of range restriction. This may explain why these algorithms generally produced smaller differences for those with and without particular complications, than algorithms based on EQ-5D utility values. This has also been observed in other disease areas such as patients with liver transplantation in whichA final criterion is the simplicity or ease of administration of the instrument. The collection of health-related quality of life information is often subject to cost or time constraints, as the contact time with a patient in trials is limited. Hence the administration of the health-related quality of life instrument has an opportunity cost in terms of reducing the time available to collect other information. The SF-36 is usually administered as a self-completed questionnaire which contains 36 items covering different aspects of health-related quality of life, and administered when patients attend clinics. While the developers of the SF-36 state that it can usually be completed in 5 to 10 minutes, at leasSince researchers must choose a utility algorithm in addition to choosing a quality of life instrument, the differences in the utilities for the EQ-5D derived using the algorithms developed by Shaw for a US population and original tariffs that were derived in the United Kingdom are of note. For example, the Dolan algorithm indicated patients with no complications had a utility around 0.8 , whiFinally it is important to consider the limitations of the study. First, patients were restricted to Australian patients with diabetes who were eligible and willing to participate in a clinical trial, and hence it may not be a representative sample. However, we were not trying to estimate population values but rather to analyze the relationship between health states and utility, and there appeared to be sufficient diversity of the sample for this. Second, and more crucial, was the limited data on the nature and timing of the prior and intercurrent events. For example, though we have treated stroke as a single state, its effects are diverse ranging from full recovery to severe disability. Third, we ignore multiple morbidities within individual patients, but as these were relatively rare it is unlikely to make much difference to the comparisons. Fourth, while we had patients complete the full SF-36, some of the utility scorings only used a subset of questions. Finally, our estimate of test-retest stability is based on patients with no event re-measured after 2 years, and it is likely that the variability represents measurement error plus some real, though minor, changes. However, this is common across all the utility measures and hence should not greatly influence the relative signal-to-noise ratio.In conclusion, there was considerable variation across the different algorithms for translating responses to the EQ-5D and SF-36 into utilities. Algorithms based on survey instruments covering more comprehensive aspects of health-related quality of life did not appear to measure greater variations in utility than those based on simpler instruments such as EQ-5D. Taking this into account, the lower administration time of the EQ-5D suggests that it has real advantages over the SF-36 when collecting health-related quality of life information as part of a clinical trial.ADVANCE Action in Diabetes and Vascular Disease: Preterax and Diamicron MR Controlled EvaluationUKPDS United Kingdom Prospective Diabetes StudyThe author(s) declare that they have no competing interests.PG conceived of the study, and drafted the manuscript. PC contributed to both the design of the study and the final manuscript. EB assisted in the statistical analyses and contributed to the final manuscript. JA carried out the data analyses and contributed to the draft of the manuscript and the final manuscript. All authors read and approved the final manuscript."} +{"text": "Mapping has been used to convert scores from condition-specific measures into utility scores, and to produce estimates of cost-effectiveness. We sought to compare the QALY gains, and incremental cost per QALY estimates, predicted on the basis of mapping to those based on actual EQ-5D scores.In order to compare 4 different interventions 389 individuals were asked to complete both the EQ-5D and the Western Ontartio and McMaster Universities Osteoarthritis Index (WOMAC) at baseline, 6, 12, and 24 months post-intervention. Using baseline data various mapping models were developed, where WOMAC scores were used to predict the EQ-5D scores. The performance of these models was tested by predicting the EQ-5D post-intervention scores. The preferred model (that with the lowest mean absolute error (MAE)) was used to predict the EQ-5D scores, at all time points, for individuals who had complete WOMAC and EQ-5D data. The mean QALY gain associated with each intervention was calculated, using both actual and predicted EQ-5D scores. These QALY gains, along with previously estimated changes in cost, were also used to estimate the actual and predicted incremental cost per QALY associated with each of the four interventions.The EQ-5D and the WOMAC were completed at baseline by 348 individuals, and at all time points by 259 individuals. The MAE in the preferred model was 0.129, and the mean QALY gains for each of the four interventions was predicted to be 0.006, 0.058, 0.058, and 0.136 respectively, compared to the actual mean QALY gains of 0.087, 0.081, 0.120, and 0.149. The most effective intervention was estimated to be associated with an incremental cost per QALY of \u00a36,068, according to our preferred model, compared to \u00a313,154 when actual data was used.We found that actual QALY gains, and incremental cost per QALY estimates, differed from those predicted on the basis of mapping. This suggests that though mapping may be of value in predicting the cost-effectiveness of interventions which have not been evaluated using a utility measure, future studies should be encouraged to include a method of actual utility measurement.Current Controlled Trials ISRCTN93206785 Given that health care resources are scarce there is a need to evaluate the cost-effectiveness of different health care interventions. Within such studies economists generally seek to measure the benefits in terms of utility, a scale where 0 represents death and 1 is equivalent to full health, in order for the benefits of many interventions to be compared on a common scale . However2, and gave consent to be randomised to one of the four interventions.All individuals were taking part in the Lifestyle Interventions for Knee Pain (LIKP) study, which was designed to compare the effectiveness and cost-effectiveness of four different interventions. The four interventions were receipt of a leaflet, advice on knee strengthening exercises, dietary advice, and both dietary and exercise advice . Ethical approval for this study was granted by the UK Nottingham Research Ethics Committee. Recruitment into the LIKP study began in May 2003 and ended in March 2005, where all registered patients in five Nottingham general practices who were aged \u2265 45 years, and deemed to be well enough to complete a questionnaire, were sent an ascertainment questionnaire. Additionally a local media campaign was conducted, which included adverts in the local press and on the local radio. Responding individuals were recruited into the LIKP study if they reported that they had had knee pain on most days of the last month, were aged \u2265 45 years, had a body mass index (BMI) > 28.0 kg/mAt both pre-intervention (baseline) and post-intervention participants in the LIKP study were asked to complete both the WOMAC (Western Ontario and McMaster Universities Osteoarthritis Index) and the EQ-5D.The WOMAC contains 24 questions and measures the amount of pain (5 questions), stiffness (2 questions), and difficulty in physical functioning (17 questions), where the response options are none (0), mild (1), moderate (2), severe (3) or extreme (4) ,26. PrevThe EQ-5D has five questions, where the respondent is asked to report the level of problems they have with regard to mobility, self-care, usual activities, pain/discomfort, and anxiety/depression . ResponsWe adopted a split-sample approach to the mapping of condition-specific scores into utility scores. The baseline scores from the aforementioned LIKP study were used to develop various mapping models (to predict the EQ-5D scores). The performance of those models was then assessed on the post-intervention scores in order to identify our preferred model. Finally, for each of the four interventions, the actual QALY gains , and the incremental cost per QALY estimates, were compared to those that would have been predicted on the basis of our preferred model.In line with previous mapping models -19,22,23Model A: total WOMAC;Model B: pain, stiffness, functioning;2Model C: total WOMAC, total WOMAC2, stiffness2, functioning2;Model D: pain, stiffness, functioning, pain*stiffness, pain*functioning, stiffness*functioning, painModel E: best of above models plus patient characteristics of age and sex.2squared and the root mean square error (RMSE) (the RMSE is the positive square root of the average squared prediction error). Finally, in order to assess how well the mapping formulae performs across the range of EQ-5D scores, we also plot the actual follow-up EQ-5D scores against the prediction errors from our inferred preferred model.We sought to identify our 'preferred' model, out of the five aforementioned models, by comparing actual EQ-5D scores to EQ-5D scores predicted on the basis of each of the five mapping models. This comparison was performed at 6, 12, and 24 months post-intervention for individuals who had complete study data . Baseline data was not used within these comparisons as, in line with previous studies ,19, we s2squared. Additionally, we also identified our 'preferred' Grootendorst et al. model to be that which had the lowest MAE.In line with the mapping models which are developed here, a previous study has also attempted to predict utility scores using scores on the WOMAC . The stuThe LIKP study sought to estimate the effectiveness of four different interventions. We thereby used the following methods to compare the mean QALY gain for each of the four interventions, as estimated by actual data, to that predicted on the basis of our preferred mapping model and our preferred Grootendorst et al. model. With regard to actual data, for those participants who had complete study data, the baseline and post-intervention EQ-5D scores were used to estimate the QALY gain using the area under the curve (AUC) method, with adjustment for baseline scores . The meaWith regard to our preferred model, and our preferred Grootendorst et al. model, EQ-5D scores were predicted at baseline, 6, 12, and 24 months post-intervention for individuals who had complete study data . Using the same methods as for the actual EQ-5D data (see above), these predicted EQ-5D scores were then used to estimate the QALY gain for each individual who had complete study data, and the mean QALY gain for each intervention, where these calculations were performed for both our preferred model, and our preferred Grootendorst et al. model. Finally, we compared the mean QALY gain for each of the four interventions according to actual EQ-5D data to that predicted on the basis of our preferred mapping model, and our preferred Grootendorst et al. model. The paired t-test was also used to assess whether the actual mean QALY gains differed significantly (p < 0.05) from those predicted on the basis of our preferred model and our preferred Grootendorst et al. model. Finally, it should be noted that discounting was not undertaken in any of the above analysis as we sought to identify the differences between the QALY gains based on actual EQ-5D scores and those based on predicted EQ-5D scores, and we sought to identify the difference that arose due to the use of the mapping procedure.As described elsewhere , levels of resource use were combined with unit cost data to estimate the change in cost over the two year study period for all participants in the LIKP study . The change in costs, rather than total costs, was estimated due to the presence of baseline differences in the analgesic costs across each of the four interventions, and was calculated using the same aforementioned AUC technique as was undertaken for QALYs. The mean change in cost was thereby calculated for each of the four interventions. These values along with the previously calculated QALY gains based on i) actual EQ-5D scores, ii) the EQ-5D scores predicted from our preferred model, and iii) the EQ-5D scores predicted by our preferred Grootendorst et al. model were then used to estimate the incremental cost per QALY gain associated with each of the four interventions , and her2), 50.4% as class I obese (30 to < 35 kg/m2), 16.9% as class II obese (35 to < 40 kg/m2), and 9.9% as class III obese (\u2265 40 kg/m2). At baseline 348 individuals fully completed both the EQ-5D and the WOMAC, and data for these individuals were used to develop the five mapping models. The mean score for these 348 individuals was 0.557 (0.528 to 0.587) on the EQ-5D, 7.76 (7.39 to 8.13) on the pain sub-scale, 3.91 (3.74 to 4.07) on the stiffness scale, 27.89 (26.54 to 29.23) on the physical functioning scale, and 39.55 (37.77 to 41.34) on the total WOMAC scale.Across the five general practices 12,500 individuals were sent an ascertainment questionnaire, and 8,044 (64.4%) were returned. Subsequently, 318 individuals met the entry criteria for the LIKP study, and gave consent to be randomised to one of the four interventions. An additional 71 individuals were recruited via the media campaign. The mean age of these 389 individuals was 62.0 years, 66.0% were female, and 23.4% were classified as overweight (BMI 25 to < 30 kg/m2) + (0.0326027536*62) + (-0.0002352456*622) + (0.0475889687*0)), the actual mean baseline EQ-5D score was 0.566 . Figure The parameter estimates for each of the five models that we developed to predict the baseline EQ-5D scores are summarised in Table The parameter estimates for models G1 and G2 are published in the appendix of the paper by Grootendorst et al. . In termThe WOMAC and EQ-5D were fully completed at baseline, 6, 12 and 24 months post-intervention by 259 individuals . Based on the actual EQ-5D scores for these individuals the mean QALY gain , for each of the four interventions, was estimated to be 0.089, 0.081, 0.120 and 0.149, respectively. In Table Based on the responses for the 259 individuals who had complete study data the mean change in costs (standard deviation) for each of the four interventions (1\u20134) was estimated to be \u00a37.75 (\u00a3122.66), \u00a3321.12 (\u00a3131.12), \u00a3832.85 (\u00a3171.39) and \u00a3792.24 (\u00a3248.19), respectively. These four mean change in costs were subsequently combined with the estimated mean QALY gains, based on both actual EQ-5D data and our preferred mapping models , and the ICER for intervention 4 was estimated to be \u00a36,068 (when compared to intervention 2) which might not be undertaken in standard cost-effectiveness analysis. Techniques such as discounting and imputation were notThe main strength of our paper is that this is one of the first studies to compare the actual QALY gain associated with particular interventions to the QALY gain that would have been predicted, for the same interventions, on the basis of mapping. Moreover, this comparison has been undertaken using both mapping models developed from both the LIKP study data, and from a previous paper . We are We have shown how mapping can be used to estimate both the QALY gain, and incremental cost per QALY, associated with different interventions, and compared these predictions to actual results. In our study the mapping models developed from the WOMAC tended to underestimate the QALY gain associated with each of four interventions, compared to that which was derived from actual EQ-5D scores. Similarly, the incremental cost per QALY estimates based on the mapping models also differed from those based on actual data. This suggests that future trials should include a measure of utility, however mapping may still be useful in estimating the cost-effectiveness of interventions which have previously only been evaluated with a condition-specific measure.2)Model C: Predicted EQ-5D score = 0.746652555353163 + + + (0.0326027536*age) + (-0.0002352456*age2) + (0.0475889687*sex))Model E: Predicted EQ-5D score = -0.3474012785 + + (-0.0001081560* total WOMACsex is equal to 1 if Female and 0 if male.The authors declare that they have no competing interests.GB and TS conceived the idea for the paper, undertook the analysis and drafted the paper. CJ, AA, MD, and KM assisted in the acquisition of data, interpretation of the analysis, and commented on drafts of the manuscript. All authors read and approved the final manuscript."} +{"text": "This study was carried out to compare the HRQoL of patients in general practice with differing chronic diseases with the HRQoL of patients without chronic conditions, to evaluate the HRQoL of general practice patients in Germany compared with the HRQoL of the general population, and to explore the influence of different chronic diseases on patients' HRQoL, independently of the effects of multiple confounding variables.A cross-sectional questionnaire survey including the SF-36, the EQ-5D and demographic questions was conducted in 20 general practices in Germany. 1009 consecutive patients aged 15\u201389 participated. The SF-36 scale scores of general practice patients with differing chronic diseases were compared with those of patients without chronic conditions. Differences in the SF-36 scale/summary scores and proportions in the EQ-5D dimensions between patients and the general population were analyzed. Independent effects of chronic conditions and demographic variables on the HRQoL were analyzed using multivariable linear regression and polynomial regression models.P < 0.001 for all) and showed significantly higher proportions of problems in all EQ-5D dimensions except for the self-care dimension . The mean EQ VAS for general practice patients was lower than that for the general population . The HRQoL for general practice patients in Germany seemed to be more strongly affected by diseases like depression, back pain, OA of the knee, and cancer than by hypertension and diabetes.The HRQoL for general practice patients with differing chronic diseases tended to show more physical than mental health impairments compared with the reference group of patients without. Patients in general practice in Germany had considerably lower SF-36 scores than the general population (General practice patients with differing chronic diseases in Germany had impaired quality of life, especially in terms of physical health. The independent impacts on the HRQoL were different depending on the type of chronic disease. Findings from this study might help health professionals to concern more influential diseases in primary care from the patient's perspective. Primary care addresses the most common problems in the community by providing preventive, curative, and rehabilitative services to maximize health and well-being . \"The EcHealth-related quality of life (HRQoL), representing people's subjective assessment of their sense of well-being and ability to perform social roles, has been well accepted as a health indicator in medical interventions or health surveys. The HRQoL of patients with one single chronic disease has been explored in primary care -7. For eIn the current study, we compared the HRQoL of patients in general practice with differing chronic diseases with the HRQoL of patients without chronic conditions. We evaluated the HRQoL profiles of consecutive patients presenting for general practice consultation in Germany and compared them with those of the general population. Finally, we tried to estimate the effect of each chronic disease independently of the effects of multiple confounding variables.A cross-sectional survey was conducted in 20 general practices from the regional mailing list of the Institute of General Practice, University Hospital Schleswig-Holstein between June and December 2002. Each practice was asked to complete 50 questionnaires. Several large practices were ready to include more patients.On given days chosen by each practice, all consecutive patients over 14 years old were invited to self-administer the survey before consultation. Each participant put the completed questionnaire into an anonymous envelope and gave it to his or her doctor. For each patient, the doctor recorded up to three diagnoses for the actual encounter and three existing chronic conditions or major health problems. The protocol was approved by University Hospital Schleswig-Holstein Ethics Committee and all subjects provided informed consent.The Medical Outcomes Study 36-item Short Form Health Survey (SF-36), consists of 36 items which measure eight scales: physical functioning (PF), role limitations due to physical problems (RP), bodily pain (BP), general health (GH), vitality (VT), social functioning (SF), role limitations due to emotional problems (RE), and mental health (MH). On the basis of these separate subscales, component summary scores can be calculated to provide a global measure of physical and mental functioning , respectively. The scale scores range from 0 to 100, with higher scores indicating a better health status. The PCS and MCS have been standardized on the basis of a normative US general population data set, with the mean set at 50 (SD 10) [ (SD 10) .The EQ-5D questionnaire is a simple generic HRQoL instrument. It comprises two pages: on the first page respondents record the extent of their problems in each of five dimensions (self-classifier) concerning mobility, self-care, usual activities, pain/discomfort, and anxiety/depression; on the second page, they record their perception of overall health on a visual analogue scale (EQ VAS). EQ VAS scores may range between 0 and 100 [ health) .Besides HRQoL instruments, demographic questions were included in the questionnaire. These variables included age, gender, marital status, employment status, smoking, educational attainment , academic degree or qualification, medical insurance, and self-reported severe illness experience.The diagnoses and morbidity data were coded according to the International Classification of Primary Care (ICPC-2) . Thirteeno problem and reporting any problem). As well, the proportions reporting any problem for each disease group were compared with those for the reference group by means of the chi-square test.The SF-36 scores were calculated according to the established scoring algorithms for the German version of the SF-36 . The dist test and non-parametric Mann-Whitney U test were used to allow the comparison of results, allowing for the possibility that the data might not match normal distribution. The proportions reporting any problem in the EQ-5D dimensions for each disease group were compared with those for the general population [t test. The EQ index derived from the responses to the five dimensions was not analyzed in this paper, because we think the index is conventionalized and can be regarded as a societal valuation of the respondent's health state, not the respondent's own assessment of his or her health state.The eight SF-36 scale and two summary scores of patients in general practice were compared with the general population in Germany . Both papulation using thThe independent effects of differing chronic diseases, self-reported severe illness experience, age, gender, marital status, employment status, smoking, education attainment , academic degree or qualification, and medical insurance on the PCS and MCS scores of the SF-36 and EQ VAS score were analyzed using multivariable linear regression (Variable selection procedure: Enter). Additional regression analyses explored the possibility of non-linear relationships between age as a continuous variable and the PCS and MCS scores of the SF-36 and EQ VAS score. We also examined interactions between age and chronic diseases.All statistical analyses were carried out using SPSS for Windows .Of the 1231 patients recruited by 20 practices, 1041 agreed to participate, representing a response rate of 84.6%. Twenty-four questionnaires were deleted because diagnoses were missing (in one practice). Eight other questionnaires were completed by accompanying persons and therefore excluded.Among the 1009 eligible respondents, 61.4% were women, and the mean age was 48.5 years . A total of 428 (42.4%) respondents did not have any of the selected chronic diseases, 377(37.4%) had one, 155 (15.4%) had two, and 49 (4.9%) had three or more of the diseases. More than one third (35.1%) of patients with the selected chronic diseases had at least one other chronic disease. The 190 non-respondents had a mean age of 57.0 years . A total of 176 non-respondents reported the reasons why they refused to participate. Thirty-two percent of them attributed their refusal to visual or comprehension problems. The demographic characteristics of the sample are shown in Table Table any problems in the EQ-5D self-classifier for each disease group, with those for the reference group. The presence of any chronic disease tended to increase the risk of reporting any problem in at least one dimension. Similarly, the proportions reporting any problem in the dimension of anxiety/depression were significantly higher only for patients with depression and other mental illness.Complete data in all EQ-5D dimensions were only available for 914 respondents. A total of 707 (77.4%) of respondents reported problems in one or more of the EQ-5D dimensions. Pain/discomfort was the dimension most frequently (68.7%) noted as causing problems. . The differences observed in the scales concerning daily role limitations (RP and RE) were particularly salient. Table any problem in the EQ-5D self-classifier between general practice patients and the general population. The proportions of general practice patients reporting any problems were significantly higher than those of the general population in all dimensions except for the self-care dimension. The mean EQ VAS for general practice patients was lower than that for the general population .The comparison of the SF-36 scores for general practice patients and for the general population is shown in Table Multivariable linear regression showed that OA of the knee, back pain, experience of own illness, old age, having never married, and seeking work were significant predictors of a lower SF-36 PCS score. Depression, experience of own illness and divorced/separated were significant risk factors, and back pain was a significant mitigating factor in the regression equation for the SF-36 MCS score. Depression, cancer, experience of own illness, and having never married were significant risk predictors of the EQ VAS score, while patients with more education tended to have a higher score (Table P < 0.05). The MCS score tends to decrease during the initial period of getting old, and then begins to increase. The EQ VAS score tends to have the inverse order. The relationships between age and the PCS score were considered to be linear association. The joint effects on the SF-36 PCS score between age and hypertension were less negative due to the positive interaction effect (P < 0.05). Interaction effects between age and all other chronic diseases were not statistically significant.Table any problems in all EQ-5D dimensions except for the self-care dimension, compared with the general population. Finally when we controlled for demographic variables such as age, gender, marital status, employment status, smoking, educational attainment, academic degree or qualification, medical insurance, and self-reported severe illness experience, we found that OA of the knee and back pain predicted of a lower SF-36 PCS score, depression predicted of a lower SF-36 MCS score, and that depression and cancer were risk factors for the EQ VAS score.In this study, we found that general practice patients with chronic diseases seemed to have an impaired quality of life, compared with patients without any of the selected chronic conditions in a consecutive sample in Germany. Except for psychiatric disorders, these impairments were greater in physical functioning than in mental health. We also found that general practice patients in Germany had considerably lower scale scores and component summary scores for the SF-36 and higher proportions reporting Twenty percent of consecutive patients visiting the general practice had more than one of the thirteen chronic diseases. The proportion of multimorbidity in general practice patients varied in previous studies: e.g. 3.6% , 16.2% and 29.7Based on the results of univariate analysis, patients with chronic diseases seemed to have a lower quality of life, compared with patients without any of the thirteen chronic conditions. Except for psychiatric disorders, these impairments were, as expected, stronger for dimensions of physical health than for dimensions of mental health. Patients with depression experienced both physical and mental health impairments significantly. Patients with hypertension and diabetes experienced better mental health than the reference group. Similar results were described in other studies ,20-22. HQuality of life rating is subjective and relative to a person's life expectations . PatientThe clinically important difference (CID) reflects the amount of change (either improvement or decline) in HRQoL that is meaningful to patients and/or their health care providers . The CIDany problem in the self-care dimension of the EQ-5D.The HRQoL for patients was measured with generic HRQoL measurements, the SF-36 and EQ-5D. Both the SF-36 and EQ-5D are applicable to a wide range of health conditions, which are suitable for the primary care setting. The SF-36 measures health status over the past four weeks and the EQ-5D measures health status on the day. The advantages of the SF-36 include its broader coverage of HRQoL dimensions , while tThe associations between demographic variables and the HRQol were generally in line with literature. Self-reported severe illness experience is predictive for worse HRQoL. Old age is indicative of worse physical health and better mental health ,20,35,36The study reported here is part of a project to make a cross-cultural comparison of HRQoL for patients consulting in general practice between Germany and China. The study included more than 1000 patients. We could only use a convenience sample of general practices, but as the observation unit was the patient, we were confident that neither the regional limits nor the specificity of the study practices would substantially constrain the sample. The practices were basically comparable to the region. Of course, our survey is not easily comparable to other countries, as the \"ecology\" of primary care differs in every health care system.There is difference between the HRQoL for general practice population and those for \"stable\" patients in the community. It is more salient for some diseases than others. For example, patients with back pain as their reason for encounter were likely to have worse pain and role limitations, whereas patients with hypertension as their reason for encounter saw the doctor probably for regular prescription and check. There is a bias with consecutive visit-based sampling: practice population has very different contact frequencies and thus more frequent users (likely to be sicker patients) are selected which will bias the associations in the direction of their own profile . Our stuThe number of patients with specific diseases such as polyarthritis was insufficient, which led to difficulties in showing a statistical significance for smaller effects. This suggests the possibility of false negative results (type II error). We performed a large number of hypothesis tests, which suggests the possibility of false positive results (type I error). The absence or presence of chronic diseases in our research sample was recorded by the doctors, which could preclude the possibility of confounding due to personal or mood characteristics . HoweverThis study indicated that general practice patients with differing chronic diseases in Germany had impaired quality of life compared with patients without chronic conditions and the general population, especially in terms of physical health. We found that OA of the knee and back pain predicted of a lower SF-36 PCS score, depression predicted of a lower SF-36 MCS score, and that depression and cancer were risk factors for the EQ VAS score. Findings from this study might help health professionals to concern more influential diseases in primary care from the patient's perspective. Further research is needed to identify the clinically important differences in HRQoL scores for primary care patients with differing chronic diseases. This research should also be done in patient samples representative of both high and low users of general practice, so that results may generalize to the broader practice population. Independent influences of both disease type and severity on the HRQoL need to be observed. Additionally, to determine causal relationships, further longitudinal studies in the primary care setting will be needed to test for the associations between the demographics and the HRQoL.The authors declare that they have no competing interests.HMW participated in the design of the study, carried out the study, performed the statistical analysis and drafted the manuscript. MB participated in the design of the study, supervised the data collection and entry and helped to draft the manuscript. JG and FMG participated in the design of the study and revised the manuscript. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:"} +{"text": "The EQ-5D is a generic questionnaire which generates a health profile as well as index scores for health-related quality of life that may be used in cost-utility analysis.To examine validity and responsiveness of the EQ-5D in patients with anxiety disorders.389 patients with anxiety disorders completed the EQ-5D at baseline and 6-month follow-up. Subjective measures of quality of life (WHOQOL-BREF) and psychopathology were used for comparison. Validity was analyzed by assessing associations between EQ-5D scores and related other scores. Responsiveness was analyzed by calculating effect sizes of differences in scores between baseline and follow-up for 3 groups indicating more, constant or less anxiety. Meaningful difference scores for shifting to less or more anxiety were derived by means of regression analysis.88.4% of respondents reported problems in at least one of the EQ-5D dimension at baseline; the mean EQ VAS score was 63.8. The EQ-5D dimension most consistently associated with the measures used for comparison was 'anxiety/depression'. EQ VAS and EQ-5D index scores were highly correlated (|r|>0.5) with scores of the WHOQOL-BREF dimensions 'physical', 'mental' and 'overall' as well as BAI and BDI-II. The EQ-5D index tended to be the most responsive score. Standardized meaningful difference scores were not significantly different between EQ VAS, EQ-5D index and measures used for comparison.The EQ-5D seems to be reasonably valid and moderately responsive in patients with anxiety disorders. The EQ-5D index may be suitable for calculating QALYs in economic evaluation of health care interventions for patients with anxiety disorders.Current Controlled Trials ISRCTN15716049 The EQ-5D is a short generic patient-rated questionnaire for subjectively describing and valuing health-related quality of life (HRQOL); it is often used as an outcome measure in both clinical and health care services research (see complete list of references provided by the EuroQol Group ). The EQSince decisions about the suitability of the EQ-5D in economic evaluation need to be based on a clear conceptual framework, the validity of the EQ-5D has been demonstrated for various diseases as well as the general population (see EuroQol Group's complete list of references). Although QALYs have been recommended as a measure of health effects in patient with anxiety disorders , and somThe purpose of our study was to analyze the EQ-5D's psychometric properties in patients with anxiety disorders in more detail. More precisely, we analyzed its construct validity (Does the EQ-5D adequately measure the underlying construct?) as well as its responsiveness .Our study used a patient sample which was enrolled in a cluster randomised controlled trial . For this trial, 8472 consecutive patients under treatment were screened for anxiety disorders with the German version of the Patient Health Questionnaire (PHQ-D) at 54 prThe research protocol of the study was reviewed and approved by the Committee of Research Ethics at the Medical Faculty of the University of Leipzig.Besides the EQ-5D, all patients were assessed by a set of patient-rated questionnaires including the World Health Organization Quality of Life-Bref questionnaire (WHOQOL-BREF), the Beck Depression Inventory (BDI-II) as well as anxiety-specific measures of psychopathology (Beck Anxiety Inventory (BAI), Body Sensation Questionnaire (BSQ), Agoraphobic Cognitions Questionnaire (ACQ), and Mobility Inventory (MI)).5 = 243 different health states can be defined. The EQ-5D descriptive system is followed by the EQ VAS, which is similar to a thermometer, ranging from 0 to 100 . The EQ VAS records the respondent's subjective overall rating of his/her own health state on the day of administration (EQ VAS score).The EQ-5D questionnaire comprises five questions (items) relating to current problems in the dimensions 'mobility', 'self-care', 'usual activities', 'pain/discomfort', and 'anxiety/depres-sion' ,3,16. ReThe EQ-5D index represents societal preference values for the full set of 243 EQ-5D health states with the state '11111' and 'death' a priori (i.e. by definition) being assigned values of 1 and 0, respectively. The EQ-5D index scores used in the present study were obtained from a random sample of the British general population (n = 2997), where the Time Trade-Off (TTO) method was used to derive preference values for given EQ-5D health states . The BriThe WHOQOL-BREF is a generic questionnaire for subjectively measuring quality of life in the previous two weeks . It is anot at all bothered) to 3 (severely bothered). The total score for all 21 items ranges from 0 to 63, with higher scores indicating higher levels of anxiousness. The BAI has excellent internal consistency (Cronbach's \u03b1 = 0.93) [The BAI is a 21-item measure designed to assess the severity of self-reported anxiety [ = 0.93) and good = 0.93) ,24. Conv = 0.93) , becauseThe BDI-II is a 21-item self-report depression screening measure . The iteThe BSQ is 17-item self-report instrument to evaluate fear of the physical sensations generally associated with a panic attack . The BSQThe ACQ is a 14-item self-report instrument which measures the frequency of fearful cognitions associated with panic attacks and agoraphobia . In a sar = 0.75 to 0.90, and good construct validity has been shown. The MI is divided into two subscales, Avoidance Alone (MIA) and Avoidance Accompanied (MIB), with good internal consistency for both subscales.The MI is a 29-item self-report instrument measuring the severity of behavioral avoidance ,29. InteScores of BSQ, ACQ, MIA and MIB each may range from 0 (best) to 4 (worst). German versions of these instruments are described in .The EQ-5D is a generic instrument intended to measure overall HRQOL in a wide range of populations, including patients with anxiety disorders. Yet, the extent to which the EQ-5D is successful in measuring HRQOL in patients with anxiety disorders has not been examined in depth. Therefore the approach taken in this study was to compare the EQ-5D with other measures of psychopathology and quality of life. Thereby we assessed aspects of the EQ-5D's construct validity and responsiveness.Construct validity refers to the extent to which the measurement corresponds to theoretical concepts (constructs) concerning the phenomenon under study . In thisThus, construct validity of the EQ-5D descriptive system was assessed by analysing the association between the response level of EQ-5D items and the scores of the other measures used in the study. Specifically, we hypothesized that the association was particularly strong between the EQ-5D dimension 'anxiety/depression' and the anxiety-specific BAI score as well as the mental health domain score of the WHOQOL-BREF. Construct validity of the EQ VAS and the EQ-5D index was assessed by analysing their correlation with the scores of the other measures used in the study. Specifically, we hypothesized that EQ VAS and EQ-5D index scores were strongly correlated with the BAI score and the mental health domain score of the WHOQOL-BREF.Responsiveness was assessed by the criteria of the United States Food and Drug Administration (FDA), which raised a draft on patient reported outcomes including methods to calculate responsiveness and to interpret the detected changes as meaningful . The recs) was used for analysing correlations, since the EQ VAS score and the EQ-5D index were not normally distributed. Correlation was considered large for |rs|\u22650.5, moderate for 0.3\u2264|rs|<0.5, and small for 0.1\u2264|rs|<0.3 [1-M0/SDbaseline; where M0 is the mean score of the baseline assessment, M1 the mean score of the follow-up assessment, and SDbaseline the standard deviation of the baseline assessment. The method to calculate SRM was: SRM = M1-M0/SDM1-M0; where the numerator remains the same as for calculating ES, but the denominator represents the SD of the difference in scores. We considered an absolute magnitude of difference scores expressed by ES and SRM <|0.20| as trivial, from \u2265|0.20| to <|0.50| as small, from \u2265|0.50| to <|0.80| as medium, and \u2265|0.80| as large based on Cohen's interpretation guidelines [n = 43). Patients whose BAI score decreased by more than 0.5 SD were categorized into a group labelled 'less anxiety' (n = 83). All other patients were categorized as 'no shift in anxiety' (n = 124). Categorizing of patients was performed independently of any intervention. Five linear regression models with the difference scores of EQ VAS, EQ-5D index, WHOQOL-BREF domain score 'mental health', BSQ and ACQ used as dependent variables were estimated. Each dependent variable was regressed on dummy variables for 'more anxiety', 'less anxiety' as well as respondents' age, the BDI-II score and the score of the respective measure at baseline. The absolute values of coefficients of the dummy variables were tested for significant differences within each regression model. For better comparison between the models, difference scores and baseline scores were standardized to SD = 1 and mean = 0. Cross-model hypotheses were tested using seemingly unrelated estimation (SUEST) [2 due to incorporation of the anchor was tested using LR-tests with hierarchical nested regression models. For statistical testing, the level of significance was set at \u03b1 = 0.05. Calculations were performed using the software package STATA [The non-parametric Spearman rank correlation coefficient (r|rs|<0.3 . Responsidelines . Meaningidelines : Patient (SUEST) . Statistge STATA .Problems in at least one of the EQ-5D dimension were reported by 88.4% of the respondents at baseline. Most frequent were problems in the dimension 'anxiety/depression' (77.4%), followed by 'pain/discomfort' 71.5%), 'usual activities' 40.8%), 'mobility' (23.0%) and 'self-care' (3.9%). In all dimensions problems were reported more frequently than in a German general population sample [.8%, 'mob.5%, 'usuThe most frequently reported EQ-5D health state was the one with moderate problems in the two dimensions \"pain/discomfort\" and \"anxiety/depression\" 11122), which was indicated by 21.2% of all respondents was 63.8 (70) for the EQ VAS score and 0.66 (0.73) for the EQ-5D index was found, but also with the BDI-II (d = 1.52). ES of all other measures were smaller, yet still large (|d|>0.8), except for the WHOQOL-BREF domain score 'environment' and the MI scores. For different levels of all other EQ-5D dimensions, ES of the WHOQOL-BREF domain score 'physical health' were largest .For almost all EQ-5D dimensions, different response levels were associated with significantly different scores of the WHOQOL-BREF domains and measures of psychopathology. As hypothesized, the strongest association was found between the EQ-5D dimension 'anxiety/depression' and the BAI score: For respondents reporting moderate or extreme problems in the EQ-5D dimension 'anxiety/depression', the mean BAI score was 23.7, whereas for those reporting no problems in this dimension it was 9.2. This difference was highly significant and corresponds to an ES of The WHOQOL-BREF domain score 'physical health' and the 'overall' score showed large ES for different levels of all EQ-5D dimensions, whereas the ES of the WHOQOL-BREF domain score 'mental health' was only large for different levels of the EQ-5D dimensions 'self-care' and 'anxiety/depression'. The scores of BAI and BDI-II showed large ES for different levels of the EQ-5D dimensions 'anxiety/depression', 'usual activities' and 'self-care'. The scores of BSQ and ACQ showed large ES only for different levels of the EQ-5D dimension 'anxiety/depression', whereas the scores MIA and MIB did not show any large ES.Regarding the construct validity of the EQ VAS score and EQ-5D index, Table S6, Additional file Table S7, Additional file Table S8, Additional file 2 in all six models. When testing cross-model hypotheses with SUEST, the effects of 'more anxiety' (P = 0.30), 'less anxiety' (P = 0.42) and 'constant anxiety' (P = 0.30) on standardized outcome measures were not significantly different in the five regression models. Effects of standardized baseline scores differed significantly across the six outcome measure (P = 0.03).When testing intra-model hypotheses, the difference scores in the categories 'less anxiety' and 'more anxiety' were significantly different for all outcome measures, whereas the absolute values of difference scores in both categories were not significantly different. The inclusion of the dummy variables for 'more anxiety' and 'less anxiety' resulted in a significant increase of the RAlthough the EQ-5D has been used in patients with anxiety disorders before ,9, littlPatients with anxiety disorders were mostly burdened in the EQ-5D dimensions 'anxiety/depression', 'pain/discomfort', and 'usual activities'. Only 11.4% of respondents reported no problems in any of the EQ-5D dimensions, and only 1.0% rated their health states with the best possible score 100) on the EQ VAS. Thus, the ceiling effect of the EQ-5D which has been described repeatedly in other patient groups as well 0 on the The EQ-5D dimension most consistently associated with the subjective measures of psychopathology and quality of life was 'anxiety/depression' followed by the dimensions 'self-care' and 'usual activities'. As hypothesized, the strongest association was found between the EQ-5D dimension 'anxiety/depression' and the BAI score. This is indicative of an adequate construct validity of the EQ-5D. This is also emphasized by the strong correlation of EQ VAS and EQ-5D index scores with the BAI score and the 'mental health' domain score of the WHOQOL-BREF. Not surprisingly, association with the BDI-II was also strong, as the EQ-5D does not differentiate between anxiety and depression. Nevertheless, we would have expected to find larger ES and stronger correlations with the BSQ and ACQ since these measures are considered to be more sensitive than the BAI. Yet being a generic HRQOL instrument designed to measure problems in all major dimensions of well-being, the EQ-5D inevitably has only limited content validity for specific diseases. Only one out of five questions of the EQ-5D specifically refers to anxiety or mental health.The EQ-5D index tended to be more responsive than the EQ VAS score, showing larger ES and SRM and significant coefficients associated with both, shifts to more and less anxiety in the regression model analyzing meaningful differences. However, when comparing regression coefficients across the five models using SUEST, no significant differences in meaningful differences between the various measures were found, pointing at similar responsiveness of the EQ-5D and the measures used for comparison.more anxiety than to the shift to less anxiety statistical testing indicated that, while significantly different, both response levels did not differ significantly in their absolute values. Therefore, greater responsiveness of EQ-5D scores for a shift to 'worse health status' than for a shift to 'better health status' as reported in a study by G\u00fcnther et al. [Although the EQ-5D index seemed more responsive to the shift to r et al. in patier et al. that, asThe 'physical health' domain score of the WHOQOL-BREF showed strong association with all EQ-5D dimensions as well as strong correlation with EQ VAS and EQ-5D index scores. Changes in anxiety defined the BAI score were often associated with changes in problem levels of EQ-5D dimensions other than 'anxiety/depression'. This indicates the important role of psychosomatic aspects and somatic comorbidity in patients with anxiety disorders. Unfortunately, we did not specifically assess co-morbid somatic conditions in our study. Therefore responsiveness statistics and estimates for meaningful difference scores might be confounded by somatic co-morbidity which is a limitation of our study. However, controlling for mental co-morbidity measured by the BDI-II hardly affected meaningful difference scores. Yet, somatic co-morbidity may explain the conspicuously large ES of the EQ-5D index in the group with more anxiety. In this small group (n = 43), changes in the EQ-5D index were largely due changes in the EQ-5D dimension 'anxiety/depression' and/or 'mobility', the latter possibly caused by somatic co-morbidity. However, the fact that the corresponding SRM is much smaller (due to a large SD of the change score of the EQ-5D) points at the presence of outliers for which this small patient group is more sensitive than the larger groups with constant or more anxiety.A limitation of this study results from including patients based on the results of a screening instrument (PHQ-D) and not on formal diagnosis of an anxiety disorder. As the PHQ has a high specificity (97%) , probablAlthough the use of country-specific EQ-5D index scores have been recommended, we used the British EQ-5D index instead Analyzing the validity of the EQ-5D by determining its relationship with the measures used for comparison might be problematic, since these measures might lack validity for themselves. Yet, psychometric properties reported in the literature of BAI, BSQ, ACQ and MI for patients with anxiety disorders appear to be good. However, we used only patient-rated but no clinician-rated measures for comparison, which also limits the analysis of validity.2 when the BAI-anchor was included in the regression analysis.Moreover, the responsiveness analysis might have suffered from the absence of a practical clinical criterion. For defining the anchors we used the BAI score which, because of its excellent psychometric properties, good convergent validity and better discriminant validity than other measures of anxiety, is the most commonly measure to assess the construct of anxiety. However, the anchors were built by a rather statistical approach which does not necessarily imply \"meaningfulness\". Yet, the statistical significance of the EQ-5D's responsiveness is clearly indicated by significant increase of RDue to differences in the applied measures for comparison and in statistical methods, our results are difficult to compare with other studies which have analyzed the psychometric properties of the EQ-5D in patients with psychiatric disorders. Yet, other studies reported slightly larger correlations of EQ VAS and EQ-5D index scores with the score of the WHOQOL-BREF-mental domain in alcohol dependent patients and in pThe EQ-5D appears to be a reasonably valid instrument with moderate responsiveness in patients with anxiety disorders. Being a short and easy to administer questionnaire, the EQ-5D may easily be added to disorder-specific measures, when overall HRQOL and its valuation are considered important outcomes. The EQ-5D index may be suitable for calculating QALYs in economic evaluation of health care interventions for patients with anxiety disorders. Future studies should also use clinician-rated measures for analyzing validity and responsiveness.The authors declare that they have no competing interests.HHK designed the study, wrote the protocol, and wrote the first draft of the manuscript. AB conducted the field work. HM undertook the statistical analyses. OG, AB, SGRH, MCA, SH and CR designed the study, wrote the protocol and managed the field work. All authors contributed to and have approved the final manuscript.Table S1. Socio-demographic sample characteristics at baseline (N = 389)aClick here for fileTable S2. The 10 most frequently reported EQ-5D health states at baseline (N = 372)aClick here for fileTable S3. Descriptives of the EQ VAS score and the EQ-5D index at baselineaClick here for fileTable S4. Score of measures used for comparison at baselineClick here for fileTable S5. Association between response level of EQ-5D items and score of other measures at baselineaClick here for fileTable S6. Correlation between EQ VAS score, EQ-5D index and scores of other measures at baselineaClick here for fileTable S7. Comparison of responsiveness statistics for EQ-5D scores and scores of measures used for comparison by anchor of change defined by BAI scoreClick here for fileTable S8. Results of the regression models estimating meaningful difference scores for various measures according to the anchor defined by the BAI scorea, controlled for measure's baseline score, BDI-II score and age of respondent (N = 230)bClick here for file"} +{"text": "EQ-5D is a generic measure that permits comparisons in quality of life across disease states, and which may provide useful data for health policy and resource allocation decision-making. There are no published reports on the acceptability and psychometric properties of the EQ-5D in the Arabic language. We therefore investigated the validity and reliability of the Arabic translation of the EQ-5D in Jordan.The study was conducted on a convenience sample consisting of consecutive adult Arabic-speaking outpatients or visitors attending a university teaching hospital. Subjects were interviewed twice using a standardized questionnaire containing the EQ-5D, Short Form 36 Health Survey (SF-36). To assess the validity of the Arabic version of the EQ-5D, ten hypotheses relating responses to EQ-5D dimensions or the visual analogue scale (EQ-VAS) to SF-36 scores or other variables were examined and test-retest reliability was assessed.The study included 186 subjects who had a mean age of 45.3 years and included 87 (47%) females. The major problem reported in more than 102 (55%) of the subjects was anxiety/depression. All of the ten a-priori hypothesis relating EQ-5D responses to external variables were fulfilled. Cohen's \u03ba for test-retest reliability (n=52) ranged from 0.48 to 1.0.The Arabic translation of EQ-5D appears to be valid and reliable in measuring quality of life in Jordanian people. Measurement of health-related quality of life (HRQL) has become an imperative in clinical trials and disease management programs for a variety of diseases. HRQL can be considered a major outcome in clinical trials in the absence of objective measures. In Jordan, where Arabic is the first language, conducting clinical trials is difficult due to the lack of validated Arabic translations or versions of quality of life instruments. The EQ-5D is a standardised generic instrument for use as a measure of health and quality of life outcomes. Applicable to a wide range of health conditions and treatments, it provides a simple descriptive profile and a single index value for health status. The EQ-5D is now available in most major languages with cultural adaptations.The study group was a convenience sample that consisted of consecutive adult Arabic-speaking outpatients or visitors attending the University of Jordan hospital in the period between June to August 2007. The inclusion criteria were that the subject should be an adult Jordanian and should have no obvious cognitive deficit. The hospital is located at the center of Amman, the capital of Jordan, and is considered one of the oldest and largest hospitals in Jordan serving more than 0.5 million people every year. The study site was ideal for testing the instrument as it serves a diverse group of patients from all over the country.Translation and cross-cultural adaptation was done according to the EuroQol group's guidelines.The translation process was smooth and straightforward. The translators only disagreed on the translation of \u201cdiscomfort\u201d during the forward translation process as it can be translated into several closely related words. A discussion session was conducted until the translators agreed on the most appropriate translation. During the interview with the ten laypersons, they reported no concerns with the phrasing of the Arabic EQ-5D. In general, the instrument was very easy to complete and clear to all readers.The study was approved by the University of Jordan Academic and Research Committee. All participants were interviewed by trained research assistants using a questionnaire containing the Arabic version of the EQ-5D and the short form health survey (RAND SF-36-Arabic version).The EQ-5D6 consists of a self classifier with five single item health dimensions, each with three response levels, and a visual analogue scale (EQ-VAS). Both the health state descriptors and the visual analogue scale of the perceived health state of the Arabic version of the EQ-5D were used in the current study. The SF-36 is a validated,57Known-groups construct validitySubjects reporting problems for any EQ-5D dimension would have lower scores for all SF-36 scales;10Subjects reporting problems for EQ-5D mobility, self-care, usual activities or pain/discomfort dimensions would have larger score reductions for SF-36 physical functioning (PF), role limitation due to physical problem (RP) and bodily pain (BP) scales than for role limitation due to emotional problem (RE) and mental health (MH) scales;Similarly, subjects reporting problems for the EQ-5D anxiety/depression dimension would have larger score reductions for SF-36 RE and MH scales;Subjects with mobility, self care, or usual activities problems should have their lowest score in role limitation due to a physical problem;Elderly (age \u226560 years) orSubjects with chronic diseases should report more problems than other subjects.Hypotheses for the EQ-VAS were:EQ-VAS scores would be higher in subjects reporting better global health measured using a 5-point scale (i.e lower score on the first question of the SF-36);1112EQ-VAS scores would correlate negatively with increasing age;1213Females will report lower (worse) EQ-VAS scores;Subjects with chronic disease will report lower (worse) EQ-VAS scores than those without.t test, the Mann-Whitney test, and Pearson or Spearman correlation coefficients. To minimize false-positive tests of significance, a significance level of P<.01Hypothesized trends were tested as appropriate depending on the type of data and distribution using the chi-square, the Fisher exact test, During the study period, 200 subjects were asked to participate and only 14 refused. The main reason behind refusal was lack of time. The demographic and clinical characteristics of those who refused to participate were similar to the study subjects. One hundred eighty-six subjects completed the baseline questionnaires. Cronbach's \u03b1 was 0.75 indicating that the EQ-5D has an acceptable internal consistency.P\u2264.001 for all dimensions). Intraclass correlation coefficient for the EQ-VAS between the two periods was 0.78.Fifty-two subjects (28.0%) participated in the follow-up telephone interview, with a 3-week median interval (interquartile range: 2 to 4 weeks). Cohen's \u03ba values for EQ-5D mobility, self care, usual activities, pain/discomfort and anxiety/depression items were 0.66, 1.0, 0.48, 0.66, and 0.48 respectively . The \u03ba values in our study were in general better than those reported in previous studies of subjects after stroke using EQ-5D 16 and in those with rheumatic diseases .The results have demonstrated that the major problem reported by 55% of participants was anxiety/depression. Anxiety and depression are commonly associated with the etiology of many diseases including asthma, diabetes and hypertension. This reuslt is very important in the view of the large prevalence of diabetes and hypertension in Jordan, which exceeds 25%.17We have utilized the Arabic version of the EQ-5D in several clinical settings including diabetes, rheumatoid arthritis and allergic rhinitis; the instrument was found to be of high clinical value and was strongly correlated with the clinical indicators. This indicates that the Arabic version of the EQ-5D is externally valid. It should be noted that the participants have completed the EQ-5D with the help of a research assistant. EQ-5D is a very simple instrument; therefore we think there will not be any major difference in the results if the EQ-5D was self administered.One study limitation was that we used a convenience sample, which may limit the generalizability of the results. This limitation was obvious as the sample was characterized by a high level of education. However; this study is a pilot investigation and we hope in the near future to conduct a population-based investigation. It would have been more appropriate to validate the EQ-5D using a similar utility measure rather then using the SF-36. However, in our case this was not possible as currently the SF-36 is the only available well validated and well translated generic QOL instrument in the Arabic language."} +{"text": "To assess the practicality, validity and responsiveness of using each of two utility measures (the EQ-5D and SF-6D) to measure the benefits of alleviating knee pain.Participants in a randomised controlled trial, which was designed to compare four different interventions for people with self-reported knee pain, were asked to complete the EQ-5D, SF-6D, and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) at both pre- and post-intervention. For both utility measures, we assessed their practicality (completion rate), construct validity (ability to discriminate between baseline WOMAC severity levels), and responsiveness did not improve, ii) improved by <20%, and iii) improved by \u226520%).The EQ-5D was completed by 97.7% of the 389 participants, compared to 93.3% for the SF-6D. Both the EQ-5D and SF-6D were able to discriminate between participants with different levels of WOMAC severity (p < 0.001). The mean EQ-5D change was -0.036 for group i), 0.091 for group ii), and 0.127 for group iii), compared to 0.021, 0.023 and 0.053 on the SF-6D. These change scores were significantly different according to the EQ-5D (p < 0.001), but not the SF-6D.The EQ-5D and SF-6D had largely comparable practicality and construct validity. However, in contrast to the EQ-5D, the SF-6D could not discriminate between those who improved post-intervention, and those who did not. This suggests that it is more appropriate to use the EQ-5D in future cost-effectiveness analyses of interventions which are designed to alleviate knee pain.Current Controlled Trials ISRCTN93206785 In the UK it has been estimated that nearly 50% of those aged >50 years experience knee pain each year, and that 33% of these consequently consult their general practitioner . EconomiThe importance of such an analysis is further highlighted by two potentially opposed views. Firstly, the National Institute of Health and Clinical Excellence (NICE) has recently stated that the EQ-5D is the preferred measure of utility to be used in economic evaluations . However2, and gave consent to be randomised to one of the four interventions.All participants were taking part in the Lifestyle Interventions for Knee Pain (LIKP) study, which was designed to compare the effectiveness and cost-effectiveness of four different interventions . Ethical approval for this study was granted by the UK Nottingham Research Ethics Committee. In order to recruit people into the LIKP study all registered patients in five Nottingham general practices who were aged \u226545 years, and deemed to be well enough to complete a questionnaire, were sent an ascertainment questionnaire, and a local media campaign was also conducted. Responding individuals were recruited into the LIKP study if they reported that they had had knee pain on most days of the last month, were aged \u226545 years, had a body mass index (BMI) >28.0 kg/mParticipants in the LIKP study were asked to complete, amongst other things, three outcome questionnaire measures at both pre- and (6 months) post-intervention \u2013 the WOMAC (Western Ontario and McMaster Universities Osteoarthritis Index), EQ-5D and SF-36 . The WOMAC was chosen as primary outcome measure within the LIKP study as the pain subscale of the WOMAC was considered to be the best way of capturing knee pain severity.96) scale, where higher scores denote a worse response [The WOMAC measures the amount of pain (5 questions), stiffness (2 questions), and difficulty in physical functioning (17 questions), where the response options are none (0), mild (1), moderate (2), severe (3) or extreme (4) . Scores response and respresponse ,20.The EQ-5D has five questions, where the respondent is asked to report the level of problems they have with regard to mobility, self-care, usual activities, pain, and anxiety/depression , which wIn a similar way, responses to eleven of the questions on the SF-36 were useThere are many approaches to assessing validity and, as Fitzpatrick et al. point ouPracticality was assessed in terms of completion rates, where the SF-36 appeared before the EQ-5D in the ascertainment questionnaire. We assessed whether sufficient information was provided in order to calculate a utility score for the EQ-5D and SF-6D, as outlined by Gerard et al. .96 score \u2013 i) none to mild , ii) >mild to moderate , iii) >moderate to severe , and iv) >severe to extreme . Similar severity levels were also created for each of the three sub-scales: i) none to mild was denoted by total scores of 0 to \u22645 (pain), 0 to \u22642 (stiffness), and 0 to \u226417 (functioning), ii) >mild to moderate was denoted by total scores of >5 to \u226410 (pain), >2 to \u22644 (stiffness), and >17 to \u226434, iii) >moderate to severe was denoted by total scores of >10 to \u226415 (pain), >4 to \u22646 (stiffness), and >34 to \u226451 (functioning), and iv) >severe to extreme was denoted by total scores of >15 to \u226420 (pain), >6 to \u22648 (stiffness), and >51 to \u226468 (functioning). On the overall WOMAC96 score, and each of the three WOMAC subscales, in order to assess whether there were significant (p < 0.05) differences between the utility scores of participants in each of these four severity levels a one-way analysis of variance (ANOVA) was conducted. This analysis is akin to that conducted previously [Validity was assessed in terms of both construct and convergent validity. Construct validity relates to whether a measure can discriminate between two patient groups, one which has a certain trait, and the other which does not . This haeviously ,31.96 score according to the Spearman rank test.Convergent validity is determined by how closely a measure is related to other measures of the same construct . Thus, i96 scale and each of the three WOMAC subscales, and the paired t-tests was conducted to assess whether there was a significant change in the mean utility score. For both the EQ-5D and the SF-6D a one-way ANOVA was also conducted to assess whether there was a significant difference between the mean change in utility across each of the three groups. The above analysis is in line with that undertaken previously [Responsiveness, which is different to sensitivity , is deteeviously .2), 50.4% as class I obese (30 to <35 kg/m2), 16.9% as class II obese (35 to <40 kg/m2), and 9.9% as class III obese (\u226540 kg/m2). Pre-intervention the mean score on each of the pain, stiffness and functioning dimensions of the WOMAC was 7.81 (N = 360), 3.92 (N = 360), and 27.90 (N = 359), respectively, the mean WOMAC96 score was 39.59 (N = 359).Questionnaires were returned by 8,044 of the 12,500 people (64.4%) who were sent an ascertainment questionnaire. Of these, 318 were eligible to take part in the LIKP study and consented to be randomised to one of the four interventions. An additional 71 participants were recruited via the media campaign. The mean age of these 389 participants was 62.0 years, 66.0% were female, and 23.4% were classified as overweight (BMI 25 to <30 kg/mPre-intervention the EQ-5D was wholly completed by 378 of the 389 participants (97.2%). Four of these participants were categorised as being in full health (11111), and a total of 36 different EQ-5D health states were reported \u2013 29 participants had health states rated as worse than death, the lowest score was -0.239 (22333), and the mean score was 0.550 .Pre-intervention, SF-6D scores could be calculated for 366 of the 389 participants (94.1%). None were categorised in full health, but one person did report that they had the lowest score on all six dimensions (645655). SF-6D scores ranged from 0.296 to 0.948, 194 different health states were reported, and the mean score was 0.646 .96 could be calculated (pre-intervention), participants who had higher scores (increased severity) tended to have lower utility scores on both the EQ-5D and SF-6D \u2013 the mean EQ-5D (SF-6D) utility score for those with a WOMAC96 score between 0 and 24 was 0.722 (0.731), compared to 0.069 (0.460) for those with a WOMAC96 score between 73 and 96. These differences were significant according to the one-way ANOVA, and similar results were also obtained for each of the three WOMAC subscales .In terms of construct validity the results in Table .722 0.73, compare96 scores could be calculated for 324 participants. Post-intervention the WOMAC96 score did not improve for 33.8% of the participants, for 25.2% the WOMAC96 score improved by <20%, and for 40.9% the WOMAC96 score improved by \u226520%. The mean change in utility (post-intervention) for each of these three groups was -0.036, 0.091 and 0.127 for the EQ-5D, compared to 0.021, 0.023 and 0.053 for the SF-6D was lower for the SF-6D, even though the SF-36 appeared first in the ascertainment questionnaire. In terms of validity both the EQ-5D and SF-6D were able to discriminate between groups with different levels of severity according to the WOMAC, and were also highly correlated with the WOMACWe are aware of only one other study which has compared the performance of the EQ-5D and SF-6D with regard to similar criteria in a similar clinical area . In lineWithin this paper we have used the WOMAC to assess the validity and responsiveness of the EQ-5D and SF-6D. Evidence of adequate performance of the WOMAC on these criteria -20 justiEconomic evaluation plays a major role in decision making . Our finThe SF-6D was less responsive even though it had a greater descriptive ability . This is an important finding as researchers are currently investigating whether to expand the number of responses within each of the five dimensions of the EQ-5D from 3 to 5 levels . One potThough the construct and convergent validity of the EQ-5D and SF-6D were similar the EQ-5D had a higher completion rate and was more responsive. This suggests that these two measures may provide different estimates of effectiveness, and that it is more appropriate to use the EQ-5D to estimate the cost-effectiveness of alleviating knee pain.The authors declare that they have no competing interests.GB and TS conceived the idea for the paper, undertook the analysis and drafted the paper. CJ, AA, MD, and KM assisted in the acquisition of data, interpretation of the analysis, and commented on drafts of the manuscript. All authors read and approved the final manuscript."} +{"text": "The EQ-5D health-related quality of life instrument comprises a health state classification followed by a health evaluation using a visual analogue scale (VAS). The EQ-5D has been employed frequently in economic evaluations, yet the relationship between the two parts of the instrument remains ill-understood. In this paper, we examine the correspondence between VAS scores and health state classifications for a large sample, and identify variables which contribute to determining the VAS scores independently of the health states as classified.A UK trial of management of low-grade abnormalities detected on screening for cervical pre-cancer (TOMBOLA) provided EQ-5D data for over 3,000 women. Information on distress and multi-dimensional health locus of control had been collected using other instruments. A linear regression model was fitted, with VAS score as the dependent variable. Independent variables comprised EQ-5D health state classifications, distress, locus of control, and socio-demographic characteristics. Equivalent EQ-5D and distress data, collected at twelve months, were available for over 2,000 of the women, enabling us to predict changes in VAS score over time from changes in EQ-5D classification and distress.In addition to EQ-5D health state classification, VAS score was influenced by the subject's perceived locus of control, and by her age, educational attainment, ethnic origin and smoking behaviour. Although the EQ-5D classification includes a distress dimension, the independent measure of distress was an additional determinant of VAS score. Changes in VAS score over time were explained by changes in both EQ-5D severities and distress. Women allocated to the experimental management arm of the trial reported an increase in VAS score, independently of any changes in health state and distress.In this sample, EQ VAS scores were predictable from the EQ-5D health state classification, although there also existed other group variables which contributed systematically and independently towards determining such scores. These variables comprised psychological disposition, socio-demographic factors such as age and education, clinically-important distress, and the clinical intervention itself.ISRCTN34841617 The EQ-5D is a well-established and widely-used generic instrument for assessing health-related quality of life . Designesocietal [sic] valuation of the respondent's health state, in contrast to the respondent's or patient's own assessment of his/her health state (EQ VAS scores)\" .There is an extensive body of research on the use of the VAS in population studies. It is now evident, for example, that VAS-derived utility weights differ from those elicited using the time trade-off or standard gamble techniques ,6. The wIn view of the sequence of completion, the EQ VAS score relates to that which the individual thinks about the health state in which s/he has declared her/himself to be. Moving from the first to the second part of the EQ-5D questionnaire requires the subject to translate her/his description of personal well-being, represented by the extent of health problems in five dimensions, into a uni-dimensional value of health, however s/he cares to define it. Whilst we would certainly expect individuals to interpret the presence of more health problems, each of higher severity, as poorer rather than better health, the specific translation for each person must remain essentially subjective.Comparing EQ-5D classifications with VAS scores amounts to an exploration of differential item functioning within the instrument . SpecifiOur analysis used data collected during the TOMBOLA randomised controlled trial, a multi-centre UK study of the management of women recording low-grade cytological abnormalities (pre-cancers) as a result of routine cervical screening. TOMBOLA was instigated because of uncertainty over the most effective means of managing such women, the principal alternatives being immediate referral to colposcopy, with treatment if indicated, and cytological surveillance until the abnormality is seen to regress or progress . The immAs is required for all national trials in the UK, TOMBOLA's recruitment and analysis protocol, including the research reported in this paper, had been granted full ethical approval . CervicaWith anxiety and distress expected to be the principal morbidity, TOMBOLA employed the Hospital Anxiety and Depression Scale (HADS) as a specific measurement instrument. The HADS was developed to identify \"caseness\" with respect to anxiety, mood disorders and depression in non-psychiatric settings. It has been validated as a screening tool in a clinical context and has been used as a primary instrument in investigations of both patients and populations ,27. The The HADS, EQ-5D and MHLCS data were all scored according to the conventional algorithms. Subjects with missing HADS or EQ-5D data were excluded from the analysis. The MHLCS algorithms permit imputation when data is missing in part, although imputation was necessary only in a small number of cases (< 3 per cent). The EQ-5D index scores were derived from the current UK tariff ,30, whicWe modelled EQ VAS scores using ordinary least squares linear regression. Given the hypothesis under investigation, the model contained EQ-5D health state classifications as independent variables. In addition we included, first, the HADS classification, to appraise the possibility that the EQ-5D classifications pertaining to the principal morbidity were insufficient in themselves to explain health state values. Second, we included the MHLCS scores, anticipating that individuals who believed that they controlled their own health destinies would report higher subjective values of their health state. Finally, we included a range of socio-demographic variables, with no necessary expectation of sign on the coefficients, on the basis of previous reports of associations between health values and socio-demographic factors. Carstairs scores were not included as potential explanatory variables because they proved to be collinear with the majority of individual characteristics.To assess the stability of any relationship, we modelled changes in the EQ VAS score over the 12 months between the two questionnaire arrays using, as independent variables, changes in the EQ-5D and in the HADS classifications, plus the socio-demographic variables. We investigated the impact of one further factor in this second model, hypothesising that EQ VAS scores reported at the second round of questionnaires would have been influenced by the allocation to trial arms, for two reasons. First, recruits to clinical trials necessarily accept that they cannot pre-determine the management method to which they will be assigned, yet agreement to be randomised need not imply indifference to the randomisation outcome. It is established that a preference for the new practice under investigation (i.e. an intervention not routinely available) is a principal explanation for volunteering to participate in trials , whilst The initial analysis was based on data from the recruitment questionnaire array for 3,132 subjects. All were aged between 20 and 59 years. 53 different EQ-5D vectors were represented in this recruitment sample, although 11111 was the most frequently cited, by 53.9 per cent of subjects. Only 3.9 per cent of subjects recorded an index score at or below 0.6, the lowest being -0.23. A further 41.8 per cent recorded scores higher than 0.6 but up to and including 0.85. The proportions of EQ VAS scores up to 60, and higher than 60 but up to and including 85, were 7.2 and 45.8 per cent, respectively. 24.9 per cent of subjects recorded scores of 90 and above, including 5.4 per cent who recorded the maximum score of 100. For those individuals recording the 11111 health state, the mean EQ VAS score was 87.0 (SD 10.7); for the remainder, it was 74.5 (SD 17.5). The index and EQ VAS scores were significantly correlated .Table All of the Table Matched EQ-5D and HADS data over two time points (recruitment and 12 months thereafter) were available for 2,176 of the subjects. Of these, 50.6 per cent had been randomised after recruitment to immediate colposcopy, leaving the remainder to undergo cytological surveillance (current practice). The data enabled us to calculate, for each individual, (i) the change in the EQ VAS score over the period, (ii) changes in the severity of health problems in each of the five EQ-5D domains, (iii) the change in the likelihood of HADS caseness. With respect to (ii), we constructed two dummy variables for each domain, one taking the value of unity if the severity of health problem had increased , the other being unity if it had decreased . Likewise, with respect to (iii), dummies represented the likelihood of caseness increasing over time or decreasing . In this two-period sample, the likelihood of HADS-anxiety and HADS-depression caseness changed for 35.9 and 12.3 per cent of subjects, respectively. The EQ VAS scores changed for 85.0 per cent of subjects, with a mean fall over the period of 1.5 .Movements in the EQ-5D domains and changes in the HADS likelihood of caseness were entered into a regression model as independent variables, with the fall in EQ VAS score as the dependant variable. The socio-demographic and MHLCS variables used in the previous model were also included, as was a dummy variable representing trial randomisation. The regression was estimated and re-estimated after excluding variables with insignificant coefficients, to produce the model displayed in Table 2 = 43.10, p < 0.01). Of the sample used in the Table Moving between the Table In the light of the relatively low coefficients of determination, an analysis of residuals was conducted for each of the regressions. In each case, the scatter-plot of residuals against predicted values revealed a random pattern in the distribution of outliers, and the normal probability plot was essentially linear.2 = 0.23).It appears that very few studies directly comparable to ours have been conducted. One employing the same method was based on EQ-5D data obtained from around 1,200 inhabitants of a South African suburb . This stOur basic approach is also comparable with that of an Israeli study of public perception of health-related quality of life . Again, Turning towards explanations of particular variables in our models, predicting the sign on an age coefficient defies intuition. We note that the positive sign on our coefficient contrasts with the negative sign identified in the South African and Israeli models, although this might well result from the absence of elderly individuals in our sample. Our age coefficient pertains to a narrower age range. It is possible that the cigarette smokers valued their health states lower relative to non-smokers simply by virtue of being smokers. The messages of public health promotion initiatives over the past few decades have emphasised constantly the damage to health entailed by cigarette smoking. \"Nearly all smokers regret having started smoking. Regretful smokers are those who believe themselves to be addicted. These regretful smokers report that smoking has lowered their quality of life and will continue to do so in the future. Although they are more likely to perceive that there are benefits of quitting, they have tried to quit multiple times, they have failed, and now they fear the future consequences to their health\" [ p.349]. The lower value placed on health by those with a university education replicates the greater distance between index and EQ VAS score found for those with longer periods of schooling in a US study . Why theThe presence of anxiety and depression effects in both the Table is genuinely random, we would nominate personality factors, such as extroversion and conscientiousness, as strong candidates to fill at least some of the explanatory void in future research. Indeed, personality factors have been shown to be significant predictors of self-perceived health, independently of actual health problems . Thproblems .The results confirm our hypothesis that there exist group variables which contribute systematically towards determining EQ VAS scores independently of EQ-5D health state classification. In our study, these variables comprised psychological disposition, socio-demographic factors, management method and clinically-important distress.The authors declare that they have no competing interests."} +{"text": "Transfusion Transmitted virus (TTV) is a novel single-stranded DNA virus that was identified in patients with post-transfusion hepatitis of non-A-G type. Clinical significance of TTV infection was analyzed in Egyptian hepatocellular carcinoma (HCC) patients. The present study attempted to clarify these issues in Egypt, particularly in Qaluobia governorate, a country known for its high endemicity of liver disease and hepatotropic viruses.HaeIII, DraI, EcoRI and PstI, we are able to distinguish between the four TTV genotypes.TTV are determined in the serum of 60 samples obtained from HCC and liver cirrhosis (LC) patients and 30 healthy individuals. TTV DNA is amplified by nested-PCR with TTV-specific mixed primers derived from the conserved open reading frame 1 (ORF1) region followed by digestion with restriction enzyme. Using the enzymes The positive rate of TTV detection was 46.7%, 40% and 36.7% among HCC, LC patients and healthy individuals respectively. The more prevalence genotype was detected in the positive serum samples was genotype 1 (35.7%) in HCC patients, (50%) in LC and (63.3%) in healthy individuals, Genotype 5 (21.4%), (25.5%) and (18.2%) in HCC, LC and healthy individuals respectively.This study indicates that TTV is commonly present in adult patients with HCC and LC as well as healthy individuals. The most prevalence TTV genotype is genotype 1. It seems that the infection neither contribute to the severity of liver disease no to the causation of HCC. Hepatocellular carcinoma (HCC) is the fifth most common cancer but the third leading cause of cancer death in the world. The major etiology of HCC/liver cancer in people is hepatitis B virus (HBV), followed by hepatitis C virus infection (HCV). A small single-stranded DNA virus, named TT virus (TTV), was discovered in Japan from patients with non-A-G transfusion-acquired hepatitis . KnowledAnalyses based on a phylogenetic tree constructed using the open reading frame (ORF) 1 sequence of TTV, showed that the virus could be classified into different genotypes. At least four groups comprising 23 genotypes of TTV have been identified ,11. In aIn Africa, HCV is reported to have very high prevalence in many countries with the unique genotypes 4 and 5 . In EgypThe aim of the present study was to assess the prevalence of TTV infection among Egyptian patients with LC and HCC, and to detect its genotypes. The present study attempted to clarify these issues in Egypt, particularly in Qaluobia governorate, a country known for its high endemicity of liver disease and hepatotropic viruses. Also to assess the impact of this virus on the severity of liver disease and its association with the development of HCC.The study was approved by ethical committee and informed consents were obtained from all parents of each patients participating in the study. This study included ninety cases, 30 patients with HCC and 30 patients with LC; they were selected from outpatient's clinic and in-patients of Benha university hospital. Both cases and control were subjected to full history, clinical examination and investigations required for proper clinical diagnosis. Serum samples were collected from patients and healthy individual in a period from December 2004 to January 2006 and stored at -20\u00b0C until used. The mean age of the patients ranged is 60.3, 53.2 and 38.7 years for HCC, LC and healthy individuals respectively.Patients and control were examined for HBsAg and HCV-Ab (INNOGENATICS N.V. Belgium) according to the manuscript.The QIAamp DNA extraction kit was employed for DNA extraction from serum samples according to the manufacturer's instructions.TTV sequences were amplified in hemi-nested PCR using primers NG059, NG061, and NG063. The first round PCR was carried out in 35 cycles consistent of 9 min at 96\u00b0C, followed by 35 cycles consisting of denaturation for 30 s at 94\u00b0C, annealing for 45 s at 60\u00b0C, and extension for 45 s at 72\u00b0C, with the sense primers 5'ACAGACAGAGGAGAAGGCAACATG3' and anti-sense primer 5'CTGGCATTTTACCATTTCCAAAGTT3' . The second round of PCR was performed with the sense primer 5'GGCAACATGTTATGGATAGACTGG3' and the anti-sense primer NG063 for 25 cycles, under the same conditions as used for the first round of PCR. In each PCR assay, one negative and two positive controls were tested together with the serum samples. The amplification products 271 bp were visualized on an ethidium bromide-stained 2% agarose gel figure A new genotyping assay, based on RFLP analysis, was developed. The alignment of sequences determined as above revealed the presence of genotype-specific restriction sites, combinations of which determined each genotype as shown in figure For categorical variables differences between groups were analyzed by using analysis of student t test for two groups' comparison and chi square test for non parametric values.The present study is conducted on sixty patients classified into two groups: group one includes thirty patients with hepatocellular carcinoma (HCC) and the second group includes thirty patients with liver cirrhosis (LC) . They selected from inpatients and outpatients' clinic of Benha university hospital, and thirty healthy volunteers were collected from blood bank and considered as control group. All Characteristic features of the different studied groups are shown in table TTV DNA was found in 26 out of the 60 subjects included in this study (43.3%). Mean ages were similar in TTV-infected and uninfected subjects of the HCC, LC and the control group. There is a significant different was observed between male and female in different studies groups in HCC 11/25(44%) in male, 3/5(60%) in female whereas in LC 5/19(26.4%) male was infected compared to 7/11(63.6%) in female whereas in control group 7/17(41%) male and 7/11(63.6%) female was infected.In HCC patients with blood transfusion, 75.1% had TTV infection. In LC patients with blood transfusion 50% had TTV infectionAlthough a higher prevalence of circulating TTV DNA was detected in HCC patients 46.7%(14/30) in which 42.9% had HCV, 7.1% had HBV infection, non had both HCV and HBV and (11/30)36.7% in healthy blood donors in which 4(36.4%) had HCV, the differences between groups were not statistically significant. In the LC patients, TTV DNA was found in twelve out of 30 LC patients in which 8(41.7%) had HCV, 1 (7%) had HBV, 2(16.7%) had both HCV and HBV table There were no statistically significant differences between TTV-infected and non infected patients in relation to virological features of HCV and HBV.The highest TTV genotypes in the HCC group were genotype 1 and 5 which represent 4/14 (28.6%) and 3/14 (21.5%), whereas in LC the genotype1 was 6/12 (50%) and 3/12 (25%) genotype 5 whereas among control group genotype 1 was 7/11(63.6%) and 2/12 (16.6%) genotype 5. There is no significant different was observed among different study group in relation to TTV genotype.There is no significant different was observed among different study group in relation to TTV genotype and HCV and/or HBV coinfection. In HCC patient, TTV-coinfected with HCV 2/4 (50%) is genotype 1 and 2/3 (66.7%) genotype 5. In LC patient, TTV-coinfected with HCV 4/6 (66.7%) is genotype 1 and 3/3 (100%) genotype 5. Three out of 7 (42%) genotype 1 was observed among control group whereas 1/2 (50%) genotype 5.TTV was first detected in subjects with post-transfusion hepatitis and indicated as a possible an etiologic agent of non A-non C hepatitis . AlthougIn this study, nucleic acids were extracted from a convenience sample comprising 60 serum samples collected from HCC and LC patients and 30 control groups. We detected an overall prevalence of TTV infection of 43.3%, which is higher than previously reported prevalence in patients with liver disease, in volunteer or commercial blood donors and in high risk populations from Western countries (1\u201313%) . By contThe use of a seminested PCR protocol gave estimates for the prevalence of TTV infection of 46.7%, 36.7% and 41%. This value is lower those reported for Turkish 75%) , Polish % , PolisA study even describes an overall prevalence of 94% in a sample representative of the general population . Such diTTV is characterized by an unusually high degree of sequence variability compared to other DNA viruses and several distinct TTV genotypes have been described ,19,28. GCharacterization of the genotypes of TTV circulating in our study population was carried out by restriction fragment length polymorphism (RFLP). Our analysis reveals the existence of six different genotypes of TTV and G1 shows the highest distribution among patients in Qaluobia governorate. The RFLP of all TTV-DNA positive samples revealed that prevalent genotypes 1 was the most frequently found 17/36 (47%), while 8/36 (22%) showed genotypes 5. A similar epidemiological profile for TTV genotypes has also been described for Italian subjects ,36.Maggi, [In regard to TTV, the prevalence of G1 and G2 is very high worldwide, and these are probably major genotypes of TTV. The distribution of the major TTV genotypes, G1 and G2, was not related to their geographic distribution. This suggests that TTV, a single-stranded DNA virus, probably spread all over the world a long time ago and coexisted with humans for long without pathogenicity. Our data is in accordance with others that G1 was the most common genotype of TTV in Japan; however, it is still unclear whether any correlation exists between the TTV genotypes and their geographical distribution or pathogenicity. Genotype 6 has the lowest found, similarly Genotype 6 has rarely found outside Japan, even in large surveys including patients from different parts of the world and its Maggi, , on the As the distribution of the different TTV genotypes might have potentially important clinical and epidemiological implications, it is necessary to evaluate the association of particular genotypes of TTV with the severity of liver diseases. However, our results show that no significant association could be identified between TTV genotypes and either LC or HCC.The pathogenic implications of TTV genomic heterogeneity are unknown. Available data showing low disease associations of TTV infection are derived from studies that considered mostly patients infected with genotype 1. The possibility that TTV genotypes may differ in their pathogenic potential cannot be excluded, since the prevalence and clinical correlations of uncommon TTV genotypes have not been explored so far. Analysis of each TTV genotype revealed that co-infection of TTV genotype 5 with HCV is more frequent 66.7% in HCC, 100% in LC and 50% in control group, comparing to TTV genotype1 50%, 66.7% and 42% respectively. The multiple TTV-genotype co-infections was not found, others did not find any relationship between liver diseases and TTV genotypes and reported that TTV has several different genotypes as does HCV, and so there probably are specific TTV genotypes causing severe liver diseases or other diseases, although it still remains unclear whether TTV is a direct cause of disease or not ,28."} +{"text": "Multi-attribute utility measures are preference-based health-related quality of life measures that have been developed to inform economic evaluations of health care interventions. The objective of this study was to compare the empirical validity of two multi-attribute utility measures (EQ-5D and SF-6D) based on hypothetical preferences in a large maternity population in England.Women who participated in a randomised controlled trial of additional postnatal support provided by trained community support workers represented the study population for this investigation. The women were asked to complete the EQ-5D descriptive system and the SF-36 , social functioning, bodily pain, general health, mental health, vitality and role limitations ) at six months postpartum. Their responses were converted into utility scores using the York A1 tariff set and the SF-6D utility algorithm, respectively. One-way analysis of variance was used to test the hypothetically-constructed preference rule that each set of utility scores differs significantly by self-reported health status . The degree to which EQ-5D and SF-6D utility scores reflected alternative dichotomous configurations of self-reported health status and the Edinburgh Postnatal Depression Scale score was tested using the relative efficiency statistic and receiver operating characteristic (ROC) curves.p < 0.001). Both measures demonstrated statistically significant differences between subjects who described their health status as excellent, very good, good, fair or poor (p < 0.001), as well as monotonically decreasing utility scores (test for linear trend: p < 0.001). The SF-6D was between 29.1% and 423.6% more efficient than the EQ-5D at detecting differences in self-reported health status, and between 129.8% and 161.7% more efficient at detecting differences in the Edinburgh Postnatal Depression Scale score. In addition, the SF-6D generated higher area under the curve (AUC) scores generated by the ROC curves than the EQ-5D, indicating greater discriminatory power, although in all but one analysis the differences in AUC scores between the measures were not statistically significant.The mean utility score for the EQ-5D was 0.861 , whilst the mean utility score for the SF-6D was 0.809 , representing a mean difference in utility score of 0.052 (95% CI: 0.040, 0.064; This study provides evidence that the SF-6D is an empirically valid and efficient alternative multi-attribute utility measure to the EQ-5D, and is capable of discriminating between external indicators of maternal health. Economic evaluations of health care interventions are increasingly being conducted throughout the industrialised world to inform the efficient allocation of finite health care resources . In manyAlternative approaches to deriving the health-related quality of life component of the QALY for the purposes of economic evaluation include scaling techniques, such as the standard gamble, time trade-off and person trade-off approaches, and multi-attribute utility measures, which are essentially health status classification systems with pre-existing utility scores (or preference weights) that can be attached to each permutation of responses . In pracempirical validity, that is, that the measure generates utility scores that reflect people's preferences. Brazier and Deverill [The selection of a multi-attribute utility measure for application within an economic evaluation framework should be informed by its psychometric properties in each clinical context, including its practicality, reliability and validity . A cruciDeverill propose Deverill ), and hyDeverill . Most coDeverill . To our Women who participated in a randomised controlled trial of additional postnatal support provided by trained community support workers represented the study population for this investigation ,21. The Two key outcome measures completed by the women in postal questionnaires at six months postpartum acted as the external indicators of health status in this current investigation. The first was general health status, which was categorised as excellent, very good, good, fair or poor. Self-reported health status has been shown to have high internal consistency, construct validity and reliability, as well as representing a good predictor of morbidity and mortality ,23. The As part of the postal questionnaire completed at six months postpartum, women completed the United Kingdom versions of the EQ-5D and SF-35) different health states. For the purposes of our investigation, we applied the York A1 tariff to each set of responses to the descriptive system in order to generate an EQ-5D utility score for each woman [n = 3337), which used the time trade-off valuation method to estimate preference weights for a subset of 45 EQ-5D health states, with the remainder of the EQ-5D health states subsequently valued through the estimation of a multivariate model [The EQ-5D was developed by the 'EuroQol Group', a multi-disciplinary group of researchers from seven centres across five countries, which was formed to generate a cardinal preference-based index of health for comparative purposes . The EQ-ch woman . The Yorte model ,27. Utilx 4 x 5 x 6 x 5 x 5) unique health states. A study using a fractional factorial design identified 249 health states from this universe of health states, which were valued by a representative sample of 611 members of the UK general population using the standard gamble valuation method [et al. [The SF-36 health survey was developed from the RAND Corporation's Health Insurance Experiment in the United States . The SF-n method . The uti [et al. to predi [et al. .2 test.All analyses were based upon responses for women who fully completed all external indicators of health status and multi-attribute utility measures at six months postpartum; no replacement or imputation was performed on missing response items. The economic, socio-demographic and clinical characteristics of women who did and did not complete all items for the relevant health measures were compared using the \u03c7t-test. The distribution of data points within each SF-6D dimension was calculated in cases where the EQ-5D utility score equalled 1.0 and the SF-6D utility score was less than 1.0. Similarly, the distribution of data points within each EQ-5D dimension was calculated in cases where the SF-6D utility score equalled 1.0 and the EQ-5D utility score was less than 1.0.Descriptive statistics for the EQ-5D and SF-6D utility scores were computed. The within-individual difference in mean utility score was tested using the paired The empirical validity of the EQ-5D and SF-6D utility scores was examined in a number of ways. One-way analysis of variance was used to test the hypothetically-constructed preference rule that utility scores should differ significantly between self-reported health status groups and should decrease monotonically with deteriorating self-reported health status . Furthert-statistic of the comparator instrument (assumed to be the SF-6D utility score for the purposes of this study) over the square of the t-statistic of the reference instrument (assumed to be the EQ-5D utility score for the purposes of this study) [The ability of the EQ-5D and SF-6D instruments to detect differences in external indicators of health status was tested using the relative efficiency (RE) statistic. Self-reported health status and the EPDS score represented the external indicators of health status in our study. The relative efficiency statistic has been widely applied in the broader health-related quality of life literature -40. It is study) . A relatversus very good, good, fair or poor, (ii) excellent or very good versus good, fair or poor, (iii) excellent, very good or good versus fair or poor, and (iv) excellent, very good, good or fair versus poor, and the relative efficiency statistic was recalculated. Similarly, two alternative cut-off points were applied to the EPDS score: (i) < 13 versus \u2265 13, and (ii) < 10 versus \u2265 10, on the basis that a score of 13 or more is considered to indicate a significant 'case' of postnatal depression, whilst scores of 10 to 12 indicate a borderline 'case' [In order to calculate the relative efficiency statistic, self-reported health status had to be converted into a dichotomous variable by dividing the study population into two groups. The cut-off point used to create this dichotomous variable is necessarily arbitrary and may lead to different conclusions depending on which cut-off is chosen . Therefoe 'case' . In addie 'case' , which iFinally, the discriminatory properties of the EQ-5D and SF-6D instruments in a maternity context were compared using receiver operating characteristic (ROC) curves . The ROCp-values were considered statistically significant if they were less than 0.05. All analyses were performed with a microcomputer using Statistical Package for the Social Sciences (SPSS) software.All p < 0.01). A full breakdown of the economic, socio-demographic and clinical characteristics of the study population is available from the authors upon request.Of the 623 women who participated in the randomised controlled trial of additional postnatal support (20), 493 (79.1%) completed all relevant health measures for the purposes of our investigation. An examination of the characteristics of the women who did not fully complete these measures revealed that they were more likely to be less than 25 years of age, of non-white ethnic origin, unemployed, living in rented accommodation and without a car (p < 0.001) that exceeded the utility score difference of 0.03 cited as a minimum clinically important difference for evaluative purposes [Descriptive statistics of the EQ-5D and SF-6D utility scores are presented in Table purposes ,44.A total of 177 women had an EQ-5D utility score of 1.0 and a SF-6D utility score of less than 1.0. Notably, amongst women who did not identify problems in any of the EQ-5D dimensions, 54 , 22 (4.5%), 27 (5.5%), 54 (10.9%), 144 (29.2%) and 168 (34.1%) identified problems (levels 2\u20136) on the physical functioning, role limitations, social functioning, bodily pain, mental health and vitality dimensions of the SF-6D, respectively. In contrast, only 1 woman , who identified moderate pain or discomfort on the EQ-5D descriptive system, had a SF-6D utility score of 1.0 and an EQ-5D utility score of less than 1.0.p < 0.001). In addition, both multi-attribute utility measures generated utility scores, which decreased monotonically with deteriorating self-reported health status (test for linear trend: p < 0.001). The mean EQ-5D utility score was greater than the mean SF-6D utility score for women who described their health status as excellent (0.964 versus 0.916), very good (0.908 versus 0.856) or good (0.819 versus 0.741), but lower for women who described their health status as fair (0.651 versus 0.652) or poor (0.366 versus 0.507). This reflected, in part, the distribution of data points illustrated in Figure p < 0.001), as well as monotonically decreasing utility scores (test for linear trend: p < 0.001). The only sub-groups for which this was not the case were women of non-white ethnic origin and women who had delivered twins, although this might be explained by the relatively small numbers for these sub-groups .Tables The relative efficiency statistic was used to test how efficient the EQ-5D and SF-6D instruments were in detecting differences in external indicators of health status in this context. When the self-reported health status variable was dichotomised in alternative configurations, the SF-6D was found to be between 29.1% (relative efficiency statistic of 1.291 versus 1.0) and 423.6% more efficient than the EQ-5D at detecting differences in self-reported health status (Table p < 0.05). The only exception was the failure of the EQ-5D to discriminate between women who reported excellent, very good, good or fair health and women who reported poor health in the restricted sample .The analytical strategy that we adopted also tested the versus 243 EQ-5D health states) and, consequently, a possibly greater degree of sensitivity to maternal health indicators. Third, the wording of the SF-6D response items, which includes positive as well as negative aspects of health, might independently result in a greater degree of sensitivity to maternal health indicators. Fourth, the longer time frame covered by the SF-6D, which frames its questions in terms of health 'over the past 4 weeks', as opposed to the time frame covered by the EQ-5D descriptive system, which frames its questions in terms of health 'today', might independently increase its sensitivity to the external indicators of maternal health adopted by this study. Ultimately, a full understanding of the reasons for the greater efficiency of the SF-6D at detecting external indicators of maternal health is beyond the scope of this paper. Separate studies are required to test the hypotheses set out above.There are several possible reasons why the SF-6D might be more efficient at detecting external indicators of maternal health than the EQ-5D. First, although both measures are rooted in the World Health Organisation definition of health, which covers physical, mental and social well-being, the SF-6D may tap into broader aspects of health-related quality of life, such as role and social functioning. Second, the SF-6D has a greater number of response items to each of its dimensions, resulting in a larger descriptive system (18,000 health states There are a number of caveats to the study results which should be borne in mind by readers. First, the analytical strategy focussed on whether EQ-5D and SF-6D utility scores reflect hypothetically constructed preferences. The external indicator of self-reported health status adopted by our study represents a good predictor of morbidity and mortality ,23, whilIn conclusion, this study provides evidence that the SF-6D is an empirically valid and efficient alternative multi-attribute utility measure to the EQ-5D, and is capable of discriminating between external indicators of maternal health. Further research, which examines the psychometric properties of the EQ-5D, SF-6D and other multi-attribute utility measures in the maternity context, would strengthen the limited evidence base currently available to analysts conducting and interpreting economic evaluations.The authors declare that they have no competing interests.SP designed this empirical investigation and took the primary role in analysing the data and drafting the paper. JM and HS were the principal clinical investigators for the original postnatal support workers trial and contributed to iterative drafts of the paper.Appendices A and B.Click here for file"} +{"text": "The EuroQoL 5D (EQ-5D) is a questionnaire that provides a measure of utility for cost-effectiveness analysis. The EQ-5D has been widely used in many patient groups, including those with coronary heart disease. Studies often require patients to complete many questionnaires and the EQ-5D may not be gathered. This study aimed to assess whether demographic and clinical outcome variables, including scores from a disease specific measure, the Seattle Angina Questionnaire (SAQ), could be used to predict, or map, the EQ-5D index value where it is not available.Patient-level data from 5 studies of cardiac interventions were used. The data were split into two groups - approximately 60% of the data were used as an estimation dataset for building models, and 40% were used as a validation dataset. Forward ordinary least squares linear regression methods and measures of prediction error were used to build a model to map to the EQ-5D index. Age, sex, a proxy measure of disease stage, Canadian Cardiovascular Society (CCS) angina severity class, treadmill exercise time (ETT) and scales of the SAQ were examined.The exertional capacity (ECS), disease perception (DPS) and anginal frequency scales (AFS) of the SAQ were the strongest predictors of the EQ-5D index and gave the smallest root mean square errors. A final model was chosen with age, gender, disease stage and the ECS, DPS and AFS scales of the SAQ. ETT and CCS did not improve prediction in the presence of the SAQ scales. Bland-Altman agreement between predicted and observed EQ-5D index values was reasonable for values greater than 0.4, but below this level predicted values were higher than observed. The 95% limits of agreement were wide .Mapping of the EQ-5D index in cardiac patients from demographics and commonly measured cardiac outcome variables is possible; however, prediction for values of the EQ-5D index below 0.4 was not accurate. The newly designed 5-level version of the EQ-5D with its increased ability to discriminate health states may improve prediction of EQ-5D index values. The EuroQoL 5D (EQ-5D) is a widely used generic measure of health related quality of life (HRQoL) and can be used to generate a single index value or utility -3. This Patients participating in clinical trials and other studies often have to complete many questionnaires, sometimes at multiple points in time. The EQ-5D is a short survey that has been shown to have good acceptability and feasibility in the general public and in cardiac patients -12. HoweMapping of preference based measures using non-preference based tools is a growing area of study . Such moConsistency in relationships between the EQ-5D index, patient characteristics and cardiac outcome measures across different studies/disease severity groups have recently been assessed using both aggregate and patient level data by our group ,14. The Several studies have looked at mapping using other generic or disease-specific HRQoL measures, with one other using clinical measures to map to the EQ-5D index ,15. ThisThe authors had access to individual patient data from 5 major studies in patients with cardiovascular disease in which both the EQ-5D and one or more commonly-used cardiac measurements were available, which were a subset of the studies used in our previous study . A main The EQ-5D questionnaire consists of 5 questions covering health domains of mobility, self-care, usual activity, pain and anxiety/depression -3. Each Total exercise time was available from a modified Bruce protocol treadmill test (ETT). The Bruce protocol requires walking on a treadmill at a given speed and with a given grade, both of which increase through three stages ,20.Angina class was measured by the Canadian Cardiovascular Society Angina Scale. The CCS was recorded as a 5-point score according to the amount of exercise required to bring on angina from 0 to IV .The disease-specific Seattle Angina Questionnaire (SAQ) has five dimensions related to angina: the exertional capacity scale (ECS), anginal stability scale (ASS), anginal frequency scale (AFS), treatment satisfaction scale (TSS) and the disease perception scale (DPS). Each scale has a range of 0 to 100 with higher values representing greater functioning/satisfaction and fewer limitations.Continuous variables were summarized using the mean and standard deviation. Relationships between the EQ-5D index and continuous explanatory variables were explored by studying scatter plots and correlations between the variables. Categorical variables were summarized using frequencies and proportions. The relationship between the EQ-5D index and categorical variables was explored by summarizing the mean and standard deviation of the EQ-5D index for different levels of these variables, and using the Student's t-test or analysis of variance for comparisons.2 values. The variable that gave the largest increase in adjusted R2 was added first, and then all remaining variables were tested again one at a time. Variables were added until there was no appreciable change in adjusted R2 (less than 5%). The root mean square error (RMSE) and mean absolute error (MAE) were also calculated to assess model fit and prediction ability [2 was used for choosing models rather than one of these measures of prediction accuracy because it is penalised for larger models, with the use of the less than 5% change criterion further contributing to a parsimonious model. Only two of the five SAQ scales were available for the Appropriateness for Coronary Revascularization (ACRE) study, so interaction terms were used to examine whether there were differences in the effect of these scales in the ACRE data as compared to the other studies. Interaction terms between ETT, CCS and SAQ and the disease stage proxy variable were also pre-specified. This allowed for different relationships between these variables and the EQ-5D index in different disease stage groups, which was important given that a high degree of heterogeneity in these relationships has previously been shown [For mapping, a base linear model was fitted using ordinary least squares (OLS) estimation with EQ-5D index as the dependent variable and age, sex and a proxy for disease stage as explanatory variables in the model using the estimation dataset. The proxy 'disease stage' variable was created by taking into account both the procedures patients had undergone and the time point of the EQ-5D index measurement. Patients were classified as a) having had only medical management , b) being pre-balloon angioplasty +/- stent (PTCA) , c) pre-coronary artery bypass graft (CABG), or d) post-PTCA or e) post-CABG, if the patient had one of these procedures before the study began. This variable constituted a proxy for disease stage because patients that only had medical management were likely to be the least ill, but those that entered a study and then had PTCA or CABG were probably at a more advanced stage of disease upon presentation. Furthermore, if patients had one or more revascularisation procedures before entering the study, they are likely to have even further advanced disease. In a situation where a patient could conceivably fit into two categories, for example, if they had both a PTCA and a CABG before the study, or they had a PTCA before the study but would go on to have a CABG during the study, they were put in the category of the most invasive procedure, for example, post-CABG in the first instance, pre-CABG in the second. For the Percutaneous Myocardial Revascularization (PMR), Transmyocardial Laser Revascularization (TMR) and SpiRiT studies, the interventions were PMR, TMR or spinal cord stimulation (SCS) rather than CABG. These were grouped together with CABG since all of these trials involved patients with angina that was not controlled by medical management and for whom conventional revascularisation (PTCA or CABG) had failed or was not possible. Age, sex and disease stage proxy variables were retained in all models. To this base model ETT, CCS class and individual SAQ scales were each added in a stepwise fashion to the model each as an additional explanatory variable. A range of multiple variable models was constructed using the estimation dataset with a combination of these variables depending upon their importance based on adjusted R ability . The RMSen shown .2, RMSE and MAE.One of the multiple variable models was chosen as the mapping model based upon explanation of the maximum amount of variability in the EQ-5D index with the fewest variables, as well as relatively low RMSE and MAE values. To validate this model the regression equation was applied to the data in the validation dataset, predicted values of the EQ-5D index were obtained for each person, and these predicted values compared to the observed values. Standardised residuals and fitted EQ-5D index values from fitting the final model in both the estimation and validation datasets were plotted against one another. A Bland-Altman analysis was performed, both in the estimation and validation datasets, to see how well the observed and predicted EQ-5D index agreed and if there appeared to be any systematic measurement bias in the predicted index. The intraclass correlation coefficient (ICC) for the observed and predicted values was calculated as a further measure of agreement. The final model was also fitted to the data in the validation dataset to obtain the adjusted RThe study includes secondary analysis of results from a range of studies. All primary studies had ethical approval from Local Research Ethics committees between 1993 and 2001.There were 2855 records in the estimation dataset and 1887 in the validation dataset. The estimation and validation datasets had similar distributions of the variables of interest Tables . The EQ-Results of the mapping model constructed from the estimation dataset are described in Tables The model equations for the chosen prediction model, Model 11, which has the base variables plus ECS, DPS and AFS of the SAQ is shown below. This model explained 48% of the variation in the EQ-5D index in the estimation dataset and had an RMSE of 0.170. The equation for Model 12, which has all of the SAQ scales included, is also shown. The RMSE for this model was 0.169, so the prediction error from these two models was not appreciably different.Model 11: EQ-5D index = 0.147 + 0.002*age - 0.009 + 0.021(if MM) + 0.048(if pre-PCI) + 0.018(if post-PCI) + 0.073(if pre-CABG) + 0.0036*(ECS) + 0.0021*(DPS) + 0.0015*(AFS)Model 12: EQ-5D index = 0.071 + 0.002*age - 0.009 + 0.023(if MM) + 0.047(if pre-PCI) + 0.015(if post-PCI) + 0.071(if pre-CABG) + 0.0036*(ECS) + 0.0004*(ASS) + 0.0018*(DPS) + 0.0014*(AFS) + 0.0010*(TSS)2 of 0.44, RMSE of 0.167 and an MAE of 0.123, which were similar to the results in the estimation dataset. Figure There were 702 records with non-missing covariates in the final model in the validation dataset. The ICC for the observed and predicted values of the EQ-5D index was 0.64 . When the mapping model was applied to the validation dataset it produced an adjusted RThis study aimed to build a model to map from cardiac patients' demographic and outcome measures to the EQ-5D index. The SAQ ECS was the strongest predictor of the EQ-5D index, and had the lowest RMSE as compared to other variables available. The SAQ DPS and AFS scores also entered the model, indicating that a disease-specific measure of patient health and disease perception was an important predictor of the generic measure of HRQoL. If interest centres on mapping the EQ-5D index in another disease area, disease specific measures for the disease in question may also be important. The mapping exercise was initially performed with the EQ-5D index bounded to a 0-1 scale and logit transformed as the outcome variable for the OLS models. There was little difference in prediction results whether these transformations were applied or not, and so the non-transformed EQ-5D index was used as the outcome for simplicity. The residual plots show some potential difficulties with using OLS (Figure The final mapping model explained 48% of the variability in EQ-5D index and provided essentially the lowest RMSE at 0.17. This RMSE was, however, higher than the minimal important difference for the EQ-5D index of 0.05 ,23 and hSeveral different strategies for improving the predictive ability of the model were explored. These included adding the ETT and CCS variables back into the final model, even though they did not enter the model under the pre-specified criterion. These two variables were tried in the final model as their lack of importance in the mapping model was somewhat surprising. This is perhaps especially true for the CCS, which was found in a previous study to have a strong relationship with the EQ-5D index . These vFinally, the mean difference in observed and predicted values was smallest for patients from the CeCAT study, which was the study that contributed the most data and also that had the healthiest participants. This may mean the prediction model derived here is more applicable to patients early in the course of disease and that further study using data with more patients across the spectrum of disease could improve prediction, perhaps especially towards the lower end of the EQ-5D index range. There was a further nuance in prediction of the EQ-5D index between studies shown by these estimates - the prediction model under-predicted values of the EQ-5D index overall in the PMR study, and to some extent in the SpiRiT study - the Bland-Altman analysis shows over-prediction for the few people with an observed EQ-5D index below 0.4 for all three studies, but some under-prediction for people with EQ-5D index measurements of greater than 0.4 in the PMR and SpiRiT studies.Another potential explanation for the poor prediction is that while the 5-question, 3-response format makes the EQ-5D easy to administer and complete, it describes a relatively small number of possible health states and does not discriminate well, especially towards the end of the scale describing good health ,26. In aOne limitation of the study was that only three out of the five studies that were available had all of the necessary covariates. This limits the external validity of the findings and may have other unknown effects that users of the mapping algorithm should bear in mind. For example, the ACRE study only included two of the five SAQ scales and, when interaction terms were used to compare the effect of these two scales in ACRE versus the other studies, there was some evidence of a difference, meaning the effects might have been different had we had such information from ACRE patients or had data from more studies. Future work should include further development and validation of potential mapping models on datasets with more complete information on covariates and more data on patients with more severe cardiac disease. Secondly, the UK algorithm for calculating the EQ-5D index was used, so the models may not be applicable to cardiac patients from other countries. Thirdly, we have not explicitly accounted for the correlation between baseline and treatment measurements on individuals since baseline measurements will not always be available and the models should only be used for patients with similar clinical and demographic profiles. Future work should include validating the model on an independent sample , and forIn conclusion, it was possible to construct mapping models for the EQ-5D index using demographic, disease stage and cardiac outcome measures for a group of cardiac patients that performed better in predicting the EQ-5D index for values above 0.4, and less well for values below that level, where the EQ-5D index was over-estimated. The root mean square error derived from fitting the final model in the validation dataset was larger that the minimal important clinical difference for EQ-5D. Prediction of the EQ-5D index is possible, however, due to the relatively poor prediction across the range, inclusion of a preference-based measure in a study where cost-effectiveness analysis is an aim would be a better approach than prediction of the EQ-5D index from other measures.The authors declare that they have no competing interests.KG performed the analysis and drafted and edited the manuscript. MD edited the manuscript. MB designed the study and edited the manuscript. LS designed the study and edited the manuscript.All authors have read and approved the final manuscript."} +{"text": "The EuroQoL 5D (EQ-5D) has been widely used in studies of cardiac disease, but its measurement properties in this group are not well established. The study aimed to quantify the relationship between measures commonly used in studies of cardiac disease and the EQ-5D index across different levels of disease severity.Patient-level data from 7 studies of cardiac interventions were used, which included randomised trials and observational studies. Relationships between the EQ-5D index and commonly used cardiac measures, Canadian Cardiovascular Society (CCS) angina severity class, treadmill exercise time (ETT) and scales of the Seattle Angina Questionnaire (SAQ) were examined. Mixed effects linear regression was used to assess these relationships, with the EQ-5D index as the response.Study sample sizes ranged from 68 to 2419. Mean baseline EQ-5D index ranged from 0.77 in patients at diagnosis to 0.43 in patients with advanced disease and differed significantly across studies (p < 0.001). There was evidence of a ceiling effect in patients at diagnosis. The minimum clinically important difference of a one minute increase in ETT was associated with a 0.019 increase in EQ-5D index. One class increase in CCS was associated with a 0.11 decrease in EQ-5D index. A 10 unit increase in SAQ scales was associated with increases between 0.04 and 0.07 in EQ-5D index . Tests of heterogeneity indicated the EQ-5D-covariate relationships were consistent across levels of disease severity for ETT and the treatment satisfaction scale of the SAQ, but heterogeneous for age, gender, CCS angina class and other scales of the SAQ.The EQ-5D index varies with coronary disease severity. The relationship between the EQ-5D index and an outcome measure used in cardiac intervention studies, ETT, was consistent across disease severity levels, but the relationship between demographic variables, CCS angina class and most of the SAQ scales and the EQ-5D index was heterogeneous for patients with different levels of coronary disease. Differences in the EQ-5D index associated with clinically important differences in cardiac measures can be quantified and vary between three important examples - angina class, ETT and SAQ. Coronary heart disease (CHD) is common and new treatments for patients in various stages of the disease continue to be developed and evaluated. Figure Clinical trial-based evaluations of treatments in many fields, including cardiology, often include cost-effectiveness, which requires the elicitation of health related quality of life (HRQoL) from patients in order to calculate quality-adjusted life years (QALYs). The EuroQoL 5D (EQ-5D) is a questionnaire that provides a generic measure of HRQoL -6. RespoThe EQ-5D index has often been used to assess HRQoL and to calculate QALYs for cost-effectiveness analyses in trials of interventions in cardiac patients ,10-12 anConsistency in relationships between the EQ-5D index, patient characteristics and cardiac outcome measures across different studies/disease severity groups have not been assessed using patient level data. This study aims to use individual patient data to assess how the EQ-5D index varies in cardiac patients with different levels of disease severity and to explore and quantify the relationship between the EQ-5D index and both patient characteristics and outcome measures commonly used in cardiac studies, such as exercise treadmill time (ETT), CCS angina classification and Seattle Angina Questionnaire (SAQ) scales.The EQ-5D questionnaire consists of 5 questions covering the following health domains: mobility, self-care, usual activity, pain and anxiety/depression -6. PartiIn order to be able to study effects at the patient level, the data used were limited to those from studies that the investigators had been involved in, so that the relationship between the EQ-5D index and cardiac outcome measures could be examined using patient level records. This was, therefore, an opportunistic sample that was not obtained through a systematic review. All studies were conducted in the UK and the UK scoring algorithm for the EQ-5D index was used.Studies were further chosen to be able to study patients across the spectrum of disease by including those that had collected EQ-5D data from cardiac patients with different severities of CHD. The relationship between the EQ-5D index and measures of cardiac outcomes was the primary focus, so it was also important that the studies used measured the cardiac outcomes of interest, including ETT, CCS angina class and the SAQ, which are further described below. Some studies collected NYHA rather than CCS. The relationship between the EQ-5D index and the Short Form 6D (SF-6D), another utility measure used in cost-effectiveness analysis , was alsThe study includes secondary analysis of results from a range of clinical trials. All primary clinical trials had ethical approval from Local Research Ethics committees between 1993 and 2001.The ETT is a validated clinical test used to assess suspected or known CHD. The test follows the Bruce protocol which requires walking on a treadmill at a given speed and with a given grade, both of which increase through three stages . The modThe CCS is a rating scale for stable angina . It rangThe SAQ consists of 11 questions that can be converted into 5 scales assessing functional status for patients with angina: exertional capacity (ECS), anginal stability (ASS), anginal frequency (AFS), disease perception (DPS) and treatment satisfaction (TSS) . The SAQSeven studies of cardiac interventions conducted in the UK were used. The studies are summarized in Figure Cost-effectiveness of functional cardiac testing in the diagnosis and management of CHD (CECaT) : a randoAppropriateness for coronary revascularization (ACRE) : a prospImplantable Cardioverter Defibrillator (ICD) therapy in different patient groups (ICD) : a crossPercutaneous myocardial revascularization compared to continued medical therapy (PMR) : a RCT oTransmyocardial laser revascularization compared to continued medical therapy (TMR) : a RCT oSpinal cord stimulation (SCS) compared to PMR (SPiRiT) : an RCT Evaluation of ventricular assist devices (VAD) patients compared to patients on transplant waiting list (Tx WL) (EVAD) : an obseThe EQ-5D index and other continuous variables were summarized using the mean and standard deviation and boxplots. Categorical variables were summarized using frequencies and proportions. The difference in baseline EQ-5D index across studies was examined using a general linear model with the EQ-5D index as the outcome and study as the predictor using only data gathered pre-treatment (at study entry).ij for patient j in disease/treatment group i was used. Not all 20 groups had all explanatory variables, so i varied depending on the number of groups who had the given variable available. The explanatory variables of primary interest were age, sex, ETT, CCS and the scales of the SAQ. SF-6D was also studied. A separate analysis was undertaken for each explanatory variable. Age, ETT, the scales of the SAQ and the SF-6D were centred at their mean value in the models. For all explanatory variables, a fixed effect and a Normal random effect was assumed. In addition, the treatment applied and the study type were included as fixed effects are random effects allowing for different age effects in different disease/treatment groups, and\u03b5ij~N represents residual random error not explained by the other terms in the model.After models were fit, the importance of the treatment and study type fixed effects were tested by removing each variable from each model in turn and using a conditional F-test to compaThe minimally important difference (MID) in the EQ-5D index has been estimated to be between 0.05 - 0.07 ,34, and 2 statistic [2 uses Cochran's Q statistic and the degrees of freedom of the test to provide a measure of the percent of total variation that is due to heterogeneity between studies, or here, between disease/treatment groups.Cochran's Q test statistic and the tatistic were useStudy sample sizes ranged between 68 and 2419 (Table 2 = 61%) between studies .ETT had a small positive relationship with the EQ-5D index, where the EQ-5D index increased by 0.019 for each minute increase in ETT with each CCS class increase Table , and thi2 all equal to 87%), but was lower for angina severity (ASS) Table . There wS) Table .As expected, there was large positive relationship between the EQ-5D index and the other generic measure of HRQoL studied, SF-6D. A large proportion of the variation in the EQ-5D/SF-6D relationship was due to heterogeneity across disease/treatment groups Table .Study and treatment type fixed effects were important covariates for almost all of the patient variables of interest (data not shown), and so were left in all models for consistency.This project utilized data from several different studies of cardiovascular patients to assess the relationship between the EQ-5D index and various patient characteristics and outcomes. Using studies from a range of clinical scenarios allowed us to assess relationships between the EQ-5D index and other variables at different cardiac disease stages and in different treatment groups. A patient-level analysis such as this has substantially more power to detect effects than a meta-regression of aggregate results, and allows effects to be measured with greater precision.We observed ceiling effects of the EQ-5D index, especially in cardiac patients in the diagnosis stage of disease, and also after treatment. Ceiling effects in the EQ-5D index have been shown in cardiac patients and for other groups ,37,38. HThe relationship between the EQ-5D index and age varied between patient groups, although the pooled effect was small and not statistically significant. In patients recruited to trials, the EQ-5D index increased with age, which is contrary to the effect seen in \"normal\" populations ,41. In cMen had higher EQ-5D index scores than women. In some population studies, women reported more problems on the EQ-5D ,41 than For each minute increase in ETT, there was a 0.019 increase in EQ-5D index. Based on a recommended MID of 0.05 between health states , it seemFor CCS angina class, CECaT treatment groups and angina trials groups treated with routine medical management showed a smaller relationship between EQ-5D index and CCS than CECaT and angina groups at study entry and ACRE treatment groups. As in the case of the other relationships explored here, this may be partly due to different levels of heterogeneity in trial and cohort participants. In some studies , most patients were in CCS classes III and IV, meaning less variability in this measure. There was a relatively strong relationship between CCS and EQ-5D index. This could be because CCS is a discrete measure and a one-class change may correspond to a relatively large difference in functional limitations.Increases in the scales of the SAQ, which indicate improvements in different aspects of angina, were associated with increases in EQ-5D index greater than the MID for exertional capacity, anginal frequency and disease perception, while anginal stability and treatment satisfaction were associated with slightly smaller differences of approximately 0.04. Taken together, these indicate a reasonably strong relationship between the generic EQ-5D HRQoL measure and the disease-specific SAQ. For most of the SAQ scales (and some other variables studied), there was a smaller relationship between the scale and EQ-5D index in the PMR MM group. This was a small group with few low EQ-5D index scores, and this lack of variation may explain the different results for this group. The ECS had a smaller relationship with EQ-5D index in the CECaT groups than in most of the angina groups, perhaps reflecting greater physical disability in the angina groups allowing for larger changes in the EQ-5D index. The relationship between anginal frequency and EQ-5D index was at, or greater than, the MID for most groups. The effects were larger in the CECaT CABG group and to some extent in the ACRE CABG groups and the PMR treatment groups, perhaps because patients in these groups were treated by more aggressive means and perceived a large decrease in anginal episodes soon after treatment. For disease perception, there was a larger effect for patients in the angina trials, possibly reflecting the specificity of the scale for angina/concern about having a heart attack, which may be less relevant for healthier CECaT patients, for example. This sort of inconsistency in the relationship between both the CCS and the SAQ and the EQ-5D index across disease/treatment groups could reflect that while some cardiac patients suffer from angina, recently diagnosed patients and heart failure patients are less likely to have pain from angina at rest or with mild activity. Treatment satisfaction was not very variable and had a consistent relationship with the EQ-5D index. The ASS had a similar relationship with EQ-5D index in most groups, and in fact, with the PMR MM group removed, heterogeneity in this measure across disease/treatment groups was lower and only borderline significant .The relationship between EQ-5D index and SF-6D in angina patients was explored for completeness, and was strong, as might be expected for two measures used for the same purpose. There was an increase of 0.17 in EQ-5D index for each 0.10 unit increase in SF-6D. This relationship has been explored before for patients in different disease groups using ordinary linear regression and with SF-6D as the outcome , and wheA limitation of the study is its focus on patients recruited to randomised trials. While this does not affect the internal validity of the results, it may limit their generalisability to the overall population with CHD. Secondly, CCS class was studied in models as a continuous variable, whereas it is a discrete measure. This could be a reason for the large effect size of CCS. This was necessary in part because there were few or no patients in the lower CCS classes in studies in patients with advanced disease. Thirdly, differences by sex were difficult to assess separately for some disease/treatment groups, angina in particular, because there was a small proportion of women in many of the studies, so further work could be done in studies with more women to assess the robustness of the estimate of the relationship between sex and EQ-5D index in cardiac patients. Finally, we were not able to assess the relationship between other measures such as the Health Utilities Index or the Minnesota Living with Heart Failure score and the EQ-5D index as these are not generally used in the UK and were not therefore available in the datasets that were used.We have used individual patient level data to show that the EQ-5D index decreases as cardiac disease severity increases and that the EQ-5D index has a ceiling effect in patients with mild CHD and after treatment. The EQ-5D index has a relatively strong relationship across different levels of CHD severity with sex, the scales of the SAQ and CCS angina severity class and a smaller relationship with age and ETT. The variation seen in the relationship between the EQ-5D index and these variables, with the exception of the ETT and treatment satisfaction measured by SAQ, is in large part due to heterogeneity between groups of patients with different levels of CHD severity.The authors declare that they have no competing interests.KG performed the analysis and drafted and edited the manuscript. MD edited the manuscript. PS managed patients in the studies and edited the manuscript. MB designed the study and edited the manuscript. LS designed the study and extensively edited the manuscript. All authors read and approved the final manuscript.Canadian Cardiovascular Society (CCS) angina and New York Heart Association (NYHA) functional capacity and objective assessment of patients with diseases of the heart classification systems. The table outlines the definitions of the different classification levels of the CCS and NYHA classifications of heart disease.Click here for fileBoxplots of the EQ-5D index and other patient characteristics pre-treatment and after treatment by study. The figure shows boxplots of the raw baseline and post-treatment values of EQ-5D, SF-6D and exercise treadmill time.Click here for fileBoxplots of Seattle Angina scale scores pre-treatment and after treatment by study. The figure shows boxplots of the raw baseline and post-treatment values of the scales of the Seattle Angina Questionnaire.Click here for file"} +{"text": "S. Chiara hospital is the only neonatal intensive care unit (NICU) in the Province of Trento . It serves a population of about 460000 people with about 5000 infants per year, admitting the totality of the inborn and outborn VLBWI of the province. The aim of this work is to compare mortality, morbidity and neonatal treatment of the very low birth weight infants (VLBWI) of Trento area with those recorded in the Vermont Oxford Network (VON) during 2004.In this retrospective analysis, the rates of complications and related treatments reported in VLBWI admitted in the S. Chiara NICU during the period 2000\u20132005 were compared with those recorded in the VON in 2004. The analysis included both the total populations and different weight groups.p-value 0.003). The administration of prenatal steroids and caesarean section were significantly more frequent in the Trento area than in VON. In Trento significantly more VLBWI with BW \u2264 1000 grams were given surfactant prophylaxis compared with VON and significantly fewer VLBWI in every Trento weight group developed RDS . Overall rates of complications were significantly lower than in the Vermont Oxford Network. In CLD and PDA the differences were marked also in infants weighting less than 1000 grams. Overall rates of PNX, PVL, severe grade of ROP and mortality were similar in the two populations. In Trento, significantly more infants were discharged on human milk than in VON, in both the overall population and in BW sub-groups.The frequency of inborn infants was significantly higher in Trento than in VON: 91% vs 84% (MH 8.56; On the basis of this analysis, a less aggressive therapeutic strategy based on perinatal prevention in global management, such as that employed in Trento area, may be associated with an improvement in clinical outcomes in very low birth weight infants. Very low birth weight infants (VLBWI), i.e. those weighing < 1500 grams, account for a very small percentage of all live births but make a disproportionately large contribution to neonatal mortality and morbidity . MoreoveVLBWI vary substantially in terms of mortality and response to therapy, according to birth weight (BW) and to gestational age (GA) . MoreoveS. Chiara hospital is the only neonatal intensive care unit (NICU) in the Province of Trento . It serves a population of about 460000 people with about 5000 infants per year, of which one in 100 are VLBWI, admitting the totality of the inborn and outborn VLBWI of the province. Its provincial organization is based on the \"in-uterus\" transport to S. Chiara and emergency transport from referral delivery points for only few cases every year. S. Chiara is a 20-bed unit with eight beds dedicated to intensive care, each providing assisted ventilation and monitoring of vital parameters. NO treatment, radiography, echography and haemogas-analysis devices, and infusion pumps are also available. The working team includes 9 neonatologists and 25 nurses. Operative, surgical, orthopaedic and neuropsychiatric units are present in the paediatric department of S. Chiara. A specialised ophthalmologist is dedicated to diagnosis of retinopathy of premature (ROP). In the Trento area all the patients go directly home from S. Chiara NICU. There is no other centre where they can be transferred to. Even the follow up for the first 2 years of life is made exclusively by S. Chiara NICU of Trento. The S. Chiara neonatal intensive care unit provides emergency transport for the entire Trento area.Rather than a comparison among NICUs, this study wants to be a comparison between two areas, the small Trento-area and the big VON-area. The aim of this retrospective analysis is to compare mortality, morbidity and treatment of VLBWI in the S. Chiara intensive care unit during 2000\u20132005 with those recorded in VON during 2004. In particular, this analysis focuses on infants weighing \u2264 1000 grams.In the Trento area, only 50 VLBWI are recorded each year compared with about 40000 in VON. Therefore, consecutive VLBWI data reported in S. Chiara during a six-year period (2000\u20132005) were compared with a single year for VON (2004).\u00ae; Chiesi Farmaceutici, Parma, Italy [200 mg/kg bolus]) was recorded. Surfactant was given as a prophylactic measure in the delivery room to all babies with GA < 29 weeks. In Trento area the policy about ELBWI (22\u201324 weeks of GA) is based on the active care with resuscitation since the 22nd week. In general the Trento policy for all the VLBWI is based on the early prophylactic administration of surfactant in Trento in delivery room or in the first hours of life; this step is followed by the clinical evaluation that permits to continue with a minimal handling or, if strictly necessary, with high invasivity . Furthermore, the need for nasal continuous positive airway pressure (NCPAP) and conventional ventilation was observed. Other complications recorded included: patent ductus arteriosus (PDA), as determined by echocardiography ; necrotising enterocolitis (NEC), defined as gastrointestinal signs and symptoms associated with specific radiological and operative evidence [Baseline data . Incidences were compared using odds ratios (OR) and the respective 95% confidence intervals (95% CI). The differences between the two populations were calculated with the Mantel-Haenzel estimate (MH).A total of 250 VLBWI in the Trento area and 38895 in VON were evaluated. Baseline data for the two populations, and BW-defined sub-groups, are summarised in Table 1 . In addition, some treatments, such as the administration of prenatal steroids and caesarean section were significantly more frequent in the Trento area than in VON. The frequencies of congenital anomalies, multiple births were similar between Trento and VON. SGA infants were less frequent in Trento.Table 2 , with the use of conventional ventilation and nasal CPAP significantly less frequent in Trento. Only in the sub-group with BW 501\u2013750 grams the frequency was similar in the two populations. Greater use of surfactant prophylaxis and lower incidence of RDS in Trento compared with VON were particularly evident in the 501\u20131000 grams group. The same trend was found for CLD at 36 weeks: 5% vs 36% in VON . In Trento postnatal steroids for CLD are not used. The overall frequency of pneumothorax was similar in the two populations.Table 3 and subsequent use of indomethacin were significantly less frequent than in VON. This difference was greatest in the two lowest BW groups, as was also the case with respiratory complications. In Trento, NEC was significantly less frequent than in VON. Moreover, even if all the IVHs were significantly less frequent in Trento than in VON, the analysis of IVH-grade did not show any difference. There were no significant differences in the incidence of PVL.Table 4 . The overall incidence of ROP was significantly lower in the S. Chiara intensive care unit, in all the BW sub-groups. No significant difference was evident in the incidence of severe grade of ROP.Table 5 and in BW sub-groups [Figure Overall mortality was comparable in the two populations . Furthermore, in Trento, significantly more infants were discharged on human milk than in VON, in both the overall population , and serving the entire population , S. Chiara data might be an important source of epidemiological information. Data recorded in S. Chiara were compared with the entire VON database (S. Chiara is part of this network), therefore comparing a small area (2000\u20132005) with a global group, represented by VON (2004). In this way, it is possible to critically evaluate therapeutic strategies used in S. Chiara, in a global management of a perinatal area.This analysis reports the complications and treatments in the S. Chiara hospital neonatal intensive care unit during 2000\u20132005. As the only intensive care centre in Trento . Moreoveet al, in which surfactant prophylaxis was associated with a lower incidence of RDS compared with rescue therapy [The use of prenatal steroids with the greater use of surfactant prophylaxis may be associated with the lower incidence of RDS reported in Trento. Effective management of this condition could reduce the risk of CLD, as suggested by the present analysis and by another study . Surfact therapy . It is n therapy .In Trento, the overall rates of PDA, NEC and IVH were lower than in VON, occasionally reaching statistical significance. As observed for respiratory complications, the difference was greatest in the lowest BW groups. Overall, these data are comparable with those reported in the Bevilacqua study . It may Even the lower risk of NEC in Trento compared with VON may be associated with specific therapeutic strategies of the S. Chiara intensive care unit, such as the very early administration of human milk . In fact, the percentage of discharged infants receiving human milk was significantly higher in Trento than in VON . Since 1993, the S. Chiara unit has employed the early exclusive enteral feeding (EEEF) protocol that is widely used in Scandinavian countries . This prAmerican Academy of Pediatrics and Canadian Pediatrics Society because of its excellent energetic properties and for its important effects on neural, cognitive and psychological development [p-value 0.00000) and in BW sub-groups were discharged on human milk, compared with VON.Several studies have confirmed the importance of VLBWI feeding with human milk. The high content of oligosaccharides in human milk may improve the development of immune system and prevent onset of NEC . The admelopment ,17. In pelopment . In TrenScreening for ROP was about 2.5 times more common in Trento than in VON. This strategy allows more rapid diagnosis of the potential presence of ROP. The frequency of this condition was lower in Trento than in VON. An early diagnosis of ROP is of particular importance to prevent the risk of short- and long-term damage to vision .Mortality was comparable in the two populations, although a trend towards lower mortality in Trento was evident, especially in infants with BW \u2264 750 grams. It is possible that the therapeutic strategies adopted in Trento, such as surfactant prophylaxis and widespread use of human milk, may be associated with a reduction in complications and, as a consequence, with a lower mortality in this high-risk class of VLBWI.The comparison between VLBWI data collected during 2000\u20132005 in the S. Chiara intensive care unit of Trento and those derived from the VON database shows that the frequency of the most important complications associated with intensive treatment was, in most cases, lower in the Trento area. This difference may be due, at least in part, to a greater use of prenatal steroids, to a less aggressive surfactant approach, based on prophylactic treatment instead of rescue therapy, and greater feeding with human milk using the EEEF protocol, which may be associated with better development and lower incidence of NEC and other complications. It is noteworthy that surfactant prophylaxis is associated with reduced need for ventilation assistance. Other factors, such as more extensive screening for ROP, might contribute to decrease time and cost associated with intensive care and to limit short- and long-term consequences. These differences are particularly evident in lower BW infants, which present a higher risk.In conclusion, this study suggests that a less aggressive therapeutic strategy, mostly based on prevention and on global management, may be associated with an improvement in clinical outcomes in preterm infants.The authors declare that they have no competing interests.GDN had primary responsibility for protocol development, patients enrollment, data analysis and writing the text. MB and RM were responsible for patients evaluation schedule and Oxford Data Base maintenance. FP, AP, and AV contributed to the protocol development and execution of the study.Table 1. Baseline data for the Trento and VON populations.Click here for fileTable 2. Prenatal data for the Trento and VON populations.Click here for fileTable 3. Incidence of respiratory complications and related treatments in Trento and VON.Click here for fileTable 4. Incidence of non-respiratory complications and indomethacin administration in Trento and VON.Click here for fileTable 5. Incidence of ROP and mortality in Trento and VON.Click here for file"} +{"text": "Cognition is a multidimensional construct and to our knowledge, no previous studies have examined the independent contribution of specific domains of cognition to health related quality of life. To determine whether executive functions are independently associated with health related quality of life assessed using Quality Adjusted Life Years (QALYs) calculated from the EuroQol EQ-5D (EQ-5D) in older women after adjusting for known covariates, including global cognition. Therefore, we conducted a secondary analysis of community-dwelling older women aged 65-75 years who participated in a 12-month randomized controlled trial of resistance training. We assessed global cognition using the Mini-Mental State Examination (MMSE) and executive functions using the: 1) Stroop Test; 2) Trail Making Test (Part B) and 3) Digits Verbal Span Backwards Test. We calculated QALYs from the EQ-5D administered at baseline, 6 months and 12 months.Our multivariate linear regression model demonstrated the specific executive processes of set shifting and working memory, as measured by Trail Making Test (Part B) and Digits Verbal Span Backward Test (p < 0.01) respectively, were independently associated with QALYs after accounting for age, comorbidities, general mobility, and global cognition. The final model explained 50% of the variation in QALYs.Our study highlights the specific executive processes of set shifting and working memory were independently associated with QALYs -- a measure of health related quality of life. Given that executive functions explain variability in QALYs, clinicians may need to consider assessing executive functions when measuring health related quality of life. Further, the EQ-5D may be used to track changes in health status over time and serve as a screening tool for clinicians.ClinicalTrials.gov Identifier: NCT00426881. Health related quality of life (HRQL) is an important construct that describes an individual's overall health status. It is commonly used in economic evaluations as a meaThe use of a generic, preference-based instrument is one method commonly used to assess HRQL . The EQ-HSUVs are used to calculate Quality Adjusted Life Years (QALYs) to account for the quality of life of a patient in a given health state and the time spent in that health state. Briefly, the QALY is a useful measure of health benefit because it simultaneously captures both quantity and quality gains or losses . A key bClinical measures that are associated with HRQL include cognition, physical disability and chronic conditions such as rheumatoid arthritis, sex, social functioning and physical activity . SpecifiCognition is a multidimensional construct and to our knowledge, no previous studies have examined the independent contribution of specific domains of cognition to HRQL. We hypothesize that executive functions may be of particular importance to HRQL. Executive functions are higher-order cognitive processes that control planning, initiation, sequencing and monitoring of complex goal directed behavior ,19. ThesThe total sample for this analysis consisted of 135 women who consented and completed a randomized controlled trial of exercise that aimed to examine the effect of once-weekly and twice-weekly resistance training on cognitive performance of executive functions. The design and the primary results of the Brain Power study have been reported elsewhere . BrieflyFunctional Comorbidity Index was calculated to estimate the degree of comorbidity associated with physical functioning . This scThe MMSE is a widely used and well-known questionnaire used to screen for cognitive impairment . It is sOur assessment of executive functions were composed of three tests that measure different aspects of executive functions: 1) TrailWe used the Trail Making Part B test to assess set shifting. Set shifting refers to an individuals ability to go back and forth between multiple tasks or mental sets . The tesWe used the Verbal Digits Backward test to assess working memory . WorkingThe Stroop Test, assessed response inhibition includinThe HSUV instrument we used was the EQ-5D. Major differences between the EQ-5D and other preference based measures were outlined previously . The EQ-The EQ-5D is a short five item generic HSUV instrument designed to assess HRQL . The EQ-We used the Timed Up and Go Test (TUG) to assess general mobility . ParticiWe analysed all data using STATA version 10.0. Our base case analysis included 135 women based on recommendations for multiple imputation of missing cost and HSUV data [We report descriptive data for all variables of interest. For data that are normally distributed we report mean and standard deviation and frequencies depending on the measure. For data that were significantly skewed, we report median and interquartile range. We used the Pearson product moment correlation coefficient to determine the level of association between QALYs and age, group, education, average waist girth, functional comorbidity index, general mobility, global cognition and executive functions.2) were kept in the model. Digits Backward was entered last into the model. We assessed the assumptions of normality of the residuals and heteroscedasticity.In our multiple linear regression model, age, group, education, average waist girth, functional comorbidity index, general mobility and global cognition were statistically controlled by forcing these six variables into the regression model first (Model 1). These independent variables were determined based on the results of the Pearson product moment coefficient analyses and assumed biological relevance, such as MMSE and waist girth were entered into the model regardless of the results of the correlation analyses. Each of the executive functions was then entered sequentially into the model. Those that significantly added to the model . The total variance accounted for by our final model was 50% . Digits Backward was also a significant predictor for HRQL based on the EQ-5D (p < 0.01) based on the results of the imputed data set . Adding the Trail Making Part B and the Digits Backward resulted in an R0% Table . The R2 Persons who experience cognitive decline have a reduced quality of life . To our We specifically found that, both set shifting and working memory, were independently associated HRQL, measured by QALYs calculated from the EQ-5D HSUVs. Our novel result extends previous findings that set shifting, as the Trail Making B Test, is associated with factors that may influence QALYs: 1) mobility ,39; 2); We acknowledge that executive functions are only one aspect of cognition and were the sole cognitive processes explored in the Brain POWER study . The BraOur finding of both set shifting and working memory contributing to health related quality of life concur and extend previous studies examining the association of cognitive function and instrumental activities of daily living. Instrumental activities of daily living include the ability to prepare a balanced meal, remember appointments, keep financial records and take medications as prescribed . Health Our findings for the Stroop test and health related quality of life differ from those of previous research . SpecifiThe lack of a significant association between global cognition and HRQL for our complete case analysis was contrary to the results of our imputed data set analysis. This difference likely was due to the smaller sample size of the complete case analysis. A previous study found a linear relationship between HRQL, assessed using the Assessment of Quality of Life instrument, and MMSE in individuals with Alzheimer's disease -- a finding similar to that of our imputed data set analysis . FurtherWe found that the TUG was mostWe note that our small study sample consisted only of older community dwelling women who were cognitively intact; therefore, we cannot say with certainty that these findings are generalizable to older women with mild cognitive impairment or dementia, older men, other age groups and adults who are not community-dwelling. Thus, our study highlights the need for future prospective studies to ascertain whether our present finding apply to other clinical populations and whether changes in executive functions, specifically the cognitive processes of set shifting and working memory are causally linked to changes in HRQL assessed using generic preference based HSUV instruments, such as the EQ-5D. Our findings indicate that EQ-5D HSUVs over time can be largely explained by baseline measures of age, waist girth, functional comorbidity index, general mobility, global cognition and the cognitive processes of set shifting and working memory. Given that set shifting and working memory explain a statistically significant amount of variability in QALYs, clinicians may need to consider assessing these cognitive processes in response to patients perceived health status .The authors declare that they have no competing interests.JCD was principal investigator for the evaluation of HRQL and healthcare resource use and, was responsible for design, data analysis, data interpretation, writing of manuscript. TLA was principal investigator for the Brain Power study and was responsible for study concept and design, acquisition of data, data analysis and data interpretation, and reviewing of the manuscript. CAM and MN were responsible for design, data interpretation and critical review of manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2318/10/16/prepub"} +{"text": "The objective was to explore the relationship between left ventricular ejection fraction (LVEF) assessed during hospitalization for acute myocardial infarction (MI) and later health-related quality of life (HRQoL).We used multivariable linear regression to assess the relationship between LVEF and HRQoL in 256 MI patients who responded to the Kansas City Cardiomyopathy Questionnaire (KCCQ), the EQ-5D Index, and the EuroQol Visual Analogue Scale (EQ-VAS) 2.5 years after the index MI.p <0.001) in the three groups, respectively. The corresponding EQ-5D Index scores were 0.83 (0.18), 0.72 (0.27), and 0.76 (0.14) (p = 0.005) and EQ-VAS scores were 72 (18), 65 (21), and 57 (20) (p = 0.001). In multivariable linear regression analysis age \u2265 70 years, known chronic obstructive pulmonary disease (COPD), subsequent MI, intermediate LVEF, and reduced LVEF were independent determinants for reduced KCCQ clinical summary score. Female sex, medication for angina pectoris at discharge, and intermediate LVEF were independent determinants for reduced EQ-5D Index score. Age \u2265 70 years, COPD, and reduced LVEF were associated with reduced EQ-VAS score.167 patients had normal LVEF (>50%), 56 intermediate (40%\u201350%), and 33 reduced (<40%). The mean (SD) KCCQ clinical summary scores were 85 (18), 75 (22), and 68 (21) (LVEF measured during hospitalization for MI was a determinant for HRQoL 2.5 years later. Left ventricular ejection fraction (LVEF) is the single most used non-invasive measure of cardiac function in clinical practice and is an important prognostic factor for survival after myocardial infarction (MI), in stable coronary artery disease (CAD), and in heart failure -3. HealtHowever, the relationship between LVEF and HRQoL has not been settled and whether LVEF can predict HRQoL is still controversial. Some studies have observed an association -11 whileAccordingly, our aim was to assess the relationship between LVEF measured during hospitalization for acute MI and HRQoL 2.5 years later in an unselected MI patient population, using both a generic and a disease-specific HRQoL measure.We established a cohort of hospitalized patients with a discharge diagnosis of acute MI, defined as codes I21 and I22 in ICD-10 . We wantIn 2002, we mailed a questionnaire to patients who were still alive according to hospital information systems and the National Population Register of Statistics Norway. The questionnaires were mailed from the hospital of discharge, along with a cover letter signed by the head of the hospital's cardiology unit. After 4 weeks, we sent a reminder to non-respondents.At the time of the survey, 191 of the 754 patients had died, 8 had an unknown address, and 7 were excluded for miscellaneous reasons. Hence, we mailed the questionnaire to the remaining 548 patients of whom 408 (74%) returned completed questionnaires. A total of 256 of the 408 respondents (63%) had data on LVEF in 129 (51%) patients and echocardiography in 127 (49%) patients. MUGA is a reliable reference method, and the widely used echocardiographic method correlates fairly well with radionuclide imaging ,20. LVEFThe questionnaire focused on HRQoL, using the EQ-5D Index, the EQ-5D Visual Analogue Scale (EQ-VAS), and the Kansas City Cardiomyopathy Questionnaire (KCCQ). In addition, we asked about subsequent cardiac events and revascularization procedures after hospital discharge for the index MI.The KCCQ is a self-administered 23-item questionnaire designed for measuring HRQoL in patients with chronic heart failure. It comprises six scales: Symptoms, Symptom stability, Physical limitation, Social limitation, Self-efficacy and Quality of life . Four ofThe EQ-5D is a self-administered HRQoL instrument with 5 items: Mobility, Self-care, Usual activities, Pain/discomfort, and Anxiety/depression. Each item is scored on a 3-point Likert scale: no problems (score of 1), moderate problems (2), and extreme problems (3). Responses to these items can be converted to a utility score, the EQ-5D Index, by applying an algorithm derived from time trade-off valuations of health status obtained from the general population . A scoret-test, analysis of variance, Kruskal-Wallis test for three independent groups, Wilcoxon rank-sum test, or chi-square test where appropriate.We present descriptive statistics with means and SDs, or proportions. For group comparisons, we used the r) between independent variables. However, none of the pairwise correlations had r > 0.70. Variables with p < 0.25 in bivariable linear regression analysis were included in multivariable modeling. In the multivariable models, we first included age at admission, sex, length of education in years, and LVEF in the models, and then added the other potential independent determinant variables in a forward stepwise fashion. In addition to age, sex, education, and LVEF, we retained all independent variables with p < 0.05 in multivavariable linear regression in the final model. The final models were checked for interactions.We used multiple linear regression analysis to identify determinants for KCCQ clinical summary score, EQ-5D Index, and EQ-VAS at a mean of 2.5 years after MI. To reduce problems with multicollinearity, we checked pairwise Pearson correlations (R-square) is a measure of explained variance in regression analysis. To determine the marginal contribution of LVEF to R-square, in KCCQ clinical summary score, EQ-5D Index score, and EQ-VAS, we compared the R-square in the final models adjusted for degrees of freedom, with R-square in the final models without LVEF.The coefficient of determination . The Regional Committee for Medical Research Ethics and the Norwegian Data Inspectorate approved the study.n = 408) were younger than non-respondents (n = 140), comprised a higher proportion of males, had less cardiovascular morbidity at admission, and fewer cardiovascular indications for medication at discharge. Respondents and non-respondents did not differ in the proportion of patients with ST-segment elevation at admission, Q-wave infarction, or localization of the index MI. Respondents who had their LVEF measured (n = 256) had higher LVEF than non-respondents who had their LVEF measured (n = 71) . A more extensive comparison of respondents and non-respondents has been presented elsewhere [Respondents (n = 256) during hospitalization for the index MI were younger than respondents who had not (n = 152), had less cardiovascular morbidity at admission, and a higher proportion were smokers. Further, a larger proportion of respondents who had their LVEF measured had ST-segment elevation MI, underwent acute revascularisation, and developed Q-wave MI, and a lower proportion had medication for angina pectoris at discharge the EQ-5D Index (p = 0.005), and the EQ-VAS (p = 0.001) Table .In multivariable linear regression analysis, age \u2265 70 years, a history of chronic obstructive pulmonary disease (COPD), subsequent MI, and intermediate or reduced LVEF measured during hospitalization were all independent determinants of lower KCCQ clinical summary score 2.5 years after the index MI Table . Female R-square was 0.16 for both KCCQ clinical summary score and EQ-5D Index, and 0.10 for the EQ-VAS . When applying our final multivariable models in this subset of patients, the relationship between LVEF and HRQoL was essentially the same as in all patients with measured LVEF. In this subset, using KCCQ clinical summary score as the dependent variable, the unstandardized regression coefficient (B) and 95% confidence interval (CI) for patients with intermediate LVEF and reduced LVEF were -10.4 (-21.0 to 0.3) (p = 0.06) and -13.6 (-26.9 to -0.4) (p = 0.04) respectively. With EQ-5D Index as dependent variable B and 95% CI were -0.13 (-0.25 to -0.02) (p = 0.02) and -0.02 (-0.16 to 0.12) (p = 0.7).One hospital measured LVEF routinely in all MI patients, using MUGA (In this study LVEF measured during hospitalization for the index MI was a determinant of HRQoL 2.5 years later, with poorer HRQoL in patients with reduced LVEF. This relationship persisted after adjusting for comorbidities, sociodemographic variables, and variables related to the index MI. The summary score of the condition-specific KCCQ questionnaire, which has been validated in an earlier study , and theR-square was small indicating that the amount of variation in HRQoL scores explained by LVEF was moderate. A moderate amount of variation in HRQoL score explained by a single clinical variable can be expected if Wilson and Cleary's model is valid, as other interrelated variables intervene between pathophysiology of the heart and quality of life [The observed falling HRQoL scores with falling LVEF both for KCCQ clinical summary score and EQ-VAS indicate that the level of systolic heart function is a determinant for HRQoL. However, some influence from the mere fact that an MI has occurred cannot be ruled out since also patients with normal LVEF tend to have reduced EQ-5D scores compared to US norms . If so, of life .Three previous studies have observed an association between LVEF and HRQoL in patients with CAD -10. HoweStudies that did not find an association between LVEF and later HRQoL also varied with regard to inclusion criteria and most of them reported on selective groups of patients and not on unselected acute MI patients as we did -16. One In our study on MI patients, age \u2265 70 years was associated with lower KCCQ clinical summary score. This contrasts with previous results on heart failure patients in which increased age independently correlated with higher KCCQ Quality of life scale score . One posWe identified sex as an independent determinant of EQ-5D Index score, but not of KCCQ clinical summary score. A difference in score between men and women who are otherwise comparable might be less likely when applying a disease specific instrument than a generic instrument which has a broader perspective. Thus, the EQ-5D Index US norms have reported a small difference between men and women with poorer score in women . Our obsOur study showed that the presence of COPD was associated with reduced HRQoL after MI. COPD and CAD share some causal risk factors, and might to some extent present with similar symptoms, for example dyspnoea. Therefore, it is not surprising that patients with COPD who suffer an MI are at increased risk of impaired HRQoL. Similarly, medication for angina pectoris was associated with reduced EQ-5D Index score, and presumably, the reason for this is the fact that such medication reflects enhanced disease severity. In our study the presence of peripheral vascular disease was associated with higher EQ-5D Index score. However, this finding is based on only 11 patients with peripheral vascular disease, and therefore should be interpreted with caution.Due to the rather long time from the MI to measuring of HRQoL in our study, the association between LVEF and HRQoL could have been distorted. Although the patients reported on intervening major cardiac events, such as new MI or coronary revascularization procedures, other major life events, worsening or improvement of illness not reported in our study, might have had an effect on current HRQoL. We addressed this issue by entering the time between the index MI and HRQoL assessment as a variable in the multivariable analyses. This factor was not, however, independently associated with HRQoL.In the context of study limitations the representativeness of the sample should be discussed. The eligible patients were representative of survivors of an unselected MI population. Three quarters of the patients responded to the survey, and LVEF was measured in two thirds of the respondents, thus we completed our analysis on approximately half of the eligible patients. This might have skewed the representativeness. However, results from a sub-group analysis of patients in one hospital in which all MI patients had their LVEF measured, were largely in line with the overall results, indicating that the main results pertains to unselected MI patients. Another limitation is the uncertainty of whether the clinicians categorizing the indications for drugs prescribed at discharge did assign the most important indication for each drug, as the protocol instructed. Cardiovascular drugs may have more than one indication for use, and we did not assess the reliability and validity of this classification. However, the classification was undertaken by experienced physicians, most of them cardiologists ensuring the best possible assessment.LVEF measured during hospitalization for acute MI is an independent determinant for later HRQoL also after taking sociodemographic and clinical variables into account. The magnitude of the difference in HRQoL score between patients with normal, intermediate, and reduced LVEF was of clinical importance. As expected, in accordance with theoretical models, only a moderate amount of the observed variation in HRQoL score was explained by the level of LVEF.Restoration of myocardial function after an MI is, in addition to being important for live expectancy, also crucial for long-term daily functioning after the event.CAD: coronary artery disease; COPD: chronic obstructive pulmonary disease; EQ-VAS: EuroQol Visual Analogue Scale; HRQoL: health-related quality of life; KCCQ: Kansas City Cardiomyopathy Questionnaire; LVEF: left ventricular ejection fraction; MI: myocardial infarction; MUGA: multiple gated-acquisition radionuclide ventriculography; NHP: Nottingham Health Profile.The authors declare that they have no competing interests. The work was performed at the Norwegian Knowledge Centre for the Health Services and at the Department of Pharmacotherapeutics, University of Oslo, Oslo, Norway. The project had no external funding or grants.KIP: Had the idea to the study, organized the data collection and data preparation, performed statistical analysis, drafted the first version of the manuscript, revised the manuscript and approved the final version. EK: Participated in data collection and data preparation, participated in discussion of study findings, revision of the manuscript and approved the final version. AR: Participated in discussion of study findings, revision of the manuscript and approved the final version.KS: Participated in study design, statistical analysis, manuscript preparation and revision, and approved the final version. AR: Participated in data collection, discussion of study findings, manuscript preparation and revision, and approved the final version.The pre-publication history for this paper can be accessed here:"} +{"text": "There is little information of the validity of generic instruments in measuring health-related quality of life (HRQOL) in patients with dyspepsia. We aimed to assess the reliability and validity of the EQ-5D, a brief and simple instrument, in measuring HRQOL in adult patients with dyspepsia.Consecutive adults with dyspepsia attending the Gastroenterology clinic in a tertiary referral center were interviewed with the EQ-5D , the short-form Nepean Dyspepsia Index (SF-NDI), the SF-36 and Leeds Dyspepsia Questionnaire (LDQ). Known-groups and convergent construct validity were investigated by testing hypotheses at attribute and overall levels. A repeat telephone interview was conducted 2 weeks later to assess test-retest reliability.A total of 113 patients (mean (SD) age: 53.7 (14) years; 49.5% male; 24.8% Malays, 37.2% Chinese; 70.8% functional dyspepsia) were recruited. Response rate was 100% with nil missing data. Known-groups validation revealed 20/26 hypotheses fulfillment. Patients with more severe dyspepsia reported more problems with their usual activity (p = 0.07) and pain (p = 0.06) and demonstrated lower median VAS scores and EQ-5D utility scores . Those reporting problems in various EQ-5D dimensions had significantly lower scores in relevant SF-36 and SF-NDI dimensions. The overall EQ-5D utility score also demonstrated good correlation with the SF-36 summary physical and mental scores and the SF-NDI total score. Intraclass correlation coefficient for test-retest reliability was 0.66 (95% CI = 0.55 \u2013 0.76).The EQ-5D is an acceptable, valid and reliable generic instrument for measuring HRQOL in adult patients with dyspepsia. Dyspepsia, a collection of upper gastrointestinal symptoms due to various causes, is a common problem worldwide . As mostHowever, disease-specific instruments for dyspepsia do not allow for comparisons with patients with illnesses other than dyspepsia and with healthy individuals in the general population. Generic HRQOL instruments are therefore valuable to supplement disease-specific instruments to enable such comparisons. The Short Form 36 Health Survey (SF-36) is one of the most widely accepted generic instruments for measuring HRQOL in many countries -9. It isTo compare HRQOL of dyspeptic patients with those of the general population, the generic instrument has to be shown to be valid and reliable in dyspepsia first. To our knowledge, the EQ-5D has not been validated for this purpose before and we therefore aimed to examine this in a group of Malaysian patients with dyspepsia attending regular follow up at a tertiary institution.Ethical approval was obtained by the University Malaya Medical Centre Ethics Committee prior to the commencement of this study. Consecutive adult outpatients with dyspepsia attending the Gastroenterology clinic of this tertiary teaching institution were invited to participate in the study. Most of these patients had functional or non-ulcer dyspepsia , with the remaining attending follow up for organic disease . Patients were interviewed by a trained research assistant using HRQOL and disease severity instruments validated for use in Malaysia (see below) in English or Malay . Additional information obtained included period of medical consultation and socio-economic-demographic status. Test-retest reliability of EQ-5D was evaluated by administering the EQ-5D twice to the same subjects, 2-weeks apart, and comparing the scores obtained on these two occasions. The second interview was conducted over the telephone by our trained research assistant.The EQ-5D comprises five questions on mobility, self-care, pain, usual activities and psychological status with three possible answers for each item [roblems) . An overroblems) and haveThe SF-36 is an established generic HRQOL instrument which comprises 36 questions and eight different sub-scores: physical functioning, physical role limitations, bodily pain, general health perceptions, vitality, social functioning, emotional role limitations, mental health and 2 composite scores \u2013 Physical Component (PCS) and Mental Component Scores (MCS) scored on a 0 to 100 scale [00 scale . The max00 scale .Short Form (SF) Nepean Dyspepsia Index is a disease-specific HRQOL instrument for dyspepsia, comprising a 10-item questionnaire examining the influence of dyspepsia on five elements of health in patients, namely tension/anxiety, interference with daily activities, disruption to regular eating/drinking, knowledge towards/control over disease symptoms and interference with work/study [The rk/study . Each itrk/study . A totalrk/study Leeds Dyspepsia Questionnaire (LDQ), is an eight item symptom-based questionnaire relating to the frequency and severity of various upper G.I. symptoms, namely upper abdominal pain/discomfort, heartburn, regurgitation, dysphagia, belching, nausea, vomiting and post-prandial distension/early satiety [The satiety . The tot satiety .Psychometric properties of the EQ-5D were evaluated by assessing its frequency of missing data, ceiling and floor effects , test-retest reliability and construct validity. The reliability of an instrument refers to its ability to yield reproducible and consistent results. Construct validity is an assessment of the degree to which an instrument measures the construct that it was designed to measure. The process involves forming hypothetical models to describe the constructs being assessed and postulating their relationship. An assessment of the relationship between the construct data is then made to confirm or refute prior expectations and hence determine the validity of the instrument being tested .Construct validity of the EQ-5D was assessed by testing 26 a-priori hypotheses related to item or utility scores as follows: a) patients with less favourable demography in relation to dyspepsia would report more problems with relevant EQ-5D dimensions, b) patients with more severe dyspeptic symptoms would have more problems with relevant EQ-5D dimensions and lower utility scores c) subjects reporting problems for any EQ-5D dimensions would have lower scores for relevant SF-36 and SF-NDI scales and d) utility scores for EQ-5D would correlate well with SF-36 and SF-NDI summary scores. Test-retest reliability of EQ-5D was evaluated by administering the EQ-5D twice to the same subjects, 2-weeks apart, and comparing the scores obtained on these two occasions. The first interview was conducted face-to-face and the second interview was conducted over the telephone, both by our trained research assistant.Hypothesized trends were tested using Chi-square or Mann-Whitney tests, or Spearmans' correlation coefficient where appropriate. Strong, moderate and weak correlations were defined as > 0.60, 0.30 \u2013 0.60 and < 0.30 respectively . Test-reA total of 113 consecutive patients with dyspepsia were interviewed between May and October 2006 and their characteristics and basic demography are summarized in Table The response rate was 100% with no missing data for all variables. The calculated utility score had a median value of 0.725 (skewness \u2013 1.78), with a range from as low as 0.077 to a maximum of 1.00 . The overall VAS had a median value of 70.0 (skewness \u2013 0.52), with a range from 20.0 to 95.0 patients participated in the follow-up telephone interview, which was conducted at a median of 16 days (range 13 \u2013 18) after the original interview. Intraclass correlation coefficient for the EQ-5D utility score was 0.66 .Twenty of the 26 hypotheses relating EQ-5D dimensions/summary scores to other variables were fulfilled. At the attribute level, problems with usual activity and pain were associated with worsening dyspeptic symptoms but these were not statistically significant. However, significantly lower values for the EQ-5D utility scores and VAS were demonstrated with severe dyspepsia Table . For exaThe brevity and simplicity of the EQ-5D makes it particularly attractive for use in large scale population surveys of dyspepsia. Furthermore, a single utility score summarizing all 5 dimension states in health can be used to calculate quality-adjusted life years (QALYs) for cost-utility analysis of interventions in dyspepsia, where most patients have functional disease with variable outcomes. However, before the EQ-5D can be utilized for dyspepsia in this manner, it has to demonstrate satisfactory psychometric properties in this condition. In this study of patients with dyspepsia from a variety of causes, from different ethnic backgrounds, of varying ages (from 17 \u2013 83 years) and with > 90% secondary education, the EQ-5D was found to be reliable and to have acceptable construct validity, suggesting that it could be a useful generic HRQOL measure for patients with dyspepsia.Reliability assessment of a HRQOL instrument consists of determining that a measurement yields consistent and reproducible results . We usedThe validity of the EQ-5D was demonstrated by the fulfillment of twenty of the 26 hypotheses based on known-groups construct validity. Hypothesized relationships for the remaining six hypotheses were present, but failed to reach statistical significance. For dyspepsia in particular, the total utility score and the dimension of \"pain\" were able to demonstrate poorer HRQOL outcomes in patients with more severe symptoms. As the EQ-5D derives information for each dimension of HRQOL from only one item, it is important that we demonstrate this to be sufficient by comparing it against a more detailed and established multi-dimension instrument. In this study, we demonstrated that patients reporting problems in all five dimensions of the EQ-5D had significantly lower scores in relevant dimensions of the SF-36. Furthermore, the overall EQ-5D utility score showed good correlation with the SF-36 physical and mental summary scores, further substantiating the validity of the EQ-5D.A possible limitation of many generic HRQOL instruments are that dimensions of health being measured tend to be more physical or mobility-based. In this context, published literature on the validity of the EQ-5D in specific diseases have mainly been shown for physically limiting illnesses such as Parkinson's disease , rheumatA limitation of this cross-sectional study was the inability to assess other properties of the EQ-5D in relation to dyspepsia, such as its' responsiveness. The latter requires a cohort study to examine the ability of an instrument to detect change in HRQOL status.We are able to conclude that the EQ-5D is an acceptable, valid and reliable generic instrument for measuring health-related HRQOL in adult patients with dyspepsia. Our data are consistent with other studies exploring the validity of the EQ-5D in various disease states ,9,19, alThe authors declare that they have no competing interests.SM and HLW designed the study, analysed and interpreted the data, and drafted the manuscript. KLG provided administrative support and contributed to data collection with SM. JT provided technical support and critical revision of the manuscript. All authors reviewed and approved final version of the manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-230X/9/20/prepubMedian scores and correlations of SF-36 (generic) and SF-NDI (disease-specific) dimensions with those of various EQ-5D domains. The data provided represents correlation analysis between HRQOL domains of the SF-36 and SF-NDI against the EQ-5D domains, whereby similarities in relevant domains of HRQOL are highlighted.Click here for file"} +{"text": "C. elegans and has also been found in MAR from a wide range of other eukaryotes. However the effectiveness of the MRS in specifically and sensitively identifying MAR remains unresolved.Matrix attachment regions (MAR) are the sites on genomic DNA that interact with the nuclear matrix. There is increasing evidence for the involvement of MAR in regulation of gene expression. The unsuitability of experimental detection of MAR for genome-wide analyses has led to the development of computational methods of detecting MAR. The MAR recognition signature (MRS) has been reported to be associated with a significant fraction of MAR in C. elegans genome. We find that MRS have a distinctive chromosomal distribution, in which they appear more frequently in the gene-rich chromosome centres than in arms. Comparison to distributions of MRS estimated from chromosomal sequences randomised using mono-, di- tri- and tetra-nucleotide frequency patterns showed that, while MRS are less common in real sequence than would be expected from nucleotide content alone, they are more frequent than would be predicted from short-range nucleotide structure. In comparison to the rest of the genome, MRS frequency was elevated in 5' and 3' UTRs, and striking peaks of average MRS frequency flanked C. elegans coding sequence (CDS). Genes associated with MRS were significantly enriched for receptor activity annotations, but not for expression level or other features.Using custom software, we have mapped the occurrence of MRS across the entire C. elegans we have shown that they have a distinctive distribution, particularly in relation to genes. Due to their association with untranslated regions, it is possible that MRS could have a post-transcriptional role in the control of gene expression. A role for MRS in nuclear scaffold attachment is not supported by these analyses.Through a genome-wide analysis of the distribution of MRS in As genome sequencing and annotation has progressed, it has become clear that even relatively compact eukaryotic genomes have large amounts of non-coding DNA. This DNA harbours elements that control genomic activity such as gene regulators, non-coding RNAs and less well characterised elements that position the chromosomes on the nuclear matrix. The nuclear matrix forms a three dimensional protein network onto which chromatin fibres are attached. Interaction between chromatin and the nuclear matrix is believed to occur at specific sites from 300 bp to several kb long, termed matrix attachment regions (MAR) .in trans. For example, active genes from different chromosomes have been shown to migrate through the nuclear space to converge on \"transcriptional factories\" [There is increasing evidence for the involvement of MAR in gene regulation. For example, expression levels of some genes alter depending on their position relative to the matrix . MAR havctories\" . Localisctories\" .Experimentally, MAR have been defined as either DNA fragments that remain bound to the nuclear matrix after chromatin proteins and other DNA have been removed, or DNA that binds to extracted nuclear matrix in the presence of competitor DNA ,11. The in silico, genome-wide mapping of MAR in Arabidopsis thaliana using SMARTest revealed that genes containing predicted MARs had low transcription levels [MAR-associated sequences for approximately 500 experimentally defined MAR are catalogued in the S/MAR transaction Database . The oven levels . SIDD idn levels . ChrClasn levels . The limn levels .A. thaliana [et al. mapped all the MRS and experimentally detected MAR on a single C. elegans genomic DNA segment, ~40 kb long. All MRS were located in six of the seven MAR sites. Further analysis of >300 kb of genomic sequence from 7 other eukaryotic organisms showed that MRS were present in 80% of MAR, leading van Drunen et al. to suggest that the MRS was a specific sequence element representative of a subset of MAR [The most complex motif associated with MAR sequences is the bipartite MAR recognition signature (MRS). The MRS was identified through analysis of MAR from three independent genomic regions of >30 kb in thaliana . To asset of MAR .et al. used the MRS to identify novel MAR in the human major histocompatibility complex class II region [Entamoeba histolytica and was found in MAR from Bombyx mori [et al. reported that MAR prediction based on MRS had a specificity of 41%, with 29 of 49 predictions lying outside experimentally defined MAR [Donev I region . The regbyx mori ,23. Howebyx mori . In theiined MAR . There iC. elegans in an attempt to determine the validity of the MRS. If MRS constitute a feature with real biological meaning their distribution would be expected to be non-random with respect to other genome features. We found that the MRS signature had a distinctive pattern of distribution along chromosomes, similar to that of genes. Further, we show that there is a marked increase in the frequency of MRS in the regions flanking C. elegans coding sequence (CDS).We have undertaken a genome-wide mapping and analysis of MRS in C.elegans genome.The MRS is a degenerate bipartite motif consisting of a 16 bp pattern, AWWRTAANNWWGNNNC , within which one mismatch is allowed, and an 8 bp pattern, AATAAYAA (where Y = C or T) . To be sC.elegans chromosomes at an average frequency of 249 per Mb, similar to the frequency of genes (228 per Mb). At small scales (<100 kb), the motif distribution was noisy , we estimated the number of MRS expected in the sequence due to nucleotide composition alone. Additional randomisation models were used in order to account for relationships between adjacent bases. The mononucleotide randomisation model generated sequence in which the frequency of each of the four nucleotides matched that observed in the chromosomal sequence. More complex first, second and third order Markov chain randomisation processes reflected the di-, tri- and tetra-nucleotide content of the chromosomal sequence. For each 2 Mb non-overlapping window used in Figure Figure C. elegans chromosome I. The number of MRS found in the whole chromosome under each mononucleotide randomisation regime, averaged over 1000 iterations, is shown in Figure One effect of randomising the genome sequence in relatively large sections of 2 Mb is that nucleotide content becomes more uniform across each section, eliminating, for example, local peaks of very high AT%. To identify the effects of local areas of extreme nucleotide composition, mononucleotide randomisation was applied to smaller sections of sequence to C. elegans genome is distinct from that found in random sequence. To investigate how this distribution is related to other genome features, the degree of overlap between MRS and different functional parts of the genome was assessed. The number of MRS occupying the same genome space as exons, introns, 3' untranslated regions (UTR), 5' UTR, genes and intergenic regions, is given in Table The above results show that the number and distribution of MRS in the The ratios of actual and expected MRS numbers showed large differences in MRS abundance in each of the genome features. MRS were particularly rare in exons, which contained less than half the MRS expected. As a result, the number of MRS in genes was also lower than expected, despite enrichment for MRS in introns and untranslated regions. Intergenic regions had slightly more MRS than expected. However, the 5' UTR and 3' UTR were by far the most MRS-enriched parts of the genome, by factors of 4.2 and 2.8 respectively. The relative enrichment of introns, 5' UTR and 3' UTR for MRS provides an explanation for the spatial relationship between genes and MRS described in Figure The MRS is AT rich and so is more likely to occur in AT rich sequence through the first 400 bp of the coding sequence (CDS) from each n Figure .As expected from the overlap of MRS with genes and intergenic regions reported in Table One explanation for the MRS spikes bounding CDS is that they are related to AT content of these areas. For example, in the case of 3' UTR the apparent over-representation of MRS was reduced when AT content was taken into account Table . PlottinAnother difference was that the AT content dropped to 58% in the first 50 bp of the CDS, then rose to about 62% for the middle part of the CDS. The pattern was similar at the end of the CDS, where the AT dropped to near 58% in the last 50\u2013100 bp. In both locations this AT dip was not matched by a dip in the MRS frequency. The variation in AT content in the vicinity of gene boundaries is an intriguing observation. A similar pattern was described previously by Zhang et al. but furtCaenorhabditis briggsae . However, the possibility that the C. briggsae gene set is systematically lacking upstream exons cannot be excluded.An analysis of the MRS frequency surrounding gene boundaries was also performed on a related nematode, e Figure . As in CC. briggsae than in C. elegans. Although C. briggsae lacked an upstream MRS peak, an increase in AT content from about 63% to 66% was evident in the 50 bp immediately preceding the CDS start. In common with C. elegans, the downstream AT peak occurred 50 bp before the MRS peak and the AT dip at the start and end of the CDS was not matched by a dip in MRS frequency.The difference between MRS frequency and AT content is even more marked in C. elegans and C. briggsae CDS could be due to conservation of MRS in specific genes, or simply a reflection of a general tendency. To investigate this, the occurrence of MRS within 200 bp of the CDS stop codon in C. elegans genes was compared to MRS occurrence in the same region of the corresponding C. briggsae ortholog . Therefore, the peak of average MRS frequency at the downstream end of C. elegans and C. briggsae CDS was due partly to apparent conservation of MRS in specific genes.The distinctive increase in MRS frequency at the downstream end of both cis regulatory function then the presence of an MRS near a gene may be associated with a particular functional group of genes. This possibility was examined by identifying the set of C. elegans genes with an MRS within 200 bp of the CDS stop codon, and searching for over-represented Gene Ontology (GO) terms within this set. The top most over-represented GO slim terms are shown in Figure If the MRS is related to a C. elegans, we have shown these sites to have a specific distribution, particularly in relation to genes. These observations support the validity of the MRS as a real genomic feature, though not necessarily indicative of MAR, and may also provide an insight to specific roles for MRS.In describing and analysing MRS frequency in the genome of C. elegans genome is not simply a product of small- or large-scale base-compositional biases. MRS frequency in some classes of genomic regions was elevated compared to the surrounding sequence. Coincidence of MRS and genes was apparent from their similar chromosomal distributions and position in operons, but no significant associations were obtained. The presence of MRS in C. elegans 5' and 3' UTRs suggest that they may be transcribed and therefore also have a role in mRNA stability or translational control. The MRS is therefore an element that is perhaps of limited value in predicting MAR, but serves as a clear marker of some CDS boundaries.Although C. elegans. Two distinct patterns of MRS frequency were identified. MRS were less frequent that would be predicted by nucleotide content but more frequent than predicted by di-, tri and tetra-nucleotide pattern. In comparison to the rest of the genome, there were striking peaks of average MRS frequency flanking C. elegans CDS. Although C. briggsae surprisingly lacked a peak in average MRS frequency upstream of CDS, C. briggsae orthologs showed conservation of MRS in the region immediately downstream of the CDS. The results presented here reveal the MRS to have a non-random genomic distribution, with particularly close association with genes. The results further suggest that, rather than acting as a marker for MAR, the MRS is an indicator of CDS, and may have role in control of gene expression.We have carried out a genome-wide analysis of the distribution of MRS in et al. [The identification of MRS on a genome-wide scale was automated through the use of a custom perl program, MRSfinder. Using the description of the MRS given by van Drunen et al. , MRSfindet al. .C. elegans genome was downloaded from the WormBase ftp site [Version WS150 of the ftp site . The assftp site and addiftp site .C. briggsae genome was downloaded from WormBase ftp site [Version cb25 of the ftp site . This veftp site .Each chromosome was divided into consecutive, non-overlapping 2 Mb windows, with the first window starting at chromosome base position 1. Where the final window did not contain 2 Mb, the counts for that window were scaled proportionally. For each window, the number of MRS (from MRSfinder) and gene start positions (from WormBase) were assessed. Where a gene was annotated as having more than one transcript or gene model, one transcript and model was randomly selected.For randomisation of sequences >= 32,000 bp, a roulette wheel selection algorithm was used where a nucleotide's chance of selection was based on its frequency in the original sequence. Due to the stochastic nature of this randomisation method the nucleotide frequency was verified to ensure it fell within 0.2% of that found in the original sequence. For sequences <32,000 bp, the sequence was randomised using a Fisher-Yates shuffle. Each sequence was randomised 1000 times. Each chromosomal sequence was split into consecutive, non-overlapping windows of the appropriate length with correction for shorter end windows as above. Following randomisation, MRSfinder was used to identify all the MRS in the randomised sequence. The mean and standard deviation of the MRS counts for each randomised version of the sequence were calculated.First, second and third order Markov chain processes were used to randomise the genome sequence following the algorithm of Workman and Krogh . In a fiC. elegans chromosome. Intergenic regions were defined as all sections of DNA not annotated as belonging to a gene. Where two or more incidents of a single feature type overlap, they were joined to form a single incident of that feature. The genomic coordinates of each feature were used to identify MRS that lay wholly within and partially overlapping a unit of that feature.Genes, introns, exons, 3' UTR and 5' UTR were identified based on the GFF file for the appropriate The number of MRS expected to lie wholly within each feature type (i.e. complete overlap) was calculated using the formula:The expected number of MRS expected to partially overlap a feature:When the average size of the MRS exceeds that of the feature, a complete overlap is defined as a feature lying wholly within an MRS. The expected number was calculated using the formula:The expected number of partial overlaps when the average size of the MRS exceeds that of the feature:where M = number of MRS, F = number features of specific type, f = average length of feature, m = average length of MRS, w = minimum number of nucleotides required for a partial overlap and c = chromosome length.Three different scoring methods were used to combine the number of partial and complete overlaps to give an overall score. In method 1 complete overlaps = 1 point, partial overlaps = 0 points, method 2 complete overlaps = 1 point, partial overlaps = 1 point method 3 complete overlaps = 1 point, partial overlaps = 1/2 point. In all scoring methods, the minimum number of nucleotides required for a partial overlap was 12. An AT content correction factor was calculated based on the ratio of the number of MRS found in random sequence with the same AT content as each feature to the number of MRS found in random sequence with the same AT content as the genome. The number of MRS found in random sequence of specific AT content is shown in Additional File C. elegans CDS originally identified, 20,032 passed these filters. The 19528 C. briggsae CDS were reduced to 12954 after filtering. Each successfully filtered CDS was then split into consecutive, non-overlapping 50 bp windows, starting 1000 bp upstream of the CDS start site and continuing to 1000 bp downstream of the CDS stop site. The total number of MRS mid-points occurring in each window across all CDS was divided by the number of CDS used to produce a frequency of MRS occurrence in that window.In this analysis, one CDS per gene was used: where a gene was annotated with multiple transcripts and/or gene models, a single transcript/model was randomly selected to represent the gene. The CDS were then subjected to quality filters to remove poor quality sequence (containing Ns), CDS with insufficient sequence upstream or downstream and CDS that did not start with ATG or end with a stop codon. Of the 20,052 CDS were selected, filtered and split into consecutive, non-overlapping 50 and 10 bp windows as described above. For each window the AT content was calculated as a percentage of the window length. The mean AT% for each position across all CDS was calculated.C. briggsae genome sequence and annotated orthologs to C. elegans were downloaded from WormBase. After subjecting the 11,953 orthologs to filtering for length , poor quality (sequence containing Ns), and CDS not starting with ATG or ending in a stop codon, 4132 genes remained. MRSfinder was used to detect MRS within 200 bp of the CDS stop for each of these filtered genes in C. elegans and C. briggsae. To test for association between a C. elegans gene having an MRS and the C. briggsae ortholog having an MRS we calculated the log odds ratio (a \u00d7 d)/(b \u00d7 c) where a is the number of orthologs with an MRS within 200 bp of the CDS stop codon in C. elegans and C. briggsae, b is the number of orthologs where an MRS is only found within 200 bp of the CDS stop codon in C. briggsae, c is the number of orthologs where an MRS is only found within 200 bp of the CDS stop codon in C. elegans and d is the number of orthologs where neither organism has an MRS within 200 bp of the CDS stop codon.The cb25 version of the C. elegans genes with an MRS within 200 bp of the CDS stop codon was analysed to identify over or under-represented Gene Ontology (GO terms). The Gene Ontology annotation file for C. elegans was downloaded from the Gene Ontology website [et al. [C. elegans genes. The Perl script map2slim and version 1.2 of the generic GO slim ontology /(b \u00d7 c) was calculated, where a is the number of genes in the MRS set associated with the term, b is the number of genes in the reference set associated with the term, c is the number of genes in the MRS set not associated with the term and d is the number of genes in the reference set not associated with the term. To account for multiple testing, the Benjamini and Hochberg method was used to calculate a p value threshold for a 5% false discovery rate [A set of website . Followi [et al. , only GO website ) were usery rate .AA carried out the analyses and wrote the manuscript. MB assisted with the analyses and writing the manuscript and supervised the project. Both authors read and approved the manuscript.C.elegans chromosomes at window sizes of 100 kb and 500 kb. Number of gene (black) and MRS (red) start positions in non-overlapping 100 kb and 500 kb windows. To account for short sequence length in the end window, the number of genes and MRS in the last window was scaled.Distribution of genes and MRS in Click here for fileCorrelation between MRS frequency and distance to centre of chromosome. Each 2 Mb chromosome window was given a number based on its distance from the centre of the chromosome. The windows at the far ends chromosome were assigned 1, the next windows towards the chromosome centre were assigned 2 and so on until all windows had been assigned a number. The correlation between the MRS frequency in each window and its number was then calculated using Pearson's r correlation coefficient.Click here for fileMRS in second order Markov chain randomised chromosome I, II, III, IV, V and X. The chromosomes were randomised in non-overlapping 2 Mb windows using a second order Markov chain process. The average number of MRS over 1000 randomisations (+/- one standard deviation) in the 2 Mb windows (black) is compared with the number of MRS in real sequence (red).Click here for fileNumber of MRS in random sequence of defined AT content. The number of MRS in 2 Mb of random sequence with AT content ranging from 90% to 50% was calculated. Random sequence for each AT value was generated 1000 times, error bars show +/- 1 standard deviation.Click here for file"} +{"text": "Background. Autoimmune process and immunosuppressive therapy of pemphigus vulgaris would predispose the patients to infections. Aim. We aimed to study the prevalence of infection and pathogenic agents in pemphigus vulgaris patients admitted to dermatology service. Material and methods. This retrospective study was conducted on 155 pemphigus vulgaris patients admitted to dermatology service between 2009 and 2011. In this study, the diagnosis of pemphigus vulgaris was confirmed by light microscopic and direct immunofluorescence findings. Data were collected through a questionnaire. Results. Of 155\u2009pemphigus vulgaris patients, 33 had infection at admission and 9 acquired nosocomial infection. In addition, 37\u2009cases of oral candidiasis and 15\u2009cases of localized herpes simplex were recorded. Totally, 94\u2009cases of infection were recorded. The occurrence of infection was significantly related to the severity of disease, number of hospital admissions, and presence of diabetes mellitus. The most common pathogenic germs isolated from cultures were Staphylococcus aureus and Escherichia coli. Conclusion. Severity of pemphigus vulgaris and diabetes were directly related with tendency to infections. Staphylococcus aureus and Escherichia coli were the most common pathogenic agents. Due to limitations of retrospective study, a prospective study is recommended. Pemphigus vulgaris (PV) and pemphigus foliaceus (PF) are organ-specific autoimmune bullous diseases characterized by loss of cell adhesion (acantholysis) and blister formation , 2. ThesThere are many reports regarding predisposition to infections due to immunosuppressive therapy and the immunocompromised state of pemphigus patients , 7.PV has a high prevalence in Iran; in this regard, we have studied this autoimmune disease from many different points of view \u201310. The This retrospective study was performed on 155 PV patients admitted to the dermatology service of Razi Hospital of Tehran in Iran, between 2009 and 2011. The mean age of patients was 41.66 \u00b1 13.29 years (range: 14\u201370). Of 155 admitted PV patients, 104 patients (67.10%) were first admitted and the 51 remaining patients (32.90%) had multiple admissions.Patients with a clinical diagnosis of PV with compatible histopathology and direct immune fluorescence (DIF) findings confirming the clinical diagnosis of PV entered the study. Light microscopic and direct immunofluorescence findings in favor of pemphigus vulgaris were suprabasal bullae and acantholysis and IgG and C3 depositions in the intercellular regions of epidermis, respectively. The severity of PV was evaluated by a \u201cseverity index for pemphigus,\u201d namely, mild, moderate, and severe . All of 3/microliter or less) who were not suitable for azathioprine adjuvant therapy were treated with 2\u2009mg/kg/day prednisolone alone. 117 patients with mild, moderate, and severe disease were treated with 2\u2009mg/kg/day prednisolone and 2.5\u2009mg/kg/day azathioprine. Twenty PV patients with moderate and severe disease with upper limit of the normal range of liver function tests who were not suitable for azathioprine adjuvant therapy were treated with 2\u2009mg/kg/day prednisolone and 2\u2009g/day (4 \u00d7 500\u2009mg/day tablet) mycophenolate mofetil [Regardless of the severity of pemphigus, the patients were treated with 2\u2009mg/kg/day prednisolone and 2.5\u2009mg/kg/day azathioprine . In this mofetil .The phenotype of PV recorded in order of frequency was mucocutaneous in 104 (67.10%), cutaneous in 30 (19.35%), and mucosal phenotype in 21 patients (13.55%).Demographic data including age, gender, number of admissions, severity of the disease, underlying medical disorders such as history of diabetes and hypertension, treatment protocols, and infections recognized during the admission period were registered in the appropriate questionnaires. The ethical committee of Tehran University of Medical Sciences approved the study.t-test were used for data analysis. P value less than 0.05 was assigned as statistically significant.Data were collected by questionnaire and analyzed by statistical software, SPSS. Chi-square test and Student's In total 94 cases of infections were recorded . Fifty tExcluding oral candidiasis and herpes infections, with regard to the rate of infection in men and women (20/68 versus 22/87), there was no statistically difference between the two genders.P < 0.001) had infections; while from the 51 patients with multiple admissions to hospital, 23 (45.10%) had infections (< 0.001) .With regard to 42 patients with pulmonary, bacterial skin, and urinary infections, 33 patients had infections at admission (day 0 to 2), while 9 patients were infected from day 3 and thereafter. Namely, these 9 patients had hospital-acquired infection . P = 0.011).Severity of the disease is shown in With regard to 42 patients with pulmonary, bacterial skin, and urinary infections, 16 patients had skin infection, 13 patients had urinary infections, and 13 patients had pulmonary infections . The resP = 0.151).P = 0.044).Of 155 patients, 14 patients were diabetic. The rate of infection in diabetic versus nondiabetic PV patients was 50% and 24.82%, respectively . The mean dose of prednisolone at the time of nosocomial infection onset was 55.8 \u00b1 17.9\u2009mg/day.No mortality was recorded in this study.PV is a well-known autoimmune disease . NowadayOur search in the literature revealed some similar studies performed in other countries . In our The study of Ljubojevi\u0107 et al. on 159 PV patients during 19 years revealed several complications associated with high doses of corticosteroids and immunosuppressive therapy . These cIn our study, the occurrence of infection had a direct relationship with disease severity, and the difference between mild and severe was significant. In Ljubojevi\u0107 et al.'s study, severe cutaneous and mucosal involvement was also consistent with a higher mortality rate .Mourellou et al. followed 48 patients for 11 years; they concluded that complications and mortality rate of PV were related to the severity of PV. Our study is consistent with the study by Mourellou et al. .P = 0.044). Belgnaoui et al. also reported more severe bacterial infection in diabetics PV patients [In the current study, the rate of infection in PV patients with diabetes was significantly higher than in nondiabetics are prone to infections. It should be noted that we did not include the PV patients treated with rituximab (which may be a susceptibility factor for infection). Kim et al. found that there was no difference in prednisolone alone or prednisolone plus adjuvant with regard to prognosis and time to remission in PV patients .Staphylococcus aureus. In other studies in PV patients, skin infections due to Staphylococcus aureus have been reported as well [Staphylococcus aureus [Most bacterial skin infections detected in our patients were due to as well . In the s aureus .Escherichia coli was the most frequent cause of urinary tract infection in our study. Obviously, Escherichia coli is the most common cause of urinary tract infections in the general population [pulation .In the current study, 9.68% of patients had localized herpes simplex infection, while in the study of Belgnaoui et al. 17% of patients had localized herpes infection , 24. AltIn the current study, 23.87% of patients had oral candidiasis, while in the study of Belgnaoui et al. 30% of patients had oral candidiasis . With reInfection rate had a positive significant relationship with the number of admission sessions. Patients with multiple admission sessions had a rate of infection approximately two times more than patients admitted for first time. Logically, patients with a more severe disease would have more admissions, and consequently the rate of infections would increase.Retrospective nature and relatively short period of the study (2 years) are major limitations of this project. Another limitation of the study is PV patients on different immunosuppressive adjuvant therapy included in this study. A prospective study with followup is recommended.We concluded that PV patients with multiple admission sessions, diabetes mellitus, and severe disease are at higher risk of infection. According to a high rate of antimicrobial resistance, antibiograms are recommended for antibiotics therapy."} +{"text": "Interest in cellulose degrading enzymes has increased in recent years due to the expansion of the cellulosic biofuel industry. The rumen is a highly adapted environment for the degradation of cellulose and a promising source of enzymes for industrial use. To identify cellulase enzymes that may be of such use we have undertaken a functional metagenomic screen to identify cellulase enzymes from the bacterial community in the rumen of a grass-hay fed dairy cow.Cel14b22, was expressed at a high level in Escherichia coli and purified for further characterization. The purified recombinant enzyme showed optimal activity at pH 6.0 and 50\u00b0C. It was stable over a broad pH range, from pH 4.0 to 10.0. The activity was significantly enhanced by Mn2+ and dramatically reduced by Fe3+ or Cu2+. The enzyme hydrolyzed a wide range of beta-1,3-, and beta-1,4-linked polysaccharides, with varying activities. Activities toward microcrystalline cellulose and filter paper were relatively high, while the highest activity was toward Oat Gum.Twenty five clones specifying cellulose activity were identified. Subcloning and sequence analysis of a subset of these hydrolase-positive clones identified 10 endoglucanase genes. Preliminary characterization of the encoded cellulases was carried out using crude extracts of each of the subclones. Zymogram analysis using carboxymethylcellulose as a substrate showed a single positive band for each subclone, confirming that only one functional cellulase gene was present in each. One cellulase gene, designated The present study shows that a functional metagenomic approach can be used to isolate previously uncharacterized cellulases from the rumen environment. Cellulose is a principal component of plant cell walls. Efficient cellulose hydrolysis requires the synergistic activity of three classes of cellulase: endo-1,4-\u03b2-glucanase EC3.2.1.4), cellobiohydrolase (EC3.2.1.91) and \u03b2-glucosidase (EC3.2.1.21). In recent years, interest in plant cell-wall-degrading enzymes, including cellulases, has increased due to the numerous potential industrial applications of these enzymes[.1.4, celCellulases are produced by a variety of organisms, including archaea, prokaryotes, fungi, plants, and animals. The most effective known natural systems for rapid biomass conversion, however, involve complex communities of microorganisms, primarily prokaryotes and fungi, maintained in a symbiotic relationship with an animal host. This apPerhaps one of the best characterized examples of an effective complex biomass degrading community is that harboured within the rumen. The natMetagenomic approaches have been widely used to isolate novel biocatalysts from environmental samples. SeveralA metagenomic BAC library of ~6000 clones was constructed with high molecular weight DNA isolated by a freeze grinding technique from dairy cow rumen samples. Screening for hydrolase activities resulted in the identification of ten independent clones expressing carboxymethyl cellulase (CMCase) activities, nine expressing \u03b2-glucosidase activities and seven expressing hydrolase activities for other substrates were isolated Table.The total library encompassed an estimated 900 Mb of insertion DNA. The positive rate of hydrolase activity in the library was approximately 0.15% of examined clones, or one expressed hydrolase gene per 10 Mb of insert DNA. Subcloning and sequence analysis of a subset of these hydrolase-positive clones identified twenty endoglucanase genes family 5 catalytic domain and a signal peptide. The C6c02 contained a CBM_II, but Cel14b22 contained a C-terminal module with no significant homology to known CBMs. Unfortunately, despite our best efforts the overexpressed product of C6c02 was insoluble and could not be purified. SDS-PAGE analysis of the crude extract of Cel14b22 showed expression of 6xHis tagged proteins, as observed by the appearance of an extra protein band migrating at about 63 kDa upon induction , whereas SDS completely abolished the activity of Cel14b22 . The high number of hydrolytic clones is consistent with the adaptation of the rumen microbial community for the digestion of plant cell-wall material in the rumen,17. Howesequence.The recombinant enzyme Cel14b22 was over-expressed and purified. It comprises an N-terminal signal peptide (amino acids 1\u201319), a catalytic module belonging to the glycoside hydrolase family 5 (amino acids 40\u2013339), and a C-terminal module with no known functional homologue. The conserved catalytic residues were identified by homology to other GH5 family members as the Glu 178 and Glu 289 residues. As with the two catalytic residues, the other six well-established conserved residues in the GH5 family were also verified in the Cel14b22 sequence: Arg 83, His 125, Asn 177, His 253, Tyr 255 and Trp 331. Studies suggested that these eight residues are conserved in all GH5 family enzymes,22.Prevotella ruminicola 23 , uncultured ruminal microbial cellulases ACA61137 (aa 334\u2013546) and ACA61140 (aa 334-537aa), and uncultured ruminal bifunctional/cellulase enzymes ABB46200 (aa 715\u2013917) and ADA62505 (aa 721\u2013919) showed that nine aromatic amino acid residues were conserved in the sequences showed no significant homology to known CBMs, but it shared 28% identity with the C-terminal module of another GH5 cellulase, ACA61140. This GH5 family cellulase, from another uncultured ruminal microorganism, also shows no significant homology to known CBMs. Almost M EDTA, suggesting that Cel14b22 does not absolutely require divalent cations to degrade CMC. Furthermore, addition of 10 mm Ca2+ or Co2+ to the incubation buffer did not alter Cel14b22 activity. This is the case for the majority of glycoside hydrolases from family 5, whereas these cations seem to stimulate several family 9 glycoside hydrolases[2+ did enhance enzyme activity, which is consistent with most cellulases[3+, Cu2+, Zn3+, exert an inhibitory effect on family 5 glycoside hydrolases[3+, Cu2+ and Fe3+. The activity of Cel14b22 was significantly higher toward mixed-linkage \u03b2-glucans from barley and oats than toward -\u03b2-glucans, including CMC. Activity was also lower toward the mixed-linkage \u03b2-glucan lichenan, perhaps due to the higher proportion of \u03b2--linkages in this polysaccharide. The Cel14b22 product could also hydrolyse birchwood xylan and oat-spelt xylan, but had limited activity toward microcrystalline cellulose and filter paper, which are largely resistant to hydrolysis by many of the previously characterized GH 5 glucanases[Cel14b22 shares physico-chemical properties with many other family 5 endoglucanases. Several cellulases from fungi and bactdrolases,30. The llulases-33. It idrolases, especiaucanases includinucanases. The broucanases-41. Althucanases, its enzOur study confirmed the utility of a freeze grinding method for the isolation from a complex microbial community of high molecular weight metagenomic DNA for use in the construction of BAC libraries. Such libraries allow functional screening for the isolation of novel hydrolytic enzymes and facilitate the analysis of gene clusters containing functionally related genes that may or may not be expressed in the heterologous host. In addition we identified and characterized a novel family 5 glycoside hydrolase with significant activity towards a variety of \u03b2-1,4- and \u03b2- glucans, including microcrystalline and filter paper celluloses, and \u03b2-1,4-xylans.Rumen contents (mixed solids and liquid) were sampled from a rumen cannulated dairy cow maintained on a grass/hay diet. The samples (~15 g) were centrifuged , and the pellet suspended in 30 mL of 100 mM Tris\u2013HCl pH 8.0, 500 mM EDTA pH 8.0, 1.5 M NaCl, 1 mg/mL Proteinase K and rapidly frozen in liquid nitrogen. Frozen samples were pulverized in a Retsch RM 100 Mortar Grinder and ground in the presence of liquid nitrogen for 5 min. Following grinding, samples were incubated in a water bath at 50\u00b0C for 40 min, combined with 3 mL 2% SDS and incubated at 65\u00b0C for another 45 min. The lysate was centrifuged at 19 200 \u00d7 g for 10 min at room temperature to pellet debris and the supernatant was combined 1:1 (v/v) with warm (65\u00b0C) 2% agarose (w/v in distilled water) by gentle inversion. This mixture was poured into 90 mm square petri plates to a depth of 5\u20136 mm thickness and allowed to solidify at room temperature. The agarose containing the embedded DNA was then cut into 5 mm strips and the strips were equilibrated 3 times over 24 h against 30 volumes of TE buffer and stored at 4\u00b0C. Low molecular weight DNA (< 25Kb) was removed by a single fractionation by field inversion gel electrophoresis in 1% agarose and 0.5\u00d7 TBE using a Hoefer PC750 pulse controller set at 3 s forward, 1 s reverse with a 0.5\u00d7/h increasing time ramp, run at 4 V.cm-1 for 16 h at 4\u00b0C. Fragments of DNA larger than 50 Kb were concentrated by electrophoresis at a constant 4 V/cm onto a piece of 6 000\u20138 000 Da cutoff dialysis membrane secured in the gel at the 50 Kb point. After sufficient time to move all DNA to the membrane the field was reversed and the DNA run back off the membrane into the gel a distance of 2 mm. The 3 mm strip of agarose containing the concentrated high molecular weight (50 to ~ 500Kb) DNA was removed and stored in sterile TE buffer at 4\u00b0C.Sau3AI (New England BioLabs) was added at a concentration of 0.01U/\u03bcL of agarose. The mixture was incubated at 37\u00b0C for 10 min and digestion stopped by the addition of EDTA to a final concentration of 20 mM, producing a limited partial Sau3AI digest. The partially Sau3AI-digested DNA was then further sized as described above to remove fragments less than 50 kb before being used for ligation.Agarose containing 50\u2013500 Kb rumen metagenomic DNA was equilibrated three times for 30 min in 1 \u00d7 New England BioLabs buffer 1, 1 \u00d7 Bovine Serum Albumin . The agarose was then melted at 65\u00b0C for 5 min, cooled to 37\u00b0C, and 2PO4, 0.67 g K2HPO4, 0.05 g sodium citrate, 0.09 g (NH4)2SO4, 4.4 mL glycerol, 20 \u03bcL 5 N NaOH, per 100 mL water). After autoclaving sterile Mg SO4 was added to a final concentration of 0.4 mM containing 12.5 \u03bcg/mL chloramphenicol and clones were cultured overnight at 37\u00b0C before storing at \u221280\u00b0C.Agarose containing partially digested and sized metagenomic DNA was equilibrated 3 times over 24 h in 10 volumes of TE. A portion was melted, diluted two-fold and used to determine DNA concentration using a NanoDrop3300 fluorospectrometer . Metagenomic DNA (25\u201350 ng) in no more than 12.5 \u03bcL of agarose was used in ligation reactions set up according to the manufacturer\u2019s directions using 25 ng pSMART BAC vector in a final volume of 50 \u03bcL. Ligation reactions (1 \u03bcL) were transformed into 20 \u03bcL of BAC-Optimized Replicator v2.0 Electrocompetent Cells (Lucigen Corporation) in a 1 mm gap cuvette using a BTX ECM 600 set with a resistance of 129 ohms and charging voltage of 1.2 kV. Positive transformants were selected on YT agar containing 5% sucrose and 12.5 \u03bcg/mL chloramphenicol. Positive clones were picked using a Genetix QPix into 384 well plates containing Luria-Bertani (LB) freezing medium and Glimmer[http://www.ncbi.nlm.nih.gov) and genome comparisons were made using IMG and IMG/M[http://smart.embl-heidelberg.de). The nucleotide sequence of the cellulase gene (Cel14b22) was deposited into the GenBank database under accession number JN98181.BAC clones expressing positive cellulase activities were selected for shotgun 454 sequencing . Sequence data was assembled using Mira3 after vend IMG/M. The modSau3AI. Fragments between 2 and 8 kb were extracted from agarose gel with a QIAquick Gel Extraction Kit according to the manufacturer directions and subcloned into BamHI digested, calf intestinal phosphatase dephosphorylated plasmid vector pUC19 . The resulting transformants were screened for cellulase activity as described above. Ten subclones expressing different CMC hydrolases (CMCases) were identified and grown in 200-mL cultures overnight. The cells were harvested by centrifugation , resuspended in 4 mL of 0.1 M sodium-phosphate buffer (pH 6.5) and lysed by sonication. Crude cell lysates were centrifuged at 10 000 \u00d7 g for 20\u201330 min at 4\u00b0C to remove cellular debris and supernatants were used as crude protein extracts for subsequent assays. pH profiles for individual subclones was determined at 40\u00b0C by monitoring enzyme activity over a range of pHs . Optimal activity over a temperature range of 25\u00b0C to 75\u00b0C was also determined. To analyse substrate specificities, the hydrolase activity of the protein extracts was measured after 30 min incubation at the optimal temperature in the optimal buffer containing 1% (w/v) polysaccharides. The tested polysaccharides were CMC, Avicel, lichenan, barley glucan, methyl cellulose, oat spelt xylan, birch wood xylan, oat gum, and filter paper. Reducing sugars released from the substrates were measured with 3,5-dinitrosalicylic acid as described by Miller[Subcloning was performed to localize the hydrolase genes, to shorten the inserts for effective sequencing, and to increase expression levels for biochemical characterization. Extracted BAC DNA was obtained from hydrolase-positive clones using a large and partial digest with y Miller. One uniSodium dodecyl sulfate polyacrylamide gel electrophoresis (SDS-PAGE) was performed according to the method of Laemmli. Native Cel14b22, was amplified by polymerase chain reaction (PCR) with the primers 5' GGAAGATCTTATGAAGAAAATTCTACT -3' (forward) and 5'- CCGGAATTCTTATTTCATAACGTATT -3' (reverse). PCR product was digested with BglII and EcoRI and ligated into the expression vector pET-30a (+) for expression of the recombinant protein with an N-terminal 6-His tag. The resulting expression construct was transformed into Escherichia coli BL21(DE3) and positive clones were selected on plates containing kanamycin. Cells were grown in LB broth containing 25 mg/mL of kanamycin at 37\u00b0C with shaking at 200 rpm and protein expression was induced with 1 mM IPTG when an optical density (600 nm) of 0.6 was reached. Protein expression was carried out at room temperature for 3\u20135 h. Cells were harvested by centrifugation , resuspended in lysis buffer and lysed by sonication. Cell debris were pelleted by centrifugation (30 000 \u00d7 g for 30 min) and the supernatant was loaded onto a 2 mL Ni-NTA (nickel-nitrilotriacetic acid) column. The imidazole concentration was increased to 0.04 M and the resin was washed with 10 mL of buffer. Protein was eluted by increasing the imidazole to 0.25 M in the final wash. The final purified protein solution was desalted using a PD-10 ultrafiltration column by gravity flow according to the manufacturer\u2019s directions and eluted with 0.05 M citrate-phosphate buffer, pH 6.0. Protein concentration was determined using a Quick Start Bradford Protein Assay kit .The endoglucanase gene harboured in BAC clone 14b22 (subclone p13), designated m and Vmax, were calculated by directly fitting the data to the Michaelis\u2013Menten equation by nonlinear regression. Reactions were carried out under optimal condition with CMC of different concentrations, ranging from 5 to 35 mg/mL.Cellulase activity was measured by incubating 0.7 \u03bcg of recombinant Cel14b22 with 1% CMC in 0.5 mL 0.1 M citrate phosphate buffer, pH 6.0, at 50\u00b0C for 15 min. Optimal pH and temperature were determined as described above. Substrate specificities of the enzyme and the effect of several metal chloride salts at 10 mM , a chelating agent (EDTA) at 1 mM, and the detergent SDS at 1% (w/v) were investigated at optimal pH (6.0) and temperature (50\u00b0C). The pH stability was determined by measuring residual cellulase activity after the enzyme was incubated at 4\u00b0C for 24 h at the test pH. Thermal stability data were compared after incubating the enzyme at various temperatures from 30 to 70\u00b0C for 1 h, and measuring the residual cellulase activity. The kinetic constants, KBAC: Bacterial artificial chromosome; CBM: Carbohydrate binding module; CMC: Carboxymethylcellulose; EDTA: Ethylenediaminetetraacetic acid; GH: Glycosyl hydrolase; SDS-PAGE: Sodium dodecyl sulfate polyacrylamide gel electrophoresis; Ni-NTA: Nickel-nitriloacetic acid.The authors declare no competing interests.XG carried out functional screening and characterized the enzymes. LP isolated metagenomic DNA and constructed the BAC library. RG and SQ analysed data and wrote the manuscript. RF, TM, RT conceived of the study and participated in its design and coordination and helped to draft the manuscript. All authors read and approved the final manuscript."} +{"text": "Toxoplasma gondii (henceforth toxoplasma) is an often-cited example. Chronic toxoplasma infection reduces aversion of rodents to cat odors, plausibly increasing predation by its definitive felid host [The behavioral manipulation hypothesis predicts that parasites can change host behavior in a way that benefits the parasites and not the host (extensively reviewed in \u20139). In olid host . Here, ICats are infected by toxoplasma when they eat infected prey. The parasite undergoes gametogenesis in cat intestines, resulting in eventual shedding of fecal oocysts that are ingested by intermediate hosts. Entry in the cat is important for the parasite because it permits a) sexual recombination; b) infection of herbivore hosts who otherwise cannot be infected through carnivory between intermediate hosts; and c) the discharge of highly infectious and resilient oocysts into the environment. Yet, entry of the parasite in the cat is constrained by predation rates. Preys of cats avoid cats and cat odors . AproposToxoplasma is also sexually transmitted through the male ejaculate in rats . AproposBiological pathways underlying mate choice and innate aversion to predator odor are relatively well-studied in rodents. This has allowed researchers to study proximate mechanisms of parasitic behavioral manipulation in greater detail in this association compared to other host\u2013parasite relationships. This mechanistic research has focused on three main narratives.This narrative posits that toxoplasma preferentially concentrates in certain brain regions; and this tropism can explain host behavioral changes through local manipulation of neuronal signaling and/or damage. Toxoplasma exhibits a decided tropism to brain, testes, and eyes. These organs are immune-privileged, in the sense that immune cells have limited access to these sites. Some experimental evidence suggests that toxoplasma gains entry into these sites through brain endothelial cells or by usAn important candidate in the nontropic model is disruption of brain dopamine signaling. The genome of toxoplasma contains two genes (AAH1 and AAH2) that bear striking sequence similarity to a mammalian enzyme called tyrosine hydroxylase . This enRecently, a mutant parasite with ablation of one of the AAH genes (AAH2) has been described . This abAn alternative nontropic model invokes parasite-induced tweaking of communication lines between brain and gonadal hormones. Toxoplasma invades rat testes upon infection, leading to a heavy cyst burden in epididymis and the ejaculates . This isThis narrative nonetheless provides a plausible chain of events. In male rats, testosterone sustains synthesis of major urinary proteins in the liver. These proteins are necessary and sufficient to signal sexual attractiveness in a dose-dependent manner to females when eventually excreted in the urine . TestostThe narrative detailed above encompasses substrates that are highly dimorphic between genders. Congruent to males, toxoplasma also reduces aversion to cat odors in female mice and rats ,39. ThusRats and mice infected with toxoplasma exhibit behavioral change in their aversion to cat odor and their sexual attractiveness to females. Previous work has resulted in three main classes of hypotheses pertaining to proximate mechanism of this phenomenon. Current work continues to test these hypotheses. More clarity about the mechanisms will plausibly inform ultimate causation of host behavioral change."} +{"text": "In this issue of Annals of Intensive care, Costa et al. reported on the association between a lower erythrocyte superoxide dismutase (SOD)1 activity and the development of acute kidney injury (AKI) in septic shock patients. At a given cutoff level, SOD1 was found to predict sepsis-induced AKI (SAKI) earlier than the classic KDIGO criteria. The authors suggested that erythrocyte SOD1 activity could act as an early marker of SAKI and, by extension, as a novel target of SAKI biomarker research [First, how strong is the oxidative stress response associated with SAKI? An honest answer is that we do not know! Sepsis indeed evolves along an inflammation\u2013ischemia\u2013reperfusion scenario. An important hallmark of the disease, amongst others, is a devastating oxidative burst substantiated by a harsh combat opposing tissue-aggressive reactive oxygen species (ROS) to intrinsic antioxidant body defense systems . SAKI, hSecond, is erythrocyte SOD1 an ideal biomarker? Arguably! Amidst the turmoil of oxidative aggression and antioxidant riposting, Costa et al. selected this particular scavenger probably because SOD is recognized as one of the first-line antioxidant \u201cfirefighters.\u201d By definition, an ideal biomarker is released by injured organ-specific cells, is rapidly and repeatedly measurable, exhibits plasma concentrations proportional to the extent of injury, allows evaluating ongoing or receding organ damage, and reacts to therapy. SOD hardly corresponds to any of these criteria. Mammals possess three SOD isoforms: a predominantly intracellular copper\u2013zinc SOD1, a mitochondrial manganese SOD2, and a copper\u2013zinc SOD3 in the vascular extracellular space. Although catalyzing the same reaction, these isoforms are products of distinct genes and their specific subcellular location results in compartmentalized redox signaling. In fact, SOD2 might be a more specific marker than erythrocyte SOD1. SOD2 is abundantly present in the mitochondrial matrix where it is involved in dismutating superoxide anions generated by the respiratory enzyme chain . Renal, Thirdly, do the study results offer convincing evidence to pursue further research in this domain? Here, the answer is negative! An area under the receiver operating curve (AUROC) of 0.686 constitutes a rather weak correlation between SOD1 activity and SAKI development . To dateIntensive care nephrologists crave to abandon serum creatinine as a late, highly biased, and poorly predictive marker of SAKI for an early, reliable, and kidney-specific biomarker. Within this context, Costa et al. provided interesting data of high scientific value. However, when \u201cdo not know,\u201d \u201carguably\u201d and \u201cno\u201d are the answers to pertinent questions regarding the clinical relevance of these findings, there is little reason to believe that a \u201cnovel avenue\u201d of biomarker research in SAKI has been opened."} +{"text": "Microgels are intra-molecular crosslinked macromolecules that can be used as vehicles to deliver and release drugs at the point-of-need in the patient\u2019s body. Here, gelatin microgels were formed from microfluidics droplets, stabilised by aldehydes and frozen into a spheroidal shape. Microgel morphology and response to external stimuli were characterised. It was found that the behaviour of the spheroidal microgels was sensitive to both pH and ionic strength and that the distribution of charges into the microgels affected the behaviour of swelling and uptake. The uptake of molecules such as Rhodamine B and Methylene Blue were investigated as a model for drug uptake/release mechanisms. Under physiological conditions, the uptake of Rhodamine was rapid and a uniform distribution of the fluorescent molecules was recorded inside the microgels. However, the mechanism of release became slower at lower pH, which mimics the stomach environment. Under physiological conditions, Methylene Blue release occurred faster than for Rhodamine. Anionic and neutral molecules were also tested. In conclusion, the dependence of uptake and release of model drugs on basic/acid conditions shows that microgels could be used for targeted drug delivery. Different shaped microgels, such as spheres, spheroids, and rods, could be useful in tissue engineering or during vascularisation. Over the years, microgels have gained a reputation as an intriguing class of polymeric materials; that is, they exhibit exceptional properties in regard to loading and releasing applications7. These properties derive from the unique combination of their colloidal nature with the inherent features of macroscopic hydrogels, i.e. their internal network structure and characterised by parameters such as mesh size, polymer volume fraction or interaction with embedded functional compounds. To date, the ability to control these factors by the application of external triggers represents the underlying concept of stimuli-responsive microgels9.Microgels, which constitute a new form of polymer, are structures with intra-molecular crosslinked macromolecules10, intended as the formation and stabilisation in an emulsion, to the most recent based on microfluidics11, which enables a deep control on the dimensions and shape of the microgels as well as on their composition. In fact, special attention also has been given to the shape of microgels. The possibility to shape microgels with high control enables a wide variety of applications related to self-assembly. Assembling heterogeneous and homogeneous architectures from crosslinked microgel building blocks is in great demand in various applications, particularly in tissue engineering12 for mimicking biological functions and in the production of novel materials with engineered properties13.Methods of microgel preparation are widely documented and range from solution bulk protocols14. Indeed, anisotropic, injectable microgels could mimic local extracellular matrix architectures that cells encounter in complex tissues and could be extremely interesting for tissue engineering as well as for drug delivery.Another intriguing aspect of these highly controllable processes refers to the fabrication of spherical and spheroidal microgels with anisotropic properties15 or hematite and magnetite spindles17 are some of the templates reported in the literature. Indeed, the design of non-spherical colloids makes them interesting candidates for self-assembly processes. Ideally, the key requirement towards complex assembled structures with desirable properties is the accurate engineering of colloidal particles. To qualify as suitable building blocks with anisotropy in shape and interactions, they need to be highly monodisperse in size and highly uniform in anisotropy. Finalised to biological applications, the preparation of the microgels starting from native biological raw materials resembles a crucial step for the advances in this field18. Indeed, thoroughly analysing the state of the art, many applications based on artificial materials or native mixed with non-native can be found20.Anisotropic hybrid microgels have been prepared using anisotropic particles as seeds for the later synthesis of responsive shells. Janus dumbbellsin vivo mechanisms. The variation of pH will simulate the mechanisms inside the intestinal tract or during digestion. To date, this will represent an optimal model to be pursued to design new suitable materials compatible with living organisms and useful for drug delivery applications.Starting from that, we intend to fabricate microgels from native proteins, such as gelatin, with controlled shape and composition and characterise them when stimulated by sudden variations of the environmental conditions to mimic Gelatin , Rhodamine B (Mw \u223c479.02\u2009g/mol), and glutaraldehyde (50%) were purchased from Sigma-Aldrich. Gelatin was used without further purification and prepared as a 15% wt solution at 50\u2009\u00b0C. A three\u2013stage Millipore Milli-Q plus 185 purification system with a resistivity higher than 18.2\u2009M\u03a9 was used.23. Briefly, the microfluidic chip had three inlets mixed and the microgels spheroidal particles were formed. The gelatin was pre-loaded inside a reservoir.The fabrication of the microgels in the microfluidic environment was reported elsewhereESI Fig.\u00a0 and the For the experiments, the flow rate was controlled by high sensitivity pumps (Nemesys apparatus) and for the fluidic setup, glass syringes (1\u2009mL and 2.5\u2009mL) and PTFE tubing (0.8\u2009mm ID) were used. The microfluidic device was housed vertically on an inverted microscope and the microgels were collected inside a Petri dish ESI Fig.\u00a0. The flogel: oil: glutaraldehyde. To visualise the streams inside the channel, blue and red natural colours were used was performed with a Zeiss Sigma apparatus and TESCAN Vega3 . For both investigations, the samples were sputtered with gold for 2\u2009min. To analyse the structure, the microgel particles were washed with acetone at least five times and then dried. The microgel section was obtained by cutting the particle with a surgical blade. The investigations were done using an Extra-High Tension (EHT)\u2009=\u200916\u2009kV.To explore microgel behaviour in response to different external stimuli, the microgels first were extracted by acetone and incubated in deionised water. After stabilisation in water, the microgel samples were added to NaCl solutions ranging in concentration from 0.25\u2009M to 1\u2009M. An analogous protocol was followed for studying response to pH change. In particular, HCl and buffered solutions were used to set the pH range of the microgels.For both ionic- and pH-conditioned solutions, the analysis was done by controlling and recording the weight of the samples as well as the characteristic dimensions. The latter set of data was obtained by observing the samples at set timeframes by inverted microscope and analysing the images with ImageJ software.The zeta potential of the microgels was measured by varying the pH in the Zetasizer . About 3\u2009mL of the suspension (1\u2009mg/mL) was added to a cuvette and adjusted to pH values in the range from 2\u201310 using HCl and NaOH. The suspension was equilibrated for 4\u2009min at 25\u2009\u00b0C. The measurement was performed with three runs, with each run consisting of 10 single measurements.The uptake of Rhodamine B was achieved by incubating the microgels for 10\u2009h in a solution with 0.1\u2009mg/mL. The gelatin microgels were loaded with Rhodamine B in buffer solution pH 7.4 at 37\u2009\u00b0C, while the release was carried at pH 7.4 and pH 6.7. In both cases, they were rinsed in water three times to remove excess fluorescent tag. Spectrometer combined with an optical investigation (Olympus inverted microscope) was used to estimate the release. After each washing step, the supernatant was withdrawn from the samples; in turn, fresh buffer was added for the new interval of incubation. The absorbance of Rhodamine B at \u03bb\u2009=\u2009540\u2009nm was recorded to determine the calibration curve of the absorbance spectrum. Following, the released amount was calculated for each measurement with concentrations extrapolated by the Rhodamine calibration curve.For estimating the mechanism of release of Methylene Blue (MB) the microgels were incubated with MB solution for 24\u2009h. To measure the mechanism of release, the microgels were washed and then incubated in buffer at pH 7.4 for 30\u2009h. After each washing step, the supernatant was withdrawn from the samples; in turn, the same volume of fresh buffer was added for the new interval of incubation. During the time of the experiment, the absorbance of MB in buffer was measured using a spectrometer at a wavelength of 580\u2009nm. The amount of MB was determined from the calibration curves from the readout of the solution at several dilutions. The absorbance of the samples at different times of incubation provided the amount of the MB released at the sampling time.\u22124\u2009g/mL \u03bcM) for 24\u2009h. To measure the mechanism of release, the microgels were washed and then incubated in buffer at pH 7.4 and 6.7 for 30\u2009h. After each washing step, the supernatant was withdrawn from the samples; in turn, the same volume of fresh buffer was added for the new interval of incubation. During the time of the experiment, the absorbance of Fluorescein and Indocyanine Green in buffer was measured at a wavelength of 490\u2009nm and 680\u2009nm, respectively. The amount of dyes was determined from the calibration curves from the readout of the solution at several dilutions. The absorbance of the samples at different times of incubation provided the amount of the dyes released at the sampling time. It worth observing that an absorption and fluorescence properties of Fluorescein depends on the pH of the solution24; to date, before the measurements, the pH was adjusted with NH3. The calibration curve was built under the same conditions.Uptake/release mechanisms of Fluorescein and Indocyanine Green were studied as well. For estimating the mechanism of release of Fluorescein (332.1\u2009g/mol) and Indocyanine Green (774\u2009g/mol), the microgels were incubated with the dye solutions After fabrication, the stabilised microgels were collected at the exit of the microfluidic channel, washed and finally stored at room temperature in acetone for several days Fig.\u00a0. The sizFollowing, the microstructure of the microgels was analysed. Despite several washings with acetone, scanning electron micrographs of the microgels did not show surface defects or collapses Fig.\u00a0. The int26. Here, the microgels were suspended in water and the swelling was measured by recording the dimensional variations and pH 5 (pH\u2009=\u2009pI). At the end of the incubation time, the two samples displayed different diameters: 120\u2009\u03bcm for microgels stabilised at pH 7.4 and 85\u2009\u03bcm for microgels stabilised at pH\u2009=\u2009pI. Then, the microgels were dried for seven days at room temperature and their weight was recorded. The samples were re-suspended in aqueous solutions and the pH adjusted to 7.4 and 5, respectively. After three days, from dry to swelling equilibrium, the weight of the microgels suspended at pH 7.4 increased from 140\u2009\u03bcg to 360\u2009\u03bcg, whereas the weight of the microgels suspended at pH 5 increased from 140\u2009\u03bcg to 230\u2009\u03bcg. To date, the swelling capability of the microgels resulted increased at pH higher than pI.The charge of the crosslinked microgels was investigated by measuring the zeta potential (\u03b6) according to the pH. It was recorded that the zeta potential of the microgels swollen in a buffer at pH 7.4 resulted in \u03b6\u2009=\u2009\u221213.2\u2009\u00b1\u20090.5\u2009mV. The negative value of the zeta potential was explained as the consequence of crosslinking reactions. The glutaraldehyde links with the amine groups of the gelatin by reaction of condensation, while the carboxylic acid groups remain in the native state and generate negative charges at the pH 7.4. At pH 8.5, the zeta potential was measured to be \u03b6\u2009=\u2009\u221230.1\u2009\u00b1\u20090.6\u2009mV. Upon increasing the pH, the amine groups not involved with the condensation reaction deprotonate and, indirectly they become additional sources of negative charge.27.In conclusion, at pH\u2009\u226b\u2009 pI, the carboxylate and amine groups, according to pH strength, were ionised and generated negative charges distributed along the chains. The negative charges enhanced electrostatic anion\u2013anion repulsions and caused an improved swelling capacity29. In fact, at this pH, the carboxylate anions and the amine groups not linked with the glutaraldehyde in the reaction of crosslinking are protonated, so that the microgels charge resulted almost null.At the pI, the zeta potential is about null and the microgels displayed a modest swellingUnder acid conditions, at pH 4 (pH\u2009<\u2009pI), the zeta potential was measured to be \u03b6\u2009=\u2009\u22126.5\u2009\u00b1\u20090.3\u2009mV as consequence of the partial protonation of the carboxylate anions and reduction of the anion\u2013anion repulsion, which led to a remarkable decrease in swelling capacity. Figure\u00a029. However, the salt ions hindered the molecules of water leading the shrinking of the microgels with the increase of the salt concentration in solution.Following, the microgels at pH 7.4 and pI were suspended in NaCl solutions with concentrations ranging from 0 to 1\u2009M Fig.\u00a0. The micThe isoionic microgel was able to capture either positive or negative ions through electrostatic interactions, with the addition of ion salt in solution. The charges distributed along the chains and inside the microgels increased; as a result, the free negative charges available on the chains of the protein were able to retain water while the microgels swelled.30. In fact, this anomalous behaviour of the microgels could be the consequence of network constrictions formed inside the protein structure, which reduced the capability of the microgels to grasp the water molecules and constrained the movement of the chains31.As a consequence of the last phenomenon, the microgels underwent an anisotropic swelling along the two main directions (length and diameter)The cyclic and repeatable response to external stimuli is an important aspect for the microgels in both drug loading and release mechanisms. To test this property, the same microgels were incubated in NaCl solution (0.5\u2009M) and aqueous solution at pH 6.7, by turns. Figure\u00a0In fact, during cycle II, it was observed that changing the environment from water to salt did not bring the microgels to the native size, whereas the recurring behaviour of the microgel properties was observed starting from the cycle II onward.31. Furthermore, Rhodamine and MB have a positive charge and low molecular weight; therefore, they are perfect models for drugs32.An important application of microgels is in the field of nanomedicine, such as the uptake/release of molecules for effective therapies. Here, the spheroidal microgels were investigated for the uptake/release of Rhodamine B and MB, common payload-model molecules for drug delivery applications. These molecules are interesting models to investigate as they recently have been shown to selectively induce apoptosis in cancer cellsThe microgels were incubated with Rhodamine B according to the conditions reported above and the analysis was carried out analysing both the microgels and supernatant. The release was carried at pH 7.4.A micrograph of the microgels is displayed in Fig.\u00a0\u22128\u2009mg/mL), which lead to conclude that in almost one day, the payload was delivered inside the surrounding environment. The release of Rhodamine was also studied at pH 6.7 to display that raising the pH of the suspending solution, the permeability of the microgels increased due to higher charge repulsion, thereby allowing the faster release of Rhodamine B from the microgels.During the same timeframe, the supernatant withdrawn from the tubes was examined. The curve of the emission of the supernatant is plotted versus the time and compared with the spectra of the fresh buffer and Rhodamine Fig.\u00a0. In lessTo mimic a gastric acid environment, the release of Rhodamine was analysed at pH 3.5. Table\u00a0In conclusion, the mechanism of release is also affected by the charge distribution and, as consequence, the drug release can be controlled by variations in pH or the medium\u2019s ionic strength. The pH-dependent behaviour makes the gelatin an interesting biomolecules for drug delivery. In fact, the gelatin microgels are excellent carriers for drugs, as they can protect the drugs from undesired interactions with gastric fluids and release them when they reach the target cells.The mechanism of release of drugs was also mimicked with MB according to the protocol used with Rhodamine. In particular, drug release efficiency was investigated at pH 7.4. The concentration of the payload released over time is displayed in Fig.\u00a0\u22124 \u03bcM after about 40\u2009hours. Comparing the value of Rhodamine and MB at physiological pH, the mechanism of release of MB was faster than for Rhodamine. In fact, the initially loaded concentrations of the molecules differed by one order of magnitude (200\u2009\u03bcM versus 12\u2009\u03bcM) while the payload concentrations in solution were 0.1\u2009\u03bcM Rhodamine versus 2\u2009\u00d7\u200910\u22124\u2009\u03bcM MB. However, Rhodamine molecules are bigger than MB ones, to date, the faster release of the latter can be a consequence of the diffusion mechanism inside the gelatin network.The MB released within the first 24\u2009h of incubation brings the concentration of released Rhodamine to 0.50\u2009\u03bcM; however, after 28\u2009h, the concentration of MB released by the microgels reduced to 0.05\u2009\u03bcM and reached a value of 2\u2009\u00d7\u200910To understand the behaviour of the gelatin microgels in presence of negative and neutral dye molecules, fluorescein and indocyanine green release was examined at pH 7.4 and at pH\u2009=\u20096.7. The quantification of fluorescein payload released over time is displayed in Fig.\u00a031. The latter result confirmed that the Fluorescein permeating the network was not anchored to the chains, due to the absence of electrostatic interactions and of the ionic effects.The Fluorescein molecules permeated the gelatin by diffusion; however, the mechanism of release is quite fast and it ended less than 7\u2009h, when more than 98% of the payload was releasedIn contrast, it was impossible to detect a significant amount of uploaded and released Indocyanine Green ESI Fig.\u00a0, the neg21.In conclusion of this section, biodegradability and biocompatibility are essential properties for materials used in drug delivery. Microgels can be digested in a few hours in the presence of trypsinThe present work details an in-depth investigation and characterisation of natural microgels made from native, chemically stabilised proteins after preparation in a microfluidics environment.In particular, an accurate analysis of the results showed that microgels have uniform size distribution while displaying anisotropic swelling. The microgels display different responses to environmental stimuli, e.g. swelling or shrinking under different conditions of pH and ionic strength. These properties were explained in light of the chain and charges available in the gelatin network.Finally, using Rhodamine and MB as payload models, the uptake/release mechanisms were recorded in conditions that mimicked the release of a drug in humans. The combination of unique shape and response behaviour documented here suggest that these microgels could be used for tissue engineering. Furthermore, by controlling the microgels\u2019 shape one can control the direction of cell growth as well as drug delivery.Finally, it worth concluding that the simplicity of microgel fabrication, which is a one-step process, makes the protocol easily scalable.Supplementary"} +{"text": "P < 0.003), IGT , and diabetes groups was significantly higher than that for high SD of SBP in the NGT group. Similarly, the OR for high CV of SBP in the IGT and diabetes groups was significantly higher than that for high CV of SBP in the NGT group. In participants without CVD, impaired glucose metabolism may modulate visit-to-visit BP variability.We evaluated data from 10,088 participants without cardiovascular disease (CVD) who underwent 75\u2009g oral glucose tolerance tests and had more than four visits during the first 5 years following the test to investigate the association between impaired glucose metabolism and visit-to-visit blood pressure (BP) variability. Participants were classified into groups of normal glucose tolerance (NGT), impaired fasting glucose (IFG), impaired glucose tolerance (IGT), and diabetes. Visit-to-visit BP variability was estimated for each individual using standard deviation (SD) and coefficients of variation . SDs and CVs of systolic BP (SBP) values were divided into quartiles. The samples falling in the highest quartile were considered as having high SD/CV. The adjusted odds ratio (OR) for high SD of SBP in the IFG (OR, 1.39; Visit-to-visit blood pressure (BP) variability reflects arterial stiffness and may be predictive of cardiovascular morbidity and mortality , 2. SeveIn the present study, we investigated the association between visit-to-visit BP variability and the status of glucose metabolism, alternating from normal glucose tolerance (NGT) to intermediate hyperglycemia including IFG, IGT, and diabetes in a large-scale population without CVD.n = 2,103] and/or having systolic BP [SBP] \u2265 140\u2009mmHg and/or diastolic BP [DBP] \u2265 90\u2009mmHg); 1,072 (11%) had dyslipidemia (defined as taking antihyperlipidemic medications); 1,731 (17%) were current smokers (defined as having a current smoking habit regardless of the number of cigarettes smoked per day); and 4,388 (43%) were habitual drinkers [The present study used data collected from the Hiroshima Aging, Blood pressure, and Diabetes study (Hiroshima ABD study), a cross-sectional and longitudinal study that examined the interrelationship among aging, blood pressure, glucose metabolism, and cardiovascular outcomes. Potential participants were recruited between April 1988 and March 2012, after undergoing annual health examinations at the Health Management and Promotion Center of Hiroshima Atomic Bomb Casualty Council. Potential participants were considered eligible if they (1) were aged \u226518 years, (2) had no symptomatic heart failure, (3) had no history of treatment for diabetes, and (4) agreed to undergo the 75\u2009g oral glucose tolerance test (OGTT). We asked all participants about their regular medications and medical histories, including treatment for hypertension, diabetes, dyslipidemia, and CVD, and information about their drinking and smoking habits. The present study reports on 10,088 participants enrolled between April 1988 and March 2007. Included participants had no current or a prior history of CVD and had more than four visits during the first 5 years for health examinations. Among the 10,088 participants, 4,759 (47%) had hypertension . CV was defined as SD/mean. SDs and CVs of SBP and DBP values were divided into quartiles. The samples falling in the highest quartile were considered as having high SD/CVs and those in the remaining three quartiles as having low SD/CVs.We divided the participants into four groups according to their glycemic status as defined by the 2006 World Health Organization criteria and the P value < 0.05 was considered statistically significant. All statistical analyses were performed using the JMP 10 statistical software .Continuous variables were expressed as mean \u00b1 SD. Differences among the four groups were evaluated using analysis of variance. Fisher's least-significant-difference method was used for multiple comparisons. Categorical variables were summarized as percentages and were analyzed using the chi-square test. The odds ratios (ORs) of high SD/CV of SBP and DBP were calculated using univariate and multivariate logistic regression analysis, adjusting for age, gender, BMI, habitual drinker (yes or no), current smoker (yes or no), taking antihypertensive medication (yes or no), dyslipidemia (yes or no), and number of visits. A Clinical characteristics of the study population are presented in P < 0.005), IGT , and diabetes groups was significantly higher than that for high SD of SBP in the NGT group. The OR for high CV of SBP in the IGT and diabetes groups (but not the IFG group) was significantly higher than that for high CV of SBP in the NGT group.In this study, we demonstrated higher visit-to-visit SBP variability in participants with intermediate hyperglycemia (including IFG and IGT) compared with those with NGT. The rate of high visit-to-visit SBP variability during the first 5 years gradually increased, starting with low increases in NGT cases, moderate increases in intermediate hyperglycemia cases, and highest increases in diabetes cases after the baseline 75\u2009g OGTT. These results suggest that, in participants without CVD, impaired glucose metabolism may modulate visit-to-visit BP variability. In particular, we found that IGT, as well as diabetes, was significantly associated with high SD and CV of SBP. Although IGT has been reported to be a significant risk factor for CVD , the undAlthough the determinants of visit-to-visit BP variability are not completely understood, arterial stiffness is thought to be one of the key factors . It is wIn patients with diabetes, most studies reported visit-to-visit BP variability as an independent risk factor for macro- and microvascular complications , 20, 21.This study has some limitations. First, the types of antihypertensive agents used were not recorded for participants currently under treatment for hypertension and the effects on visit-to-visit BP variability may differ based on the use of different antihypertensive agents. Second, participants with CVD were excluded based on careful interview inquiring about regular medications, medical history, and a physical examination. Nonetheless, we cannot rule out the possibility that the present study population included participants with subclinical CVD, given that we did not assess cardiac function using more objective methods.In conclusion, our results suggested that impaired glucose metabolism may modulate visit-to-visit BP variability. Intermediate hyperglycemia, especially IGT, was associated with visit-to-visit BP variability. This may explain the adverse cardiovascular consequences observed in patients with IGT."} +{"text": "The first enantioselective sulfa-Michael addition of alkyl thiols to alkenyl benzimidazoles, enabled by a bifunctional iminophosphorane (BIMP) organocatalyst, is described. The first enantioselective sulfa-Michael addition of alkyl thiols to alkenyl benzimidazoles, enabled by a bifunctional iminophosphorane (BIMP) organocatalyst, is described. The iminophosphorane moiety of the catalyst provides the required basicity to deprotonate the thiol nucleophile while the chiral scaffold and H-bond donor control facial selectivity. The reaction is broad in scope with respect to the thiol and benzimidazole reaction partners with the reaction proceeding in up to 98% yield and 96\u2009:\u20094 er. Their functionalization, especially when performed in an enantioselective manner, is therefore of particular interest in the field of organic synthesis. Alkenyl azaarenes have been used extensively as synthetic precursors for the functionalization of N-containing heterocycles.Our research has focused on developing enantioselective methods utilizing novel bifunctional iminophosphorane (BIMP) organocatalysts,E)-2-propenyl-1-tosyl-benzimidazole 1 and commercially available 1-propanethiol as model coupling partners to investigate reactivity and selectivity with a selection of bifunctional Br\u00f8nsted base/H-bond donor catalysts using 3 eq. of thiol at 0.5 M concentration in THF at 22 \u00b0C for 24 hours (A (entry 1) only provided 2 in 12% yield and a negligible 53\u2009:\u200947 er. We therefore chose to investigate the more basic and more active BIMP catalysts in this reaction and were very pleased to find that known BIMP catalyst B2 in 80% yield and 83\u2009:\u200917 er (entry 2). With significant catalyst-enabled reactivity and stereocontrol identified we then proceeded to investigate second generation catalyst C2 in improved yield and er at 92% and 86\u2009:\u200914 respectively (entry 3). Shifting the thiourea moiety further away from the iminophosphorane (D\u2013E)B (entries 4 and 5). We therefore focused on exploring catalysts built around the same chiral scaffold as C. Catalyst FtBu groups at both stereocenters in the configuration afforded 2 in 90% yield and 90\u2009:\u200910 er (entry 6). Interestingly, a control reaction without any catalyst was found to go to completion (entry 7), indicating that an uncatalysed background reaction2O, provided 2 in 93% yield and 94\u2009:\u20096 er using catalyst F (entry 8). Surprisingly a further decrease of the temperature to \u201340 \u00b0C led to an erosion of the enantiomeric ratio (entry 9). To further boost the enantiomeric ratio, diastereoisomeric catalyst GG outperformed corresponding diastereomer F affording the desired product in 98% yield and 95\u2009:\u20095 er (entry 10).We chose the readily prepared24 hours , Table 13\u20135) with high yields and enantioselectivities. The introduction of a phenyl ring was well tolerated providing 6 in outstanding yield and good er. Appending a silyl group to the thiol nucleophile showed no detrimental effect providing 7 in excellent yield and er. Benzyl thiols provided corresponding Michael adducts 8\u201310 in high yields in all cases and good enantioselectivity, albeit slightly diminished when compared to simpler alkyl thiols.With optimal conditions established, we proceeded to explore the scope and limitations of this transformation . Initial11 in 81% yield and 86\u2009:\u200914 er. Alternating monosubstitution between C5 and C6 did not have a large effect, with bromine containing substrates affording the corresponding Michael adducts in greater than 75% yield and 86\u2009:\u200914 er allowing for potential further functionalization at both positions.17Having investigated the thiol component, we then focused on substituent effects on the benzimidazole core . VariatiN-tosyl to N-Cbz (14) or N-Boc (15), however in these cases reactivity was found to diminish. This was easily circumvented by running the reaction at 22 \u00b0C using 3 equivalents of 1-propanethiol.18We were pleased to find that the high enantioselectivity of the reaction was largely maintained when the nitrogen protecting group was changed from n-propyl thiol Michael additions providing the corresponding products (16\u201319) in excellent yield and enantioselectivity. When substituting the alkene moiety with an aromatic group, the solvent was switched to THF and reactions were run at 22 \u00b0C due to decreased solubility and reactivity of the substrates. When a phenyl substituent was introduced on the alkenyl moiety, catalyst G only provided a moderate Michael adduct 20 in 77\u2009:\u200923 er, however this was boosted to 88\u2009:\u200912 when using diastereomeric catalyst F. Introducing electron withdrawing groups at either the para or meta positions of the phenyl ring afforded the corresponding products 21\u201323 in good yield and enantioselectivity; in these cases, however, catalyst G proved superior to F. Finally, when the phenyl ring was exchanged with a 3-pyridyl moiety, it smoothly afforded the corresponding adduct 24 in 74% yield and 90\u2009:\u200910 er.Having varied the substitution pattern on the benzimidazole, we proceeded to investigate the scope with respect to substituents on the alkenyl moiety. The introduction of higher order linear alkyl chains, bearing aromatic, alkene and alkyne substituents, was well-tolerated with all 2 in equal yield and er, which upon treatment with HCl (5 M aq.) gave corresponding deprotected product 25 in quantitative yield. Single crystal X-ray analysis of 25 allowed the absolute configuration of sulfa-Michael product 2 to be determined as S when using catalyst G. We were also pleased to find that, upon treatment of 2 with m-CPBA, sulfone 26 was obtained in 95% yield with no loss of optical purity afforded l purity .3-derived catalyst G* with the PMP-groups of G modelled by Ph-groups. The most stable conformation of (most enantioselective) catalyst G* has substituents either side of the urea oriented with a hydrogen atom towards sulfur: other rotamers are disfavoured. This creates a pocket with the iminophosphorane positioned above the thiourea (from the perspective of Avs.B) and either could in principle lead to the formation of the major observed enantiomer. Computationally, we find that the interaction of the thiolate nucleophile with the protonated iminophoshorane and the benzimidazole with the thiourea (mode A) is energetically favored by 4\u20135 kcal mol\u20131 over the alternative (mode B) in which the thiourea binds the nucleophile and the benzimidazole to the protonated iminophoshorane. This mode of activation is consistent with the observed sense of enantioselectivity, and with earlier mechanistic proposals of Takemoto. Recent theoretical studies of Grayson and Houk have emphasized the importance of activation mode B in sulfa-Michael reactions promoted by Cinchona-derived catalysts.21We used density functional theory (DFT) to investigate the origins of enantioselectivity, performing calculations at the wB97XD/6-31G(d) level of theory .19 CalcuIn summary, the first enantioselective sulfa-Michael addition of alkyl thiols to alkenyl benzimidazoles has been described. Excellent yields and good enantioselectivities were achieved across a broad range of alkyl thiol and alkenyl benzimidazole reaction partners using a second generation BIMP organocatalyst. This work further demonstrates the versatility and high activity of the BIMP catalyst family, as well as expanding its use in methodology for the synthesis of biologically relevant chiral benzimidazole derivatives. Further investigations into new catalyst designs and applications for BIMP promoted reactivity are underway in our laboratories.There are no conflicts to declare.Supplementary informationClick here for additional data file.Crystal structure dataClick here for additional data file."} +{"text": "In CUR-BCSC@PCs with an average hydrodynamic diameter of 160.3\u2009\u00b1\u20099.0\u2009nm, the biomimetic protein corona gave the nanoparticles excellent stability and the potential to avoid protein adsorption in blood circulation. The in vitro release experiment verified that CUR-BCSC@PCs with redox responsive shells were sensitive to high concentrations of glutathione. In addition, CUR-BCSC@PCs were effective at increasing the inhibitory activity on the proliferation of A549 cells by enhancing the intracellular uptake of CUR. These results indicated that CUR-BCSC@PCs have great application prospects in cancer therapy as effective drug delivery carriers.In this paper, a type of phycocyanin (PC)-functionalized and curcumin (CUR)-loaded biotin-chitosan oligosaccharide-dithiodipropionic acid-curcumin (BCSC) nanoparticles, called CUR-BCSC@PCs, were designed to enhance the biocompatibility of CUR. The structure of BCSC was confirmed using D-glucosamines is a de-polymerization product prepared mainly by deacetylation and enzymatic hydrolysis of chitosan or chitin, which is derived from arthropod exoskeletons or the cell walls of fungi [Chitosan oligosaccharide (COS) with the structure of \u03b2-1-4)-linked -4-linkedof fungi . It is wof fungi . A numbeof fungi , 6.In order to improve the solubility of hydrophobic anti-cancer drugs and reduce toxicity to normal tissues, medical researchers have been studying copolymers, which can self-assemble into micelles of a certain particle size range , 8. ThesCurcumin (CUR) is one of the main chemical constituents of turmeric . In recePhycocyanin (PC), mainly obtained from cyanobacteria, is known as a water-soluble and light-harvesting pigment protein, which plays a role in capturing and transferring light into chemical energy during photosynthesis . PC exerIn the present study, a novel type of PC functionalized nanocarrier was constructed, and the preparation of CUR-BCSC@PCs is presented in Fig.\u00a0CUR was purchased from Zhanyun Chemical Co., Ltd. . COS was procured from Shandong Weikang Biomedical Science and Technology Co., Ltd. PC was obtained from Zhejiang Binmei Biotechnology Co., Ltd. 3.3-Dithiodipropionic acid was obtained from Adamas Reagent Co., Ltd. . Carbonized carbodiimide hydrochloride (EDCI), dimethylamino pyridine (DMAP), tetrahydrofuran (THF), oxalyl chloride, and biotin were procured from Aladdin Chemistry Co., Ltd. L-Glutathione (GSH) and Hoechst 33342 were acquired from Sigma-Aldrich . Dialysis bags (MWCO 300\u2009Da) were obtained from Beijing Biotopped Technology Co., Ltd. Formamide was prepared by Tianjin Fuyu Fine Chemical Co., Ltd. Deionized water was self-made in the laboratory.An A549 cell line (human lung carcinoma cells) ) was chosen to evaluate the cytotoxicity of the novel nanocarrier. A549 cells were grown in DMEM ). Fetal bovine serum (FBS) was obtained from Hyclone . Penicillin and streptomycin were purchased from Sigma-Aldrich . 3--2,5-diphenyl-2-H-tetrazolium bromide (MTT) was also procured from Sigma-Aldrich .The synthetic routes used to prepare CUR-BCSC@PCs are shown in Fig.\u00a03.3-Dithiodipropionic acid-functionalized COS was synthesized by esterification catalyzed by acid chloride via a two-step reaction.Step 1: 3.3-Dithiodipropionic acid and dry THF (4\u2009mL) were charged into a brown round-bottom flask, with a stirrer to dissolve the acid. Then, oxalyl chloride (0.3\u2009mmol) diluted with THF was added to a flask, placed in an ice bath. The reaction was maintained at 35\u2009\u00b0C. After stirring for 3\u2009h, the unreacted oxalyl chloride was removed by rotary evaporation. Product 1 was prepared by the above steps. CUR was dissolved in 3\u2009mL of THF, containing 34\u2009\u03bcL of triethylamine, that was added dropwise to the flask containing product 1 under ice bath conditions and then stirred for 15\u2009min. Subsequently, the mixture was stirred at 50\u2009\u00b0C under a nitrogen atmosphere for 6\u2009h. The obtained product was subjected to rotary distillation to remove triethylamine and THF and was then purified by column chromatography to acquire the pure product HOOC-S-S-CUR.Step 2: The pure product HOOC-S-S-CUR was activated with EDCI (1.2\u2009eq) and DMAP (1.2\u2009eq) in formamide for 2\u2009h. Subsequently, COS dissolved in 4\u2009mL of formamide was added and stirred at 55\u2009\u00b0C for 12\u2009h. After the reaction was complete, the solution was dialyzed with a dialysis bag (MWCO 300\u2009Da) and freeze-dried for 12\u2009h.In brief, biotin, EDCI, and DMAP were dissolved in 3\u2009mL of formamide and transferred into a brown round-bottom flask. After stirring for 2\u2009h at 30\u2009\u00b0C, COS-S-S-CUR was dissolved in 3\u2009mL of formamide and added dropwise into the flask. The reaction was maintained at 45\u2009\u00b0C for 2\u00a0days. The final products were dialyzed (MWCO 300\u2009Da) in deionized water and underwent centrifugation and lyophilization to obtain redox-sensitive BCSC. In addition, the synthesis of biotin-COS was conducted by the same method to link biotin to the COS chains.1H-NMR of COS-S-S-CUR, BCSC, and biotin-COS were measured using a mixture of DMSO-D6 and D2O as the solvent.CUR-BCSCs were prepared through the self-assembly method. Ten milligrams of BCSC was dissolved in 4\u2009mL of formamide and then mixed with 1\u2009mL of CUR solution (1\u2009mg/mL) that was dissolved in formamide. The mixed solution was dialyzed using a dialysis bag (MWCO 300\u2009Da) in deionized water for 24\u2009h and the deionized water was changed every 2\u2009h. CUR-BCSCs were filtrated using millipore membranes of 800\u2009nm, 450\u2009nm, and 220\u2009nm.The prepared CUR-BCSCs were mixed with an aqueous solution of PC (1.0\u2009mg/mL) and incubated for 30\u2009min at 4\u2009\u00b0C. Subsequently, PC was removed using a 100\u2009kDa centrifugal filter and rinsed with water three times. The final product (CUR-BCSC@PC) was stored at 4\u2009\u00b0C in darkness for further study.Dynamic laser scattering (DLS) measurements were carried out on a Particle Analyzer Delsa Nano C (Beckman Coulter Inc.) to observe the particle size, zeta potential, and polydispersity index (PI). The morphology of CUR-BCSCs and CUR-BCSC@PCs was confirmed by transmission electron microscopy measurements..6\u2009mm, 5 um) was adjusted to 25\u2009\u00b0C, while the flow rate of the mobile phase was set to 1.0\u2009mL\u00b7min\u2212\u20091. The ratio of 0.5% glacial acetic acid to acetonitrile was 40:60 (v/v). In the detection process, with a detection wavelength of 425\u2009nm, 20\u2009\u03bcL of samples was injected [HPLC (Agilent 1260GB12C) was used to determine the EE and DL of nanoparticles. First, 2\u2009mL of CUR-BCSCs or CUR-BCSC@PCs was mixed with 3\u2009mL of acetonitrile and demulsified by ultrasound, in which acetonitrile was then added to 10\u2009mL. Before the measurement, the column temperature of the Phenomenex C18 column containing GSH was prepared and treated with CUR-BCSC@PCs for 4\u2009h to observe the changes in particle size under different concentrations of glutathione at 37\u2009\u00b0C. In addition, the hydrodynamic diameter of CUR-BCSC@PCs was investigated in PBS solution using a Particle Analyzer Delsa Nano C (Beckman Coulter Inc.) at 37\u2009\u00b0C at different time points .The in vitro CUR release behaviors of CUR-BCSC@PCs were investigated using the dialysis method. PBS solutions containing glutathione were prepared, and 0.5% Tween 80 was added. PBS buffer (45\u2009mL), containing different concentrations of GSH, was added to 50\u2009mL centrifuge tubes; then, a dialysis bag containing 1\u2009mL of CUR-BCSC@PCs was placed in each centrifuge tube, which was shaken at 37\u2009\u00b0C. At different time points , 2\u2009mL of release medium was collected, and fresh release medium of the same type was added to keep its volume unchanged. HPLC was used to determine the concentration of CUR in the collected release medium.2 atmosphere [The human lung carcinoma A549 cells were cultured in DMEM, which included 10% FBS and 1% penicillin-streptomycin, and were incubated at 37\u2009\u00b0C in 5% COmosphere , 32.2 atmosphere, the MTT solution was replaced with 150\u2009\u03bcL of DMSO to dissolve the purple MTT-formazan. Subsequently, a microplate reader was used to measure the absorbance of each well at 570\u2009nm.The in vitro cytotoxicity of CUR, BCSC micelles (BCSCs), CUR-BCSCs, and CUR-BCSC@PCs against the A549 cell line was evaluated using a standard MTT assay . The A544 cells per well and were co-incubated with CUR-BCSCs and CUR-BCSC@PCs (CUR concentration: 20\u2009\u03bcg/mL) at 37\u2009\u00b0C in a humidified atmosphere containing 5% CO2 for 1, 2, and 4\u2009h. The A549 cells were washed with PBS three times after removing the culture media containing drugs. Then, PBS containing 4% paraformaldehyde was added for 20\u2009min and washed with PBS for another three times. The cell nuclei were stained by Hoechst 33342 for 15\u2009min and observed using an inverted fluorescence microscope.The cellular uptake ability of CUR-BCSCs and CUR-BCSC@PCs was investigated under a fluorescence microscope . A549 cells were seeded in 24-well plates at 4\u2009\u00d7\u200910t test. P\u2009<\u20090.05 was set as statistically significant, and P\u2009<\u20090.01 was considered highly significant.All experiments were carried out at least three times and expressed as means \u00b1 SD. Statistical tests were analyzed using the Student\u2019s 2-S-S-CH2 appeared on the 1H-NMR spectrum of COS-S-S-CUR, proving the successful conjugation of CUR to the COS chains. Compared with the peaks of COS in Fig.\u00a03), while the resonance of CH2-S-S-CH2 at 2.5\u2009ppm was unchanged. As shown in and 3.39\u2009ppm (\u2212CH\u2013S\u2013). 1H-NMR spectrum of BCSC is shown in Fig.\u00a02-S-S-CH2 with redox sensitivity were synthesized successfully and verified using"} +{"text": "To discuss the value of applying magnetic resonance diffusion-weighted imaging (DWI) to evaluate inflammatory activity from chronic viral hepatitis B.2), and the apparent diffusion coefficients (ADCs) were measured and compared with the biopsy results of hepatic tissue.One hundred forty-two patients with chronic viral hepatitis B who received treatment at The Fifth Medical Center of Chinese PLA General Hospital from January 2014 to December 2015 and 20 healthy persons in the control group who were scheduled to undergo nuclear magnetic resonance scanning and DWI examinations , and the ADC value of the group with mild inflammation (G1) significantly differed from that of the group with moderate inflammation (G2) and that of the group with severe inflammation (G3-G4) (P<0.05).Magnetic resonance diffusion-weighted imaging technology has high clinical value for evaluating the inflammatory activity from chronic hepatitis B, and the measured ADC value corresponds to the pathological grade well, so this method is worth clinical promotion and application. In China, the number of carriers of hepatitis B accounts for ten percent of the total population. Chronic viral hepatitis is persistent and recurrent and ultimately develops into hepatic fibrosis, hepatic cirrhosis and even hepatic carcinoma, all of which gravely threaten patient health.2The current gold standard for evaluating the inflammation indexes of chronic hepatitis B is liver biopsy. However, liver biopsy is invasive and has various disadvantages, such as limited sampling, low patient compliance, and poor examination repeatability. Thus, a simple and noninvasive method with high repeatability is sorely needed to evaluate the inflammatory activity of chronic hepatitis B. Magnetic resonance diffusion-weighted imaging (DWI) technology has a clear advantage in diagnosing hepatic diseases. This study aimed to preliminarily discuss and compare magnetic resonance diffusion-weighted imaging and pathological grading in assessing inflammatory activity from chronic hepatitis B; DWI is hopefully of great clinical significance in guiding clinical diagnosis and treatment, therapeutic evaluations and follow-up visits for chronic hepatitis.One hundred forty-two patients with chronic viral hepatitis B admitted to The Fifth Medical Center of Chinese PLA General Hospital from January 2014 to December 2015 were observed, including 89 male patients and 53 female patients. The patients were aged 18 to 67 (42.5\u00b15.8 on average).The study was approved by the Institutional Ethics Committee of The Fifth Medical Center of Chinese PLA General Hospital, and written informed consent was obtained from all participants. All the selected patients complied with the diagnostic criteria as specified in the 2005 Guideline on Prophylaxis and Treatment of Chronic Hepatitis B,2/s, slice thickness 8 mm, interlayer spacing 1 mm, view 38 cmx38 cm, matrix 128x128, number of excitations 2, number of scanning layers 20, and scan time 29 s; the diffusion direction was all directions, breathless collection was conducted on the end-expiratory row, and two breath holding cycles were conducted to complete scanning.The selected patients received conventional MR scanning and DWI scanning. For the MRI examination, a GE HD x 3.0T high-intensity magnetic resonance imaging system and an 8-channel phased-array body surface coil were adopted, and the scanned area was from the diaphragmatic dome to the inferior margin of the liver. DWI scanning was followed by axial T1WI and T2WI scanning. The scanning parameters were as follows: TR 1900 ms, TE 64 ms, b=800 mm2, and blood vessels, bile ducts, and chemical shift artifacts were avoided; the average of the nine values was taken as the observed ADC value of the liver.The ADC values of three regions of interest of the same size in different locations on each of the three consecutive layers of the right rear lobe of the liver were measured with the Function tool of the software in the AW4.5 workstation equipped with a GE HDxt3.0T MR machine. The area of the region of interest was approximately 200-300 mmSPSS 21.0 software was applied for data processing and analysis, and the mean\u00b1standard deviation (\u03c7\u00b1s) was used to denote measurement data; variance analysis was adopted for intergroup comparisons, the LSD-q test was adopted for intragroup pairwise comparisons, and P<0.05 indicated statistical significance. The receive operator characteristic (ROC) curve was used to evaluate the efficiency of diagnosing liver G2 or higher inflammation via the ADC value.2 are shown in The box plots of the normal control group and different grades of inflammatory activity from chronic hepatitis B when b=800 s/mmThe overall objectives of treating patients with hepatitis B according to the Guideline on Prophylaxis and Treatment of Chronic Hepatitis B are to inhibit HBV for as long as possible, alleviate hepatocyte inflammatory necrosis and hepatic fibrosis, to delay and reduce liver decompensation, liver cirrhosis, hepatocellular carcinoma and complications thereof, to improve patient quality of life and to prolong survival time. Both domestically and internationally, it is universally considered that the key to delaying the progression of chronic hepatitis B is antiviral therapy. Sometimes, clinical and laboratory examinations are not reliable for guiding clinical treatment. Thus, pathological results are needed to guide clinic treatment, and it is noted that an ALT\u22652ULN or inflammation graded as G2 or higher and/or as S2 or higher is an indicator to initiate antiviral therapy.Early diagnosis of diffuse hepatopathy is of great significance for guiding clinical treatment and evaluating curative effects but is rarely detected with imaging, which is mainly applied for observing anatomical structure and morphological changes.2, hemoperfusion has a slight impact, and the diffusion motion of water molecules can be truly reflected, which means that clear images are obtained, and the measured ADC value is stable.The ADC value varies with the b value. Thus, it is important to apply a proper b value. The liver is a solid organ with rich blood circulation, so hemoperfusion will affect the accuracy of the ADC measurements. Studies have shown that a small b value leads to a high image SNR and a clear image; however, hemoperfusion has a great impact on the ADC value because the diffusion motion of water molecules cannot be reflected well, so the measured ADC value is overestimated. The impact of hemoperfusion is negatively correlated with the b value; a large b value will lead to a relatively accurate ADC value,The ADC value of the liver is determined by liver inflammation and fibrosis. Most previous reports did not include layering research on these two aspects, and the impact of hepatic fibrosis on the ADC value was not excluded, so the measured ADC value was relatively inaccurate. The studies by Ying et al.2, the differences between mild (G1) and moderate (G2) inflammatory activity and between mild (G1) and severe inflammatory activity are statistically significant. According to the therapeutic standards specified in the Guideline on Prophylaxis and Treatment of Chronic Hepatitis B, patients with G2 or higher inflammation should receive antiviral therapy. Thus, patients G2 or higher inflammation were taken as the inflammation group in this study, and those patients with G0-1 inflammation were taken as the non-inflammation group. According to the characteristics of the ROC curve (This study suggests that when b=800 s/mmOC curve , the areFirst, there are differences between the liver biopsy method and the method for measuring ADC values. To address this problem, an ROI of the right rear lobe of the liver was selected to measure the ADC value to be as consistent as possible with the biopsy method. Second, a single b value was applied to research the degree of inflammatory necrosis of the liver to avoid balancing the impacts of hemoperfusion and diffusion on the ADC value. Thus, multiple b values should be applied to ensure the accuracy of the measurement, which will be further discussed and studied in the future. Although DWI can be regarded as a quantitative analysis method, this study suggests that the differences in ADC value between the hepatitis group and normal control group and between the inflammation group and non-inflammation group are significant and can help make clinical antiviral therapeutic schemes, provided that the other clinical laboratory indexes are referred to.In summary, magnetic resonance diffusion-weighted imaging can reflect early diffuse lesions of the liver well, ADC measurements can help with the diagnosis, and dynamic observations of the ADC value can reveal the progression of inflammatory activity in the liver and the therapeutic effect; DWI has high application value in evaluating the inflammatory activity of patients with chronic hepatitis B and is worth clinical promotion and application.JD &YL: Collected and analyzed clinical data and prepared this manuscript, are responsible for integrity of research.HY: Designed this study.WA &HR: Significantly revised this manuscript."} +{"text": "Cervus elaphus, had \u03b413C values significantly higher than any available for such species in Europe.Proving voyaging at sea by Palaeolithic humans is a difficult archaeological task, even for short distances. In the Mediterranean, a commonly accepted sea crossing is that from the Italian Peninsula to Sicily by anatomically modern humans, purportedly of the Aurignacian culture. This claim, however, was only supported by the typological attribution to the Aurignacian of the lithic industries from the insular site of Fontana Nuova. AMS radiocarbon dating undertaken as part of our research shows that the faunal remains, previously considered Aurignacian, actually date to the Holocene. Absolute dating on dentinal collagen also attributes the human teeth from the site to the early Holocene, although we were unable to obtain ancient DNA to evaluate their ancestry. Ten radiocarbon dates on human and other taxa are comprised between 9910\u20139700 cal. BP and 8600\u20138480 cal. BP, indicating that Fontana Nuova was occupied by Mesolithic and not Aurignacian hunter-gatherers. Only a new study of the lithic assemblage could establish if the material from Fontana Nuova is a mixed collection that includes both late Upper Palaeolithic (Epigravettian) and Mesolithic artefacts, as can be suggested by taking into account both the results of our study and of the most recent reinterpretation of the lithics. Nevertheless, this research suggests that the notion that Aurignacian groups were present in Sicily should now be revised. Another outcome of our study is that we found that three specimens, attributed on grounds both of morphological and ZooMS identifications to The Making of the Middle Sea, Broodbank in a ratio of 1:1 with eluate. Spots were left to dry for three hours. Mass spectrometry was performed using a Bruker Ultraflex III MALDI-TOF-MS instrument in reflector mode with laser acquisition set to 1200. The generated spectral output was analysed using the open-source software mMass v.5.5.0 (www.mmass.org) and peptides were identified based on published unique marker ions [Prior to protein extraction, each bone chip was incubated in 100 \u03bcL of 50 mM ammonium bicarbonate solution and 8600\u20138480 cal BP (R-EVA 1871: 7775\u00b120 BP), which means that they are all early Holocene (and not Late Pleistocene). In addition, it should be noted that, with the exception of two specimens (i.e. R-EVA 1862 and 1871), all other samples have overlapping calibrated age ranges . The two human teeth (R-EVA 1895 and 1896) have yielded practically identical dates (respectively 8675\u00b125 BP and 8658\u00b125 BP) and can be considered fully contemporary, which supports the hypothesis proposed by Chilardi et al. are respectively -20.2\u00b10.7\u2030 and 5.8\u00b10.4\u2030. The \u03b415N of the only S. scrofa specimen for which data are available has a lower value than red deer, which suggests that the wild boar in question subsisted on plants and did not have a truly omnivorous diet. However, the fact that the single wild boar sample for which we have data is not contemporary to the humans precludes us from attempting to reconstruct the importance of S. scrofa relative to C. elaphus in the diet of the occupants of Fontana Nuova.The animal bones that yielded well-preserved collagen are 7 specimen . Four reC. elaphus both on morphological [13C values between -16.8\u2030 and -15.9\u2030 (mean = -16.3\u2030 \u00b1 0.5\u2030). The \u03b415N values of these specimens are all quite similar (range = 0.2\u2030) and comprised between 6.0\u2030 and 6.2\u2030 (mean = 6.1 \u00b1 0.1\u2030). This evidence suggests that the red deer in question, which as mentioned above may be represented by three or possibly four individuals, fed on a mixed diet of C3 and C4 plants and that there may have been an extremely large variability in carbon isotope ratios in early Holocene SE Sicily. Red deer are intermediate feeders, given that they are mainly browsers but can obtain around a third of their food from grasses, sedges and forbes [C. elaphus individuals with such high \u03b413C values been encountered [4 photosynthetic pathway, neither of which have been attested for prehistoric wild mammals on the northern side of the Mediterranean basin. Similarly, high \u03b413C values have been recorded in modern C. elaphus from North America, albeit from metabolically more active tissues than bone collagen (i.e. muscle) and not even in tissues with more intermediate turnover times such as the hoof [4 grasslands, but even in such cases deer prefer feeding on C3 plants [4 plant consumption during warm periods of the year [4 grasslands and, if so, how C. elaphus may have adapted to such conditions. Another theoretically possible interpretation of the high \u03b413C values is that the red deer in question were not local and had been introduced from parts of the Mediterranean Basin where C4 plants were widely present even in prehistoric times, although it is not clear why this should have been done given the abundance of this ungulate in Sicily during the early Holocene.This is also not the case of other prehistoric specimens from across Europe, even though the whole range of environments in which red deer can be found have been sampled \u201348. The elaphus . In factactylon) with C4 the hoof ,51. Thes3 plants , with po13C values are enriched by around 1.0\u2030 relative to the mean (= 20.2 \u00b1 0.6\u2030) for the faunal specimens typical of environments dominated by C3 plants. The \u03b415N values are around 6.2\u2030 higher than the mean for the four deer specimens contemporary to the humans and typical of environments dominated by C3 plants. These offsets suggest that the meat of terrestrial animals, such as C. elaphus (and possibly S. scrofa), were the main sources of dietary protein.The dentinal collagen extracted from the two human teeth has very similar isotopic compositions ; Fig 2, Bos primigenius, which in the Mediterranean context is known to have had higher \u03b415N values than C. elaphus , it is us (e.g. ). Other ell\u2019Uzzo , howeverell\u2019Uzzo ,40,41,534.5 and 5.8 million raw reads were generated respectively for samples R-EVA 1895 and R-EVA 1896. We could not identify any authentic human sequences for sample R-EVA 1895. Six reads could be aligned to the human mitochondrial genome and 429 reads to the nuclear genome of sample R-EVA 1896. The low content of authentic human DNA in sample R-EVA 1986 did not allow any further analysis.https://doi.org/10.5284/1049180). ZooMS is not currently able to distinguish between red deer (Cervus elaphus) and European elk . This is because the amino acid sequences of their collagen triple helices are almost indistinguishable, and the few peptides displaying differences do not ionize under the current experimental conditions of the MALDI-TOF-MS. However, since elk was not part of the endemic fauna of Sicily during this period [Peptide mass fingerprinting by ZooMS followed established protocols. Seven samples produced spectra that enabled species identification that were in agreement with morphological examination as part of traditional zooarchaeological analysis see . One sams period , the bonThe main outcome of our study is to have clarified the chronology of Fontana Nuova, demonstrating that the faunal and human remains, used by Chilardi and colleagues to back up their attribution of the site to the Aurignacian , actuallOverall, there are no more grounds to support the interpretation that Riparo di Fontana Nuova was the southernmost Aurignacian site in Europe , as wellA second outcome of our study is to have generated a small isotope dataset that allows us to attempt a broad reconstruction of Mesolithic diets in south-eastern Sicily. The carbon isotope composition of the two analysed human teeth is similar to that of other Mesolithic individuals from Sicily ,36,41, dC. elaphus specimens, for instance in connection to short-term climatic and environmental instability attested in Sicily during the early Holocene [4 plants from extensive grasslands (the presence of which is not attested in south-eastern Sicily), of forbes, sedges and wetland C4 vegetation or of their non-local origin. In the absence of human intervention in deer feeding, the first two scenarios would, as mentioned above, imply an unprecedented degree of niche partitioning within the same species, which is not likely in nature. In the latter case, it is possible that the deer originated from regions with a relatively high proportion of C4 grasses, which are more common around the eastern or southern coasts of the Mediterranean Sea, as hypothesized for an ovicaprid with similar isotopic values from the site of Grotta d\u2019Oriente on Favignana in western Sicily [C. elaphus, which is something that has been speculatively claimed only for protohistoric times in Sicily [C. elaphus was common in Sicily during the early Holocene, it is not clear why these animals should have been introduced. To date the only prehistoric ungulates from southern European contexts that have been found to have \u03b413C values as high as the three deer specimens from Fontana Nuova are domestic cattle specimens from the Late Neolithic site of Makriyalos in northern Greece [Bos taurus from this site have shown that some individuals acquired large proportions of their feed from pastures rich in C4 vegetation that may have included weeds such as Cynodon dactylon or, more likely, plants in marshy coastal environments enriched in 13C. In the case of the cattle from Makriyalos, their feeding areas were influenced by human management, whilst it is not clear why, if the 13C-enriched C. elaphus were actually feeding in coastal marshes, this behavior has not been documented in any of their conspecifics elsewhere in the Mediterranean or further afield.The possibility of different isotopic baselines should also be considered in attempts to explain the high carbon isotope values on three Holocene . This hyn Sicily . Anothern Sicily . This han Sicily , where in Sicily . Howevern Greece . Recent The AMS radiocarbon dates on collagen from ten skeletal remains retrieved at Riparo di Fontana Nuova assign both the fauna and humans to the Holocene. As these were used by Chilardi et al. to argueS1 Table(DOCX)Click here for additional data file.S1 Fig(JPG)Click here for additional data file.S2 Fig(JPG)Click here for additional data file.S3 Fig(JPG)Click here for additional data file.S4 Fig(JPG)Click here for additional data file.S5 Fig(JPG)Click here for additional data file.S6 Fig(JPG)Click here for additional data file.S7 Fig(JPG)Click here for additional data file.S8 Fig(JPG)Click here for additional data file.S9 Fig(JPG)Click here for additional data file.S10 Fig(JPG)Click here for additional data file.S11 Fig(JPG)Click here for additional data file.S12 Fig(JPG)Click here for additional data file.S13 Fig(JPG)Click here for additional data file.S14 Fig(JPG)Click here for additional data file.S15 Fig(JPG)Click here for additional data file.S16 Fig(JPG)Click here for additional data file.S17 Fig(JPG)Click here for additional data file.S18 Fig(JPG)Click here for additional data file.S19 Fig(JPG)Click here for additional data file.S20 Fig(JPG)Click here for additional data file.S21 Fig(JPG)Click here for additional data file.S22 Fig(JPG)Click here for additional data file.S23 Fig(JPG)Click here for additional data file.S24 Fig(JPG)Click here for additional data file.S25 Fig(JPG)Click here for additional data file.S26 Fig(JPG)Click here for additional data file.S27 Fig(JPG)Click here for additional data file.S1 Appendix(DOCX)Click here for additional data file."} +{"text": "Oridonin, a diterpenoid natural product commonly used in East Asian herbal medicine, is garnering increased attention in the biomedical community due to its extensive biological activities that include antitumor, anti-inflammatory, antimicrobial, hepatic fibrosis prevention, and neurological effects. Over the past decade, significant progress has been made in structure activity relationship and mechanism of action studies of oridonin for the treatment of cancer and other diseases. This review provides a brief summary on oridonin and its analogs in cancer drug discovery and antiinflammation and highlights its emerging therapeutic potential in neuroprotection applications. Rabdosia rubescens, a herbal plant also known as Donglingcao, was used in East Asian traditional medicine for the treatment of inflammation and cancer [1, ent-kaurane diterpenoid isolated from Rabdosia rubenscens, was first identified as an antitumor compound in 1967 [2, l-alanine-(14-oridonin)ester trifluoroacetate, www.chinadrugtrails.org.cn) in China for the treatment of acute myelogenous leukemia. In this review, we will first provide a summary of oridonin, its analogs, and their promising potential in cancer drug discovery and antiinflammation, and second, we will highlight its emerging therapeutic potential for neuroprotection. To our knowledge, this will be the first review article in the field that discusses the oridonin class of compounds as potential neurotherapeutics.Natural products derived from animals, plants, and microbes have played an important role in the treatment of human diseases since the dawn of medicine. Natural products have high chemical diversity, bio-compatible characteristics, and other molecular properties that make them advantageous as lead scaffolds for drug discovery ,2,3,4. Ad cancer . Oridoni in 1967 . It has in 1967 ,15,16,17 in 1967 ,19,20, a in 1967 , and hep in 1967 ,23,24,25 in 1967 ,27,28. O in 1967 ,30,31. F in 1967 and MDA-MB-231 (IC50 = 0.2 \u03bcM) cells, which are approximately 33-fold and 147-fold more potent than oridonin, respectively [3 has been significantly improved with a saturated concentration of 42.4 mg/mL, which is approximately 32-fold better than that of oridonin (1.29 mg/mL). Moreover, 3 significantly suppresses MDA-MB-231 xenograft tumor growth in vivo , while oridonin shows no significant efficacy at the same dose. Among the dihydropyran-fused derivatives, 4 shows the highest inhibition potency against MCF-7 (IC50 = 0.44 \u03bcM), MDA-MB-231 (IC50 = 0.54 \u03bcM), and MDA-MB-468 (IC50 = 0.52 \u03bcM) cell lines and an improved ability to overcome chemoresistance in a MCF-7/ADR cell line (IC50 = 1.6 \u03bcM) [5\u20139 display significant antiproliferative effects relative to oridonin against MCF-7 and MDA-MB-231 cells with low micromolar to submicromolar potency. Compared to oridonin, 8 shows lower toxicity in normal mammary epithelial cells and increased antitumor efficacy at a dose of 5.0 mg/kg with no significant loss of body weight in an MDA-MB-231 xenograft tumor model. Our group developed efficient and concise synthetic approaches to rapidly and diversely introduce azide functionalities at the C-1, C-2, or C-3 positions of oridonin in a highly regio- and stereospecific manner. Subsequent functionalization of these azides through click chemistry yielded triazole derivatives. These derivatives with 1,2,3-triazole installed in the A-ring system exhibit significantly improved activities against breast cancer cells compared to oridonin. Among them, 1-triazole derivative 10 displays the most potent inhibitory activities against MCF-7 (IC50 = 0.38 \u03bcM) and MDA-MB-231 (IC50 = 0.48 \u03bcM) cell lines [Compound 3 , with anectively . The aquIC50 = 0. \u03bcM cell 11 (11 exhibited more potent antiproliferative activities compared to oridonin in HepG2 (IC50 = 2.6 \u03bcM), A549 (IC50 = 5.1 \u03bcM) and Hela (IC50 = 2.0 \u03bcM) cell lines. 11 was used to confirm that a mitochondrial pathway is involved in oridonin-mediated apoptosis and that cytochrome C plays an important role in the oridonin-mediated apoptotic process. Compound 13, bearing 1-ene and a trans-cinnamic acid moiety on the 14-position designed and synthesized from compound 12, is 200-fold (IC50 = 0.08 \u03bcM) more potent than oridonin against MCF-7 cancer cells [13 significantly decreased tumor volume and reduced tumor weight by 69.8% at a dose of 20 mg/kg/day (iv) in an MCF-7 breast cancer xenograft nude mice model, which was greater than that of the positive control, cyclophosphamide (64.6%).The B-ring is inert due to the low reactivity of the 7-hydroxy group and the hydrogen bond of 6-hydroxy group with the 15-carbonyl group. The \u03b1,\u03b2-unsaturated ketone in the D-ring is the active pharmacophore of oridonin, and studies have shown that reduction or opening will significantly reduce the antiproliferative effect of oridonin ,50,51. A11 using a er cells . 13 sign14\u201315 [16\u201318 [18 at a dose of 40 mg/kg was found to exhibit greater anti-gastric cancer effects when compared to oridonin in mice [ent-kaurane diterpenoid derivatives with simpler structures and retained bioactivities serves as another key research direction for oridonin modification and diversification. The antiproliferative activities of compounds 1\u201318 against various human cancer cell lines are summarized in As oridonin is abundant in natural sources and is commercially available, it can also be used as an advantageous starting material to semi-synthesize other types of diterpenoid derivatives that are otherwise rare ,57,58,5914\u201315 ,55 and e5 [16\u201318 ,57, syntThe effect on immune and pro-inflammatory mediators is another important bioactivity of oridonin . Studies7 . Similar results were observed for 7 and 12 when compared to oridonin in HSC-T6 cells. However, no significant antiproliferative effects were observed on the human hepatocyte cell line C3A. These two derivatives were found to induce LX-2 cell apoptosis and S-phase cell cycle arrest and were associated with the activation of p53, p21, and cleaved caspase-3. It was also shown that 7 and 12 may mitigate endogenous production of \u03b1-SMA and ECM proteins type I collagen and fibronectin and inhibit TGF-\u03b2 induced type I collagen and fibronectin production at much lower concentrations compared to oridonin. Thus, oridonin and its derivatives may hold great potential as antifibrogenic agents for the treatment of hepatic fibrosis.Additionally, it has been reported that oridonin and derivatives 7 and 12 mouse model [1\u201342 induced I\u03baB\u03b1 phosphorylation and degradation, attenuating mitochondrial dysfunction, and reducing cognitive impairment in an A\u03b21\u201342 induced AD mouse model [1\u201342.Oridonin was reported to suppress microglia and astrocyte activation in the hippocampus of the A\u03b2se model . A rangese model . In conc1\u201342 in vivo and in vitro and rescued the dendritic morphological changes observed in the hippocampus of an AD mouse model. In addition, oridonin increased the expression of PSD-95 and synaptophysin and ameliorated the A\u03b2-induced reduction of mitochondrial activity in the synaptosomes of an AD mouse model [1\u201342 induced AD mouse model.\u03b2-Amyloid (A\u03b2)-mediated synaptic dysfunction plays a critical role in the pathophysiology of AD, but the underlying mechanisms for this process remain unknown ,73,74,75se model . The expse model ,77. In ase model . Oridonise model . AdditioNeurodegenerative disorders are a heterogeneous group of diseases that display diverse etiologies and may impact both the CNS and the peripheral nervous system (PNS) ,80,81. M1\u201342 induced neuroinflammation, prevent synaptic loss, suppress the NF-\u03baB pathway, and activate BDNF/TrkB/CREB and Nrf2 signaling pathways [Oridonin was found to inhibit LPS-activated microglia inflammation and A\u03b2pathways ,95,96,971\u201342 induced AD mouse models [AD, the primary cause of dementia, is an irreversible neurodegenerative disorder with progressive cognitive dysfunction, memory impairment, and behavioral maladaptions. The pathological features of AD are comprised of A\u03b2 plaques (deposition of extracellular A\u03b2) and neurofibrillary tangles . The interesting possibility for oridonin to treat AD has already been investigated in animal models by several groups. For instance, oridonin attenuates memory and cognitive deficits in A\u03b2e models ,27. An oe models . FurtherOridonin, a natural product commonly used in East Asian herbal medicine, has drawn increased attention in recent years due to its extensive biological activities and potential in the treatment of various diseases. Its unique, relatively safe, and remarkable anticancer pharmacological profile are noteworthy for drug discovery campaigns. A number of oridonin derivatives were designed and synthesized to pursue more potent and drug-like candidates for cancer therapy . HoweverF = 4.3%) or intraperitoneal injection (F = 12.6%), and high first-pass effects [3 with a thiazole fused A-ring and an additional nitrogen-containing side chain displays improved potency and aqueous solubility [Oridonin displays limited aqueous solubility, low bioavailability via oral administration ( effects ,98. Althlubility . In addilubility ,99,100. lubility ,107,108.lubility . In shor"} +{"text": "Brain Factor-7\u00ae (BF-7), silk fibroin peptide, is known to be effective in improvement of memory and learning ability. In this study, the effects of BF-7 on neuroprotection and memory and learning functions were investigated in a rat model of transient focal cerebral ischemia and a gerbil model of transient global forebrain ischemia. Furthermore, to find the mechanism of BF-7, we examined the neuroprotective and antioxidative effects of BF-7 in vitro using neuroblastoma (SH-SY5Y) cells. In vivo model, treatment with BF-7 significantly reduced the number of errors in 8-arm maze test and significantly increased latency time in passive avoidance test at 7\u2009days after focal ischemia compared to those in the vehicle-treated group. In addition, treatment with BF-7 significantly decreased the infarct size or neuronal death at 7\u2009day following transient ischemia compared to that in the vehicle-treated group. In vitro model, 10 or 20\u2009\u03bcg/ml of BF-7 treatment significantly increased cell viability in dose-dependent manner. In addition, oxidative stress was significantly attenuated in the ischemic cells, showing that 10 or 20\u2009\u03bcg/ml of BF-7 treatment significantly reduced the generation of reactive oxygen species (ROS) compared to that in the ischemic cells. These results indicate that BF-7 treatment can attenuate ischemic damages and improve memory deficits via reduction of ROS generation. Cerebral ischemia is closely related to the development of cognitive impairment . The preIschemic stroke induced by cerebral ischemia is a common disease due to occlusion of cerebral blood flow supply. Cerebral ischemia causes cellular changes which are affected by free radical production, excitotoxicity, metabolic disorder, bioenergetics failure, and activation of proteases \u201310. In a2+ channel antagonists, and NMDA/AMPA antagonists [Three methods are widely known to treat cerebral ischemia to date: 1) rapid restoration of oxygen supply, 2) prevention of inflammation in ischemic area, and 3) protection of neural cells \u201316. Curragonists , 18. HowIt has been reported that Brain Factor-7\u00ae (BF-7), silk peptide, significantly reduces amyloid \u03b2-induced apoptosis in cultured human neuronal cell SKN-SH and increases cognitive function in healthy subjects , 20. HowTwenty-one male Sprague-Dawley rats and twenty-one male Mongolian gerbils were obtained from the Experimental Animal Center, Kangwon National University . The animals were housed at conventional states which were under adequate room temperature (24\u2009\u00b1\u20091\u2009\u00b0C) and relative humidity (50\u2009\u00b1\u20095%). A constant cycle of dark/light was kept in every 12\u2009h and freely accessible food pellets and water were provided to the animals ad libitum. The protocol applied in the present study was allowed by Institutional Animal Care and Use Committee (IACUC) at Kangwon National University and adhered to the guidelines from the current international laws and policies in \u201cGuide for the Care and Use of Laboratory Animals\u201d .Bombyx mori) cocoon shell and it was supplied by Famenity Co., Ltd. [Bombyx mori and significantly reduces amyloid \u03b2-induced apoptosis in cultured human neuronal cell SKN-SH and increases cognitive function in healthy subjects [BF-7 is a patented fibroin extract product manufactured by solubilization, degumming, desalination, enzymatic hydrolysis, and freeze-drying process from the silk were randomly divided into three groups: (1) the sham-operated group (sham group), (2) vehicle treated ischemia-operated group (vehicle-ischemia group), (3) the BF-7 (10\u2009mg/kg) treated ischemia-operated group (10\u2009mg/kg BF-7-ischemia group). BF-7 or normal saline (vehicle) were orally administered once a day for 7\u2009days before and for 7\u2009days after inducing cerebral ischemia.To examine whether BF-7 treatment attenuated ischemic brain damage (infarction) following focal cerebral ischemia, rats (n\u2009=\u200921) were grouped as follow: (1) the sham-operated group (sham group), (2) vehicle treated ischemia-operated group (vehicle-ischemia group), (3) the BF-7 (10\u2009mg/kg) treated ischemia-operated group (10\u2009mg/kg BF-7-ischemia group). BF-7 or sterilized normal saline were orally administered once a day for 7\u2009days before and for 7\u2009days after inducing cerebral ischemia.In addition, to examine neuroprotection against selective neuronal death induced by transient forebrain ischemia, gerbils in 33% oxygen and 67% nitrous oxide via face mask. Anesthesia was maintained with 2% isoflurane. A rectal temperature probe was introduced, and a heating pad maintained the body temperature at 37\u2009\u00b0C during the surgery. Focal cerebral ischemia was induced by MCAO on the right side as described previously . In brieAccording to our published procedure , spatialAccording to our published procedure , short-tn\u2009=\u20097 per group) were deeply anesthetized [According to our published procedure , the affthetized . And, thAfter TTC reaction, infarct volume was measured using Image J analysis software (version 1.6 NIH). Unstained areas were defined as ischemic lesions. The infarct volume was calculated according to the slice thickness of 2\u2009mm per section. Each side of the brain slices was measured separately, and the mean values were calculated. Infarction area at each section is expressed as a percentage of corresponding brain section volume.The surgical procedure was performed as previously described . In shorTo investigate histopathological analysis, tissues were prepared in accordance with a previously described method . BrieflyCresyl violet (CV) staining was carried out according to a previously published method . In shorFluoro-Jade B with a highly affinitive fluorescent histofluorescence staining was conducted. As described previously , in brieTo analyze changes in CV- and F-J B- positive cells, the images of CV staining and F-J B histofluorescence were obtained by using light microscope (BX53) and epifluorescent microscope (470\u2013490\u2009nm of blue excitation light) , respectively, which were equipped with a digital camera (DP72) coupled with a PC monitor. Cell count was done by averaging total numbers of the CV- and F-J B-positive cells using an image analyzing system (software: Optimas 6.5) .SH-SY5Y (human neuroblastoma) cells were provided by the Korean Cell Bank . Dulbecco\u2019s modified Eagle\u2019s medium and 10% heat-inactivated fetal bovine serum (FBS) were purchased from Thermo Fisher Scientific .2 incubator. The cells were transferred to low serum media (10% FBS) for two hours before the treatment with BF-7.According to the previous study , Human n4 cells/well in 100\u2009\u03bcl of 10% FBS/DMEM and incubated for twenty-four hours. The media was replaced with 90\u2009\u03bcl of 10% FBS/DMEM. The BF-7 (10 and 20\u2009\u03bcg/ml) were treated to cells and incubated for four hours. And then, H2O2 (0.25\u2009\u03bcM) was treated to cells and incubated for twenty-four hours. After the treatment, cell viability was evaluated according to the previous study [The SH-SY5Y cells were plated on 96-well plates at a density of 5\u2009\u00d7\u200910us study , in brieus study .2O2 was measured by incubation with a fluorescent probe 2\u2032, 7\u2032-dichlorofluorescein diacetate (DCF-DA), according to the previous study [4 cells/well in 200\u2009\u03bcl of 10% FBS/DMEM and incubated for twenty-four hours. The media was replaced with 160\u2009\u03bcl of 10% FBS/DMEM. The BF-7 (10 and 20\u2009\u03bcg/ml) and DCF-DA solution were added to the cell and incubated for four hours. And then, H2O2 (0.25\u2009\u03bcM) was added to the cell and incubated for two hours. The absorbance of the cells was measured with excitation at 485\u2009nm and emission at 530\u2009nm by a fluorometer.Hydrogen peroxide generation induced by Hus study . The celP\u2009<\u20090.05 was considered as statistical significance.The data were presented as means \u00b1 standard error of the mean (SEM). Differences of the means among the experimental groups were statistically analyzed through Student\u2019s t-test for infarction area, one-way ANOVA for latency time and ROS generation, and two-way ANOVA for number of errors. All statistical analysis was performed using SPSS 17.0 software and The number of errors from 1\u2009day to 5\u2009days showed nearly no difference in the in the sham group . In the vehicle-ischemia group, advanced infarct lesion was developed due to MCAO Fig.\u00a0a. In vehIn the vehicle-sham group, pyramidal neurons in all hippocampal subregions were well stained with CV Fig.\u00a0Aa-Ac. In2O2 group, condensation and segmentation of the cell bodies were found, and the typical apoptotic pattern was detected when the external change of cells was observed to investigate the morphological apoptotic pattern was found Fig.\u00a0. Howeversed Fig. . In the oup Fig. .Fig. 6EScrophulariae Radix, which belongs to Scrophulariaceae family, ameliorated infarct lesion in the brain of a rat model of MCAO via regulation of mitogen-activated protein kinase pathway [Until now, various kinds of natural resources have been studied because of their neuroprotective potentiality against cerebral ischemia. For example, a previous study showed that aqueous extract from pathway . In addi pathway , 30. To Many studies have demonstrated that decline in learning and memory function is closely related to hippocampus damage in in vivo cerebral ischemia models , 31. In In our in vivo assessments, the infarct lesion was visualized by TTC assay following focal cerebral ischemia induced by MCAO in rats , 33, and2O2 was applied to SH-SY5Y cells, however, BF-7 treatment exerted cellular protective effects and significantly inhibited ROS generation in dose-dependent manner. Similarly, previous studies showed that BF-7 significantly decreased ROS generation and resulted in the prevention of amyloid \u03b2 (A\u03b2) peptide-induced apoptosis in human neuroblastoma SKN-SH cells [4-induced apoptosis in neuroblastoma SK-N-SH cells [25\u201335 induced cytotoxicity in primary hippocampal neurons [In our current in vitro assessments, cell viability was significantly decreased, and ROS generation was significantly increased when oxidative stress by HSH cells and FeSOSH cells . In addi neurons . Based oIn summary, the results of our current study showed that BF-7 administration significantly attenuated cognitive deficits and prevented neuronal cell damage following focal and global cerebral ischemia in rodents. In addition, BF-7 treatment significantly reduced ROS generation in vitro. These results indicate that BF-7, a silk peptide, could protect neuronal cells from ischemic injury by inhibiting ROS generation. Therefore, it is considered to be of sufficient value to develop more accurate pharmacological mechanisms as a therapeutic agent for cognitive impairment caused by cerebral ischemia."} +{"text": "Helianthus annuus L.) extracts obtained from the aerial parts of plants harvested at five growth stages. In vitro assays were used to determine the antioxidant activity, i.e., ABTS\u2022+ and DPPH\u2022 scavenging activity, the ferric-reducing antioxidant power (FRAP) and the ability to inhibit \u03b2-carotene\u2013linoleic acid emulsion oxidation. Phenolic compounds, such as mono- and dicaffeoylquinic acid isomers and caffeic acid hexose, were identified using the LC\u2013TOF\u2013MS/MS technique. The predominant compound during the growth cycle of the plant was 3,5-di-O-caffeoylquinic acid, whose content was the highest at the mid-flowering stage. The total phenolic content was also the highest in sunflowers at the mid-flowering stage. The main phenolic compound contents were closely correlated with ABTS\u2022+ and DPPH\u2022 scavenging activity and FRAP. No significant correlation was found between the total phenolic content and the antioxidant activity in the emulsion system. The highest antiradical activity and FRAP were generally determined in older plants (mid-flowering and late flowering stages). In conclusion, the aerial parts of sunflowers, in particular those harvested at the mid-flowering stage, are a good plant material from which to obtain phenolic compound extracts, albeit mainly of one class (esters of caffeic acid and quinic acid), with high antioxidant activity.The aim of this study was to evaluate the differences in the antioxidant activity and phenolic profile of sunflower ( There is scientific evidence that the overproduction of reactive oxygen species (ROS) in cells of the body beyond those needed for the effectiveness of the antioxidant defense system may cause damage to such biomolecules as lipids, proteins and DNA, and as a consequence may lead to various degenerative diseases, including cancer, diabetes mellitus, cardiovascular disease, hypertension, rheumatoid diseases, arthritis and neurodegenerative diseases ,2,3. TheHelianthus annuus L.) is a short season plant that is native to North America and is currently grown worldwide. It is generally planted for seed and oil production purposes. Sunflower seeds are the fourth largest source of edible oil after soybean, rapeseed and peanut \u2013 parent ion at m/z 353 and MS2 base fragment ion at m/z 191 (quinic acid moiety). Moreover, a low intensity of the fragment ion at m/z 179 (caffeoyl moiety) was noted for compound 3, but not for compound 1 . Three compounds (5\u20137) showing [M\u2013H]\u2013 ions at m/z 515, and the MS2 base fragment ions at m/z 353 were found to be dicaffeoyquinic acid isomers. Further identification of these diacyl-quinic acids was performed, on the basis of the intensity of the MS/MS ions and two dicaffeoylquinic acids in sunflower leaves. Masson et al. [O-caffeoylquinic acid, 4-O-caffeoylquinic acid and four dicaffeoylquinic acid isomers in leaves. They also found hydroxycinnamaic acid derivatives, including salicylic acid glucoside, syringic acid (formide adduct) and isomers of p-coumaroylquinic and feruloylquinic acids. Chlorogenic acid, caffeic acid hexosides and four dicaffeoylquinid acids have also been determined from extractable phenolic compounds of sunflower ray and disk florets [The phenolic compounds identified in our study had previously been found in various morphological parts of sunflowers. Fernandez et al. identifin et al. detected florets . However florets ,25,26, wO-caffeoylquinic acid, and its content ranged from 11.14 to 20.45 mg/g extract, which corresponds to 0.306\u20130.722 mg/g FM. The chlorogenic acid content was almost two times lower in both the extract and plant FM . The other compounds that were observed in the extract and FM, with decreasing content, were as follows: 4,5-di-O-caffeoylquinic acid > 3,4-di-O-caffeoylquinic acid > neochlorogenic acid. The two compounds (caffeic acid hexose and cryptochlorogenic acid), which were only identified at some growth stages, were found in traces (<0.005 mg/g FM) and are therefore not presented in O-caffeoylquinic acid were present at the late flowering and stem extension stages, respectively, with similar (p \u2265 0.05) amounts as at the mid-flowering stage. Among the phenolic compounds, the 4,5-di-O-caffeoylquinic acid content was the most varied (p < 0.05) over the growth stages. Interestingly, the content of this dicaffeoyquinic acid isomer was low in the extract obtained from sunflowers at the late flowering stage, but this was not the case for the other phenolic compounds.The results of the quantitative analysis of the main phenolic compounds of the extracts and FM of sunflowers at various growth stages are presented in O-dicaffeoylquinic isomer was the main one in the florets, while 3,5-di-O-caffeoylquinic acid was the main one in the aerial parts of sunflowers.Chlorogenic acid has been determined as the main phenolic compound of sunflower seeds and it constitutes 43\u201373% of the total phenolic content when extracted from kernels ,22. DicaSclerotinia sclerotiorum. In turn, Fernandez et al. [The changes in TPC and individual phenolic content during the sunflower growth cycle reported in the present study can be linked with the physiological role of phenolic compounds in plants. In sunflower tissues, caffeoylquinic acids are considered to be precursors of coumarins which, in turn, play a role in biotic and abiotic stress resistance ,41,42. Pz et al. selectedz et al. . The pooz et al. found thO-caffeoylquinic acid and 3,5-di-O-caffeoylquinic acid contents . The correlations between TPC and the neochlorogenic and chlorogenic acid contents were also significant . Only the relationship between the TPC and the 4,5-di-O-caffeoylquinic acid content was not significant (r of 0.699) for the extracts.The sum of phenolic compounds in the aerial parts of sunflowers harvested at various growth stages determined by HPLC\u2013DAD correlated closely with the TPC. The correlation coefficients (r) were 0.961 and 0.987 for results expressed on the basis of the extracts and FM, respectively. Moreover, the relationships between TPC and contents of most of the individual phenolic compounds were significant. Very high r values were found for correlations of TPC with 3,4-di-\u2022+ and DPPH\u2022) and to reduce ferric ions. The results of these determinations are presented in 50 and FRAP values, respectively. The TEAC of the extracts at the stem extension, visible bud and early flowering stages was comparable (p \u2265 0.05) and within the 0.20\u20130.22 mmol TE/g extract range. No difference in TEAC was observed for the sunflower FM for the first 50 days of growth (6.05\u20136.16 \u00b5mol TE/g FM). In addition, the aforementioned growth stages did not lead to differences in the extract and plant FM, in terms of FRAP. The TEAC of the extract and plant FM increased significantly (p < 0.05) between the early flowering and mid-flowering stages, as did the FRAP of the plant FM. The values determined in the next growth stage\u2014late flowering\u2014did not differ significantly (p \u2265 0.05) from those at the mid-flowering stage in either assay. The DPPH\u2022 scavenging activity of the mid-flowering stage extract was significantly higher (p < 0.05) than that at the visible bud stage. The EC50 values were 0.13 and 0.21 mg/mL, respectively. The antiradical activity and reduction power of the extracts of the aerial parts of sunflowers, like the previously mentioned TPC, were comparable or higher than those reported for other sunflower by-products [\u2022 by 50% [2+/g extract, respectively [The antioxidant activity of sunflower extracts obtained from plants harvested at various stages of the growth cycle was determined as the ability to scavenge free radicals of the extracts, at various growth stages, were closely correlated with the TPC and the sum of phenolic compounds determined by HPLC\u2013DAD . Significant correlations were also found between the results of the antioxidant activity (TEAC and FRAP) on the basis of the sunflower FM and TPC , as well as the sum of phenolic compounds . The high r values of these correlations may be due to the similar antioxidant activity of the main phenolic compounds and their comparable contribution to the activity of the extract. In a previous study, Amakura et al. [O-caffeoylquinic acids isolated from sunflower seeds was only slightly higher than that of chlorogenic acid, and that the activity of 4-O-caffeoylquinic and 3-O-caffeoylquinic acids was only about 20% lower. In turn, Kim et al. [\u2022 scavenging activity of 3,5-di-O-caffeoylquinic and 3,4-di-O-caffeoylquinic acids. The abovementioned correlations indicate the main role of phenolic compounds in the antioxidant activity of the extracts of the aerial parts of sunflowers at all growth stages. In the sunflower seeds and leaves, non-phenolic antioxidants have also been determined, including tocopherols and volatile compounds [The TEAC, FRAP and DPPHa et al. found thm et al. reportedompounds ,45. Howe50) and \u22120.931 (FRAP/EC50) for the extracts and 0.964 (TEAC/FRAP) for the plant FM. Significant correlations between TPC, TEAC, FRAP and EC50 were also found in a previous study, by means of principal component analysis, on extracts of the aerial parts of other plants collected at various growth stages [High correlation coefficients were obtained when the results of antioxidant assays were correlated. These coefficients amounted to 0.914 (TEAC/FRAP), \u22120.920 was found between the percentage of non-oxidized \u03b2-carotene after 180 min of oxidation of the emulsion with the addition of extracts and the TPC of those extracts. The correlations of the TEAC, FRAP and DPPH\u2022 scavenging activity with the results of the antioxidant activity in the \u03b2-carotene\u2013linoleic acid system were not significant either (p \u2265 0.05). This phenomenon could be due to the different polarity of the antioxidant activity measurement systems and the different activities of the compounds present in the extracts under polar conditions and in the lipid emulsion system.The antioxidant activity of sunflower extracts was also determined at various growth stages using \u03b2-carotene\u2013linoleic acid emulsion. The ability of the extract to inhibit the oxidation of the model system is shown in O-caffeoylquinic acid. Phenolic compounds were responsible for the antiradical activity and reducing power of the sunflower extracts in the ABTS, DPPH and FRAP assays, as evidenced by significant correlations of the total phenolic content with the results of these antioxidant assays. The contribution of the phenolic compounds to antioxidant activity was not so obvious in the \u03b2-carotene\u2013linoleic acid emulsion system. The highest antioxidant activity in the ABTS, DPPH and FRAP assays was generally determined in older plants (mid-flowering and late flowering stages).Our study shows, for the first time, the differences in the antioxidant potential and phenolic compound profile of the aerial parts of sunflowers during the growth cycle. The extracts and fresh matter of sunflowers collected from mid-flowering plants were richer in phenolic compounds than those harvested at earlier and later (late flowering) growth stages. This result was determined considering the total phenolic content assayed with Folin\u2013Ciocalteau phenol reagent, the sum of phenolic compounds obtained by HPLC\u2013DAD and the contents of most individual phenolic compounds. The main phenolic compounds observed throughout the entire sunflower growth cycle were mono- and dicaffeoylquinic acids with the highest content being of 3,5-di-Given the above, the aerial parts of sunflowers, in particular those collected at the mid-flowering stage, and their obtained extracts can be considered as a source of phenolic compounds, that is, mono- and dicaffeoylquinic acids, which are characterized by high antioxidant activity, particularly under polar conditions. This source of natural antioxidants has the potential for future applications both as a health-promoting ingredient of functional food and cosmetics and as an additive to food and cosmetic products that increase their shelf-life."} +{"text": "Soft tissue sarcomas (STS) are heterogeneous rare malignancies comprising ~1% of all solid cancers in adults and including more than 70 histological and molecular subtypes with different pathological and clinical development characteristics. Over the last two decades, the increased knowledge of the new molecular and genomic mechanisms of different STS histotypes allowed for a reclassification of these tumors and consequently to the development of novel chemotherapeutic agents. Generally, surgery, in combination with radiotherapy only in selected cases of localized disease, represents the most common treatment of primary STS, whereas the principal treatment modality for locally advanced or metastatic disease is first-line chemotherapy. The principal treatment for the preponderance of STS patients is usually an anthracycline (epirubicin and doxorubicin) in monotherapy or in combination with other drug novel chemotherapeutic agents. However, survival for treated patients with metastatic disease is poor, and a 2-years survival rate is about 30%. In this scenario, Pharmacogenomics (PGx) biomarkers that can predict drug response play an important role in the improvement of molecular diagnostics in clinical routines and contribute to elucidating the genetic basis for the differences in treatment efficacy and toxicity among STS patients. This review focuses on recent insight in the PGx biomarkers that have been described to modulate responsiveness and toxicity parameters of conventional and new chemotherapeutics drugs in several STS histotypes. Soft tissue sarcomas (STS) are heterogeneous rare malignancies representing of about 1% of all solid tumors in adult and including more than 70 histological and molecular subtypes with a multiplicity of pathogenic and clinical development features . STSs orOver the last two decades, the increased knowledge of the new primary molecular and genomic mechanisms of different STS histotypes allowed to a reclassification of these tumors and consequently to the discovery of innovative chemotherapeutic agents . OverallDespite the prominent progress in discovering genetic aberrations and their functions in STS, the major therapeutic modality for most local recurrence and metastatic sarcomas remains cytotoxic chemotherapy. Generally, surgery, in combination with radiotherapy only in selected cases of localized disease, represents the most common treatment of primary STS, whereas the principal treatment modality for locally advanced, or metastatic disease is chemotherapy. First-line drug protocol for the preponderance of STS patients is usually an anthracycline (epirubicin and doxorubicin) alone or in combination with another drug , 10. HowTherefore, there is an urgent need to develop novel treatments and find biomarkers that can help physicians to identify patients who are possible good responders or resistant to specific therapies and predict individual predisposition to toxicity reactions associated with therapies.Differences in pharmacological response to drugs represent the most common cause of patient morbidity and mortality. From this specific point of view, pharmacogenomics (PGx) biomarkers that can predict drug response play an important role in the improvement of molecular diagnostics in clinical routines and contribute to elucidating the genetic basis for the differences in treatment efficacy and toxicity among patients. Moreover, PGx markers predicting efficacy or risk to develop adverse drug reactions (ADRs) are commonly positioned in transporters, drug-metabolizing enzyme genes, drug targets, or HLA alleles.Genetic variability harboring in the germline genome of the patient can influence systemic pharmacokinetics and pharmacodynamics of the treatments, acting as prognostic biomarkers for drug-induced toxicity and treatment efficacy. Instead, the aberrations in cancer somatic genome mostly function as drug targets and they can be used to select treatment or to be predictive of response to treatment .Very penetrant predisposed mutations and frequent genetic variants particularly single-nucleotide polymorphisms (SNPs) which heredity pass between the generations represent the mostly germline variations that are considered as useful biomarkers for ADR and drug response. Contrary, due to exposure to chemotherapeutics that likely act through damage to DNA, cells could acquire randomly somatic mutations that are potentially used as drug targets , 13.Thanks to significant improvements in biotechnology and bioinformatics knowledge, genomic research quickly advanced from investigations based on modifications at the single gene level to studies on the whole-genome scale using extensive genotyping, and Next Generation Sequencing (NGS) methods. These new methodologies considerably decrease sequencing times and costs and allow early detection of disorders and identification of pharmacogenomics markers to customize treatments , 14.Candidate gene methods are performed to recognize most of the germline variations while genome-wide association (GWAS) approach is archived sequencing up to a large number of SNPs. On the other hand, somatic mutations from cancer genomes are analyzed through NGS technique that uses the concurrent sequencing of a huge number of DNA parts to create an enormous pool of genomic arrangement information. This procedure allowed genotyping a selected number of the gene of interest (gene panel), the complete exome or the whole genome.In this review, we outline recent studies on PGx biomarkers that have been described to modulate responsiveness and toxicity parameters of conventional and new option chemotherapeutics drugs in several STS histotypes , 2.Several germline biomarkers could impact on effectiveness of therapies and survival in STS patients and may be useful to stratify patients liable to develop treatment-associated toxicities.Ecteinascidia turbinate.One of the new therapeutic alternatives among the few options of STS treatments is trabectedin (Yondelis) a marine-derived compound extracted from the Caribbean Sea squirt In phase III clinical trial in advanced leiomyosarcoma and liposarcoma patients showing progression disease after anthracycline-based chemotherapy, trabectedin significantly increases disease control respect to conventional dacarbazine treatment .Italiano et colleagues have pointed out the relationship of precise haplotypes associated with trabectedin sensitivity to specific SNPs within the BRCA1 gene of the mutated BRCA2 gene. These analyses corroborate the assumption that different DNA repair defects existing in tumors positively conditioned the response to trabectedin and that BRCAness malignant genotype is significant in influencing the effectiveness of treatment including trabectedin .VEGFRA2, VEGFA, and Solute Carrier Organic Anion Transporter Family Member 1B3 (SLCO1B3) display a correlation of these SNPs with PFS in patients with advanced GIST receiving imatinib are the most prevalent tumors of the gastrointestinal tract origin from mesenchymal lineage . Mutatioimatinib . GeneticKloth and colleagues. In this study, PFS and OS in 127 patients with advanced GIST treated with sunitinib were associated with 49 SNPs involved in the pharmacokinetic and pharmacodynamic pathway of this TKI. More specifically, PFS was significantly extended in carriers rs1056878 (TT genotype) in Cytochrome p450 oxidoreductase (POR). Otherwise, the presence in patients carrying the T-allele in SLCO1B3 rs4149117, the CCC-CCC alleles in SLC22A5 haplotype, and the GC-GC alleles in the IL4 R haplotype were predictive for OS -mediated angiogenesis and by directly blocking PDGFRs, fibroblast growth factor receptors (FGFRs), and KIT , 30. Ther damage .Genetic analysis of STS shows low mutational load including predominantly by copy number changes . Whole-eTP53 mutations were shown to have significant association with a longer PFS respect to TP53 wild-type. Predictors factors of pazopanib effectiveness and toxicity in STS patients are associated also with modulation of cytokines and circulating angiogenic factors in serum , revealsin serum . Indeed,Gemcitabine, in monotherapy or combined with docetaxel, has been usually approved in leiomyosarcoma and angiIntracellular uptake of prodrug gemcitabine into tumoral cells takes place through a transmembrane protein human equilibrative nucleoside transporter 1 (hENT1) . A recenp < 0.01) and longer median survival . Interestingly, patients with decreased level of mRNA BRCA1 showed a better median PFS and a progression-free at 6-months (PFS-6) after treatment . Moreover, a significant correlation between increased responses to trabectedin treatment with high expression level of ERCC5/XPG complex was also observed in patients showing an improvement in term of disease control rate , median PFS , and PFS after 6 months after trabectedin therapy . These data support the hypothesis of a direct association between DNA damage repair system functionality and responsiveness to trabectedin, differently from other DNA interacting agents.Not only germline variants as discussed before but also somatic alterations in the homologous repair system are reported to be responsible for a deeper and longer activity of trabectedin in STS patients where drug response is inversely correlated with the BRCA1 mRNA levels . In thisIn myxofibrosarcoma, a common adult STS characterized by a high local recurrence rate and infiltrative growth pattern surgery combined with neoadjuvant or adjuvant radiotherapy represent the standard care in localized disease \u201342. HoweGenotyping analysis in patient-derived MFS primary cultures demonstrated the promising role of surface glycoprotein CD109, a negative regulator of transforming growth factor-beta (TGF-\u03b2) pathway in the differential diagnosis of more aggressive high-grade myxofibrosarcoma identifying this marker as a possible therapeutic target . MoreoveRB1, CDKN2A, CDKN2B, CCND1, and CDK6) with a worse overall survival as well as TP53 alteration and KRAS amplification. Thus, considering as PGx markers in a specific subset of these tumors genetic alterations in the Rb pathway, comprising CCND1 or CDK6 amplification, these data will contribute to knowledge for the use of novel therapeutic approaches such as CDK4/6 inhibitors.In an extensive integrated genetic and epigenetic study of 99 myxofibrosarcoma performed by WES, RNA sequencing, and methylation analysis, a large number of driver genes were identified as potential drug targets and molecular prognostic factors in this STS histotype . This stBesides genetic factors, epigenetic modifications of DNA together with miRNA regulation of gene expression have been linked to differences in drug response, through regulation key drug-metabolizing genes or increasing expression of drug efflux transporters \u201349.Halichondria okadai. The inhibition of tubulin by eribulin induces G2/M cell-cycle arrest, disruption of mitotic spindles, and, finally, apoptosis. Patient-derived primary coltures of adipocytic and undifferentiated pleomorphic sarcoma demonstrated high sensitivity to eribulin (The role of these biomarkers in mediating chemotherapy efficacy was underlined in eribulin-based therapies in STS patients. Eribulin mesylate is a microtubule inhibitor equivalent to halichondrin B derivate from the marine sponge eribulin , 51. Moreribulin \u201354. miRNeribulin .Pharmacogenomics studies of anti-cancer drugs in STS play an important role in identifying patients avoiding adverse events, and optimizing drug dose. The aim of these investigations is to take advantage of personalized chemotherapies regarding cancer treatment and prevention. Development in NGS technologies has been open a new opportunity for characterizing the genomic landscape of these tumors, together with the possibility of applying the genetic diagnostic tests relevant in cost-benefit analysis. However, due to the several rare STS histological subtypes harboring specific fusion genes , certainFinally, future studies in this field should be considered in terms of identification and validation of drug-sensitivity test systems for routine use that include known specific PGx markers in common clinical management.CC contributed to references collection of the study. CG contributed to the writing of this manuscript. All authors approved the final version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest."} +{"text": "High dynamic range (HDR) images give a strong disposition to capture all parts of natural scene information due to their wider brightness range than traditional low dynamic range (LDR) images. However, to visualize HDR images on common LDR displays, tone mapping operations (TMOs) are extra required, which inevitably lead to visual quality degradation, especially in the bright and dark regions. To evaluate the performance of different TMOs accurately, this paper proposes a blind tone-mapped image quality assessment method based on regional sparse response and aesthetics (RSRA-BTMI) by considering the influences of detail information and color on the human visual system. Specifically, for the detail loss in a tone-mapped image (TMI), multi-dictionaries are first designed for different brightness regions and whole TMI. Then regional sparse atoms aggregated by local entropy and global reconstruction residuals are presented to characterize the regional and global detail distortion in TMI, respectively. Besides, a few efficient aesthetic features are extracted to measure the color unnaturalness of TMI. Finally, all extracted features are linked with relevant subjective scores to conduct quality regression via random forest. Experimental results on the ESPL-LIVE HDR database demonstrate that the proposed RSRA-BTMI method is superior to the existing state-of-the-art blind TMI quality assessment methods. High dynamic range (HDR) imaging, as a popular image enhancement technology, aims at recovering the detail information in bright and dark regions of images by fusing multiple low dynamic range (LDR) images with varying exposure levels . ConsequUp to now, a large number of perceptual IQA methods designed for LDR images have been proposed ,6, and cObviously, the development of blind IQA (BIQA) methods is more challenging compared with FR-IQA methods due to the lack of a reference image. Generally, most BIQA methods designed for ordinary 2D images (2D-BIQA) are based on the framework of supervised learning, that is, several quality-aware features are extracted from images and quality regression is conducted via the model trained by machine learning or deep learning algorithms ,14,15,16Actually, some BIQA methods specialized for TMIs (TM-BIQA) have been presented in the past three years ,24,25,26Towards a more accurate evaluation for TMIs, a blind TMI quality assessment method based on regional sparse response and aesthetics is proposed in this paper, denoted as RSRA-BTMI. The basic consideration of RSRA-BTMI is that we attempt to dig some quality-aware features from imaging and viewing properties of TMIs, i.e., we focus on exploring the specific perceptual characteristics for DB-regions in TMIs, so that extracting both local and global features to portray the detail loss and color unnaturalness. In summary, the main contributions of this paper are described as follows.(1)Inspired by the viewing properties in visual physiology, i.e., the quality of images is perceived by HVS from global to local regions, multi-dictionaries are specially designed for DB-regions of TMIs and entire TMIs via dictionary learning. Moreover, the self-built TMIs training dataset for dictionary learning in this study is available for the further research demand.(2)Each region is sparsely represented to obtain the corresponding sparse atoms activity for describing the regional visual information of TMIs, which is closely related to visual activity in the receptive fields of simple cells. In addition, a regional feature fusion strategy based on entropy weighting is presented to aggregate the above local features.(3)Motivated by the fact that HVS prefers an image with saturated and natural color, the relevant aesthetic features, e.g., contrast, color fidelity, color temperature and darkness, are extracted for global chrominance analysis. Besides, residual information of entire TMIs is fully utilized to simulate global perception of HVS, and the NSS based features extracted from residual images are combined with the aesthetic features to form the final global features.The rest of the paper is organized as follows: The proposed RSRA-BTMI method is described in Different TMOs will inevitably cause detail loss in DB-regions of TMIs and this kind of distortion usually affects the TMIs\u2019 quality with specific means, which indicates the importance of detail information in the DB-regions to IQA of TMI, especially in the bright and dark regions . In the To obtain the perceptual features in the sparse domain, a novel TMI training dataset is constructed as the basic of multi-dictionary learning. Specifically, we selected 20 pristine HDR images with different kinds of scenes from existing HDR image datasets ,32 and gregB, regN and regD, respectively, and the whole TMI is denoted as regG. regB, regN and regD, respectively. Obviously, it can be found that different TMIs appeared to have detail loss with different degrees in the three brightness regions. Then, these segmented images were regarded as region masks for the following block extraction with DB-regions. Specifically, TMIs were divided into multiple non-overlapping blocks with the same size, and these blocks were categorized as three subsets via the obtained region masks. Finally, each image in the TMI training dataset contained four kinds of blocks, that is, regB, regN, regD and regG, respectively.Inspired by viewing properties in visual physiology, HVS tends to perceive the detail information of TMIs from DB-regions, especially the bright and dark regions in an image. Therefore, an advanced brightness segmentation algorithm via entropy is firstm is the number of atoms and every atom is an n-dimensional vector. Let Ti represents the i-th block of DB-regions or the global region, N is the total number of blocks. In short, the input source of dictionary learning is sampled from image block samples. In the proposed method, taking t is the initial error threshold, which is set to 5 empirically. Here, the K-SVD algorithm [To conduct regional sparse representation, multi-dictionaries based on brightness segmentation were obtained first, which contained three regional dictionaries and one global dictionary. At present, several dictionary learning algorithms have been proposed, and the principle idea is to find out a set of representative atoms that can approach the training data optimally on the condition of specific sparse constraint. Generally, let lgorithm is selecregB, regN, regD and regG were obtained as shown in To obtain the regional sparse responses, the multi-dictionaries about Feature coding is an effective means to obtain a set of novel feature representations by transforming the original feature space into the target dictionary space, and the corresponding activity of each atom can be regarded as the final feature code. Here, we made a series of analyses to quantify the detail distortion of DB-regions. Firstly, we divided the distorted TMI into multiple non-overlapping blocks with the same ways in the previous dictionary learning stage, and categorized them as four subsets coeffSC denote the all sparse coefficients, coeff-lSC denote the sparse coefficients of less than zero and coeff-gSC denote the sparse coefficients of greater than zero. Moreover, coeff-lSC and coeff-gSC are extracted by setting the other type of coefficients to zero for analyzing their contributions on sparse representation, respectively. Then, image reconstruction was conducted by only using one type of coefficients to observe the restored TMIs and the corresponding histogram distribution.Actually, the obtained sparse coefficients can characterize the activity type of atoms in DB-regions, so exploring the potential statistical rules of sparse coefficients is considered as a meaningful way for feature representation. Since the sparse coefficients are made up of many values, for brevity, let coeff-lSC contained more information of the original TMI compared with the image reconstructed by coeff-gSC, which indicates that the atomic energy was mostly concentrated in coeff-lSC. To further illustrate the significant role of coeff-lSC for identifying the detail loss of DB-regions in TMI, we selected three TMIs generated by different TMOs and reconstructed them with the corresponding coeff-lSC. The reconstructed results and histogram statistics are shown in coeff-lSC could reconstruct the image well, the distortion information will also be mainly reflected in coeff-lSC, and some redundancy could be eliminated by aggregating the features with coeff-lSC.coeff-lSC, which is expressed as:coeff-lSC. If According to the above analysis for the sparse atom, visual information could be simply quantified by the activity statistics of n and the corresponding blocks were aggregated to obtain the matrices To aggregate the sparse features extracted from three brightness regions, i.e., F1 could be calculated as:F1, namely m, was set to 128, and we will give the specific explanations in Finally, the optimized sparse atomic activity statistics features Ig can be simply obtained by calculating the difference between the reconstructed TMI with pretrained global dictionary In general, HVS first focuses on the global perception of an image unconsciously, and gradually turns to some specific local regions . In termIg to quantize the distortion, which is expressed asIg at the position of Ig, respectively.Furthermore, the mean subtracted contrast normalized (MSCN) coefficients of the image appears to have a certain statistical rule, that is, when an image is impaired with single or multiple distortion, the relevant natural statistical distribution of the MSCN coefficient will be destroyed. Therefore, the MSCN operation was conducted first on the global residual image In addition, we also explored the statistical rules among the neighboring pixels of residual image, and the relevant pairwise products of neighboring MSCN coefficients along four directions were calculated asIn conclusion, the final regional sparse response features consist of two types of feature sets, i.e., sparse atomic activity and global reconstruction residual statistics, which describe the regional and global visual information in the sparse domain, respectively.Although the trend of the presented regional sparse response features is roughly in accordance with the subjective perception of TMIs caused by detail loss, the other perceptual factor in TMI cannot be ignored due to the color unnaturalness of scenes, as depicted in the first row of Cm and root mean square Crms were selected to characterize the overall contrast relating to the color naturalness of TMI, and the above features were extracted in the HSI color space, which is expressed asW and H are the width and height of TMI, respectively. F3.Contrast tends to reflect the relationship among pixels, which cannot be clearly expressed by the sparse coefficient in the sparse domain and HVS will pay more attention to the overall contrast of the image than the absolute brightness. Therefore, Michelson contrast F4.When contrast is guaranteed, color fidelity is also considered as an important feature to capture the color saturation of TMIs, which can be simply calculated by image color invariance descriptors. Since LMS space can simulate the response of cones in the retina and the three types of LMS cones can correspond to two opposing colors, which is called antagonism , we tranColor temperature reflects the spectral composition of the light source and has been applied successfully in many fields, such as photography, video recording and publishing. Generally, the level of color temperature will directly affect the brightness and contrast of images, which is closely related to the color perception of the light source. Therefore, color temperature is used X, Y and Z represent the three-channel values of XYZ color space converted from RGB color space. Then, 5-bin histogram statistics were performed on the obtained color temperature map, and five frequency values were taken as the final color temperature feature set, denoted as F5, whose dimension was 5.Among them, F6.Darkness depicts the proportion of pixels with low brightness values in the image, and has a great impact on color unnaturalness. If the whole image looks dim, its subjective quality perceived by HVS is more terrible than ones with perfect brightness. Inspired by the three-point method in camera science, a TMI was first evenly divided into three blocks from top to bottom, and the mean pixel value of TMI was calculated. Then, the proportions of three blocks and the whole image whose brightness was less than the mean pixel value were computed and these four values were used as the final darkness feature set, denoted as 4-dimensional F = {F1, F2, F3, F4, F5, F6}, where the former two were regional sparse response features and the other four are aesthetic features. After feature extraction, the feature space was mapped to predict the quality In brief, a total of 181-dimensional quality-aware features were extracted from a TMI via regional sparse response and aesthetics analysis, denoted as To verify the performance of the proposed RSRA-BTMI method, the ESPL-LIVE HDR databaseIn order to validate the accuracy of the method, 80% of the image samples in the database were selected as the training set to train a TM-IQA model, which was used to predict the quality of the remaining 20% image samples. The scenarios of the training set and testing set were independent of each other. Then, to evaluate whether the method is statistically consistent with visual perception, it is necessary to compare the predicted scores with subjective ratings. According to the objective IQA standard proposed by the Video Quality Expert Group (VQEG), Pearson linear correlation coefficient (PLCC), Spearman rank-order correlation coefficient (SROCC) and root mean squared error (RMSE) were employed to validate the consistence. With experience, a method correlates well with subjective scores if PLCC and SROCC are close to 1 and RMSE is close to 0. In addition, to get the reliable results of the proposed RSRA-BTMI method, the above procedure was repeated 1000 times using randomly divided training and testing sets. Finally, we reported the median value of performance index obtained from the 1000 random trails as the final performance index.m is set to 128. m also determines the size of the final feature vector, so the feature size extracted from each region in the sparse domain is 128.As can be found from the feature extraction in F1 and auxiliary statistics based on global reconstruction residual F2 represent regional sparse response features in the sparse domain. Contrast F3, color fidelity F4, color temperature F5 and darkness F6 constitute the aesthetic features. Actually, most of the components in the sparse eigenvector were zero, and the non-zero component justified that the sample TMI had a corresponding response in the pretrained dictionary prototype. From a biological point of view, there were a series of visual neurons in the mammalian visual system. Visual neurons can sparsely encode the stimulus, that is, when a specific external stimulus is received, the information carried by the stimulus can be correctly perceived, as long as a small number of corresponding neurons accept the stimulus. Therefore, the sparse representation coefficients based on multi-dictionaries characterize the neuron state under a particular stimulus. The non-zero positions indicate that the neuron receives the stimulus, and the zero portions indicate that the neuron is not stimulated. Therefore, the sparse decomposition process of images is a sparse response of a neuron to a specific stimulus. A TMI to be assessed is transformed into sparse coefficients, and the sparse characteristics of each coefficient contain the essential features of the TMI. The feature extraction from the sparse domain will be more visually perceptible than the original image pixels. The more coeff-lSC represents that the more stimuli are received. To percept the global distortion, the global reconstruction residual statistics feature F2 was extracted to assist F1. The aesthetic features F3, F4, F5 and F6 were also considered because color distortion is not negligible in TMIs.As described in F1 and F2 in the sparse domain was also given to confirm the validity of the proposed features, as well as the combination of aesthetic features F3, F4, F5 and F6. PLCC, SROCC and RMSE were used as the performance criteria. These results are shown in To analyze the feature contribution, the performances of each type of features were separately evaluated on the ESPL-LIVE HDR database. In addition, the combination contribution of coeff-gSC had less effect on sparse reconstruction, but whether it had the ability to distinguish a high or poor-quality of the image or not remains to be validated. By the same proposed process of sparse atomic activity feature extraction in coeff-gSC and the combination of coeff-lSC and coeff-g,SC were used to measure the performance for quality assessment. In coeff-lgSC is represented for the combination of coeff-lSC and coeff-gSC.In the previous analyses in coeff-gSC, coeff-lgSC and coeff-lSC. It can be found that coeff-gSC and coeff-lgSC also exhibited good quality discrimination performance, and even exceeded the performance of the methods such as BTMQI, which will be shown later. According to the comparison, the portion of coeff-lSC was selected as the final fusion feature in the sparse domain.In addition, to verify the advantage of multi-dictionaries in the proposed RSRA-BTMI method, To clearly show a high correlation of aesthetic features with subjective scores, we trained a quality prediction model by aesthetic features. According to the trained quality prediction model, we used the aesthetic features of different distorted TMIs to predict the quality, the results are shown in the following In order to study the influence of different training sets on quality prediction results, PLCC and SROCC values obtained via different training sets were also analyzed, as shown in Fc\u2019 in the following description.Since the total 181-dimensional features may cause an overfitting situation, we made an experiment to eliminate redundancy from the total features. RF has an ability to detect the importance of features, so it can well guide the feature selection work. Specifically, we utilized RF to predict the importance of features extracted in the ESPL-LIVE HDR database as shown in In order to prove the effectiveness of the proposed RSRA-BTMI method, it was compared with the existing advanced BIQA methods. Since the ESPL-LIVE HDR database did not provide the original HDR reference image, the FR-IQA methods designed for TMIs could not be utilized on the database directly. The proposed RSRA-BTMI method was not compared with the existing FR-IQA methods. regB and regD. Therefore, it is unsuitable to directly use the 2D-BIQA methods to evaluate the TMIs\u2019 quality. First of all, obviously, as the 2D-BIQA methods, C-DIIVINE, DIIVINE, BLIINDS-II, BRISQUE and OG only consider the corresponding distortions of ordinary LDR images, such as JPEG, JP2K compression, blur, white noise, etc., the quality prediction performances of these 2D-BIQA methods used on TMIs were usually poor, and their PLCC and SROCC values were very low, only about 0.530 and 0.523 at the best. Secondly, the PLCC values of the existing TM-BIQA methods were much higher than those of the 2D-BIQA methods, as well as the SROCC values. Among the TM-BIQA methods, BTMQI mainly considered the details and structure preservation degree of TMIs, but did not consider the color distortion carefully, which had a great impact on the TMIs\u2019 quality. HIGRADE also spares more effects on the structure and naturalness, but neglects the color distortion. The BTMIQA method mainly uses the local entropy to perceive the detail loss of TMIs but it omits the information loss in the normal exposure region. The other methods also have room for improvement. The proposed method applies sparse perception with multi-dictionaries to extract main features of TMI\u2019s DB-regions, which not only can reduce visual redundancy but also obtain the human visual perception response to different regions. Moreover, it is clear that the proposed RSRA-BTMI method had better performance than the other methods. It is mainly due to the truth that the proposed RSRA-BTMI method utilizes the compressed sensing. Combining the regional sparse response with aesthetics can obtain the detail loss especially in regB and regD of TMIs, as well as the color distortion. Therefore, the proposed RSRA-BTMI method outperformed the existing methods and was consistent with the subjective perception of the human vision. It is also attributed to the fact that the proposed RSRA-BTMI method simulated the distortion process of TM in the sparse domain.From Moreover, we also calculated the performance after feature importance selection based on the proposed RSRA-BTMI method. Clearly, the feature selection used further improved the performance of the proposed RSRA-BTMI method.Due to the particularity of TMIs in imaging and viewing properties, two kinds of perceptual factors ought to be considered in the TM-BIQA method, i.e., detail loss and color unnaturalness. In this paper, we proposed an RSRA-BTMI method by considering the impact of DB-regions and the global region of TMI on human subjective perception, whose performance on the ESPL-LIVE HDR database was better than other competing 2D-BIQA and TM-BIQA methods. From the perspective of semantic invariance in DB-regions of TMIs, multi-dictionaries were specially designed so that each brightness region could be sparsely represented to describe the regional visual information. Moreover, global reconstruction residual statistics were also conducted to identify the high frequency information loss and utilized as the compensation features in the sparse domain. For the color unnaturalness, several color related metrics, such as contrast, color fidelity, color temperature and darkness, were analyzed and discussed carefully. As an efficient metric, the proposed RSRA-BTMI method could not only serve as the quality monitor in the end-to-end TMI processing pipeline, but also promoted the development of some relevant technologies, such as tone mapping, image enhancement and denoising of TMI.Although the proposed RSRA-BTMI method achieved excellent results in evaluating TMIs degraded with detail loss and color distortion, there were still limitations in some respects. First, several special distortions may appear in the actual imaging process, e.g., abnormal exposure, violent noise and indelible artifacts. Obviously, the introduction of an artifact or noise will greatly increase the high frequency information of the image, but it is not belonging to the component of positive detail information in images and usually causes terrible visual perception. Therefore, the presented global reconstruction residual statistics will produce the opposite result in this special case. Second, for the proposed method, there is a blocking operation on TMI before multi-dictionary learning for DB-regions. However, fixed size blocks may result in regions of different brightness within one TMI block, which is not conducive to multi-dictionary learning. Thus, a more reasonable and efficient way to improve the application scope of the proposed RSRA-BTMI method is worth being explored.In this paper, a blind tone-mapped image quality assessment method based on regional sparse response and aesthetics (RSRA-BTMI) was proposed by designing novel local and global feature subsets. It is mainly inspired by the fact that the detail loss and color unnaturalness phenomena in tone-mapped images (TMIs) were perceived by human visual system from global to local patterns. In terms of local features, multi-dictionaries were first trained from different brightness regions (DB-regions) in TMIs. Then the sparse atoms activities for DB-regions were calculated to portray regional visual information of TMIs. Finally, a regional feature fusion strategy based entropy weighting was designed to aggregate the above local features. In terms of global features, the statistics of residual information obtained by sparse representation was utilized as a compensation feature in the sparse domain, and a set of aesthetic features, such as contrast, color fidelity, color temperature and darkness, were also extracted to characterize the color unnaturalness of TMIs. Experimental results on the ESPL-LIVE HDR database demonstrated the superiority of the proposed RSRA-BTMI method. In future work, we are about to expand the practicability of dictionary learning and sparse representation for further exploring the perceptual factors in TMIs."} +{"text": "Widespread use of pneumococcal conjugate vaccines (PCVs) has led to substitution of vaccine-type (VT) strains by non-vaccine type (NVT) strains in nasopharyngeal carriage. We compared the efficacy of PCV13 and a nasal protein formulation containing pneumococcal surface protein A (PspA) adjuvanted with the whole-cell pertussis vaccine (wP) in the protection against co-colonization challenge models in mice with VT and NVT strains expressing different PspAs. Immunized mice were challenged with two different mixtures: i. VT4 (PspA3) + NVT33 (PspA1) and ii. VT23F (PspA2) + NVT15B/C (PspA4). Results from the first mixture showed a reduction in loads of VT4 strain in the nasopharynx of mice immunized with PCV13. A statistical difference between the loads of the VT and NVT strains was observed, indicating a competitive advantage for the NVT strain in PCV13-immunized animals. In the second mixture, no reduction was observed for the VT23F strain, probably due to low levels of anti-23F polysaccharide IgG induced by PCV13. Interestingly, a combination of the PspA formulation containing wP with PCV13 led to a reduction in colonization with both strains of the two mixtures tested, similar to the groups immunized nasally with wP or PspA plus wP. These results indicate that a combination of vaccines may be a useful strategy to overcome pneumococcal serotype replacement. Streptococcus pneumoniae frequently colonizes the human nasopharynx asymptomatically, but it can also cause diseases such as sinusitis, otitis media, pneumonia, sepsis, and meningitis. High pneumococcal carriage rates have been described in children, especially in low-income countries, where colonization rates of 20% to 93.4% in children less than five years of age have been described [escribed . Co-coloThe capsular polysaccharide (PS) is the most important virulence factor of pneumococcus. Pneumococcal conjugate vaccines (PCVs) induce antibodies against PS from serotypes included in the formulation and have considerably reduced the incidence of invasive pneumococcal disease in children. PCVs also reduce the nasopharyngeal carriage of vaccine type (VT) strains, leading to herd immunity in non-immunized individuals. The burden of pneumococcal disease remains high though, and data from 2015 have estimated 3.7 million cases of severe pneumococcal disease and 294,000 deaths caused by pneumococcal infection in children aged 1\u201359 months worldwide ,7,8.An alternative to overcome serotype-specific protection induced by PCVs is the use of vaccines based on protein antigens. Pneumococcal surface protein A (PspA) is an important virulence factor and is considered a promising vaccine candidate. It was shown to induce protection against colonization, pneumonia, and invasive disease models in mice ,10,11. PFew papers have evaluated nasopharyngeal co-colonization using mouse models. Intranasal carriage of one strain was shown to inhibit the acquisition of a second pneumococcal strain . ColonizOur group has also tested the efficacy of intranasal immunization with PspA using mouse models of co-colonization with VT strains. We have shown that nasal immunization with recombinant PspA from clade 1 (PspA1) and PspA from clade 4 (PspA4) using the whole-cell pertussis vaccine (wP) as an adjuvant reduced colonization when challenge experiments were performed with a mixture of two isolates from serotype 6B expressing PspA1 and PspA4 or with a mixture of isolates of serotypes 6B (PspA clade 3 - PspA3) and 23F (PspA clade 2 - PspA2). The formulation did not lead to a pronounced increase in colonization of one isolate over the other, showing that the vaccine strategy would not favor replacement . We now Mice were immunized with three doses of saline, wP (adjuvant only) or PspA1 + PspA4 + wP intranasally and with PCV13 subcutaneously. The combination of intranasal immunization with protein and subcutaneous immunization with PCV13 was also tested ((PspA1 + PspA4 + wP) + PCV13). The induction of antibodies against PspA and PS was evaluated in serum samples. Animals immunized with PspA1 + PspA4 + wP and (PspA1 + PspA4 + wP) + PCV13 showed high IgG antibody titers against both PspA1 and PspA4 a,b. MiceThe presence of anti-PspA IgG and IgA antibodies was also evaluated in vaginal washes as a proxy for the presence of antibodies in the nasopharynx, since nasal immunization was shown to induce vaginal humoral response in women . Both IgWe next evaluated the binding of IgG serum antibodies to the surface of intact pneumococci by flow cytometry. VT and NVT isolates expressing different PspAs were tested: VT4 (PspA3), VT23F (PspA2), NVT33 (PspA1), and NVT15B/C (PspA4) . Antibodiga, which encodes IgA1 protease. Since IgA1 protease activity is specific for human IgA1, it does not act as a virulence factor in mouse models [To develop models of VT and NVT co-colonization, strains were transformed with vectors containing erythromycin (erm)- or spectinomycin (spec)-resistance cassettes flanked by sequences from e models ,21. MixtImmunized mice were then challenged using the established co-colonization models with the mixtures of VT and NVT strains to evaluate protection against nasopharyngeal carriage. Mice were challenged with the mixture VT4 (PspA3) + NVT33 (PspA1), and bacterial loads of each strain were determined in nasal washes collected after five days a,b. A reImmunized mice were also challenged with the mixture VT23F (PspA2) + NVT15B/C (PspA4) c,d. OnceWidespread use of PCVs has led to a rapid substitution of VT strains by NVT strains in nasopharyngeal carriage. In this work, we aimed to compare the efficacy of PCV13 and a protein formulation containing PspA with the adjuvant wP in the protection against co-colonization challenge models with VT and NVT strains expressing different PspAs. These models would mimic the common situation of colonization with more than one pneumococcal serotype observed in children in high carriage burden settings. Furthermore, a model of pediatric pneumococcal carriage evaluating drivers of the emergence of new antibiotic-resistant lineages following the introduction of a vaccine targeting more common resistant types found that antibiotic pressure is the strongest driver, but carriage burden and multiple colonization can be important drivers if antibiotic pressure is lower . These dWe constructed antibiotic-resistant strains to establish the co-colonization models, so we could distinguish VT and NVT strains in nasal wash samples from challenged mice. Since antibiotic resistance may reduce bacterial fitness in colonization , we testMice nasally immunized with wP or PspA1 + PspA4 + wP showed a reduction of VT and NVT strains after challenge with both mixtures of strains. A statistically significant reduction compared with wP was observed for animals immunized with PspA1 + PspA4 + wP for strains NVT33 (PspA1), VT23F (PspA2), and NVT15/B/C (PspA4), but not for VT4 (PspA3), which may indicate the need for incorporating another PspA clade in the formulation in order to achieve broader protection. These results also show that protection elicited by the protein formulation involves both PspA-specific responses and responses due to wP. A reduction of pneumococcal colonization induced by nasal immunization with wP has already been observed by our group ,23. NasaInterestingly, the combination of the PspA nasal formulation with PCV13 led to a reduction of both strains in the two mixtures tested. These results indicate that such combination may be a strategy to overcome serotype replacement observed with the use of PCVs. Animals immunized with the combination elicited both anti-PS and anti-PspA antibodies, which would help reduce the competitive advantage of the NVT strains over VT strains in the co-colonization challenge. Immune response against wP was not measured in this work, but there was a clear effect of the adjuvant by itself in the reduction of the bacterial load. In the case of the mixture of VT4 (PspA3) and NVT33 (PspA1), the higher recovery of the NVT strain compared to the VT strain observed in the PCV13 group was not seen in any other of the immunized groups, wP, PspA1 + PspA4 + wP, and (PspA1 + PspA4 + wP) + PCV13.Anti-PS antibodies were proposed to protect against carriage acquisition in PCV-vaccinated volunteers through agglutination . AgglutiIn this work, we have only evaluated the induction of the humoral response against PspA, and both serum and mucosal antibodies were detected in mice immunized with the nasal protein vaccine formulation. It is not clear which mechanism would be responsible for the protection elicited by anti-PspA antibodies in our model. Serum anti-PspA IgG antibodies were shown to fix complement on the surface of pneumococci , leadingThere are some caveats related to our co-colonization models. Firstly, children that become colonized with two or more strains may not be exposed and colonized at the same time with these strains, and we have used a model in which mice are inoculated simultaneously with both strains. The dynamics of carriage acquisition of two strains may be sequential rather than at the same time, and a model involving exposure to pneumococci from different serotypes showed that carriage of one strain may inhibit the acquisition of another strain . This adIn conclusion, using models of co-colonization challenge with VT and NVT strains expressing different PspAs, we showed that the combination of PCV13 with nasal immunization with a formulation containing PspA1 and PspA4 adjuvanted with wP controls the carriage of both VT and NVT strains, overcoming the competitive advantage of the NVT strain when only PCV13 was administered. PCVs are very effective against pneumococcal invasive disease caused by VT strains in children. Rather than being replaced, PCVs could be improved through combinations of different immunization strategies to overcome serotype replacement.This study was performed according to the guidelines outlined by the Brazilian National Council for Control of Animal Experimentation (CONCEA). Experimental protocols were approved by the Ethic Committee on Animal Use of the Butantan Institute (CEUAIB) under protocol number 5824140716 (17/08/2016). Animals were housed under controlled temperature and light cycle conditions with daily monitoring. Food and water were given ad libitum.Strains TIGR4 ), HU368/06 ), 4431/119 ), and 237/53 ) were groiga. The gene fragment comprising 250\u20132750 bp of iga was first cloned in pGEM-TEasy (Promega) using primers Iga 250F (5\u2032 GAGGAATAATGGAAAAGTATTTTG 3\u2032) and Iga 2750R (5\u2032 TTTTCACCGATTAAACGAC 3\u2032). The region containing 250\u20131250 bp, pGEM-TEasy, and 1750\u20132750 bp was then amplified using primers Iga 1750F XhoI (5\u2032 GTAGCTCGAGGTCCAGAAAAAACTGAAGAAG 3\u2032) and Iga 1250R BamHI (5\u2032 TAGGGATCCTGAAAATCTATTTTTGTCTCTATAG 3\u2032). Resistance cassettes were then inserted between 250\u20131250 bp and 1750\u20132750 bp of iga. Pneumococcal strains were then transformed with the constructed plasmids using CSP1 and CSP2. Clones were selected in blood agar plates containing erm (1 \u00b5g/mL) or spec (300 \u00b5g/mL). Insertion of the cassettes in the genomic DNA within iga was confirmed by PCR. Serotype/serogroup of the obtained clones was confirmed by PCR serotyping [The erm-resistance cassette was amplified from plasmid pE693, using primers ErmF BamHI (5\u2032 TAGGGATCCTTCGTGCTGACTTGCACC 3\u2032) and ErmR XhoI (5\u2032 GTAGCTCGAGAGTAACGTGTAACTTTCCAAATTTACAAAAG 3\u2032). The spec-resistance cassette was amplified from plasmid pE729 using primers SpecF BamHI (5\u2032 TAGGGATCCTAACTATAACTAATAACGTAACGTG 3\u2032) and SpecR XhoI (5\u2032 GTAGCTCGAGTATGCAAGGGTTTATTGTTTTC 3\u2032). The cassettes were inserted between regions comprising 250\u20131250 bp and 1750\u20132750 bp of TIGR4 rotyping . Express5 CFU each) was inoculated intranasally in a volume of 10 \u03bcL into both nostrils. Animals did not show any sign of sickness after challenge. For nasal washes, mice were euthanized through the ip route with a lethal dose of a xylazine/ketamine solution five days after the challenge. A catheter was inserted into the trachea of the mice, and the upper respiratory tract was rinsed with 200 \u00b5L of saline. An additional rinse with 200 \u00b5L of saline was performed; volumes were pooled and serially diluted for plating in blood-agar containing gentamycin (4 \u00b5g/mL), erm or spec. Pneumococcal loads were determined taking into account CFU recovered on the plates and total volume collected in the nasal washes. The limit of detection was 40 CFU. Samples without recovery of bacteria were plotted as 10 CFU.Five- to seven-week-old C57BL/6 female SPF mice were obtained from the Medical School of the University of Sao Paulo . Mice were anesthetized through the intraperitoneal (ip) route with a xylazine/ketamine solution , and a mixture containing two strains of pneumococci containing 1/16 of the human dose of the whole-cell pertussis vaccine wP with a 14-day interval. Recombinant proteins PspA1 and PspA4 comprise the mature \u03b1-helical region plus the proline-rich region of PspA a and werELISA against PspA was carried out as described previously in high-Medium-binding plates were coated with 10 \u00b5g/mL PS4, PS15B, PS23F or PS33 (American Type Culture Collection). Serum samples were incubated with PS22F (5 \u00b5g/mL) prior to incubation in the plate coated with PS. Anti-PS IgG was detected with anti-mouse IgG conjugated with HRP. The titer was defined as the reciprocal of the highest dilution with an Abs 492 nm \u2265 0.1.8 CFU/mL) and harvested by centrifugation. Bacteria were washed, suspended in PBS, and incubated with 1% of individual sera for 30 min at 37 \u00b0C. Samples were washed once with PBS before incubation with fluorescein isothiocyanate (FITC)-conjugated anti-mouse IgG (Sigma) for 30 min on ice. Samples were fixed with 2% formaldehyde after two washing steps and stored at 4 \u00b0C. Flow cytometry analysis was conducted using FACSCanto (BD Biosciences), and 10,000 gated events were recorded. Mean fluorescence intensity (MFI) was determined for each sample.Antibody-binding assay was performed as previously described . Brieflyt-test. Differences in colonization between immunization groups were evaluated by the Mann\u2013Whitney Test. Differences in antibody levels and MFI between groups were analyzed using one-way ANOVA with Tukey\u2019s multicomparison test. GraphPad Prism 8.1.2 was used for statistical analysis.Differences in the colonization with erm- and spec-resistant clones in the same sample in na\u00efve mice were evaluated by Student\u2019s paired"} +{"text": "Post-transplant lymphoproliferative disorder (PTLD) is a serious complication after solid organ and hematopoietic stem cell transplantation, requiring a timely and accurate diagnosis. In this study, we evaluated the diagnostic performance of FDG-PET/CT in patients with suspected PTLD and examined if lactate dehydrogenase (LDH) levels, Epstein-Barr virus (EBV) load, or timing of FDG-PET/CT relate to detection performance of FDG-PET/CT.This retrospective study included 91 consecutive patients with clinical suspicion of PTLD and a total of 97 FDG-PET/CT scans within an 8-year period. Pathology reports and a 2-year follow-up were used as the reference standard. Diagnostic performance of FDG-PET/CT for detection of PTLD as well as logistic regression analysis for factors expected to affect diagnostic yield were\u00a0assessed.k\u2009=\u20090.78). Of the parameters hypothesized to be associated with a true positive FDG-PET/CT result for the diagnosis of PTLD, only LDH was statistically significant .The diagnosis of PTLD was established in 34 patients (35%). Fifty-seven FDG-PET/CT scans (59%) were true negative, 29 (30%) were true positive, 6 (6%) false positive, and 5 (5%) false negative. Sensitivity of FDG-PET/CT for the detection of PTLD was 85%, specificity 90%, positive predictive value 83%, and negative predictive value 92%, with good inter-observer variability (FDG-PET/CT has a good diagnostic performance in patients suspected of PTLD, with a good inter-observer agreement. Only LDH levels seemed to influence the detection performance of FDG-PET/CT. EBV-DNA load and timing of FDG-PET/CT after transplantation did not affect FDG-PET/CT diagnostic yield. Post-transplant lymphoproliferative disorder (PTLD) is a serious complication after solid organ (SOT) and hematopoietic stem cell transplantation (HSCT). PTLD encompasses a heterogeneous morphologic spectrum, ranging from EBV driven polyclonal proliferations to aggressive monomorphic large B cell lymphomas. According to the World Health Organization, PTLD can be classified into 4 main groups: non-destructive lesions, polymorphic PTLD, monomorphic PTLD, and classical Hodgkin lymphoma PTLD .18F-fluoro-2-deoxy-D-glucose (FDG) positron emission tomography (PET)/computed tomography (CT) may also be performed, allowing for whole-body visualization of metabolic active lesions and direct biopsy localization.PTLD has a variable clinical presentation that may include B-symptoms, lymphadenopathy, organ/allograft dysfunction, or a combination of non-specific symptoms. It is characterized by a bimodal presentation curve, with a peak incidence within 1\u00a0year after transplantation and a second peak after 4\u20135\u00a0years , 3. HoweAlthough FDG-PET/CT is an established imaging modality in the detection of other FDG-avid lymphomas, with a reported median sensitivity of 90% and specificity of 91%, its diagnostic performance has not been extensively evaluated in PTLD , 12. FDGThis retrospective study included all consecutive patients between January 2010 and January 2019 for whom an FDG-PET/CT scan was requested. Indications for FDG-PET/CT requests are described in Table Relevant clinical and biochemical data were collected from the electronic patient files at the University Medical Center Groningen. These included age, gender, organ transplanted, time between transplantation and FDG-PET/CT, LDH levels, EBV-DNA load, and PTLD morphology and histology.All FDG-PET/CT scans were performed on a Siemens Biograph 40 or 64 slice mCT according to the European Association of Nuclear Medicine (EANM) procedure guidelines for tumor imaging . Scans wPathology reports were used as a reference standard for PTLD diagnosis. Two experienced hematopathologists were consulted for morphology clarification when necessary. In case of a PTLD-negative biopsy or lack of tissue for pathological examination, a 2-year follow-up period without pre-emptive PTLD therapy was accepted as the reference standard. Absence of lymphoma during this period has been shown to be an accurate marker for lack of disease in other lymphomas , 15. Trup value \u2264\u20090.05. Inter-observer variability between the 3 observers was calculated using Fleiss kappa. The kappa value was interpreted according to the method of Landis and Koch: poor (0 to 0.20), fair (0.21 to 0.40), moderate (0.41 to 0.60), good (0.61 to 0.80), and perfect agreement (0.81 to 1) [Baseline patient characteristics were summarized using medians with interquartile range (IQR) for non-normally distributed variables. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of FDG-PET/CT for the detection of PTLD were calculated with a 95% confidence interval (CI). Logistic regression model analysis was carried out using mean serum LDH levels, mean EBV-DNA load (mean over a 31-day period before FDG-PET/CT), and time between transplantation and FDG-PET/CT with FDG-PET/CT result as a dependent variable. FDG-PET/CT results were dichotomized as true positive or not true positive . The corresponding odds ratio (OR) and 95% CI were calculated. Statistical significance was set at 81 to 1) . All stan\u2009=\u200940, 44%) followed by the kidney , liver , HSCT , multi-organ , and the heart . According to the reference standard, 34 patients (35%) were diagnosed with PTLD. There were 21 EBV-positive PTLDs (62%) and 13 EBV-negative PTLDs (38%). The median time between transplantation and FDG-PET/CT was 5\u00a0years .One-hundred-twelve potentially eligible patients were identified. Eleven patients were excluded due to central nervous system involvement, 6 due to complete tumor resection prior to FDG-PET/CT evaluation, and 4 due to lack of a reference standard. In total, 91 patients and 97 FDG-PET/CT scans were included in this study Table . In 6 paAfter a consensus meeting, the three readers assessed 35 scans to be positive for PTLD and 62 scans negative. Pathology confirmation was the reference standard in 64 scans (66%) and 2-year follow-up in 33 (34%). According to the reference standard, 57 scans (59%) were true negative, 29 (30%) were true positive, while 6 (6%) false positive, and 5 (5%) false negative results were observed Table . On a paNocardia infection, 1 case of Aspergillus infection in the lungs, and 1 case of spontaneous recovery of the suspected lesions without medical intervention, considered very unlikely to be PTLD. False positive results could be divided into two main categories: (1) other malignancies also showing high FDG uptake, making the differentiation between PTLD and other malignancy difficult and (2) infections, also taking up FDG and leading to a differential diagnosis of PTLD or infection. Five scans were concluded to be false negative: 2 cases with focal uptake in the tonsils/adenoid, interpreted as physiological uptake but confirmed to be non-destructive PTLD, 1 case with focal uptake in the rectum, interpreted as physiological uptake but confirmed to be polymorphic PTLD, 1 case with uptake in the lungs, interpreted as a primary lung tumor or infection but confirmed to be classic Hodgkin type PTLD, and 1 case considered to be a lung infiltrate without FDG-uptake but confirmed to be monomorphic PTLD . Hence, for each 10 unit increase in LDH, the odds of having a true positive FDG-PET/CT scan were 3% higher. The remaining parameters, EBV-DNA load , and time between transplant and FDG-PET/CT were not statistically significant in the univariate logistic regression analysis. For this reason, a multivariate logistic regression analysis was not performed .According to univariate logistic regression, the only statistically significant parameter associated with a true positive FDG-PET/CT scan was serum LDH level with an OR of 1.03 (n\u2009=\u20097). The differential diagnosis for these lesions included PTLD, primary lung tumor or infection. There were 5 cases of discordant results observed in the gastrointestinal tract and 1 discordant result for lesions in the pelvic area, in which observers reported difficulty in distinguishing between pathological and physiological uptake. Finally, 1 discordant finding, located in the adenoids of a young patient, was difficult to characterize as either pathological or physiological/infectious. From the 14 discordant FDG-PET/CT scans, 2 were false positive and 3 were false negative. The inter-observer variability was found to be good at k\u2009=\u20090.78 .From a total of 97 FDG-PET/CT scans evaluated prior to consensus, discordant results were reported in 14 scans. The majority of discordant results were due to FDG uptake in the lung parenchyma (k\u2009=\u20090.78). Of the determinants hypothesized to influence detection performance of FDG-PET/CT, only LDH levels were statistically significant with an OR of 1.03 .Although metabolic imaging with FDG-PET/CT has an established role in the diagnosis of non-Hodgkin and Hodgkin lymphoma, few studies have been carried out to assert its detection performance in PTLD , 17. In Current guidelines from the British Committee for Standards in Hematology, the British Transplantation Society, and National Comprehensive Cancer Network include no concrete recommendations on the use of FDG-PET/CT for diagnosing PTLD , 19. TheAlthough the majority of studies published on the diagnostic performance of FDG-PET/CT in PTLD are limited to case series, studies by Panagiotidis et al. and Dierickx et al. also reported good FDG-PET/CT diagnostic performance , 23. PanFrom the parameters hypothesized to be associated with a true positive FDG-PET/CT result for the diagnosis of PTLD, only LDH had a statistically significant odds increase. Uncontrolled proliferation of malignant cells with high cellular turnover is characterized by increased glycolysis and LDH release. High energy metabolism may translate into higher FDG uptake in tumor tissue and seemingly increase FDG-PET/CT detection performance . NeverthDue to the retrospective design of this study, information on immunosuppression adjustments was not available. As a consequence, it was not possible to evaluate EBV-DNA load changes over time as this is affected by immunosuppression intensity. PTLD patient population is inherently heterogeneous with regard to medical history, immunosuppression regimens, and treatment approaches. In our retrospective study, heterogeneity might have been introduced by the 8-year period inclusion time within various medical departments. Lack of standardization limits the analysis on how patient selection and timing of FDG-PET/CT affect its diagnostic performance, potentially inducing selection bias. Likewise, due to the retrospective nature of this study, we were not able to evaluate how different immunosuppressive regimens might have affected PTLD pathogenesis, which is of great clinical relevance and should be considered in future studies. Despite these limitations, the data presented reflects current clinical practice, as immunosuppression regimens are often department specific and there are currently no guidelines on the use FDG-PET/CT for the diagnosis of PTLD. Additional future studies may also focus on the role of interim and end-of-treatment FDG-PET/CT on survival, already explored by Keerberghen et al. and Zimmermann et al., and on the role of FDG-PET/CT in pediatric PTLD patients , 35. ConFDG-PET/CT has a good diagnostic performance in patients with suspected PTLD. False positive results were due to other malignancies or infections while false negative results occurred in cases interpreted as physiological uptake (adenoids and rectum), other malignancy, and in 1 case of non-FDG-avid PTLD. Furthermore, a good inter-observer agreement was found, which further underlines the clinical utility of FDG-PET/CT. Only LDH levels seemed to influence the detection performance of FDG-PET/CT, while EBV-DNA load and time between transplant and FDG-PET/CT did not. The results of this study may help to implement FDG-PET/CT in future PTLD guidelines."} +{"text": "Schistocephalus solidus. Although marine stickleback and some susceptible lake fish permit fast\u2010growing tapeworms, other lake populations are resistant and suppress tapeworm growth via a fibrosis response. We subjected lab\u2010raised fish from three populations to a novel immune challenge using an injection of (1) a saline control, (2) alum, a generalized pro\u2010inflammatory adjuvant that causes fibrosis, (3) a tapeworm protein extract, or (4) a combination of alum and tapeworm protein. With enough time, all three populations generated a robust fibrosis response to the alum treatments. Yet, only the resistant population exhibited a fibrosis response to the tapeworm protein alone. Thus, these populations differed in their ability to respond to the tapeworm protein but shared an intact fibrosis pathway. The resistant population also initiated fibrosis faster in response to alum, and was able to attenuate fibrosis, unlike the susceptible populations\u2019 slow but longer lasting response to alum. As fibrosis has pathological side effects that reduce fecundity, the faster recovery by the resistant population may reflect an adaptation to mitigate the costs of immunity. Broadly, our results confirm that parasite detection and immune initiation, activation speed, and immune attenuation simultaneously contribute to the evolution of parasite resistance and adaptations to infection in natural populations.Closely related populations often differ in resistance to a given parasite, as measured by infection success or failure. Yet, the immunological mechanisms of these evolved differences are rarely specified. Does resistance evolve via changes to the host's ability to recognize that an infection exists, actuate an effective immune response, or attenuate that response? We tested whether each of these phases of the host response contributed to threespine sticklebacks\u2019 recently evolved resistance to their tapeworm Dramatic variation in resistance to parasites is common within and among populations of hosts. Yet the mechanisms underlying these evolved differences remain unclear. Many evolution studies focus on the broad outcomes of infection (infected or not) when studying resistance, without specifying what part of the immune response has evolved. Here, we experimentally partition different sequential stages in the host immune response to evaluate which stage(s) underly the evolution of host resistance to infection. This study compares three populations of threespine stickleback that naturally differ in their ability to resist infections and suppress the growth of a freshwater tapeworm. These include a \u201cresistant\u201d lake population, a \u201csusceptible\u201d lake population, and an \u201cancestral\u201d marine population that is rarely exposed to the tapeworm in nature but is susceptible when exposed in the lab. The resistant population exhibits a fibrosis immune response to infection, which has been linked to suppressed tapeworm growth and viability. We injected different immune challenges directly into the site of infection and measured the subsequent fibrosis response through time. We found that all populations were capable of producing fibrosis in response to a general immune stimulant . But only the resistant population was able to recognize and respond to tapeworm protein alone. This population also responded faster than the others, within 24 hours, and attenuated its fibrosis by 90 days post injections, whereas the other populations exhibited a slower response that did not attenuate in the study timeframe. We concluded that, in this system, rapid evolution of parasite resistance entails changes in initiation of an immune response, rather than gain or loss of the ability to perform that response.The co\u2010evolutionary arms race between hosts and parasites can shift rapidly across space and time a \u201cresistant\u201d lake population with common and severe fibrosis and small tapeworms, (2) a \u201csusceptible\u201d lake population with abundant large tapeworms and negligible fibrosis, and (3) an \u201cancestral\u201d marine population with negligible exposure to the tapeworm in nature, high susceptibility to laboratory infections, and negligible fibrosis , we were also interested in testing whether there was variation in the timing of initiating or resolving that response. We predicted that the resistant population may have evolved the ability to respond rapidly, to limit the growth of the tapeworm early in infection. The resistant population may also be faster to recover from fibrosis, to mitigate immunopathological costs.Schistocephalus solidus has a complex life cycle where it is trophically transmitted from copepods to threespine sticklebacks to birds . The sites were all within the historical tribal region of the Kwakwaka'wakw First Nation. Methods were approved by the University of Connecticut IACUC (protocol A18\u2010008).S. solidus. They are highly susceptible in laboratory infection experiments, consistently producing large tapeworms with negligible fibrosis is a breeding location for the anadromous marine stickleback are also rarely found to have fibrosis in nature, despite a high prevalence of infection with large tapeworms has a high incidence of fibrosis in nature with small tapeworms. The presence of granulomas indicates that these fish can successfully clear some infections and suppress tapeworm growth when they do establish. Roselle has a low to intermediate infection prevalence, with 7\u201340% of fish infected during field surveys depending on the year , 1 , 2 (fibrosis adhering organs together), 3 , and 4 (see fibrosis scoring video in the Supporting Information).U tests. To get an additional estimate of infection prevalence for Roselle, we euthanized and preserved 169 randomly selected fish in ethanol, which were later dissected and scored as infected or uninfected (ethanol preservation is not conducive to scoring fibrosis).We weighed tapeworms on a digital scale; tapeworms weighing less than 0.01\u00a0g were recorded as <0.01\u00a0g and were entered as 0.009\u00a0g for summary statistics. If fish were infected with multiple tapeworms, we weighed all tapeworms together to get average parasite mass. We compared infection intensity between lakes using a general linear model (glm) with a Poisson distribution, and average tapeworm mass using a glm with a gamma distribution and inverse link function. We also compared the number of tapeworms above and below the threshold of our field scale per lake using a chi\u2010square test. We compared the fibrosis scores of uninfected and infected fish between lakes using Mann\u2010Whitney In June 2018, we collected fish from our three populations for breeding. Using standard in vitro fertilization methods, we created full\u2010sibling families from each population and transported fertilized eggs to the lab for rearing 20\u00a0\u03bcL of 1\u00d7 phosphate\u2010buffered saline , (2) 10\u00a0\u03bcL of homogenized tapeworm protein solution + 10\u00a0\u03bcL PBS (tapeworm treatment), (3) 10\u00a0\u03bcL of Alum + 10\u00a0\u03bcL PBS , and (4) 10\u00a0\u03bcL tapeworm protein + 10\u00a0\u03bcL Alum . Alum is an immune adjuvant that causes the recruitment of leukocytes that initiate an immune response in 2008 that were flash frozen and stored at \u221280\u00b0C. We chose tapeworms from a different lake, watershed, and year to minimize any localized genetic structure of the parasite that may influence population level responses. Tapeworms were dipped in deionized water and placed in chilled 0.9\u00d7 PBS. Each tapeworm was sonified on ice twice for 1 min . Between sonification rounds, samples were chilled on ice (5 min). The homogenized solutions were centrifuged and the supernatant was collected and pooled. We measured the protein concentration using a Red 660 kit (G\u2010Biosciences), diluted the solution to 1\u00a0mg/mL using 0.9\u00d7 PBS, and stored it at \u221220\u00b0C.Before injection, fish were lightly anesthetized using a neutral\u2010buffered MS\u2010222 (50\u201375 mg/L). We used ultrafine syringes (BD 31G 8\u00a0mm) to inject 20\u00a0\u03bcL into the lower left side of the peritoneal cavity, slightly above where the end of ventral spine rests. Injections were shallow and at an angle parallel to the body to avoid injuring organs. We watched for visual distention of the peritoneal cavity to ensure solutions were being injected correctly. Solutions were prepared and syringes were loaded in a sterile culture hood. Fish were also given a small colored elastomer mark (Northwest Marine Technologies) corresponding to their treatment group injected subcutaneously just posterior to the neurocranium. Although injecting elastomers can impact immune responses if fish could respond within 24 hours to an immune challenge, which is when the tapeworm penetrates the gut to compare between groups using predictmeans using From the 169 preserved fish collected from Roselle lake, we found six infected fish, giving an infection prevalence of 3.55%, which was lower than previous estimates for Roselle (7\u221240%) and Gosling lake (50\u201380%) \u00a0=\u00a0\u22120.51, SE\u00a0=\u00a00.15, P\u00a0<\u00a00.001) and higher average tapeworm mass \u00a0=\u00a00.01, SE\u00a0=\u00a00.01, P\u00a0=\u00a00.27), although this was not statistically significant, likely because many infections fell below the 0.01\u00a0g limit of our field scale. When we compared the number of tapeworms above and below this threshold per lake, we found that Gosling had more large worms compared to Roselle . In infected fish, the degree of fibrosis was significantly higher in Roselle compared to Gosling . Once we broke this apart, all pairwise interactions were also significant . The three\u2010way interaction model was a better fit relative to both the pairwise model and a model with no interactions . To interpret these results, we used contrasts among subsets of data to address the three questions outlined in the methods. Figure\u00a0When examining the fibrosis response to injection, we found a significant three\u2010way interaction between treatment, timepoint, and population and the susceptible population (Gosling), fibrosis did not differ among treatments 1 day post injection, but did differ at 10, 42, and 90 days Fig.\u00a0. For botFor the control treatment, there was little fibrosis and populations did not differ at any timepoint. For the tapeworm treatment, populations differed in their fibrosis response at both 1 and 10 days, but not at 42 and 90 days, with the resistant population being the only one to produce fibrosis to this treatment Fig.\u00a0. For theFor both the ancestral and susceptible populations, fibrosis to the control and tapeworm treatments did not differ through time ; however, fibrosis did change through time for both the alum and the tapeworm+alum treatments Fig.\u00a0. For botStriking differences in parasite resistance between related groups, even to the same parasite, are common in nature, and yet, we often lack an understanding of the immunological mechanisms that generate this important variation. Although many evolutionary studies emphasize the broad outcomes of infection , we instead take a stepwise approach that breaks up different components of the host response through time to better understand resistance evolution in populations of threespine stickleback. We compared an ancestral marine population and two lake populations that differ in their resistance to a freshwater tapeworm. Using na\u00efve fish raised in a common environment and a novel immune challenge assay, we set out to test if (H1) variation in a resistance phenotype (fibrosis) observed in nature was being driven only by the environment, (H2) variation was due to population\u2010level differences in the ability to detect and initiate a respond to tapeworm antigens, or (H3) variation was due to population\u2010level differences in the ability to actuate a strong fibrosis response in the peritoneal cavity. We also tested for variation in the rate of initiation and resolution of fibrosis, with the prediction that selection in the resistant population may have favored rapid initiation and quicker resolution (to mitigate long\u2010term costs of fibrotic pathology) . We also rejected H3, because, given enough time, all populations produced a robust fibrosis response in their peritoneal cavity to a general immune adjuvant . This result is consistent with a follow\u2010up study that used our alum injection protocol on a phylogenetically diverse sample of 17 fishes, showing a deep ancestral ability to actuate peritoneal fibrosis resemble the ancestor\u2010like marine outgroup in that they permit rapid tapeworm growth . This approach can be informative, as it allows for the isolation of genes from ecology, but translating our results back to wild populations must be done with some caution. It is clear that ecology can interact with genetics to play an important role in shaping host responses to infection and generating variation between populations for fibrosis response results from the laboratory injection experiment.Click here for additional data file.SI: Video.Click here for additional data file."} +{"text": "Background: A prospective clinical study was conducted to investigate whether two different pharmacotherapy strategies of steroid administration impact hearing preservation in adult patients who underwent cochlear implantation with the Oticon Medical Neuro cochlear implant system. Methods: Twenty nine adult participants were included. Pure tone audiometry was performed before implantation, during processor activation and 12 months after activation. There were three treatment groups: (1) intravenous steroid therapy (standard steroid therapy with dexamethasone administrated intravenously at the dose 0.1 mg/kg body mass twice a day); (2) combined oral and intravenous steroid therapy at the dose 1 mg/kg body mass/24 h), and (3) no steroid therapy (a control group). Patients\u2019 hearing thresholds before implantation were on average 103 dB HL, 89 dB HL, and 93 dB HL, respectively. Results: Deterioration of hearing thresholds was observed in all three patients\u2019 groups. Twelve months after surgery the patients with and without steroid therapy had similar hearing thresholds. Conclusions: The steroid regimen used in this study did not play a significant role in patients with non-functional residual hearing, who underwent cochlear implantation with the Oticon Medical Neuro cochlear implant system. Cochlear implantation (CI) is widely regarded as one of the most effective treatments for patients with severe to profound hearing loss ,2,3,4,5.Oticon Medical\u2019s Neuro cochlear implant (CI) system consists of the Neuro Zti implant and the Neuro sound processor . This implant has a titanium base and a zirconia casing (hence the designation Zti) and has been available since 2015. It is compatible with two types of 20-channel electrode array, the Classic and the EVO. The Classic electrode array, stiffer than the EVO electrode array, is better suited for challenging anatomical situations. The EVO electrode array is better suited for a soft surgery approach . An EVO The main aim of this study was to assess two different regimes of steroids therapy (dexamethasone versus dexamethasone plus prednisone) for hearing preservation in adult patients who underwent cochlear implantation with the Oticon Medical Neuro cochlear implant system . Enrolled patients were randomly assigned to one of three subgroups: (1) intravenous only steroid therapy /12 h, (2) combined steroid therapy administrated twice a day plus prednisone at a dose of 1 mg/kg body mass/24 h with a reduction of dose over time) and (3) a control group (no steroid therapy). This research is a continuation of previous clinical research with the aim of optimizing pharmacological steroid treatment in different cochlear implantation systems. The protocol of this prospective clinical trial was approved by the Bioethics Committee of the Institute of Physiology and Pathology of Hearing in Kajetany (IFPS: KB/06/2016) and was in line with the Declaration of Helsinki. Patients enrolled in the study suffered from severe or profound hearing loss, and were classified according to Skarzy\u0144ski\u2019s classification of partial deafness treatment (PDT) : having To be included in the study the eligibility criteria were as follows: Adult patients who qualified for cochlear implantation with hearing loss in the range 65\u2013120 dB at frequencies 0.25\u20131 kHz and from 75 dB\u2013120 dB at 2\u20138 kHz. The criteria for exclusion from the study were as follows: comorbidity: hypertension, diabetes or cancer, and contraindications for steroid therapy , and hypersensitivity to the drug or its components. The inclusion criteria are in line with the international HEARRING Group consensus on hearing protection for cochlear implant users [This study was prospective and included 29 patients who planned to undergo cochlear implantation. They were divided into three groups according to steroid treatment regimen after cochlear implantation. The first group of 18 patients (7 women and 11 men) were treated with intravenous steroid therapy (standard steroid therapy) ; they we\u00ae\u00ae and prednisone under the brand name Encorton\u00ae\u00ae were administered according to the protocol of the study.Two different medical products which were commercially prepared as two different formulations were administered to patients. Dexamethasone sodium phosphate was administrated intravenously for patients in the first and second subgroups. Prednisone was administrated orally only in the second subgroup in combination with dexamethasone sodium phosphate. Dexamethasone under the brand name DexavenAudiological evaluation and hearing preservation were performed with pure tone audiometry. Frequencies ranged from 0.125 to 8 kHz . Measurements were carried out in the same soundproof cabin using the same diagnostic audiometer. The audiometer limit for each frequency was: 0.125 kHZ-90 dB; 0.250 kHZ-100 dB; 0.500 kHz\u20134 kHz-120 dB; 6 kHz-110 dB and 8 kHz-100 dB. Pure tone audiometry was performed before surgery, during activation (1 month after surgery), and in the 12th month after activation. Due to the long duration of the study, only half the patients underwent postoperative speech audiometry and speech audiometry .The primary outcome measure was average hearing threshold across in all 11 frequencies (0.125\u20138 kHz) using both octaves and half-octaves according to the International Organization for Standardization ISO 8253-1:2010. All measurements were conducted in the same soundproof cabin by an experienced technician, using the same diagnostic audiometer, the Madsen Itera II with calibrated earphones (TDH-39P) . The secondary outcome measure was hearing preservation (HP) calculated by comparing hearing thresholds in the 1-year post-operative period with the preoperative hearing thresholds, according to the HP formula (Equation (1)) .(1)HP=1PRE is the pure tone average measured in the preoperative period; PTAPOST is the pure tone average measured postoperatively; and PTAMAX is the maximum sound intensity generated by a standard audiometer . According to the HP classification, the results were divided into three groups: minimal hearing preservation 0\u201325%; partial hearing preservation 26\u201375%; and complete hearing preservation (complete HP) > 75%.In this equation, PTA is pure tone average, measured at different time periods. PTAThe assumption of normality was checked by analyzing the variables using the Kolgorov\u2013Smirnov test. This assumption was completely violated in the intravenous group, partially violated in the oral and intravenous group, and was met only in the control group. For this reason, and because of small and unequal sample sizes, the non-parametric test was used in the statistical analysis. The Wilcoxon signed-rank test (T stands for test statistic) was used for testing differences between hearing thresholds in the preoperative period and in the 12-month post-activation period. A Kruskal\u2013Wallis test (H stands for a test statistic) was performed to compare hearing thresholds from the three groups in each period separately. A chi-square test was used to assess the differences between the three groups in terms of hearing preservation. The required sample size was calculated with power 0.80 and alpha level 0.05. Results obtained in our previous study were used as an assumption. The sample size needed was established as n = 11 for each group. The analysis was blinded. The alpha-level was set to 0.05. All statistical tests were performed using IBM SPSS Statistics v24.Characteristics of the patients in terms of age, sex, operated ear and hearing thresholds in non-operated ear are shown in (1)p = 0.959.The intravenous group: the pre-op range was 32.86\u2013110.45 db HL; M = 78.75 (SD = 30.30). The 12 months range was 31.36\u2013110.45 db HL; M = 78.39 (SD = 28.54). The difference was not statistically significant: T = 0.05; (2)p = 0.463.The oral and intravenous group: the pre-op range was 59.29\u2013107.00 db HL; M = 76.70 (SD = 16.97). The 12 months range was 65.45\u2013100.91 db HL; M = 77.80 (SD = 12.75). The difference was not statistically significant: T = 0.73; (3)p = 0.500.The control group: the pre-op range was 26.25\u201389.09 db HL; M = 68.72 (SD = 25.59). The 12 months range was 24.09\u201391.36 db HL; M = 69.00 (SD = 27.13). Again, the difference was not statistically significant: T = 0.67; Additionally, hearing thresholds were observed in the patients\u2019 non-operated ears. They remained stable and were as follows:p = 0.007. The oral + intravenous group also had significantly better hearing thresholds in the preoperative period than after 12 months . The same was observed in the control group . In summary, deterioration of hearing thresholds was observed in all three groups. Average hearing thresholds were compared in the preoperative period and 12 months after activation for each group separately. The intravenous group had better hearing thresholds in the preoperative period than after 12 months, and the difference was statistically significant, T = 2.69; H = 8.87; p = 0.012); before surgery, the oral and intravenous group had slightly better hearing thresholds than either of the other two groups. However, these between-group differences disappeared 12 months after CI activation , when all three groups performed similarly. Statistical analysis revealed that there were statistically significant differences between groups in the preoperative period are shown in 2 = 13.74; p = 0.033. The majority of the patients with standard steroid therapy (72.2%) had no measurable hearing at 12 months after CI activation, while the results obtained by the patients in the oral and intravenous group were slightly better. The controls also had slightly better HP than patients in the intravenous group.There was a statistically significant difference between the three groups in hearing preservation: \u03c7Hearing preservation plays a vital role in cochlear implantation. The evidence shows that it is possible to preserve residual hearing by a combination of appropriate electric stimulation and steroid therapy, by which means hearing and speech in noise discrimination can be significantly improved . AlthougA study from 2013 demonstrated that an electrode in which dexamethasone was incorporated could continuously release steroid into the inner ear . SimilarAs far as administration of steroid during cochlear implantation is concerned, Cho et al. compared the efficacy of steroid administration for protecting residual hearing during two separate periods (preoperatively and intraoperatively). Dexamethasone at a dose of 5 mg/mL was administered systemically before cochlear implantation and locally during surgery. The study protocol did not look at prolonged steroid administration, but there was a statistically significant difference between the steroid group and the control group. This conclusion supports the benefits of steroid pharmacotherapy, even 1 year after surgery . However, different results came from a preliminary study published in 2018. Although the regimen, dose, and duration of administration of glucocorticoids in both studies was identical, the results of pure tone audiometry (PTA) were different. However, different cochlear electrodes and implants were used, and the number of patients enrolled in the study was also different (36 compared to 29). In addition, their ages were different . All patients underwent follow-up evaluation. Note that it is not always possible to preserve residual hearing after implantation in patients of more advanced age. Hearing loss isolates the elderly from society, and contributes to depression and a decline in the quality of life. Cochlear implantation has been demonstrated to be a method that can preserve hearing in this group of patients. Unfortunately, there are some factors specific to the elderly that may affect the course of surgery, performance of an implant, and its long-term benefits. In general, these are degenerative changes in the auditory pathway, progressive central auditory dysfunction, cognitive and adaptive difficulties, long-term deafness, and comorbidities. Another important factor is surgical access to the cochlea. Often there is ossification at the beginning of the basal turn, meaning a surgical maneuver is needed in order to place the electrode properly. This requires additional drilling using a diamond burr of 0.8 or 1.0 mm and a speed of no more than 4000 rpm. All these factors can influence the perioperative period and cause complications ,29.The results of pure tone audiometry (PTA) were different. In the 2018 manuscript, the PTA frequency range was 0.125\u20138 kHz, as here, but PTA was assessed in four periods: preimplantation, during processor activation, 1 month after the activation, and 6 months after activation. Hearing preservation (HP) was calculated for the 6-month period. Here, PTA was estimated at three different times: pre-implantation, during activation (1 month after surgery), and 12 months after activation. HP was calculated over 12 months. The outcomes from both studies differ. In the 2018 study, hearing remained stable in the second subgroup during the follow-up period. Based on HP, they also had the highest overall values and the smallest variability. The results of the study showed that steroid therapy stabilizes hearing thresholds and preserves hearing in adults, and that a combination of i.v. and oral steroid therapy is an optimal treatment regimen. After 12 months there was a clear advantage of a combined steroid regimen. The majority of patients had complete (80%) or partial (20%) hearing preservation . Our results with the Oticon implant are different. Deterioration of hearing thresholds was observed regardless of the type of treatment. The majority of patients with standard steroid therapy (72%) had no measurable hearing 12 months after activation. The patients from both the other groups (the second and the control group) had slightly better hearing preservation and the difference between groups was statistically significant. Average hearing thresholds were compared in the preoperative period and 12 months after surgery. The intravenous group (the first subgroup) had better hearing thresholds in the preoperative period than after 12 months, with the difference being statistically significant. The same was observed in the control group. To sum up, a deterioration of hearing thresholds was observed in all three groups. Statistical analysis revealed that there were statistically significant differences between groups in the preoperative period. Before surgery, the oral and intravenous group had slightly better hearing thresholds than either of the other two groups. The Oticon Neuro Zti EVO implant became available in 2015 and from 2017 this type of implant was included in this project. The clinical experience with the Oticon implant is therefore limited, and research on the use of corticoids along with it is still at the pioneering stage. On the other hand, the Med-El implant was launched many years earlier, although only introduced into this study from 2018. Additionally, due to the positive results for patients obtained as early as 2018, the decision to continue the studies with the same regimes of corticosteroid administration\u2014but with a different cochlear implant\u2014was accepted by researchers (and by our Ethics Committee) as a feasible, safe, and important project. However, the inclusion criteria for the present project were slightly different from those used in the 2018 study due to different inclusion criteria for implantation with the Oticon Neuro Zti EVO.The decision to administer corticosteroids orally and/or intravenously is important from the perspective of patients and surgeons. This study adds to our knowledge of pharmacotherapy as a part of surgical technique. It is the first prospective study involving the Oticon Neuro Zti implant which compares different corticoid regimens before, during, and after surgery. From a pharmacokinetic point of view the most direct form of corticoid administration is intracochlear, but this route is the most challenging. At the present time, there is no authorization by the EMA or the FDA (Food and Drug Administration) for any drug to be delivered intracochlearly. Any drug delivered this way is administered off-label. The administration of corticoids via the routes used here accords with our Ethics Committee decision about the characteristics of this medical product. According to the inclusion criteria of hearing thresholds approved by the bioethical committee, the low performance before surgery may have affected the final result that there is no hearing preservation in the patients. One reason may be the durations of the corticoids delivery. The dose level of dexamethasone and prednisone is to be optimal according the Summary of the Product Characteristics, and the ratio between risk of adverse effects and benefits of the treatment has been well rated.The limitation of this study is the number of patients included. We planned to have at least 11 patients per group, so initially we recruited more than 40 patients. However, some dropped out of the study, and we also have patients who were recruited a few months ago and have not yet completed the 12-month follow-up yet. This work is part of an ongoing project that aims to assess the effectiveness of steroids in protecting residual hearing in different groups of patients and with different cochlear implant systems.To the best of our knowledge, this study is the first prospective clinical study to compare the results of different ways of administering glucocorticoids (dexamethasone and prednisone) in patients who had undergone cochlear implantation with the Oticon Medical Neuro cochlear implant system . There are a number of factors that affect the results, effectiveness, and final patient satisfaction after cochlear implantation. One important factor is the age of the patient. The results of this study also demonstrate that the type of cochlear implant, and its electrode properties (such as flexibility) play a key role in stabilizing hearing thresholds and preserving residual hearing. The outcomes of the study relate not only to the type of electrode, but also to the age of the patients, which in our study was relatively advanced. It is not always possible to save residual hearing in elderly patients, even when additional pharmacotherapy with corticoids is administered. In such cases, the result of administration of steroids is a minor consideration, as is the type of implant. Therefore, in this study we found that, even though they underwent implantation with the Oticon Zti EVO, the steroid regimen itself did not play a significant role in preserving the hearing of these patients, who had non-functional residual hearing."} +{"text": "Using a unique longitudinal dataset collected from primary school students in Pakistan, we document four new facts about learning in low-income countries. First, children\u2019s test scores increase by 1.19 SD between Grades 3 and 6. Second, going to school is associated with greater learning. Children who dropout have the same test score gains prior to dropping out as those who do not but experience no improvements after dropping out. Third, there is significant variation in test score gains across students, but test scores converge over the primary schooling years. Students with initially low test scores gain more than those with initially high scores, even after accounting for mean reversion. Fourth, conditional on past test scores, household characteristics explain little of the variation in learning. In order to reconcile our findings with the literature, we introduce the concept of \u201cfragile learning,\u201d where progression may be followed by stagnation or reversals. We discuss the implications of these results for several ongoing debates in the literature on education from Low- and Middle-Income Countries (LMICs). Moreover, the process of learning and the variation across subgroups may be very different in Low-Income Countries (LICs) from High-Income Countries. For instance, there is suggestive evidence that children with initially lower test scores learn less in LICs due to \u201ccurricular mismatch\u201d because curricular standards are set substantially higher than children\u2019s level of preparation . Despitewhen measured relative to cross-sectional variation, are similar in a highly disparate sample of countries.We use a rich longitudinal dataset of children\u2019s test scores over four years of primary schooling in Pakistan, collected through the Learning and Educational Achievement in Punjab or LEAPS project, to document four new facts about learning in low-income countries. First, we quantify how much children learn in school. We find that an aggregate (mean) test-score measure of learning increased by 1.19 SD between Grades 3 and 6. This implies that a high-performing child at the 75th percentile of the Grade 3 distribution \u201cknew\u201d as much as a low-performing child at the 25th percentile by Grade 6. Data from two comparison groups \u2013 the Young Lives surveys of Peru, Vietnam, India, and Ethiopia, as well as administrative data from Floridagains between Grades 3 and 5 were identical for dropouts compared to those who remained in school. This is consistent with the \u2018parallel trends\u2019 assumption required for this type of difference-in-difference estimate and suggests that the gains we observe can be causally attributed to schooling itself.Second, this learning does not solely reflect natural gains in reading, writing, and arithmetic skills as children age. To distinguish \u201clearning due to aging\u201d from \u201clearning due to schooling,\u201d we tracked and tested children who had dropped-out between Grades 5 and 6, a transition that requires a change from primary to middle school and may require more travel.lost 0.49 SD. The second decile gained 0.39 SD, and the top decile gained 2.77 SD over the four years of data. The strongest determinant of how much a child learns between Grades 3 and 6 is her initial test score. Children whose test scores were in the bottom 20 % in Grade 3 learn significantly more, gaining 1.75 SD between Grades 3 and 6, than children ranked in the top 20 % (0.71 SD). Accounting for measurement error reduces the relative gains of the lowest performers but does not reverse the pattern.Third, we find significant variation in how much children learn in our sample. The bottom decile of \u201clearners\u201d in terms of test scores gains Fourth, conditional on past test scores, household characteristics explain little of the variation in test scores between Grades 3 and 6. Regression estimates suggest that 56 % of the variance in test score levels in a given year is explained by lagged test scores, but including a full set of village and school fixed effects, as well as parental and child characteristics, explains only another 6% of the variation. We focus on two characteristics\u2014gender and family wealth\u2014in greater detail and show that our results are robust to alternate methods of test scaling, an issue that has received considerable attention in recent work from the United States.does appear to be associated with learning, at least on average. While comparing the magnitude of learning gains measured with different tests across countries is difficult, we cannot reject that learning gains are similar across a variety of settings.These findings significantly broaden what we know about learning in low-income countries. Our first finding \u2013 that students\u2019 test scores increase by more than 1 SD on average over the course of 4 years of primary school \u2013 contrasts with several studies arguing that many children progress very slowly through schools with learning trajectories that \u201cflatten\u201d over the years . Yet, thgains is new to the literature.Our second finding that students who attend school experience test score gains while dropouts do not contrasts with past studies that have shown that programs incentivized to retain children in school and increase enrollment do not improve test scores among treated cohorts .4 ImportOur third finding \u2013 that test score gains are highly variant and largest among initially low performers \u2013 relates to several studies that argue that many children, especially low performers, often start off learning very little and that their learning trajectories flatten as they fall behind and stop learning at some point during primary school . We findnot highly persistent across years. One extreme consequence of low persistence is that learning trajectories are not monotonically increasing for all children or all questions. In fact, a sizeable fraction of children experience test score losses every year. Item-wise analysis shows that the fraction of children whose performance for specific questions features gains followed by losses is as high as the fraction of children who are \u201crobust learners,\u201d or children whose learning trajectories show either stability or monotonic increases every year. The difference between our results and those of levels converge, with low performers increasing their test scores relatively more, but test score levels conditional on an imperfectly persistent baseline test score do not. Understanding the causes and pedagogic basis of low persistence in low-income countries is a fertile area for further investigation.We further contribute to the literature by introducing the novel concept of \u201cfragile learning\u201d to reconcile these findings. In our setting, as in most settings, test scores are not levels) during the primary schooling years . In these villages, all schools in the choice-set were covered as part of the LEAPS project, resulting in a total of 823 public and private schools in 2003. Between 2003 and 2006, we carried out tests in 1121 schools in 119 villages.72.2We use three datasets collected as part of the LEAPS surveys. These are (1) data on test scores, (2) data on family characteristics, and (3) data collected from households. The first two datasets were collected at schools and we refer to these samples as the \u201cSchool Sample.\u201d The sample in the third dataset, which was collected at households, is referred to as the \u201cHousehold Sample.\u201d2.2.1In each year between 2003 and 2006, the LEAPS study tested children using tests designed in consultation with pedagogical and education experts in the subjects of English, Urdu, and Mathematics. Tests were administered by the LEAPS team and were then recovered at the end of the test, minimizing the possibility of manipulation or cheating. The norm-referenced tests covered a wide range of concepts and capabilities in order to track how children learned over time. See Tracking children over time for test data was challenging, especially as children do not have methods of identification and switch schools over the multiple years of the survey. Every year, the LEAPS team conducted an extensive tracking exercise, where we tried to ascertain the whereabouts of each child enrolled in the relevant grade in the past year. Most children remained in the same school, but 5\u22127 % switched schools. Sending schools had no information on whether these children had dropped-out, left the village, or were enrolled elsewhere, and teams spent several weeks trying to track the location of these children.2.2.2On the day of the test in 2003, we sampled 10 children randomly from each class and completed a short questionnaire with these students on their family background. In subsequent years, we continued to complete the questionnaire with these children and additionally surveyed randomly selected children from the same classroom.2.2.3Our third data source comes from a concomitant household survey carried out among 1875 households in 2003 in the same villages. The household survey was designed to complement the school survey and oversampled households with children between the ages of 9 and 11. In cases where such a child was located in the household and was enrolled in the school, we have the test score of the child and parental background variables that have been collected by the surveyors from the parents themselves. Furthermore, in 2006, we were worried about extensive missing test scores as children transitioned from primary to middle school. Therefore, to retain one consistent panel, we also tested children who had been part of the school test-score panel during home visits. As we will discuss in more detail, the household sample allow us to (1) assess how sensitive our results are to attrition and (2) compare the learning trajectories of students who dropout and remain in school.2.3In this subsection, we describe the two important components of our strategy to measure students\u2019 learning. We first discuss the measurement of test scores with an item response model, and then describe how we translate these test scores into our key measure of learning throughout the paper.2.3.1In the Item Response Model, the likelihood of answering a question correctly is determined by the ability of the child, labelled \u03b8, and item parameters, labelled a, b, and c for difficulty (a), discrimination (b), and a guessing parameter (c).OpenIRT, developed by Zajonc for STATA and discussed in some common questions that can be used to \u201clink\u201d items. Item parameters for these questions are assumed to be time invariant, allowing us to identify parameters for other questions that are not common across years and place every \u03b8 on a common scale. We describe how we assess item-invariance below. As \u03b8 can only be identified up to an arbitrary scale and origin, we follow the convention that \u03b8 is drawn from a distribution with mean 0 and SD (approximately) equal to 1 across the entirety of the sample.12The joint estimation of these parameters follows the standard procedure in IRT using the IRT command, 2.3.2test score trajectory, is given by With the test score measures in hand, we identify the key object of interest in this paper \u2013 learning gains. Our measure of a student\u2019 s learning gain from period 2.42.4.1The IRT model\u2019s linking procedure assumes that test parameters are invariant over time so that the increased likelihood of answering a particular question in a particular year is fully determined by a change in the child\u2019s \u03b8. This is an assumption about the stability of the item characteristic curve and assumes that, as children progress, they move along the estimated curve, while the curve itself does not change. It is similar to the assumption of \u201cno differential item functioning\u201d for horizontal test equating\u2014for any two groups , the likelihood of answering a question correctly should depend only on underlying ability and not group membership.13This is a strong assumption but one that can be empirically tested. Appendix For most items, we find a close match between the expected and observed response patterns. Many items match almost exactly suggesting that vertical linking is possible in this setting and for this test, but there are also some notable departures. Observed response patterns for Urdu Item 23, for instance, are far above the expected response patterns with fixed item parameters at \u03b8 above the mean. This particular question asks children to select the correct antonym for the word \u201cvictory\u201d among the options (a) \u201csuccess,\u201d (b) \u201cdefeat,\u201d and (c) \u201cweapon.\u201d Another example is English Item 22 (which asks children to fill in the missing letters to complete the word \u201cfruit\u201d next to a picture of fruits). Here, the observed patterns are worse than expected suggesting that similarly knowledgeable children find it harder to answer this question correctly in higher grades. It could be, for instance, that the Grade 3 curriculum included the word \u201cfruit,\u201d but the Grade 5 curriculum did not have this particular word.We tested these departures using Chi-Squared tests and are unable to reject equality for 61 of 80 common items across years 1 and 4. We have also recomputed test score gains after (a) dropping the questions where vertical equating seems to fail; and (b) including all questions, but fixing item parameters for the 61 items where they appear to be invariant and leaving item parameters to be estimated for the other 19, where vertical equating seems to fail . To evaluate the scope for attrition to affect our results, 14We can further verify the extent to which test score gains in the schooling panel are unbiased by identifying a sample where the pattern of attrition is less severe. The intuition here is similar to the idea of \u201cintensive tracking\u201d or \u201cdouble sampling\u201d in clinical data . SpecifiUsing the household sample, we are able to compare a more and less intensively tracked sample. We have constructed the analog to 3.1.2Our only recourse for comparison to other settings with similarly equated test scores is the Young Lives study, which tested children in Ethiopia, India, Peru and Vietnam, and data from Florida, where analysis was provided to us by David Figlio using administrative data from that state. This is far from an ideal comparison. LEAPS and Florida are school-level panels that tracked children who were first observed in Grade 3, while data in the Young Lives countries is collected at the household-level, and initial selection into the panel starts at age 8 rather than when children are enrolled in a specific grade. Furthermore, there are differences in the samples, with LEAPS testing children only in rural areas but in all schools and the Young Lives using a representative sample of urban and rural children in each of their settings.Surprisingly, despite these substantial differences, test score gains over equivalent ages follow a very similar pattern, with increases of 1\u20131.27 SD in these other settings. The exceptions are language gains in Peru, which are notably higher, and Mathematics gains in Ethiopia, which fall below the average. Although the similarity in relative gains is striking, we stress that this tells us little about absolute learning across countries. Whether these patterns reflect more or less learning depends on the cross-sectional variation in the baseline grade\u2019s test scores, as well as the comparability of test score gains across different parts of the learning distribution within each country. This comparison is also fragile because, if test scores are normally distributed, a 1 SD gain throughout the distribution should always imply that children at the 75th percentile in Grade 3 \u201cknow\u201d almost the same as children at the 25th percentile in Grade 6. Although this is indeed the case for Pakistan and Florida, it is generally not true in the Young Lives countries. In India, Vietnam and Peru, children at the 25th percentile at age 12 know more than children at the 75th percentile at age 8, while the opposite is true in Ethiopia. The non-normality of these data could reflect that fact that children tested at the same age are in very different grades, further complicating cross-country comparisons.3.2A second important question is the extent to which this learning reflects natural progression in vocabulary and Math skills due to \u201clearning by aging\u201d as opposed to \u201clearning by schooling.\u201d Test score gains track each other very closely between 2003 and 2005. There is a small but imprecisely estimated difference of 0.05SD to 0.09SD in test scores levels in favor of the children who continued, but there are no differences in gains. However, immediately after children dropout, the test score differences increase to 0.40 SD from 0.09 SD in the preceding year. The analog of this figure for the household panel Appendix shows sit is 2006, and equal to 0 otherwise, including for all other years. \u201cDropout Group\u201d is a time-invariant indicator variable equal to 1 for children who dropped-out between 2005 and 2006. These regressions are clustered at the child-level, since there are multiple observations per child. Columns 3 and 4 re-run these regressions, but we now allow the test score levels in time t to depend on test scores in t-1, using the frequently-used value-added specification. Specifically, the two specifications above include an additional term, Across all these specifications, the basic message remains the same. Tests score gains are significantly lower in the year that children dropout. These differences range from -0.29 SD to -0.45 SD, when we examine level test-score differences in Column 1. The coefficient is always statistically significant at the 99 % level of confidence. Children who dropout have lower test scores at baseline . There is no evidence, that conditional on lower test scores levels, their test score growth is different in any of the years prior to dropout. This provides evidence in favor of the parallel trends assumption required for the validity of this difference-in-difference approach. The finding is also novel in its own right\u2014consistent with what we find, studies thus far have shown that test scores are correlated with dropping out\u2014but have not examined the association between test score trajectories and dropping out. Finally, and we return to this later, there is clear evidence of imperfect persistence of learning from year to year. If learning perfectly persisted, the coefficient on lagged test scores would be equal to 1.because they are in school and not because of natural gains as children age. There is evidence of gains on every tested item and some evidence that the relative gains across years are similar to what we see in other settings.We conclude from these data that most of the gains we observe in test scores for children who are attending school are 3.3lower test scores in Grade 6 compared to Grade 3. Beyond this lowest decile, all children gain over the primary school years, but the gains are highly variable. At the top end, children gained an impressive 2.8 SD over the duration of our data.The second part of our description of test score gains during primary school focuses on the variation in learning across the population. We first emphasize that there is substantial variation in how much children learn during their schooling years. One concern that has become apparent in the recent literature on learning in LICs is that of \u201ccurricular mismatch.\u201d This is the idea that children are taught according to a curriculum that is far too advanced for the average child (and maybe even the best performers), and therefore, children who are behind fall even further behind every year See and 2017lowest test scores in Grade 3. While it is therefore clear that tailoring teaching to a child\u2019s specific learning level yields positive dividends, there is no data thus far that allows us to look at learning trajectories by baseline levels during the primary schooling years in LMICs to see if the children who are behind indeed fall farther behind every year.There is no divergence in test scores in this figure. In fact, there is convergence. The difference between the bottom and top 10 % is 3.52 SD in 2003, which narrows sharply to 1.92 SD in 2006. This difference is not just across the bottom and top 10th percentiles. It reflects a gradual reduction of the baseline differences across all percentile groups. We can also confirm that the overall variance of test scores (which is 1 SD in 2003) has declined by 2006 to 0.98 SD. It is not only the case that children who are performing worse in 2003 are gaining more, but also overall inequality in learning is (weakly) decreasing between Grades 3 and 6. This is similar to recent findings from the United States\u2014most test score divergence by race happens before primary school with stable gaps during the primary schooling years .3.3.1One potential complication for interpreting only between 2004 and 2006. If measurement error is idiosyncratic across years, it should affect the observed gains of a quintile calculated in 2003 from 2003 to 2004, but not the gains from 2004 to 2005 or 2004\u22122006. Again, we find greater learning between 2004 and 2006 for children classified in the bottom quintile in 2003. These gains are significantly lower than what we see when using all test scores, but these findings remain at odds with the idea that ex-ante poor performers learn less during the primary schooling years.This procedure addresses mean reversion due to measurement error, but the gains are generally not equal to the true learning gains by baseline scores due to misclassification in the quintiles.In this second case, we instrument for The instrumental variables estimates are presented in 3.4t on lagged test scores at t-1, along with parental education, average wealth over the rounds of the survey (measured through an asset index), age, sex, and whether the child dropped-out in 2005\u221206.We next explore other determinants of learning besides a child\u2019s location in the test score distribution. As is true in much of the value-added literature, most of the variation in test score levels is explained by lagged test scores, which alone account for 56 % of the variation. Conditional on lagged test scores, household characteristics all enter with the signs we would expect , but they explain little of the additional variation. One particularly striking result is the difference between parental education and parental wealth. In our data, the most beneficial household characteristics are having a father and a mother with secondary education (only 5% of our students have at least one parent with these characteristics), and relative to having parents with no education, having both parents with greater than secondary education would predict 0.21 SD higher value-added. This is approximately 50 % of average annual gains in the sample. In contrast, conditional on the other controls, wealth is less predictive of learning, with a 1 SD increase in wealth only predicting a 0.02 SD increase in value-added. Including village or school fixed effects only accounts for an additional 6% of the variation in test scores that we observe over this time.3.4.1The fact that parental education matters but wealth does not is puzzling given an emphasis on the role of credit constraints in education, particularly in LICs. Suppose a parent is not educated but wealthy. Why can\u2019t they \u201cbuy\u201d the inputs provided by an educated parent on a tutoring market (for instance)? Given this potential puzzle and its implications, we were concerned that the weak correlation between (longer) 4-year test-score gains and two important characteristics \u2014gender and family wealth\u2014 are a facet of the specific item weights generated by the Item Response procedure. This is an issue that has been raised in the literature on test score gains in school when Blacks are compared to Whites in the United States, where scale_transformation to implement this routine more generally, and the results from this bounding exercise are shown in 2 of test scores over time, which helps to benchmark the wider bounds range against a likely transformation. In combination with the bounds, these estimates do not suggest that there are large gains among children with higher wealth. If anything, the evidence points towards small or no differences by the families\u2019 wealth.4karigar\" (which means \u201cworkman\u201d).Although we find that there are test school gains over the course of primary schooling, as well as test score convergence, our results do not necessarily imply that the school system in Punjab is well-functioning. In all three tested subjects, there are basic tasks that children cannot perform correctly by the time they are in Grade 6. In English, 54 % cannot write the word \"girl\"; 80 % cannot construct a sentence with the word \"play.\" In Mathematics, 49 % cannot subtract 238\u2212129, and 74 % cannot multiply 417 and 27. Children find it hard to form plurals from singular forms in Urdu, and 55 % cannot form a grammatically correct sentence with the word \"4.1We start by discussing how gains versus value-added specifications can yield seemingly conflicting patterns, and how this is related to low persistence in learning. Suppose we estimate a \"gain\" specification of the form, As a concrete example, low persistence implies that children with more educated parents will gain less in a specification that assumes t-1. Indeed, If test scores are a surrogate welfare measure, arguably the gains specification (Xit) = 0 .focus of research, the difference between the gains and the value-added specifications can create confusion, and therefore the interpretation of \u201cYet, when learning trajectories are themselves the 4.2the likelihood of answering an item correctly is always (weakly) increasing with time for all students is incorrect. We present this argument in three parts. First, we show that a sizeable fraction of our sample experiences year-to-year learning losses. Second, we introduce the idea of \u201cfragile learners\u201d and show that this is not just due to guessing in multiple choice questions. Third, we show that the gains versus value-added specification choice has fundamental implications for modelling convergence in knowledge in these data. We emphasize that the concept of fragility is also built into the item characteristic curve \u2013the idea that there are portions of the curve where ability is such that there is a probability of answering a question correctly implies some stochasticity in the learning process (or at least how students translate knowledge into answering questions). The question is how to think concretely about this stochasticity and its implications.27We believe that studying test score trajectories requires us to have a pedagogical interpretation for the mean reversion parameter, 4.2.1In the value-added specification, test score levels increase because low persistence is balanced by additional inputs into the production function. Test score losses across years must then reflect a combination of very low levels of inputs and/or low persistence. Such losses are surprisingly frequent; in our data, 7% of children reported lower test scores in Grade 6 compared to Grade 3. More tellingly, the fraction of child-years where we see an absolute loss in test scores across consecutive years is considerably higher at 20 %. Every year, a fifth of children are measured as \u201cknowing\u201d less than they did the year before.4.2.2only these two questions administered in Grade 6 could lead us to conclude that the accumulation of counting skills is very slow during the primary years.These losses cannot just be attributed to guessing in multiple choice questions or the concavity of learning trajectories, where additions to knowledge require greater inputs at higher levels. As a specific example, consider two questions in Mathematics. Children are given two boxes: one with 4 crescent moons and one with 8, and subsequently asked to circle the one with more objects. For the second one, children are given a box with 2 stars and asked to circle the number that matches the number of stars in the box. This is a difficult question for our sample, and by Grade 6, 27 % and 22 % get it wrong. Because there are 2 and 4 options respectively, guessing would imply that the fraction who \"know\" how to do this is even lower. A test with knew how to answer these questions but then subsequently \"forgot.\"But this inference is complicated by two additional pieces of data. First, of the 25 % of children who cannot count stars in Grade 6, 82 % can add 3 + 4; 72 % can add 9 + 9+9, and 55 % can multiply 4 \u00d7 5. Children who can perform more complex tasks that involve counting still may not know how to count as required by the first two questions. More surprisingly, among those who could not count the stars in Grade 6, between 40 % and 50 % correctly answered these questions in Grade 5, and between 37 % and 46 % correctly answered the question in Grade 3. These are considerably higher than the fraction we would expect from pure guessing, suggesting that they This example leads us to introduce the idea of \u201cfragile learners,\u201d who we define as children whose learning on a specific question does not follow a (weakly) monotonic trajectory. Appendix Fragility could be attributed to children guessing correctly in a multiple-choice question (MCQ) one year and incorrectly in the next, and indeed fragile learners are a higher fraction of robust learners for MCQs, a feature that is also captured in the higher guessing parameters for these items.4.2.3Our inadequate understanding of fragility and mean reversion affects our understanding of test score trajectories. function of the pedagogic process and may vary across different students due to the pedagogic process. Unfortunately, with our data \u2013as well as virtually all other data from low-income countries\u2013 lower levels of persistence cannot be observationally separated from lower levels of learning.The fundamental problem is that we cannot tell from these data alone whether children at the top or the bottom are in fact learning less, since the answer depends on our assumptions about the constancy of the persistence parameter across the test score distribution. Assuming the persistence parameter is constant treats imperfect persistence as a \"natural dynamic,\" independent of the pedagogic process. This assumption may entirely miss the point. Persistence may itself be a Our preliminary investigation suggests that learning trajectories are extremely complicated and unpacking this complexity is a critical task for education specialists moving forward. Thus far, our heuristic definition of fragile learning and its implications for test score trajectories lack a formal exploration, both in terms of the underlying statistics and the pedagogic content. We see this area as fertile grounds for further research, particularly if more long-term panels of test scores become available.5Our findings shed light on three patterns that are widely believed to characterize education in LICs. The first is that children learn very little and \u201cflat\u201d learning trajectories lead children from low-income countries to consistently test more than 1SD below those from high-income settings. The second argues that low learning is closely tied to pedagogical styles and suggests that because the grade-level curriculum is far more advanced than what children know, poor performers fall back relative to high achievers as they proceed through school. Finally, the third argues that education is for the elite, and therefore, children from wealthier backgrounds learn significantly more.Our findings suggest that more nuance is warranted. It is certainly the case that children do not know a lot in Grade 6, particularly in Mathematics and English, but there is also clear evidence that they have learned between Grades 3 and 6, increasing performance by 20\u201330 percentage points on specific items. Our analysis of dropouts suggests that remaining in school adds considerable value, and therefore retention policies remain important to improve learning and equity in our setting.Our data also suggest that schools are an equalizing force in these settings, in that children with initially low scores experience higher gains over the primary schooling years and the overall variance of the test score distribution does not increase. It is possible that the patterns in middle school are different, like in Finally, parental wealth and child gender have little association with test score gains, although there are clear associations with parental education. However, the characteristics available in these data still only account for at most 6% of the variation in test scores, conditional on past test scores that we observe. This is consistent with emerging evidence from the U.S. that gaps in test scores have already developed by the time that children enter primary school , and they do not expand much farther.The unique data on learning trajectories available through the LEAPS project helps us rationalize this \u201cpositive\u201d message with the low accumulation of skills in Grade 6 through the novel concept of \u201cfragile learning.\u201d We have shown that rather than slow but steady progression on specific questions, children may gain rapidly but then show no further increases or reversals. We have also shown that the fraction of children whose learning is fragile is as high as those who learn in a robust, monotonic fashion. It is this fragility, usually captured in a (low) persistence parameter that is central to our understanding of learning trajectories in low-income countries. We do not know whether such learning trajectories reflect differential effort in test-taking , extremeThis is one area where more research is needed with better longitudinal data using equated test scores over the primary schooling years. Panel datasets from schools in low-income countries that have tested children each year through the primary schooling years in a psychometrically valid fashion that allows for a comparison are exceedingly limited (one example with 3 years of data follows children from Grades 1\u20133 in South Africa"} +{"text": "Uveal melanoma is a rare subset of melanoma characterized by the presence of early initiating GNAQ/11 mutations, with downstream activation of several pathways which are thought to contribute to cell growth. Based on clinical and preclinical data supporting targeting of protein kinase C (PKC) and the phosphatidylinositol 3-kinase (PI3K) pathway, we conducted a phase Ib study to assess the safety of combined sotrastaurin, a PKC inhibitor, and alpelisib, a PI3K inhibitor. We found that sotrastaurin and alpelisib can be safely administered, however there was no evidence of clinical efficacy.Uveal melanoma (UM) is a rare subset of melanoma characterized by the presence of early initiating GNAQ/11 mutations, with downstream activation of the PKC, MAPK, and PI3K\u03b1 pathways. Activity has been observed with the PKC inhibitors sotrastaurin (AEB071) and darovasertib (IDE196) in patients with UM. Inhibition of the PI3K pathway enhances PKC inhibition in in vivo models. We therefore conducted a phase Ib study of sotrastaurin in combination with the PI3K\u03b1 inhibitor alpelisib to identify a tolerable regimen that may enhance the activity of PKC inhibition alone. Patients with metastatic uveal melanoma (n = 24) or GNAQ/11 mutant cutaneous melanoma (n = 1) were enrolled on escalating dose levels of sotrastaurin (100\u2013400 mg BID) and alpelisib (200\u2013350 mg QD). The primary objective was to identify the maximum tolerated dose (MTD) of these agents when administered in combination. Treatment-related adverse events (AE) occurred in 86% (any grade) and 29% (Grade 3). No Grade 4\u20135-related AEs occurred. Dose Level 4 was identified as the maximum tolerated dose. Pharmacokinetic analysis demonstrated increasing concentration levels with increasing doses of sotrastaurin and alpelisib, without evidence of interaction between agents. Pharmacodynamic assessment of pMARCKS and pAKT protein expression with drug exposure suggested modest target inhibition that did not correlate with clinical response. No objective responses were observed, and median progression-free survival was 8 weeks . Although a tolerable dose of sotrastaurin and alpelisib was identified with pharmacodynamic evidence of target inhibition and without evidence of a corresponding immunosuppressive effect, limited clinical activity was observed. Uveal melanoma is a rare subtype of melanoma that accounts for approximately 3\u20135% of all melanomas ,2. TreatGNAQ or GNA11, with the remainder of cases harboring other alterations, such as mutations in CYSLTR2 or PLCB4, which functionally activate the G-\u03b1 pathway [GNAQ and GNA11 result in disabling of their intrinsic GTPase activity, leading to cleavage of phosphatidylinositol diphosphate (PIP2) into inositol triphosphate (IP3) and DAG, and subsequent activation of downstream effectors including protein kinase C (PKC), a mediator of the mitogen-activated protein kinase (MAPK) pathway [Uveal melanomas generally harbor early initiating mutations in genes encoding for the G-\u03b1-protein-subunits, pathway ,6. Mutat pathway ,8. The P pathway . PKC iso pathway ,11.In a completed phase I study of sotrastaurin, a potent, selective oral inhibitor of both the classical and novel isoforms of PKC, 153 patients with metastatic uveal melanoma received total daily doses of sotrastaurin ranging from 450 to 1400 mg on a twice daily or three times daily dosing schedule . The recGNAQ and GNA11 mutant uveal melanoma cell lines and tumor growth inhibition in a GNAQ-mutant xenograft tumor model. Furthermore, suppression of both the PKC/ERK and PI3K/AKT pathways was observed with combined treatment in vitro and in vivo [We previously demonstrated the induction of phospho-AKT with exposure to sotrastaurin in preclinical uveal melanoma models, suggesting upregulation of the PI3K/AKT pathway as a mechanism of resistance to PKC inhibition . Combine in vivo . Based oClinicalTrials.gov identifier, NCT02273219). Site-specific Institutional Review Boards approved the protocol and written informed consent was obtained from each subject at enrollment.This was a phase Ib, open-label, multicenter, single-arm study conducted at Columbia University Irving Medical Center , Memorial Sloan Kettering Cancer Center , and the University of Miami . This study was conducted in accordance with the Declaration of Helsinki ethical principles, Good Clinical Practices, principles of informed consent, and requirements for public registration of clinical trials (The primary objective of this study was to determine the maximum tolerated dose (MTD) for the combination of sotrastaurin and alpelisib in patients with metastatic uveal melanoma or other melanoma subtypes harboring a mutation in GNAQ or GNA11. Secondary objectives were to evaluate the efficacy of combined treatment with sotrastaurin and alpelisib as determined by investigator-assessed objective response rate (ORR) using RECIST v1.1 criteria, investigator-assessed progression-free survival (PFS), and overall survival (OS), and to evaluate the pharmacokinetic properties of combined treatment with sotrastaurin and alpelisib at varying dose levels. Exploratory objectives included pharmacodynamic analysis assessing target inhibition of the PKC and PI3K pathway via Western blot analysis and gene-expression profiling on paired tumor biopsies to assess changes in tumor gene expression. All the whole western blot figures can be found in the Subjects received sotrastaurin (100\u2013400 mg twice a day) and alpelisib (200\u2013350 mg daily) administered orally on a continuous 28-day cycle \u00a0Table A1Eligible patients were required to have a histologically confirmed diagnosis of metastatic uveal melanoma or other melanoma subtype harboring a mutation in GNAQ or GNA11. There were no restrictions on number or type of prior therapies. Eligible patients were \u226518 years old, had an ECOG performance status of 0\u20132, and had measurable disease by RECIST v1.1 criteria. Due to the known association of alpelisib with hyperglycemia, patients with a history of Type I Diabetes Mellitus (DM) or Type II DM requiring insulin were excluded, and fasting plasma glucose had to be <140 mg/dL in all patients. The study was later amended to exclude all patients with a history of Type II DM.Toxicity was graded using NCI Common Terminology Criteria for Adverse Events (CTCAE v. 4.0). For recurrent adverse events, the highest reported grade per event per patient was assessed. DLTs were defined as any treatment-related Grade 3 or higher toxicity, or intolerable Grade 2 toxicity that required a greater than 21-day treatment delay, occurring during the first 28 days of study therapy. In addition, specific DLT criteria were defined for the following adverse events: Grade 3 neutropenia and fever, Grade 3 anemia only if due to a hemolytic process related to study treatment, Grade 3 thrombocytopenia and bleeding, for subjects with liver metastases, Grade 3 AST or ALT only if \u226525% rise from baseline and not definitely due to disease progression, and Grade 3 diarrhea \u2265 48 h despite maximum prophylaxis. Patients who did not complete the 28-day DLT evaluation period were considered unevaluable for the purpose of DLT evaluation and efficacy.Imaging was obtained at baseline, at 4 and 8 weeks after the start of study treatment, and then every 8 weeks thereafter. A CT of the chest, and CT or MRI of the abdomen and pelvis with contrast were required at each time point, with additional modalities of imaging permitted at investigator discretion. Reponses were assessed using RECIST v.1.1 criteria by investigator assessment. Criteria for removal from study included radiographic or clinical disease progression, or unacceptable toxicity.Pharmacokinetic (PK) Analysis: Plasma samples were collected for PK analysis during Cycle 1 on Day 1 , Day 8 , Day 15 (pre-dose), and pre-dose on Day 1 of Cycles 2\u20136. Plasma concentration levels of sotrastaurin and its metabolite AEE800 were assessed in all subjects. Plasma concentration levels of alpelisib were performed in a cohort of patients who were enrolled at Columbia University Irving Medical Center. PK analysis was performed using a previously validated LC-MS/MS procedure . The reference standards for sotrastaurin, AEE800, and alpelisib were supplied by Novartis.3VO4. Equal amounts of protein were loaded and separated on a 4\u201312% PAGE gel (Invitrogen). Proteins were transferred to polyvinylidenedifluoride (PVDF) membranes, which were blocked in 5% nonfat dried milk. Membranes were then incubated with primary and secondary antibodies and developed by ECL. Antibodies used to probe were: pAKT , Pan AKT , pS6 , S6 ribosomal protein , pMARCKS , MARCKS , GAPDH , pERK1/2 , ERK1/2 , Cyclin D1, Cyclin E1 , Cyclin A2 , Bcl-2 , and GLUT4 , obtained from Cell Signaling Technology Inc., unless otherwise noted.Pharmacodynamic (PD) Analysis: The protocol was amended to mandate paired tumor biopsies for PD analysis in all enrolled subjects starting in April 2016 (during enrollment of Dose Level 4). Paired tumor biopsies with sufficient flash-frozen tissue for analysis were subsequently obtained at baseline (day \u221228 to \u22121) and at Cycle 1 Day 15 (\u00b13 days) in a total of 7 patients. Tumor biopsies were lysed in radioimmunoprecipitation assay (RIPA) buffer supplemented with a protease inhibitor cocktail tablet (Roche Diagnostics) and 1 mmol/L of NaTM panel (Nanostring Technologies) to assess 770 immune-related genes in 7 paired tumor biopsy samples. A total of 50 ng of RNA per sample was mixed with a 3\u2032 biotinylated capture probe and a 5\u2032 reporter probe tagged with a fluorescent barcode from the custom gene expression code set. Probes and target transcripts were hybridized at 65 \u00b0C for 16 h and then run on the NanoString nCounterTM platform according to the manufacturer\u2019s protocol. The samples were scanned at maximum scan resolution on the nCounter Digital Analyzer and data were analyzed using nSolver Analysis Software. Gene expression counts were normalized using the geometric mean of housekeeping genes included in the panel selected by the GeNorm algorithm. Differential gene expression in the on-treatment samples was compared with baseline gene expression in pre-treatment samples. Pathway scores were analyzed using the nSolver Analysis Software, which is based on previously described methods [Gene Expression Analysis: RNA was extracted from flash-frozen paired tumor biopsy samples with the RNeasy Micro Kit (Qiagen) according to the manufacturer\u2019s protocol and quantified using the NanoDrop spectrophotometer. Gene expression analysis was performed using the PanCancer IO360 methods .Between November 2014 and November 2017, a total of 25 patients were enrolled, and 24 patients were evaluable for DLT and efficacy. One patient in dose level 4 did not complete the DLT observation period due to rapid disease progression (Day 14), was deemed unevaluable for DLT and efficacy, and was replaced. Twenty-four patients had a diagnosis of uveal melanoma and one patient had melanoma of unknown primary harboring a GNAQ mutation . The medOf the 3 initial patients enrolled in dose level 1 , 1 patient experienced Grade 3 hyperglycemia attributed to study therapy and was declared a DLT. An additional 3 patients were enrolled into dose level 1 without further DLTs observed, however 1 patient experienced Grade 3 nausea and vomiting soon after the end of the DLT period (during Cycle 2 Week 1). An additional 3 patients were subsequently enrolled into dose level 1 for additional safety information. One patient in this group experienced Grade 3 nausea related to study therapy meeting DLT criteria, resulting in 2 patients out of 9 experiencing a DLT in dose level 1 . No DLTsTreatment-related adverse events (AE) occurred in 86% (any grade) and 29% (Grade 3) of patients . No GradA total of 8 patients (32%) required dose reductions for treatment-related toxicity. Dose reductions due to AEs occurred in 4 out of the 5 patients who experienced DLTs, and 1 patient with a DLT discontinued treatment due to the AE. Notably, 4 patients required dose reductions for late toxicities that occurred after the end of the 28-day DLT observation period. Late dose reductions occurred in 1 patient each in dose level 2 (Grade 2 intolerable fatigue), dose level 3 (Grade 2 intolerable fatigue and nausea), dose level 4 (Grade 2 intolerable nausea and anorexia), and dose level 5 (Grade 2 intolerable fatigue).A total of 24 patients were evaluable for response. No complete or partial responses by RECIST v1.1 criteria were observed. A best response of stable disease was observed in 66.6% (n = 16) of patients at 4 weeks from treatment initiation and 37.5% (n = 9) at 8 weeks. The median investigator-assessed progression-free survival was 7.6 weeks . The medEvaluation of plasma sotrastaurin concentration over time, although limited by small and varying sample sizes across doses, demonstrated increasing sotrastaurin plasma concentrations with higher doses a,b. PlasPlasma concentration levels of sotrastaurin in this study demonstrated a similar pattern to previously published levels seen with sotrastaurin monotherapy, suggesting a limited interaction between sotrastaurin and alpelisib .To evaluate target inhibition of PKC with sotrastaurin, MARCKS and pMARCKS protein levels were evaluated by Western blot analysis on available paired tumor biopsy specimens. MARCKS is a known substrate of PKC, and preclinical studies have demonstrated that inhibition of PKC results in reduced pMARCKS levels . A decreDespite suppression of pMARCKS, pERK1/2, pAKT, and pS6, none of the patients with paired biopsies (n = 7) derived clinical benefit. Clinical characteristics and outcomes for these corresponding 7 patients are detailed in To further assess the treatment effect on proteins associated with proliferation, apoptosis, and metabolic activity, cyclin levels , Bcl-2, and GLUT-4 were also evaluated by Western blot. Although Bcl-2, an anti-apoptotic protein known to be upregulated in uveal melanoma, was decreased in 5 of 7 samples, no clear pattern was seen with markers of proliferation or metabolic activity to further explain the lack of tumor response with treatment. Results are shown in TM IO360 panel. Differentially expressed genes with log2 fold change >1.5 are graphed and listed in PKC isoforms have been demonstrated to regulate initiation and homeostasis of immune responses. Specifically, PKC-alpha is involved in T-cell proliferation and IFN-gamma production, and PKC-theta regulates T-cell activation and IL-2 production ,18,19. GThis was the first study to assess the therapeutic strategy of combined PKC and PI3K inhibition in patients with metastatic uveal melanoma. Our findings showed that the safety profile of sotrastaurin and alpelisib was generally acceptable, with recommended phase 2 doses of sotrastaurin 200 mg twice daily and alpelisib 350 mg daily (dose level 4). The most frequently observed AEs were GI-related, including diarrhea and nausea. Most of these were low-grade, with only 8% being Grade 3. Fatigue and anorexia were also common and predominantly low-grade. However, both GI-related symptoms and fatigue were the cause of 3 out of 5 DLTs. No clinical responses were seen with the best response of stable disease in 67% of patients. No differences in response were seen across dose levels. One patient achieved the best response of prolonged stable disease for 51 weeks.We investigated several reasons why clinical activity was disappointing in this study, which demonstrated a similarly poor median PFS (7 versus 11 weeks) as the sotrastaurin monotherapy study that recommended a phase 2 dose of 700 mg twice daily . AlthougThe limited clinical efficacy in this study unfortunately compares similarly to previous negative trials using combinations such as MEK and AKT inhibition , MEK inhIn conclusion, the findings of this phase Ib study of sotrastaurin and alpelisib have demonstrated a safety profile, pharmacodynamic effects, and antitumor activity consistent with other targeted inhibitors in uveal melanoma, with key toxicities including nausea, diarrhea, fatigue, and anorexia. Given the lack of efficacy, there are no plans for development of this combination in patients with uveal melanoma. Other ongoing trials including selective PKC inhibition may offer more promise in this challenging disease."} +{"text": "Following an index episode of acute pancreatitis, sometimes the inflammation subsides completely, but sometimes inflammation persists and progresses to chronic pancreatitis, which may be or may not be preceded by recurrent acute pancreatitis. Some patients may also develop diabetes mellitus. There is only limited information on the longer\u2010term outcome of patients with acute pancreatitis. The aim of this study was to evaluate the longer\u2010term consequences of acute pancreatitis in the form of the development of recurrent attacks of acute pancreatitis, chronic pancreatitis, diabetes, or pancreatic carcinoma.The index study included 122 patients who presented with their first episode of acute pancreatitis. This retrospective, cross\u2010sectional survey was performed 5\u2009years after the index episode.Of the 122 patients, 96 were available for follow\u2010up while 4 were known to have died (one from pancreatic cancer). On reassessment after 5\u2009years, 28 of 96 patients had further episodes of pancreatitis. Fifteen patients were diagnosed as having recurrent acute pancreatitis, 13 patients were diagnosed as having chronic pancreatitis, while 17 developed new\u2010onset diabetes. Recurrent acute pancreatitis was more common in younger patients, while chronic pancreatitis was associated with alcohol abuse and a more severe index episode. The development of diabetes was more common with advanced age.In this study, a good proportion of patients progressed to chronic pancreatitis and diabetes within 5\u2009years after surviving acute pancreatitis. Cross\u2010sectional review was done after 5\u2009years of follow\u2010up of acute pancreatitis. Out of 100 patients, 15% patients developed recurrent acute pancreatitis, 13% patients developed chronic pancreatitis, and 17% patients developed diabetes. Acute pancreatitis (AP) is a common gastrointestinal emergency requiring hospital admission and causing a significant health\u2010care burden. The majority of patients recover completely after an acute attack of pancreatitis. However, some patients will go on to develop recurrent attacks of acute pancreatitis (RAP), chronic pancreatitis (CP), or endocrine insufficiency in the form of diabetes mellitus. There has been a dearth of data in this regard as studies conducted are few and far between.It is a retrospective observational study. All patients recruited in our index study with AP were followed prospectively for 1\u00a0year as per study schedule; after that, patients were advised to attend a pancreatic clinic or emergency for new\u2010onset pain abdomen or for any abdominal symptoms. Patients who developed diabetes were managed in the diabetic clinic of the same hospital. Investigations were done according to clinical situations. At the end of 5\u2009years, we did a cross\u2010sectional survey of all recruited patients. We contacted all patients or their relatives (if the patient had died) by telephonic call and letters and did a retrospective comprehensive review of their history of any illness, clinical records, and imaging data were conducted for identification of outcomes in terms of RAP, CP, diabetes mellitus, and pancreatic malignancy.Approval of the study was done from the Institutional Ethics Committee of the IPGMER, Kolkata. All patients (or their relatives if the patient had died) provided informed consent. This study was conducted in accordance with the Declaration of Helsinki.The exclusion criteria are those mentioned in our index study.AP diagnosis was established whenever two of the following three criteria were present: abdominal pain; elevated serum levels of amylase and/or lipase three times the upper limit; and imaging evidences of AP.Of 122 patients in the index study, 4 were known to have died and 96 attended the OPD for follow\u2010up. Complications after AP were determined by interview and examination of medical records. Particular attention was paid to the nature, severity, and management of further episodes of abdominal pain as well as the possible development of diarrhea, weight loss, or diabetes. All patients were advised to do a fasting blood sugar and blood sugar 2\u00a0h after 75 grams of glucose ingestion except those patients who were already diagnosed with diabetes. Fasting plasma glucose value equal to or greater than 126\u2009mg/dL and/or plasma glucose value equal to or greater than 200\u2009mg/dL after a 2\u2010h glucose load confirmed on two occasions was diagnosed as diabetes.All patients underwent transabdominal ultrasonography (USG) upper abdomen.CECT of the upper abdomen was done if the USG abdomen showed any pancreatic ductal changes like dilatation, narrowing, calcification, or any pancreatic parenchymal calcification.calcification in pancreas;ductal abnormalities (as per Cambridge classification);exocrine insufficiency is defined as pancreatic fatty diarrhea clinically reduced by enzyme supplementation; orhistology suggestive of CP.Risk factors of hypercalcemia, hypertriglyceridemia were assessed in all patients of RAP but Magnetic Resonance Cholangiopancreatography (MRCP) and genetic testing were not done.For the diagnosis of CP, the MANNHEIM diagnostic criteria were used.U for continuous variables, Fisher's exact test for categorical variables, and univariate analysis to identify baseline predictors for development for RAP, CP, and new\u2010onset diabetes. A two\u2010tailed P\u2010value <0.05 was taken as significant.SPSSTM (version 13 for Windows) software was used for statistical analysis. Descriptive data were reported as the mean and standard error of mean (SEM) for continuous variables, while percentages were calculated for categorical variables. We obtained Lambda and Mann\u2013Whitney's Of 100 patients whose outcome was known, 64 were male and 36 were female with a mean age of 42\u2009years (range 14\u201388\u2009years) at the time of the index episode of pancreatitis . Thus, 12/15 (80.0%) of them were aged \u2264\u200935\u2009years at the time of index AP vis\u2010\u00e0\u2010vis 26/72 (36.1%) of those who had remained asymptomatic. The etiology or severity of index AP was not a risk factor for recurrence.Twenty\u2010eight patients either had RAP or had developed CP at the end of 5\u2009years of follow\u2010up. Of these 28, 15 patients developed RAP during 5\u2009years of follow\u2010up. The index episode was idiopathic in nine, biliary in three, alcohol\u2010related in one, ascariasis\u2010related in one, and post\u2010ERCP in one, respectively. Their mean (\u00b1 SEM) age was 27.4 (\u00b1\u20094.1) years and nine were male. On univariate analysis, young age was the only risk factor for the development of RAP , and more likely to have a moderate\u2010to\u2010severe index AP . They more frequently required interventions for their pseudocyst/WOPN during their index AP and were more likely to have developed new\u2010onset diabetes at the end of 5\u2009years .The remaining 13 patients were diagnosed to have CP. Of these, nine had alcohol, three had biliary, and one was idiopathic as a cause for index attack of AP. A total of 42.8% of patients of alcoholic etiology went on to develop CP. Compared to the remaining 72 patients who neither developed RAP and/or CP, they were almost exclusively male , have had an alcoholic etiology , were more likely to have a necrotizing and moderate\u2010to\u2010severe index AP, have had more chance to developed organ failure , and less likely to have undergone spontaneous resolution of their pseudocysts/WOPN during their index episode of AP.On univariate regression analysis, it was found that those who developed new\u2010onset diabetes were more likely to be older at the time of index AP had a recurrent attack of pancreatitis over the follow\u2010up period. When these patients were compared with those who did not have any recurrence or chronicity 72/100) (Table\u00a0/100 (TabCP developed in 13 patients (13%). When compared to patients who did not have recurrence or chronicity (72/100), univariate analysis showed male sex, alcohol as etiology, and moderate to severe index attack as the significant risk factor for progression to chronicity. There have been several studies on long\u2010term follow\u2010up of AP reporting a progression rate to CP ranging from 4% to 24%et al.In our study, 73.5% of patients with the initial attack had necrotizing pancreatitis Table\u00a0. This isPrior studies have shown that the rate of development of diabetes after AP is nearly 20\u201325%.et al.One patient died due to pancreatic adenocarcinoma within a follow\u2010up duration of 75\u2009months (absolute risk 1%). Similar findings have been noted in the study by Lankisch This study evaluates the natural history of AP. During follow\u2010up period, 15% of patients developed AP with young age (<\u200935\u2009years) being the most significant risk factor for recurrence. A total of 13% of patients developed CP during follow\u2010up with male sex, alcohol as etiology, and moderate to severe initial attacks being the significant predictors for CP. A total of 17% of patients developed diabetes with alcoholic etiology and necrotizing pancreatitis among others, being significant predictors for the development of diabetes. A total of four patients died during the follow\u2010up period with one out of four deaths being due to pancreatic adenocarcinoma.This was a single\u2010center study with the center being tertiary care so there is an inherent selection bias to this study whereby a majority of cases were moderate to severe cases of pancreatitis. This could have led to bias in the outcomes as many of the mild cases were missed.This is a retrospective cohort study, so there is a risk of recall biases.Endoscopic ultrasound was not routinely used to work up the etiology or at the end of follow\u2010up. This could have led to the missing of microliths in a number of cases, which could have caused AP, thereby increasing the number of idiopathic cases. Lack of endoscopic ultrasound study could have led to the missing of early CP in patients of RAP.The effect of smoking as an etiology or determinant of severity was not studied. Smoking may be an independent risk factor for causing as well determining the severity of AP."} +{"text": "As the executor of the River Chief System (RCS), local governments\u2019 choice of implementation strategies directly affects the quality of regional water environment. The implementation of the RCS involves many interest subjects, and has gradually formed a game between enterprises\u2019 sewage management and local governments\u2019 RCS implementation strategies, and a game between the RCS implementation strategies of different local governments. The game behavior between the interested parties is long-term and dynamic in nature. Strategies such as reducing the cost of local governments\u2019 implementation of the RCS and increasing the rate of sewage charges will lead to the evolution of the strategy set between enterprises\u2019 treatment of sewage and local governments\u2019 RCS implementation in the direction of {complete treatment of sewage, strictly enforcing the RCS}. Analysis of the evolutionary game model between the local governments reveals that strategies such as reducing the weight of economic indicators in local governments\u2019 assessment, and increasing the material and spiritual rewards for implementing the RCS, will lead to the evolutionary game outcome of implementing the RCS between the local governments in the direction of {strictly enforcing the RCS, strictly enforcing the RCS}. The external effects of sewage discharge do not affect the evolution of the game system between the local governments. In order to alleviate a series of economic and social problems caused by water pollution, China fully implemented the River Chief System at the end of 2018 to strengthen water pollution prevention and control, comprehensively remediate black smelly water bodies, and improve the ecological and environmental governance system. Water environment is a typical public good, and water environment control depends not only on central policies but also on local governments\u2019 considerations based on political and economic interests [The implementation of the RCS involves many interest subjects, and gradually leads to the formation of a game between enterprises\u2019 treatment of sewage and local government\u2019s RCS implementation strategy, and a game between the RCS implementation strategies of the local governments. It has been found that the environmental control strategies of local governments are associated with the cost of environmental regulation enforcement, the strength of penalties for inaction, the weight of environmental indicators in the performance appraisal system, and the expected pollution emission reduction ,3. In thThe existing literature has rarely analyzed the impact of strategies between enterprises and local governments, and between local governments from the perspective of RCS. As a local government policy innovation, the RCS has its own unique factors. For example, most of the performance assessments of River Chiefs in each region are linked to the effectiveness of the implementation of the RCS, thus making it more politically risky in terms of advancing their position to focus only on economic growth and ignore water pollution. Therefore, local officials are more motivated to supervise sewage-discharging enterprises in their jurisdictions based on political promotion . In addi(1)Model assumptionsThe central government does not uniformly specify the form of the RCS implementation, and each provincial government sets up different governance models according to its own conditions. The vast majority of provinces and municipalities take the results of the RCS work assessment as an important element in the comprehensive evaluation of officials. Local governments are responsible for the quality of water bodies within their jurisdictions, while accepting supervision from higher levels of government and the public. Enterprises are guided by relevant national regulations to discharge effluent in accordance with effluent standards, and local governments will levy effluent charges for their effluent discharges, with the aim of inducing water discharge enterprises to internalize external costs.In order to reasonably set up the evolutionary game model between local governments and water discharge enterprises, drawing on existing studies ,13, the (2)Description of symbolsBased on the description of the evolutionary game between the local governments and water discharge enterprises, the relevant parameters are set as follows:In the context of RCS, the local government\u2019s control of enterprise effluent discharge is divided into strict implementation of RCS work; high frequency regulation of enterprise discharge behavior and strict control of effluent discharge; and incomplete implementation of RCS work arrangements, low frequency regulation of enterprise discharge behavior, and relaxation of effluent discharge control. The strategy set of the local government for RCS implementation is {strictly enforcing the RCS, not strictly enforcing the RCS}. Local government finances are derived from the production activities of various enterprises, which is a very important part of local government performance. Under the Chinese decentralized system, political centralization and economic decentralization give local governments a great deal of adjudication power in economic matters, and the central government guides and incentivizes local government behavior through the performance appraisal system. Economic targets imply that local governments have to achieve their goals through various types of enterprise development, and water quality assessment targets under the RCS require local governments to reasonably regulate the amount of effluent discharged by enterprises. Therefore, the economic return of the sewage water enterprises and the volume of sewage discharged are important factors influencing the level of payment by local governments. The sewage water enterprises then form the following strategy set: {complete treatment of sewage, incomplete treatment of sewage}.Under the RCS arrangement, the game behavior between a local government and a water discharge enterprise is a stochastic matching, and the mutual influence of the repeated game process, and the decision adjustment process between the two can be simulated by replicating the dynamic mechanism. When local government A chooses to strictly implement the RCS, a certain percentage of polluting enterprises will choose to fully treat their sewage, and, in turn, the amount of sewage discharged within local government A\u2019s jurisdiction will decrease and water quality will improve. If the local government A chooses not to strictly implement RCS, a certain percentage of enterprises will choose not to fully treat water pollution, and, in turn, the amount of sewage discharged within the jurisdiction of local government A will increase, and water quality will deteriorate. If the local government A chooses to strictly implement RCS and the polluting enterprises also choose to completely treat sewage, polluting enterprises will incur the cost of completely treating sewage with the cost of reasonable sewage When local government A chooses to strictly enforce the RCS and polluting enterprises choose not to fully treat the sewage, the polluting enterprises will incur part of the cost of treating the sewage (at this point the cost of treating the sewage is mainly related to the strength of the enterprise to treat the sewage) and the cost of discharging sewage When local government A chooses not to strictly implement RCS and polluting enterprises choose to completely treat wastewater, polluting enterprises will incur the cost of completely treating wastewater and the cost of reasonably discharging water. At this time, the enterprises\u2019 cost of discharging water is reduced due to less strict regulation, the reduction is related to the intensity of regulation, and the total cost is When local government A chooses not to strictly enforce the RCS and polluters choose not to fully treat the effluent, polluters will incur a portion of the cost of treating the effluent and the cost of discharging the water, The proportion of polluters choosing to fully treat the sewage is set to The expected benefits for polluters choosing to treat their wastewater completely versus incompletely are as follows:The average expected benefits of wastewater treatment for polluters are as follows:The replicated dynamic equation for the polluting firm choosing to completely treat the effluent is as follows:Bringing Equations (1) and (2) into Equation (4), the following can be obtained after calculation:The expected benefits for River Chiefs choosing to strictly implement RCS and not strictly implement RCS are as follows:The replication dynamic equation for local government A choosing to fully treat the effluent is as follows:Bringing Equations (6) and (7) into Equation (8), the following can be obtained after calculation:Equation (5) is coupled with Equation (9) to obtain a replicated dynamic system of water polluting enterprises and local government A:The joint derivative of Equation (10) is set to zero, and the five local steady state points of the game behavior of water polluting enterprises and local government A are derived separately as follows: From It can be seen that the manner in which the game process between polluters and local government A evolves is influenced by two factors: the initial state of the system and the relative position of the local equilibrium point D. When the initial game state of both parties is in the region of ADCO, the stabilization strategy of the game between polluters and local government A evolves to the \u201cPrisoner\u2019s Dilemma\u201d, and both parties do not perform the sewage improvement work completely as the stabilization strategy, and reach the equilibrium state temporarily. If the initial game state of both parties is in the region of ADCB, the stabilization strategy of the game between polluters and local government A evolves to the \u201cPareto optimal\u201d, and both parties perform the sewage improvement work completely as the stabilization strategy and reach the optimal equilibrium state. The above analysis shows that there are two possible final results of the game between polluters and local government A. Then, the choice of the evolutionary path and direction of the game between the two sides also depends on the relative position of point D. The relative position of point D directly controls the size of the area between region ADCO and region ADCB. When the area of the ADCO interval is larger than the area of the ADCB interval, the system will evolve toward the stable point In order to further analyze the factors influencing the evolutionary game path between polluters and local government A, it is necessary to discuss the effect of parameter changes at the local equilibrium point D on the size of the regional ADCB interval, where the size of the ADCO interval is From For sewage companies, the treatment of sewage is directly related to the cost of action. In the pursuit of cost minimization or profit maximization, any increase in costs needs to be carefully considered. The reduction in the cost of complete treatment of sewage gives companies an opportunity to choose the treatment of pollution, which, in line with the relevant policies, will make companies choose the complete treatment of sewage strategy.Regarding local governments, under the Chinese decentralized system, the characteristics of political centralization and economic decentralization make local governments pursue the maximization of local economic interests under the incentive of certain political goals. Similarly, the reduced cost of RCS implementation will motivate local governments to choose to strictly implement RCS to accomplish wastewater treatment goals. The reduction in the proportion of economic indicators in the performance appraisal of local governments will lead local governments to shift the focus of local affairs slightly to non-economic affairs, such as water pollution control, and increase the possibility that local governments will tend to strictly implement RCS.The stabilization strategy of the dynamic game between the discharging enterprises and the local government A is that the enterprises themselves increase their efforts to treat sewage, while the local government chooses to strictly enforce the RCS strategy. The increase in the sewage charge rate of enterprises increases their sewage costs, and after reaching a certain threshold, enterprises prefer to completely treat their sewage instead of incurring the more costly sewage charge, forcing both sides of the game system to choose the optimal set of stable strategies . At presFor firms, the cost of sewage charges becomes smaller after complete treatment of sewage and they prefer to choose the complete treatment strategy. The stable state of the game between enterprises and local government A is the optimal strategy set. The greater the volume of sewage discharged by enterprises choosing incomplete treatment, the more fees are paid at a constant sewage charge rate, and the dynamic game between polluting enterprises and local government A results in both parties gradually choosing the optimal strategy of {complete treatment of sewage, strictly enforcing the RCS}.In order to reasonably set up the evolutionary game model among local governments, all the assumptions in The RCS implementation game between local governments is a repetitive game process in which officials are randomly paired, learn from each other, and influence each other. This can be simulated using a replicated dynamic game model. When local government A chooses to strictly implement the RCS, a certain percentage of River Chiefs in neighboring local government B choose to fully implement the RCS for the better water environment. If local government A chooses not to strictly implement RCS, a certain percentage of River Chiefs in local government B may also choose to follow suit.If local government A and B choose to strictly implement the RCS at the same time, local government A will incur implementation costs When the local government A chooses to strictly enforce the RCS, while local government B chooses not to strictly enforce the RCS, local government A will incur implementation costs, loss of water environmental indicators, loss of economic performance, loss of externalities If both sides do not strictly implement the RCS, each side suffers from the externalities of the other, in addition to the normal cost\u2013benefit payoff, and the penalties imposed on them by the higher government. Repeatedly, the game is played by randomly selecting participants in two groups of local government A and water discharge enterprises in its jurisdiction. In the 2 \u00d7 2 asymmetric repeated game, the payoff matrix of its stage game is shown in Suppose the proportion of River Chiefs at all levels in the jurisdiction of local government B who choose to strictly implement the RCS is As seen in It can be seen that the game process between local governments is influenced by two factors: the initial state of the system and the relative position of the local equilibrium point D. When the initial state of the game is in the region ADCO, the stabilization strategy of the game between local governments evolves to the \u201cPrisoner\u2019s Dilemma\u201d, and both parties do not strictly implement the RCS as the stabilization strategy, and temporarily reach the equilibrium state. If the initial game state of both parties is in the region ADCB, the stabilization strategy of the local government game evolves to \u201cPareto optimal\u201d, and both parties strictly implement the RCS as the stabilization strategy to reach the optimal equilibrium state. The management of water quality in the bordering areas is coordinated by the higher-level government, and joint meetings of experts at all levels are held to discuss and formulate strategies.The above analysis shows that the relative position of point D directly controls the size of the interval area between region ADCO and region ADCB. When the interval area of ADCO is larger than the interval area of ADCB, the system will evolve toward the point D; when the interval area of ADCO is smaller than the interval area of ADCB, the system will evolve toward the point D; when the interval area of ADCO is equal to the interval area of ADCB, the evolution of the system direction is unknown. As seen in Under the strict RCS assessment, local governments will choose to exchange a smaller economic loss for a better water quality environment and to improve social welfare. Increasing the enforcement of the RCS by local governments means spending more human, material, financial and other resources, leading to an increase in the area of ADCB, and the choice of the dynamic game strategy set among local governments gradually evolves in the direction of {strictly enforcing the RCS, strictly enforcing the RCS}. In China\u2019s environmental governance, the role of public participation is not reflected. Even if there are channels for participation, there are relatively few people who actually implement it. This is also a point that needs to be paid attention to in China\u2019s environmental reform in the future.The increase in the proportion of water quality and environmental indicators in the performance appraisal of local governments A and B by the higher-level government, or the decrease in the proportion of economic indicators in the appraisal, are conducive to the evolution of the strategy set of the dynamic game between local governments in the direction of {strictly enforcing the RCS, strictly enforcing the RCS}. If local governments continue to ignore the local water quality, their overall political appraisal will be affected and the political demands of local governments will be hindered by the failure to meet the water quality index appraisal.The rewards and punishments applied by higher-level governments to lower-level governments for RCS implementation also affect the choice of game strategies. Both the increase in the material and moral rewards, and the punishment, will lead to the evolution of the game strategy set among local governments toward the \u201cPareto optimal\u201d direction. Under the Chinese decentralized system, the political promotion of local officials depends on the performance evaluation of the higher-level government. At this stage, according to the relevant documents of local governments in various provinces and cities, most of them have set up a \u201cone-vote veto\u201d system for RCS appraisal arrangements, and the deterioration in the water quality due to improper implementation of the RCS means the cancellation of the promotion opportunities of the local personnel, or their demotion; worse, they will be held accountable for life. This assessment mechanism is designed to eliminate the possibility that some local officials are only concerned about their personal political future and economic interests, and thereby approve projects with significant water pollution hazards. In fact, the positions of China\u2019s River Chiefs are concurrently held by the main leaders of each region, and they all make their own decisions when setting goals according to the specific conditions of their respective regions. Therefore, the impact of individual abilities will be relatively small.From The full implementation of RCS is an inevitable requirement for promoting ecological sustainability and an effective measure to solve China\u2019s complex water problems. The choice of the RCS implementation strategy by local governments directly affects the quality of the water environment in the watershed. Therefore, this study analyzes the evolutionary game process between wastewater governance of enterprises and RCS implementation by local governments, and between local governments, based on the reform context of the RCS.It is found that reducing the cost of complete sewage treatment by enterprises, the cost of RCS implementation by local governments, and the amount of sewage discharged by enterprises after complete sewage treatment will lead to the evolution of the strategy set in the direction of {complete treatment of sewage, strictly enforcing the RCS}. Increasing the enterprises\u2019 own efforts to treat wastewater, and the rate of charging enterprises for wastewater discharge will also lead to the evolution of the strategy set in the direction of {complete treatment of sewage, strictly enforcing the RCS}.The game analysis of RCS implementation among local governments found that reducing the cost of RCS implementation and the proportion of economic indicators in the assessment of local governments, and increasing the implementation intensity of the RCS, the proportion of water quality and environmental indicators in the performance assessment, and the assessment strength will lead to the evolution of the strategy set in the direction of {strictly enforcing the RCS, strictly enforcing the RCS}. The external effects of sewage discharge will not have an impact on the evolution of the whole game system."} +{"text": "This paper proposes a collision avoidance algorithm for the detection and avoidance capabilities of Unmanned Aerial Vehicles (UAVs). The proposed algorithm aims to ensure minimum separation between UAVs and geofencing with multiple no-fly zones, considering the sensor uncertainties. The main idea is to compute the collision probability and to initiate collision avoidance manoeuvres determined by the differential geometry concept. The proposed algorithm is validated by both theoretical and numerical analysis. The results indicate that the proposed algorithm ensures minimum separation, efficiency, and scalability compared with other benchmark algorithms. There is increasing demand for the development of key technologies for Unmanned Aircraft Traffic Management (UTM), with its versatile applications such as reconnaissance and surveillance, service and support, and logistics in both civilian and military domains. Key aspects in developing safe and efficient UTM services include detection and avoidance systems for multiple Unmanned Aerial Vehicles (UAVs), which is different from the conventional system of Air Traffic Management (ATM) in its scale and diversity of platforms.The main aim of the detect and avoidance capability in UTM is to guide each UAV to ensure minimum separation with respect to the other UAVs, manned aircrafts, and no-fly zones in the in-flight stage. In contrast to the ATM\u2019s conventional detection and avoidance system, there are several options available for UAV detection and avoidance: rule-based approaches ,2, geomeOne issue of the aforementioned detection and avoidance methods is that most of them are developed under the assumption that the obstacles have circular or elliptical shapes . This asAnother issue to be considered is the uncertainties in the UAVs\u2019 relative position to the moving intruders. There have been several methods proposed to quantify the collision risk as collision probability considering these sensor uncertainties: the integration of a multi-variate Gaussian probability density function ,18,19, GThe proposition of a new collision detection and avoidance algorithm that achieves the following properties:-Multiple irregularly shaped obstacles and moving intruders can be considered in tactical de-confliction;-Uncertainties in UAVs\u2019 relative position are considered in determining the collision avoidance manoeuvre by utilising the collision probability;-Minimum separation for safety can be analytically proven by differential geometry concept.Validation of performance of the proposed algorithm using analytical and numerical analysis.Demonstration of the safety, scalability, and efficiency of the proposed approach in comparison with other well-known benchmark algorithms.This paper proposes a probabilistic\u2013geometric collision avoidance algorithm that can consider multiple irregularly shaped no-fly zones and sensor uncertainties of multiple intruder UAVs. The collision probability is computed by integrating a multi-variate Gaussian probability density function and thenThe rest of the paper is composed as follows: the problem formulation and some definitions are given in The relative position error with the intruder UAVs satisfies the Gaussian distribution. This assumption was validated by the empirical studies and used in many related works .There exists no correlation between the estimated positions of UAVs. In the scenarios considered in this paper, it is assumed that the UAV estimates the positions of intruders and its position using onboard sensors. Under these scenarios, it is reasonable to assume that the estimated positions of UAVs are uncorrelated. This assumption makes the covariance matrix of the relative position estimates the summation of individual UAVs\u2019 covariance matrices .V and The ground speeds of the vehicle and intruders are assumed to be constant at Consider a 2D scenario with a UAV guided to a waypoint, and there exist multiple intruder UAVs and polygonal obstacles. There exist position errors especially with respect to the intruder UAVs, and we assume the following conditions:i-th intruder vehicle is shown in relative velocity of the UAV.Then, the relative geometry of the UAV to the j-th polygonal obstacle is shown in k-th feature points, k, is known. The range j-th obstacle\u2019s k-th feature points are computed with respect to the position and velocity of the UAV, respectively. For instance, j-th obstacle\u2019s centre are defined to distinguish the feature points from other obstacles. The range of the whole j-th obstacle, j to the UAV in The relative geometry of the UAV to the Based on the relative geometries of the UAV, the recognition and collision is defined as in :Definition\u00a01 (Recognition).The UAV is able to recognisethe intruder i if the polygonal obstacle j if where Definition\u00a02 (Collision).The UAV collides withthe intruder i if the polygonal obstacle j if where x\u2013y position of the UAV varies with time t but is denoted as x and y for simplicity in integration. Assuming the Gaussian distribution with mean The collision probability is defined as the probability that the UAV would collide if maintaining the current heading angle. This can be calculated by integrating the probability density function as (1)P(t)=t but denoted for simplicity as integration\u00a0variables.Converting the Cartesian coordinate to the polar coordinate, i.e., Here, the mean distance between the UAVs i, the bearing angle ensuring the minimum separation is obtained asL and R stand for the left and right-hand side with respect to the line-of-sight to the i-th intruder. Here, Any conflicting intruders or obstacles are detected considering the computed collision probability. For the recognised intruder i with minimal detour.The physical meaning behind j, two nodes that are most at risk of collision can be identified fromL and R stand forthe left and right-hand side with respect to the line-of-sight to the obstacle\u2019s centre.In a similar manner for each recognised polygonal obstacle The bearing angle of the two nodes to ensure the minimum separation isThen, the union of the conflicting intervals can be obtained asThis set of intervals shows which line-of-sight leads to potential collision, as shown in If the conflict is detected, let us define the largest interval i is plotted considering its relative velocity. The largest interval in Note that this interval proposed in this work is different from the union of the intervals that contain voidance ,27. The Once the interval This choice of the heading angle change is made to minimise the time to reach the waypoint. Otherwise, to reduce control efforts, one may consider choosing the heading angle asThe heading angle control to achieve the desired change The summary of the proposed algorithm is shown in Algorithm 1. This algorithm enables the consideration of multiple irregularly shaped obstacles and moving intruders by measuring their current relative positions and velocities only. Lines 3\u20135 enable the consideration of sensor uncertainties in the avoidance manoeuvre, and Line 18 is critical in analytically proving the minimum separation. It is shown that the computations are mainly divided into iterative loops for each moving intruder and fixed polygonal obstacle, which implies that the computational complexity of the proposed algorithm is linearly increasing.Algorithm 1 Collision Avoidance AlgorithmInput:Output:for each moving intruder UAV i\u00a0do\u2003\u2003\u2003\u2003\u2003\u00a012: \u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a01: Equation\u00a0;if\u00a0then\u2003\u2003\u2003\u2003\u2003\u2003\u2003\u00a0\u00a0\u2003\u200913: \u00a0\u00a0\u00a0\u00a0end if\u00a0\u00a02: \u00a0\u00a0\u00a0\u00a0end for\u00a0\u00a03: \u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Equation\u00a0;\u2003\u2003\u2003\u2003\u2003\u2003\u2003\u2003\u00a0\u00a04: \u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Equation\u00a0;\u2003\u2003\u2003\u2003\u2003\u2003\u2003\u2003Equation\u00a0;ifthen\u00a0\u00a05: \u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Equation\u00a0;\u2003\u2003\u2003\u2003\u2003\u2003\u2003\u2003\u00a0\u00a06: \u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Equation ;\u2009\u2009\u2009\u2009\u2009\u2009\u2009\u2009Equation\u00a0;end if\u2003\u2003\u2003\u2003\u2003\u2003\u2003\u2003\u2003\u2003\u2003\u2003\u2003\u2003\u2003\u2003\u2009\u2009\u2009\u2009\u2009\u200918: \u00a0\u00a0\u00a0\u00a0\u00a0\u00a07: \u00a0\u00a0\u00a0\u00a0Equation\u00a0;end for\u2003\u2003\u2003\u2003\u2003\u2003\u2003\u2003\u2003\u2003\u2003\u2003\u2003\u2003\u00a0\u00a0\u2003\u2003\u2003\u200919: else\u00a0\u00a08: for each fixed obstacle j\u00a0do\u2003\u2003\u2003\u2003\u2003\u2003\u2003\u2003\u200320: \u00a0\u00a0\u00a0\u00a0\u00a0\u00a09: if\u00a0then\u2003\u2003\u2003\u2003\u2003\u2003\u2003\u00a0\u00a0\u00a0\u2009\u2009\u2009\u2009\u2009\u00a0\u00a021: end if10: \u00a0\u00a0\u00a0\u00a0return11: \u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Equation\u00a0;\u2003\u2003\u2003\u2003\u2003\u2003\u2003\u2003If the desired heading angle change control ,27. Its Theorem\u00a01.If the ground speed of the main UAV is greater than or equal to that of the intruder UAV, i.e., Proof.\u00a0The guarantee of the minimum separation is identical to the convergence of the desired heading angle change to zero. If there exists a non-zero interval a satisfying As it is clear that function . SubstitConsidering that the obstacles are assumed to be fixed and that intruder isnon-manoeuvring, Equation , the LyaThis proves that the desired heading angle change asymptotically converges to 0, guiding the UAV on the line-of-sight to avoid the collision. \u25a1Theorem\u00a02.For the ground speed of the main UAV less than that of the intruder UAV, i.e., Proof.\u00a0From the geometric relationship in refer to . \u25a1Theorem\u00a03.For where Proof.\u00a0The minimum time required to complete the avoiding turn isIn order to complete the turn before colliding, the distance of the UAV and obstacle/intruder should satisfy\u25a1V and Numerical simulations are conducted to validate the performance of the proposed collision avoidance algorithm. Three fixed obstacles are modelled from the no-fly zones and buildings near the test site, Messolonghi Airport in Greece as shown in j-th obstacle. Note that conventional APF can consider only circular/ellipsoidal obstacles. PSO is set to minimise the following cost function:The performance of the proposed collision avoidance algorithm is evaluated in three main metrics: minimum separation distance, total flight time, and computation time. These metrics are selected to verify the safety, efficiency, and scalability of the algorithm, respectively. In addition, these metrics of the proposed method\u2014noted as the differential geometry concept (DGC)\u2014are compared with two benchmark algorithms: artificial potential field (APF) and particle swarm optimisation (PSO). APF was set using repulsive fields against the intruders and fixed obstacles and an attractive field to reach the waypoint asSimulation results are presented for a single scenario to intuitively show how the selected algorithms perform. For a single scenario, the trajectories of the selected algorithms are shown in For rigorous validation, Monte-Carlo simulations are conducted with 100 different scenarios. For each algorithm, the minimum separation distance and total flight time are shown in The simulation results are summarised in For rigorous validation, the numerical simulations are repeated for different variances of sensor noise. The scenario is set in the same way as in The mean and variance of resultant minimum distance and the flight time are shown in The effect of the number of intruders on the detection and avoidance performance is analysed to investigate the scalability of the proposed algorithm. For instance, the trajectories of 9 UAVs successfully avoiding the collision with all the other UAVs and no-fly zones are shown in By increasing the number of UAVs from 1 to 9, the separation distance is guaranteed above the threshold, as shown in A new probabilistic\u2013geometric approach has been proposed for detection and avoidance systems for future UTM. The proposed algorithm can enable UAVs to avoid multiple moving intruders and large irregularly shaped no-fly zones, considering the detection uncertainties in sensors. The main ideas are to compute collision probability with uncertainties and to utilise it to detect a conflict and adjust the avoidance manoeuvres. This fills the gaps in research where most of the UAV collision avoidance algorithms are based on circular-shaped obstacle avoidance, and the effect of sensor uncertainties on the collision avoidance performance is largely unknown. The proposed algorithm is validated by both theoretical and numerical analysis, compared with benchmark algorithms. The result suggests that the proposed approach can provide safety, efficiency, and scalability to the future UTM solution. A future direction of this research is suggested as an extension to fully utilise cooperative UAVs\u2019 flight plans. While the current approach is applicable to uncooperative UAVs with their position and velocity measured from the sensors, the efficiency could be improved by further utilising the flight plan and manoeuvre strategy in the case of cooperative UAVs. The research objective will be to provide an analytical safety guarantee compared with other learning-based methods ."} +{"text": "R2independent validation > 0.8600). Due to the good mathematical correlation of the experimental and predicted values, the \u03c3 profile generated with COSMOtherm could be used as a DES molecular descriptor for the prediction of their pH values.The aim of this work was to develop a simple and easy-to-apply model to predict the pH values of deep eutectic solvents (DESs) over a wide range of pH values that can be used in daily work. For this purpose, the pH values of 38 different DESs were measured (ranging from 0.36 to 9.31) and mathematically interpreted. To develop mathematical models, DESs were first numerically described using \u03c3 profiles generated with the COSMOtherm software. After the DESs\u2019 description, the following models were used: (i) multiple linear regression (MLR), (ii) piecewise linear regression (PLR), and (iii) artificial neural networks (ANNs) to link the experimental values with the descriptors. Both PLR and ANN were found to be applicable to predict the pH values of DESs with a very high goodness of fit ( Green chemistry presents a way of creating and applying chemical products and processes that reduce or eliminate the use or production of substances that are hazardous to human health and the environment . A growiDESs were first described by Abbott et al. in 2003 as a mixture of a hydrogen bond donor (HBD) with a hydrogen bond acceptor (HBA), which exhibited much lower melting points than the pure compounds due to the formation of hydrogen bonds between constituent compounds ,5,6. LatThe pH values of aqueous solutions affect the enzyme activity, extraction efficiency, and stability of biologically active molecules. As such, the pH value is an important property of a solvent and, especially for DES design, one of the critical parameters. Though several papers have analyzed the pH behavior of DESs, there are still gaps in the understanding of how DES-forming compounds influence its pH value ,9. DespiSo far, the search for an ideal DES for a particular system has been guided by an empirical trial-and-error approach, with no systematic research into the structure\u2013activity of DESs. Therefore, the rational design of these solvents for specific purposes is still in its infancy. Data collection on the application properties of DESs and the development of mathematical methods as a tool for the design of novel solvents are imperative for the industrial application of these solvents. The Conductor-like Screening Model for Real Solvents (COSMO-RS) is an ab initio computational method that may be used for the generation of the \u03c3 profile of a molecule. The \u03c3 profile shows the probability of finding surface segments with \u03c3 polarity on the surface of the molecule and contains the most relevant chemical information needed to predict the compound\u2019s electrostatic, hydrogen bonding, and dispersion interactions . The disIn this work, we report a model for the prediction of the pH values of acidic and basic DESs. For this purpose, the experimental pH values of 38 different DESs were evaluated, described, and mathematically interpreted. For the development of mathematical models, DESs were firstly numerically described using \u03c3 profiles estimated by the COSMOtherm software. After the description of DESs, the following models were used: (i) MLR, (ii) PLR, and (iii) ANN to link the experimental values with the descriptors. In the end, the prepared models were statistically verified.Simix descriptors. To develop a user-friendly model to predict pH values in the wide range, we selected both acidic and basic DESs from our database. We chose 38 DESs by carefully selecting and varying different HBA, HBD, and water shares (w/w) to 9.31 for Ch:U containing 10% water (w/w). Monitoring the pH values of the same HBA/HBD pair while varying the DES water content shows that water influences the measured pH value. However, this influence is a distinctive characteristic of an individual DES and cannot be extended to all DESs studied in this work.This work aimed to develop a simple and robust mathematical model for predicting the pH values of DESs based on r shares . Selecter shares . OverallFurthermore, DESs were mathematically described using the \u03c3 profile defined with the COSMOtherm software. The HBA and HBD molecules were optimized in TmoleX, both from an energy and geometry point of view. The generated COSMO files contain all information necessary for the calculation of the \u03c3 profile function and thus for the calculation of the \u03c3 profile descriptors. For the preparation of the descriptor set, the DESs were modeled as a molar mixture of HBA and HBD according to R2, R2adj, and RMSE. The obtained model coefficient values and the basic statistical analysis are presented in The assessment of the MLR and PLR model applicability to predict the pH values of DESs was based on the correlation coefficient values, R2 = 0.7758) and PLR (R2 = 0.9654) models developed in this work are applicable for the description of DESs\u2019 pH values based on Simix descriptors but not with the same accuracy. When analyzing RMSE errors, it is evident that the PLR model (RMSE = 0.6558) in comparison to the MLR model (RMSE = 1.1865) , the coeLR model b ensures 1.1865) a. As preR2 value alone does not guarantee that the model fits the data well, so the model\u2019s goodness of fit was further confirmed by residual analysis. The residuals from a fitted model are the differences between the responses observed and the corresponding prediction of the response computed using the regression function. If the model\u2019s fit to the data was correct, the residuals would approximate the random errors that make the relationship between the explanatory variables and the response variable a statistical relationship. Therefore, if the residuals appear to behave randomly, it would suggest that the model fits the data well [A high ata well . Analyziata well .b6 (coefficient multiplying S6mix), were statistically significant. It can also be noticed that for both models, the coefficients from b1 to b5 have a positive influence on the output variable while the coefficients from b6 to b10 have a negative influence on the analyzed model output. The results are easily interpreted in terms of b1 to b5, which are associated with the negative potential region and thus with hydrogen bond accepting and basicity properties on the one hand, and b7 to b10, which are associated with the positive potential region and thus with hydrogen bond donating and acidity properties on the other hand. b6 turns out to be related to the neutral potential region insignificantly contributing to the pH value. As for the other b coefficient values, the more distant the potential region is from the zero , the stronger its influence (whether positive or negative) on the pH value. Thus, the model seems to have a clear and rather simple physical significance. Although statistical analysis showed that the coefficient b6 was not significant, the variable S6 was not excluded from the modeling. This result indicates that there is no correlation with the dependent variable at the population level, but this could be changed if a different data set was used.Analysis of the MLR and PLR model coefficients showed that all coefficients, except p values < 0.001. Moreover, higher F-test results and lower p values, according to Greenland et al. (2016) [The ANOVA revealed that the created MLR and PLR models were statistically significant, with R2 and RMSE for training, test, and validation sets taking into account the number of neurons in the hidden layer. The properties of the created networks that were chosen are shown in R2\u00a0validation = 0.9797, RMSEvalidation = 0.0012). As presented in The applicability of the artificial neural network models for predicting the DES pH values based on the \u03c3 profiles was also studied. The best neural network was chosen based on the following criteria: R2 values and the residual analysis, it can be concluded that both the PLR and ANN model can be efficiently applied for the prediction of the DES pH values based on the \u03c3 profiles. Due to the simplicity of the PLR model, this model is proposed for the prediction of physicochemical properties.Based on the presented results, it can be concluded that the \u03c3 profiles are good molecular descriptors of DESs since the mathematical correlation of the experimental and predicted values is high. Moreover, based on the obtained R2 and RMSE and the obtained values were as follows: (i) for MLR R2 = 0.7097, RMSE = 1.1140; (ii) for PLR R2 = 0.8605, RMSE = 0.7652; and (iii) for ANN R2 = 0.8885, RMSE = 0.82926.Validation of the MLR, PLR, and ANN models developed for the prediction of the DES pH values based on the \u03c3 profiles was performed on the independent set of data. The validation set included the \u03c3 profiles of 16 DESs. Comparisons between the experimental data and model-predicted data are shown in R2 between the experiment and model-predicted data was obtained for ANN prediction of the analyzed DES pH values while the lowest R2 between the experiment and model-predicted data was obtained for the MLR model. These findings demonstrate that \u03c3 profile ANN modeling is a useful and reliable method for predicting DES pH values based on the \u03c3 profiles. Nevertheless, considering RMSE, it can be noticed that the PLR model can efficiently be used for the prediction of pH values based on the \u03c3 profiles. As described, the R2 values are scaled between 0 and 1, whereas the RMSE is not scaled to a specific value and, therefore, provides explicit information about how much the prediction deviates.It can be noticed that all three proposed models predict the pH value with high accuracy. As expected, the highest As stated before, it was relatively easy to link the parameters of the MLR and PLR models to their physical significance. On the other hand, ANNs, by definition, belong to a class of agnostic models and, thus, it is difficult, if not impossible, to reveal their physical meaning. At the same time, this is the reason why they behave much better in interpolation than in extrapolation. The independent validation presented here may be considered as interpolation since the DES members of the independent validation dataset belong to the same DES classes as those used for constructing the model. However, given the rather simple and rather clear relation between the \u03c3 profile and pH as revealed by MLR, there is no true reason to believe that the models would behave poorly in extrapolation, even for ANN, i.e., for DES classes not involved in the development of the models. However, this is yet to be checked, e.g., for DESs based on metal chlorides or DESs containing ionic liquids, etc.The current literature data refer to the prediction of other physicochemical properties (such as viscosity and density) and only a narrow range of values characteristic for limited groups of structurally related DESs ,12,13,14l-(\u2212)-proline, oxalic acid, sucrose, sorbitol, and xylitol were all purchased from Acros Organics, USA. Citric acid, d-fructose, d-(+)-xylose, d,l-malic acid, ethylene glycol, glycerol, and urea were all purchased from Sigma-Aldrich, USA. BIOVIA TmoleX19 version 2021 software was used for geometry and energy optimization of the HBAs and HBDs used in this study. BIOVIA COSMOtherm 2020 version 20.0.0. software (Dassault Syst\u00e8mes) was used for the \u03c3 profile calculations of the defined DESs.Betaine, choline chloride, glucose, w/w) of water. Then, the flasks were sealed, and the mixtures stirred and heated to 50 \u00b0C for 2 h until homogeneous transparent colorless liquids formed. The DES abbreviations and corresponding molar ratios are given in DESs were prepared by mixing defined molar ratios of HBA to HBD. The two or more components were weighed in a specific ratio in a round-bottomed glass flask, adding 10\u201350% , all within the pH measuring range 0.36\u20139.31 at room temperature. The instrument was calibrated using standard pH buffer solutions. Additionally, the pH values were checked with litmus paper (range 1\u201314). All measurements were carried out in duplicates and the results were expressed as an average value \u00b1 standard deviation.All molecules used for DES preparation: HBA, HBD, and water, were geometrically and energetically optimized in the BIOVIA TmoleX19 version 2021 (Dassault Syst\u00e8mes) software. Quantum chemical calculations were performed by adopting DFT with the BP86 functional level of theory and def-TZVP basis set . To crea2, covering the range from \u22120.025 to +0.025 e/\u00c52. The areas under the curve were integrated separately for each defined region. This was achieved by simple summation of the tabulated \u03c3 profile data point ordinate values as presented by the BIOVIA COSMOtherm 2020 software. The ordinate values lying on the boundaries of the regions were split into halves and each half was attributed to one of the neighboring regions. Thus, 10 S descriptors (S1\u2013S10) of the \u03c3 profiles were calculated exactly as the numerical values of these 10 areas were calculated from the HBA and HBD component (and in some cases water) descriptors according to Equation (1) proposed by Benguerba et al. (2019) [i denotes the descriptor number (1\u201310), j stands for the DES constituent number, jX is the molar fraction of HBA or HBD or some other constituent such as water if present in the mixture, Si\u03c3-profile,j is the j-th constituent i-th descriptor, and NC is the total number of constituents from which DES is prepared. All the experiments were performed at 20 \u00b0C.Any change in the DES composition can be described by a change in its \u03c3 profile and the associated numerical value of its descriptors. To obtain a unique descriptor set for each particular DES, the \u03c3 profiles of its constituents were processed in the following manner. The descriptors of the studied DESs (. (2019) :(1)SmixiIn further calculations, it was assumed that the measured DES pH value can be described as a function of the \u03c3 profile of the mixture, expressed by a set of Simix descriptors in Equation (2):Multiple linear regression (MLR) with Equation (3), piecewise linear regression (PLR) with Equation (4), and artificial neural network (ANN) models were attempted to describe the relationship between the input and output variables. The dataset included 142 data points (that included replicates), of which 126 were used for model development and 16 (randomly selected) for independent model validation:y) less than or equal to the breakpoint (bn) and the other for dependent variable values (y) higher than the breakpoint.The PLR technique is based on estimating the parameters of two linear regression equations: one for dependent variable values (The MLR parameters in Equation (3) were estimated using least square regression while the PLR parameters in Equation (4) were estimated using the Levenberg\u2013Marquardt algorithm implemented in the software Statistica 13.0 . The algorithm searches for optimal solutions in the function parameter space using the least squares method. The calculations were performed in 50 repetitions with a convergence parameter of 10\u20136 and a confidence interval of 95% .In addition, multilayer perceptron (MLP) ANNs were used for the prediction of DES pH values based on the Simix descriptors. The ANN models included an input layer, hidden layer, and output layer. The input layer included 10 neurons representing the Simix descriptors, the output layer had only one neuron, and the number of neurons in the hidden layer varied between 4 and 13 and was randomly selected by the algorithm. The hidden activation function and output activation function were selected randomly from the following set: Identity, Logistic, Hyperbolic tangent, and Exponential. The dimension of the data set for ANN modeling was 126 \u00d7 11 and was randomly divided into 70% for network training, 15% for network testing, and 15% for model validation. Model training was carried out using a back error propagation algorithm and the error function was a sum of squares implemented in Statistica v.13.0 Automated Neural Networks. The developed model\u2019s performance was estimated by calculating the R2 and root mean squared error (RMSE) values for the training, test, and validation sets.RMSE).Validation of the developed MLR, PLR, and ANN models was performed on an independent data set, including the Simix descriptors for 16 randomly selected DESs. The validation performance of the developed models was estimated based on the R2 and root mean squared error (R2 > 0.8600). The contribution of this work lies in the development of a user-friendly model to predict pH values in a wide range (from 0.525 to 9.25), indicating that the developed models are good for the prediction of the pH value of newly synthesized DESs. However, due to the simplicity of the developed PLR model, it could be suggested as a model of choice for use in daily work and screening purposes.The applicability of MLR, PLR, and ANN to predict the pH values of DESs was evaluated. The results indicate that although simple linear regression can be used for the description and prediction, its effectiveness and applicability are limited. On the other hand, PLR and ANN are applicable to predict the pH values of DESs with a very high goodness of fit (Nevertheless, this approach can also be extended to other physicochemical properties since this study confirmed previous findings that showed how the \u03c3 profile generated in COSMOtherm is a valuable DES molecular descriptor. It could be a good basis for the evaluation of various mathematical models to develop a simple and applicable prediction model for everyday laboratory or industrial applications.It is interesting to comment on the influence of the addition of water to a DES. In our previous article , based o"} +{"text": "Klebsiella pneumoniae (CRKP). Intermittent catheterization was used to reduce biofilm occurrence and exercise bladder function on the basis of an active and adequate anti-infection strategy. Simultaneously, combined with acupuncture treatment and strengthening the patient\u2019s pelvic floor muscle training to improve urinary retention, the catheter was eventually removed to obtain autonomous urination in this patient, and this led to the successful treatment for a CRKP catheter-related urinary tract infection.Catheter-related urinary tract infections, especially those caused by multidrug-resistant (MDR) bacteria, are extremely difficult to treat due to limited therapeutic choices. Therefore, removing catheters as soon as possible is pivotal to successful treatment. Herein, we report a case of catheter-related urinary tract infection caused by carbapenem-resistant Enterobacteriaceae (CRE), Pseudomonas aeruginosa and Acinetobacter baumannii is considered critical, being classified as Priority 1 group because of its resistance to this last resource antibiotic class, among which Klebsiella pneumoniae and Escherichia coli are the most common (Klebsiella pneumoniae (CRKP) can cause bloodstream infections, abdominal cavity infections and urinary tract infections, and these patients are often in critical condition with limited therapeutic strategies and poor prognosis , carbapenem-resistant strains in t common , becominrognosis . One of rognosis . Furtherin vitro susceptibility test showed that the MIC of polymyxin B was 64 mg/L, which indicated high-level resistance; thus, we stopped the administration of polymyxin B use and started oral SMZco 0.96 BID. During the treatment, we tried 3 times to remove the catheter, but it had to be reset due to urinary retention. The patient was still unable to urinate autonomously and relied on the persistent use of urethral catheters, leading to the failure of controlling the infection source. The patient\u2019s routine urinalysis was reexamined: the white blood cell (WBC) count was 22.4/UL, the bacteria count was 23564.9/UL, and nitrite was negative. The temperature of the patient did not drop into the normal range. Then, intermittent catheterization was performed based on the use of SMZco. At 10 am every day, urine was taken from the catheter for culture and routine urinalysis. Then, the catheter was removed, and the catheter tip was submitted for culture. Aseptic urethral catheterization was performed again within 2-4 hours, and catheterization was performed until 10 am on the next day. A size 12CF catheter was selected to reduce the urethral mucosal damage. The patient was given a reasonable amount of drinking time and amount of water, with a total daily intake of 2000\u00a0ml, 200\u00a0ml between 10 am and 13 pm, and the patient could have water intake at other times as required. At the same time, the acupuncturist in the department of rehabilitation administered acupuncture treatment once a day. The patient was required to perform pelvic floor muscle function training with the decubitus position, actively contracting and clamping the anus and urethral orifice, by contracting and relaxing the muscles for 5-10 seconds, which was repeated 5-10 times for 1 cycle. Two cycles were performed each day in the morning, mid-day and evening. The patient\u2019s intermittent catheterization lasted for 9 days. The catheter tip culture showed CRKP in the first 2 days but was negative from the third day to the ninth day, and the urine culture was negative starting on the fifth day of intermittent catheterization. After 11 days of rehabilitation treatment, the catheter was removed, and the patient urinated successfully with a urine volume of 230-330\u00a0ml each time. Both the patient\u2019s urine WBC and blood CRP levels returned to normal ranges, as did her body temperature . Her underlying diseases included sicca syndrome, cerebral infarction and hypertension. After admission, the patient was treated with fosfomycin ambutritol 3\u00a0g QD orally, and her body temperature and C-reactive protein (CRP) gradually decreased to normal. The catheter was removed on the 8th day after admission. Unfortunately, the patient was admitted to the ICU with advanced life support due to septic shock on the night of extubation. Both blood and urine cultures showed CRKP, which was subsequently confirmed to produce KPC carbapenemase. The patient\u2019s anti-infection therapy included tigecycline 100 mg q12 h and polymyxin B 50wu q12 h. Her blood culture turned negative 2 days later, but the urine culture continued to grow CRKP. After the administration of polymyxin B for 16 days, an perature Figure\u00a01The limited therapy strategies for CRKP infections raise more challenges for clinical situations. In particular, catheter-related CRKP infections often cause not only urinary tract infection but also secondary bloodstream infections, which can endanger the life of patients. The formation of bacterial biofilms leads to difficulty in the thorough removal of pathogenic bacteria in catheter-related infections. Thus, the removal of catheters at an early stage is the most important measure for the treatment of urinary tract infections associated with catheterization. In our study, the patient was diagnosed as urinary tract infection by CRKP according to the persistent fever, elevated CRP and the culture of urine. After the removal of the catheter, the patient could not urinate autonomously, resulting in urinary retention. However, long-term indwelling of catheters could easily form biofilms, causing the inability to remove bacteria and an uncontrollable infection, even we used last resource antibiotic class like tigecycline and polymyxin B. Worse still, we found the isolate with high-level resistance to polymyxin B during the therapy without removal of the catheter. On the other hand, bladder irrigation is no longer recommended as a treatment method for urinary tract infection, while cystostomy may destroy the patient\u2019s quality of life with its many complications and high risk of infection . PromotiAcupuncture is an effective method to reduce urinary retention and urinary tract infection and shorten hospital stays . A previTo our knowledge, the successful application of intermittent catheterization combined with rehabilitation in the treatment of catheter-associated CRKP urinary tract infection was rarely reported. As there is an increment in the reports of carbapenem-resistant strains in other groups with limAt present, systemic antibiotics are still the most commonly used method for catheter-associated CRKP urinary tract infections. Most studies have focused on oral or parenteral anti-infective therapy, while data on anti-infective therapy are limited. In this case, in addition to a rational application of antibiotics, intermittent catheterization was used to remove catheter bacterial biofilm, which was conducive to infection control. For patients with urinary retention, the recovery of autonomous urination is the premise. Acupuncture treatment and strengthening the pelvic floor muscle through training can promote autonomous urination and ultimately improve the cure rate of CRKP catheter-related urinary tract infections. Functional exercise further promotes the coordination between pelvic floor muscles and the bladder and improves urination function in the long term. Therefore, intermittent catheterization combined with rehabilitation adjuvant therapy provides a new approach for the treatment of CRKP catheter-related urinary tract infections.The original contributions presented in the study are included in the article/supplementary material. Further inquiries can be directed to the corresponding author.The studies involving human participants were reviewed and approved by Sir Run Run Shaw Hospital, Zhejiang University School of Medicine (No. 2022-571-01). The patients/participants provided their written informed consent to participate in this study.LS and HW contributed to both in the conception and design of the study. HC and LS organized the data together. HW wrote the first draft of the manuscript. LS and YJ helped perform the analysis with constructive discussions. All authors contributed to manuscript revision, read, and approved the submitted version.This work was supported by the Natural Science Foundation of Zhejiang Province, China (No. LY22H190001) and the China International Medical Foundation for Young Scientists (No. Z-2018-35-2003).The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher."} +{"text": "Interventions involving direct community stakeholders include a variety of approaches in which members take an active role in improving their health. We evaluated studies in which the community has actively participated to strengthen tuberculosis prevention and control programs. A literature search was performed in Pubmed, Scopus, ERIC, Global Index Medicus, Scielo, Cochrane Library, LILACS, Google Scholar, speciality journals, and other bibliographic references. The primary question for this review was: what is known about tuberculosis control interventions and programs in which the community has been an active part?.Two reviewers performed the search, screening and selection of studies independently. In cases of discrepancies over the eligibility of an article, it was resolved by consensus. 130 studies were selected, of which 68.47% (n=89/130) were published after 2010. The studies were conducted in Africa (44.62%), the Americas (22.31%) and Southeast Asia (19.23%). It was found that 20% (n=26/130) of the studies evaluated the participation of the community in the detection/active search of cases, 20.77% (n=27/130) in the promotion/prevention of tuberculosis; 23.07% (n=30/130) in identifying barriers to treatment, 46.15% (n=60/130) in supervision during treatment and 3.08% (n=4/130) in social support for patient. Community participation not only strengthens the capacities of health systems for the prevention and control of tuberculosis, but also allows a better understanding of the disease from the perspective of the patient and the affected community by identifying barriers and difficulties through of the tuberculosis care cascade. Engaging key community stakeholders in co-creating solutions offers a critical pathway for local governments to eradicate TB. Tuberculosis(TB) is an infectious disease that, despite being a preventable and curable disease, continues to be a problem for global public health, with a estimation of 1.6 million people died from this disease in 2021.To control TB, one of the strategies used is Directly Observed Therapy, Short Course (DOTS) . This stThe World Health Organization (WHO) approach called \u201cENGAGE-TB\u201d mentions that community participation is fundamental to improve the scope and sustainability of tuberculosis services for the community. This approach allows the implementation of integrated community TB activities within health programs, and WHO provides technical guidance, community training, and encourages the creation and development of alliances between tuberculosis control programs and civil societies. MoreoveCommunity-based participatory research (CBPR) is an approach in which the community is involved in all stages of research from conception, design, execution, implementation and follow-up of research. CBPR alWe carried out a scope review following the guidelines of the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Revisi\u00f3n de alcances (PRISMA-ScR) Supleme and a prWhat is known about tuberculosis control interventions and programs in which the community has been an active part in the development and implementation of the study?a) What strategies are being used to strengthen the participation of communities in interventions and programs for tuberculosis control? and b) What opportunities, lessons learned, and challenges impact the sustainability of community-driven interventions and programs?The protocol is available upon request from the corresponding author. This scoping review followed the five-stage methodological framework that was developed by Arksey and O\u2019Malley and an aTo identify the studies, we systematically searched Medline (through Pubmed), Scopus, ERIC (Education Resources Information Center), Global Index Medicus, Scielo, Cochrane Library and LILACS . A search of the gray literature was performed through Google Scholar and MedRxiv. In addition, we performed a manual search identifying the journals of internationally recognized organizations in tuberculosis and by rThis scoping review included studies that describe or analyze the role of direct involvement of key community members in the development and implementation of tuberculosis prevention and control programs. Studies such as randomized clinical trials, non-randomized trials, and observational studies were included. Letters to the editor, expert opinions, review articles, book reviews, or conference abstracts were excluded. In One reviewer (LCR) performed initial title identification and duplicate removal using an Endnote X9 (Clarivate) reference manager. Before starting the study selection process, a calibration process was carried out between two reviewers (LCR and MJB) with 10 randomly selected studies to select the studies according to the eligibility criteria. Subsequently, in a first phase, a selection of the studies was made based on the titles and abstracts; and in a next phase, a full-text evaluation was carried out according to the eligibility criteria. All these processes were closely supervised by a researcher (MJB).For data extraction, the \u201cdescriptive-analytic\u201d method was used, which consists of applying a common analytical framework to all included studies and collecting standard information from each study. In addiThe results were presented through diagram tables that summarize the different modalities of the participation of community members in the different aspects evaluated, such as in the promotion and prevention of tuberculosis , detection and active search for cases, results and adherence to tuberculosis treatment (identification of barriers and difficulties for tuberculosis treatment/supervision and surveillance during tuberculosis treatment), implementation of interventions for tuberculosis control and social support and support programs for patients affected by tuberculosis. Also, the evidence was synthesized on how the community has been strengthened in its participation and finally on the challenges in the implementation of these interventions (sustainability).Our scoping review initially identified 1909 titles and abstracts. Of these studies, 1707 studies were excluded based on our eligibility criteria. 389 full-text studies were evaluated, of which 130 studies finally met the pre-established inclusion criteria. The study selection flowchart is presented in Of the included studies, over the years, there has been a gradual increase in the amount of research in which the community has been actively involved in tuberculosis control. The studies identified in our review were conducted in all WHO regions, mainly in the African region , the Americas , and in Southeast Asia . In relation to the types of articles, the most frequent were the quantitative ones followed by the qualitative ones and finally the mixed methods . These characteristics are presented in The participation of communities in research studies on tuberculosis has been evaluated and categorized considering the classification of the study by Asha et al., who evaIn the included studies, community participation in the development of research studies or as part of a program for the prevention and control of tuberculosis was identified in the following scenarios: 20.77% (n=27/130) of the studies included the community on activities related to the promotion and prevention of tuberculosis. 20.00% (n=26/130) of the studies involved the community in the detection and active search for tuberculosis cases. The 21.54% (n=28/130) of the studies in the identification of barriers and difficulties for the antituberculosis treatment. 46.15% (n=60/130) of the studies on supervision and surveillance for tuberculosis treatment and 3.08% (n=4/130) of the studies evaluated the participation of the community in social support and support for the affected patient for tuberculosis. Finally, it was identified that 12.31% (n=16/130) of the studies evaluated the participation of the community in other related aspects such as greater understanding of the disease, identification of factors related to the search and quality of care for patients. affected by tuberculosis and studies that explored the experience of community health workers in tuberculosis control .6.15% (n=8/130) of the studies included in our review used the community-based participatory research approach. However, only half (n=4/130) of these studies complied with the CBPR principles. On the other hand, 37.69% (n=49/130) of the studies carried out some type of education or training for community workers to carry out their functions in tuberculosis research studies.4.62% (n=6/130) of the studies evaluated the sustainability of the interventions in which the community had participated. In addition, 2.31% (n=3/130) of the included studies evaluated the cost-effectiveness of community participation in tuberculosis care\u201320. KhanIn our scoping review, we identified 130 studies that reported genuine involvement of community members. Most of these studies were conducted in Africa (44.62%), the Americas region (22.31%), and Asia (19.23%). According to the 2021 Global Tuberculosis Report, the highest burden of tuberculosis disease occurs in the Asian and African regions (69%) approach. However, only 4 of these studies involved the community in all phases of the research and allowed to establish a closer link between the community and academic researchers, 35\u201337. These principles are adapted to the sociocultural context of the communities, 10. In The inclusion of strategic research partnerships that allow the establishment of an equal relationship between the community and academic researchers requires time and financial resources. In low-Among the reported functions of CHWs is providing health education (increasing awareness and knowledge about tuberculosis), detection and active search for cases, and patient follow-up. HoweverThe sustainability of interventions are those programs that continue to be implemented after a defined period of time while they are adapted and adapted to continue producing benefits for people, 51. SusTB programs that consider the community as an important part of their activities need to establish sustained communication (system for contacting volunteers) and frequent contact with the community organization. In addition, the CHWs must receive feedback on the progress of the program, as well as be involved in any changes or new initiatives. In addition, the empowerment of CHWs allows them to train new volunteers to carry out the activities.This scoping review has some limitations. We made an identification of studies published in English (97.69%) and Spanish (2.31%) because the largest source of evidence is presented in those languages. We do not rule out the possibility of having studies that meet our eligibility criteria and that have been published in other languages. However, a comprehensive search was performed in recognized health databases, a gray literature search was performed, and studies were collected through the literature search and contacting authors for more information. In addition, a critical evaluation of the design of the included studies was not carried out, which limits the evaluation and characterization of the quality and certainty of the evidence that makes it possible to visualize the methodological bases of the current evidence on this topic. It would be important that this be evaluated in future systematic reviews. However, we believe that our study, by synthesizing current evidence on interventions or studies in which the community has taken an active part in their development and/or implementation, adds additional value for local and local tuberculosis prevention and control programs. global organizations consider the community as a fundamental part of the strategies to achieve their goals of eradicating tuberculosis.Based on our scoping review, we have identified that there is a paucity of information from studies that comply with the basic principles of CBPR in the population affected by tuberculosis. In addition, more studies are required to evaluate the cost effectiveness and sustainability of community participation interventions in tuberculosis control in the long term. Strategic CBPR research partnerships can mobilize and organize larger-scale community efforts to establish policies that enable social and economic policy change needed to achieve health equity, 57, 58.Direct community involvement in tuberculosis prevention and control in research with a community-based participatory research (CBPR) approach has not been consistently reported. However, according to our analysis, the studies found show that the active participation of the community presents a positive tendency towards the strengthening of programs for the prevention and control of tuberculosis. In addition, the participation of key members of the community not only strengthens the capacities of the health systems to generate strategies and action plans for the prevention and control of tuberculosis, but also allows a better understanding of the disease from the perspective of the patient by identifying barriers and opportunities along the cascade of care for patients affected by tuberculosis in the \u2018Global South\u2019. This scoping review also makes it possible to show that there is a need to carry out studies with the CBPR approach in the population affected by tuberculosis due to the large social component, such as the social determinants of health, that impacts this disease. This seems to indicate that studies are required that restructure the focus of a traditional investigation to one with a CBPR approach, where the population is considered as an end for the objectives of the study. The active participation of communities in co-creating solutions goes beyond the biomedical sphere and offers a critical path for regional and local governments in the fight to eradicate tuberculosis.Supplement 1S1 file. PRISMA \u2013 ScR checklistSupplement 2S2 file. List of scientific journalsSupplement 3S3 file. Search terms and keywordsSupplement 4S4 file. Search strategies in each database and information repository."} +{"text": "As a result of the test, Jump Height from Take Off Velocity, Jump Height from Take Off Velocity, Jump Height from Flight Time, Counter Movement Acceleration, Push Off Acceleration, Average Velocity, Average Power, and Average Force were analyzed. Differences in the jump performances among the groups were tested by one-way analyses of variance (ANOVA) with Tukey's post-hoc follow-up testing when necessary for jump test. As a result, this is the first study to investigate the number of jumps and jump height, the force produced, acceleration at the time of jump, and jump velocity during 30 s in deaf and non-deaf basketball and volleyball players within the scope of individual Repeated Counter Movement Jump test. Based on the biomechanical changes according to our results, our findings show a greater decrease in the number of jumps and jump heights, the force produced, the acceleration at the moment of the jump and the jump velocity in all athletes, especially those that affect the deaf.The aim of this study was to compare the performances of Repetitive Counter Movement Jumping of deaf/non-deaf athletes. Athletes playing in the Turkish Deaf Basketball and Volleyball national teams and in Basketball and Volleyball First Leagues participated in the study. The study group consisted of 51 male athletes, including deaf basketball ( The term \u201cdeaf\u201d is defined by the International Sports Committee for the Deaf as the perception of sound only at 55 dB or more through the ear that hears better Jordan, . Deaf atp < 0.05). In another study, mean values of CMJ were higher in the control group than in deaf football players, but the difference was not statistically significant (p = 0.07). Based on this, it was planned to determine the effect of neuromuscular fatigue on an important performance component of the repetitive jumps of deaf and non-deaf basketball/volleyball players.Repetitive Counter Movement Jump (RCMJ) is a vertical jump, mainly including cyclic eccentric/concentric muscle movement that involves muscle movements of the trunk, hip, knee, and ankle extensors. RCMJ is a vertically successive jump performance parameter in which characteristics such as joint range of motion (ROM), strength and flexibility of muscles during movement are at the forefront , deaf volleyball , non-deaf basketball , and non-deaf volleyball players. In the study, an \u201cCross-Sectional\u201d model was employed, including the application of the factor, the relationship of which would be measured, to the athletes under certain conditions and rules, the measurement of athletes' responses to the factor, comparison of the results obtained, and making a decision. Criteria for athlete selection included being older than 18 years of age and competing at an elite level, deaf athletes' having a medically diagnosed hearing impairment (>55 dB hearing in both ears without cochlear implantation) and being able to understand the basic instructions given. Furthermore, the anatomical structures of all athletes participating in the study were healthy, and they had no injury-induced medical and orthopedic problems in the lower/upper extremities. Some of the athletes were not included in the study because they did not want to participate in the study (n = 5) . The athThe body weights and heights of the athletes were measured with a stadiometer .g[m/(s\u22272)]) . RCMJ is performed for 30 s in succession and continuously, reaching the highest point at each jump. A three dimensional Kistler force plate was used as the gold standard and criterion device for the Repetitive Counter Movement Jump (RCMJ) test of the athletes. The force plate was firmly placed on the ground to measure vertical reaction forces during RCMJ. The force plate was connected to a personal computer , and calculation was made using the proprietary software , the above-mentioned formula, and gravitational force (\u22272)], Push Off Acceleration (POA) , Average Velocity (AV) , Average Power (AP) , and Average Force (AF) were analyzed on the device's software (MARS) .*Power 3.1.6. Based on the effect sizes reported in comparable studies, the analysis indicated that minimally 14 participants for an \u03b1 of 0.05 and a power of 0.95 would be required was used for statistical data analysis. To estimate effect sizes, eta squared (\u03b72) was computed with \u03b72 \u2265 0.01 indicating small, \u22650.06 medium and \u22650.14 large effects for a Cross-Sectional design was conducted using G Taylor, . In datas Cohen, . StatistAt the end of the study, the statistics of the variables of \u201cJHTOV, JHFT, CMA, POA, AV, AP, AF\u201d regarding the RCMJ performances of deaf and non-deaf basketball/volleyball players were reported in tables as mean and standard deviation (mean \u00b1 SD).p > 0.05). A statistically significant difference was observed between the deaf and non-deaf volleyball groups in terms of JHTOV, JHTOVA, JHTOVB, JHTOVC, JHTOVD, JHFTA, JHFTB, and JHFTD parameters. This difference was determined to be significant in favor of the non-deaf volleyball group. In the JHFTC parameter, a difference was found in favor of the non-deaf volleyball group, but this difference was not statistically significant (p > 0.05).Upon reviewing p < 0.05). A statistically significant difference was determined in AVA, AVC, and AVD parameters in favor of the deaf basketball group, and the difference in CMAA parameter was statistically significant in favor of the non-deaf basketball group. No statistically significant difference was observed in other parameters (p > 0.05). A statistically significant difference was revealed in terms of CMAA, CMAB, POAA, POAC, AVA, and AVD parameters between the deaf and non-deaf volleyball groups (p < 0.05). In CMAA, CMAB, POAA, AVA, and AVD parameters, there was a significant difference in favor of the non-deaf volleyball group and there was a statistically significant difference in POAC parameter in favor of the deaf volleyball group. No statistically significant difference was found in all other parameters (p > 0.05).When p < 0.05). A statistically significant difference was found in favor of deaf volleyball players in APA, APB, and AFA parameters and there was a statistically significant difference in favor of non-deaf volleyball players in APC, AFC, and AFD parameters.Upon reviewing According to p > 0.05).Upon examining p > 0.05). A statistically significant difference was determined between the non-deaf basketball and non-deaf volleyball groups in APA, APB, APC, APD, AFA, AFC, and AFD parameters (p < 0.05). This difference was found to be significant in favor of the non-deaf basketball group. Although there was a difference in favor of the basketball group in the AFB parameter, this difference was not found to be statistically significant (p > 0.05).As seen in In the present study, RCMJ performances of (deaf/non-deaf) basketball and volleyball players were analyzed. The main highlight of our study is that it is the first study in the relevant literature, and it has added new reference points to the literature. When the results were evaluated, the jump performance parameters [jump height , accelerP = 0.01), double-leg (P = 0.03), and single-leg (P = 0.04) performances during training were statistically significant from the start of CMJ onward, by referring to multiple joints to produce a functional movement (Peng et al., The time taken to produce the highest amount of force in quick actions is quite short, and the change in the actual force-speed graph differs according to the isometric force produced Zemkov\u00e1, . Due to Our study has limitations and strengths. Our participants were male basketball and volleyball players who received chronic training and had adequate exercise experience. Therefore, our results may not be valid for female or recreational athletes since they may give different physiological responses to these mechanical loads associated with jumping. Moreover, the athletes were at the preparation stage. Attention should be paid when comparing the results of our study with other athletes who may be at different training and physical preparation levels. Furthermore, a cross-sectional design was used in the study. Longitudinal studies should be conducted to reveal whether such relative jump parameters can ensure different training adaptations. It is deemed necessary to conduct further studies on relative and absolute jump parameters and their effects on the magnitude of the load, such as muscle, joint, connective tissue, muscle activation, and Hoffmann's reflex. Especially the fact that more athletes were not analyzed to determine the differences in the different playing positions of the players. The strongest aspect of our study is that this sample group is at an elite level and it also reveals new suggestions for the field in terms of the performance components examined.This is the first study to investigate the number of jumps and jump height, the force produced, acceleration at the time of jump, and jump velocity during 30 s in deaf and non-deaf basketball and volleyball players within the scope of individual RCMJ test. The present study provided new information on the RCMJ performances of deaf and non-deaf athletes. The concept will pioneer the information similar to anaerobic scaling, based on the athlete's continuation of his maximum jump for 30 s and creating fatigue in the lower extremity. Relying on the biomechanical changes observed in this study, our findings indicate that there is a decrease in the number of jumps and jump heights, the force produced, the acceleration at the time of jump, and the jump velocity in all athletes, which particularly affects deaf athletes more. Trainers and other practitioners should consider measuring their athletes' performances before training or applying repetitive CMJ exercises in training to adjust the number of jumps and jump heights, the force produced, the acceleration at the time of jump, and jump velocity more effectively.The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author.The studies involving human participants were reviewed and approved by Clinical Ethics Committee of Karamanoglu Mehmetbey University. The patients/participants provided their written informed consent to participate in this study.RS: idea, concept, design, control, supervision, and writing the article. AU: data collection and processing, references, and fundings. \u00d6\u00d6: analysis and interpretation, literature review, and critical review. AU and \u00d6P: materials. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher."} +{"text": "Respiratory syncytial virus (RSV) is an increasingly common cause of respiratory illness in adult non\u2010immunocompromised patients. Oral ribavirin was reported to improve outcomes of RSV infection in immunocompromised patients. This study aimed to determine the outcomes of non\u2010immunocompromised patients hospitalized with RSV\u2010associated acute respiratory illnesses (RSV\u2010ARI), the factors independently associated with the outcomes and the effect of oral ribavirin treatment.This retrospective, observational cohort study included 175 adults admitted to the hospital with virologically confirmed RSV\u2010ARI during 2014\u20132019. Severe ARI was identified using Infectious Diseases Society of America/American Thoracic Society (IDSA/ATS) criteria for severe community\u2010acquired pneumonia. The primary outcome was all\u2010cause mortality within 30\u2009days after enrollment. A multivariable Cox model was performed to identify significant predictors of mortality.2, severe ARI, systemic corticosteroids, and bacterial infection were independently associated with higher risk of mortality. Treatment with oral ribavirin was the only factor associated with reduced mortality .Mean age was 76\u2009\u00b1\u200912.7\u2009years. Seventy\u2010eight (44.6%) patients met the diagnostic criteria for severe ARI. Thirty\u2010six (20.6%) patients required invasive mechanical ventilation, and 11 (6.3%) required vasopressor. Ninety\u2010nine (56.6%) patients received oral ribavirin treatment, and 52 (29.7%) received systemic corticosteroids. Forty\u2010one (23.4%) patients had evidence of bacterial infection. Overall mortality was 7.4%. Mortality among patients with non\u2010severe ARI and severe ARI was 1.04% and 15.4%, respectively. Estimated glomerular filtration rate <50\u2009ml/min/1.73\u2009mRSV\u2010ARI may result in significant mortality and health care utilization. Treatment with oral ribavirin may improve survival in these patients. Patients with RSV infection were identified from our center's inpatient database using the ICD\u201010 code related to RSV infection . RSV infection was defined by a positive reverse transcription polymerase chain reaction (RT\u2010PCR) to any of the following samples: pharyngeal swab, nasal swab, nasopharyngeal aspirate, sputum, or bronchoalveolar lavage (BAL). Patients with RSV infection that met all of the following criteria were included: age \u226518\u2009years; admitted from outside the hospital with signs or symptoms of ARI, defined as two or more respiratory symptoms, including cough, dyspnea, pleuritic chest pain, and/or respiratory distress; and diagnosis of RSV infection within 48\u2009h after admission. Patients who were pregnant, who had received immunosuppressants or long\u2010term corticosteroid therapy, or who had concomitant acquired immunodeficiency syndrome were excluded.2.12 was inferred from the oxygen saturation as measured by pulse oximetry (SpO2).Electronic and written medical records were reviewed for all patients. A protocol for data collection was applied in all cases. Information that was collected included age, gender, comorbidities , functional status , time of illness onset, and hospital admission. The following clinical data at admission were recorded: presenting symptoms and signs, mental alterations, heart rate, respiratory rate, and blood pressure. The need for non\u2010invasive or invasive mechanical ventilation or vasopressors within 48\u2009h of hospital admission was assessed. Chest radiographic findings were also documented . The chest radiographs at admission were retrospectively reviewed by three independent physicians (two pulmonologists and one radiologist) with all interpreters blinded to all clinical information and outcomes. The images were then collectively interpreted so that a consensus determination could be reached and documented. The recorded laboratory data included complete blood count, chemical parameters, and arterial blood gas analysis. If the results of arterial blood gas analysis were unavailable, the PaO4\u2009cfu/ml) or a predominant microorganism isolated from a sputum sample (>25 polymorphonuclear leukocytes and <10 squamous cells per low\u2010power field) with moderate or high quantity.All microbiological studies for bacterial infection, including blood cultures, sputum cultures, pleural fluid cultures, or BAL cultures, at admission and during the course of hospitalization were recorded. Etiologic diagnosis was considered positive in the following situations: isolation of a respiratory pathogen in a usually sterile specimen or bacterial growth in BAL fluid for the study illness for \u226524\u2009h during hospitalization. Replacement doses and inhalation treatment were excluded. Inhaled bronchodilator used to treat the study illness for \u226524\u2009h. Antibiotic referred to the initial antibiotic prescribed within the first 24\u2009h.Four types of medications prescribed during admission were recorded. 2.3Severe ARI was defined according to Infectious Diseases Society of America/American Thoracic Society (IDSA/ATS) criteria for severe community\u2010acquired pneumonia (CAP)Bacterial coinfection was defined in patients having one or more positive cultures of a known respiratory pathogen thought to be causing a true infection from blood and/or a respiratory sample collected within 2\u2009days of admission. Bacterial superinfection was defined in patients having one or more positive cultures of a known respiratory pathogen from blood and/or a respiratory sample collected more than 2\u2009days after admission. Adequate antibiotic therapy was defined as treatment with at least one agent to which all recovered isolates were susceptible in vitro. Non\u2010respiratory nosocomial infection was defined in patients having one or more positive cultures with a bacterial pathogen thought to be causing a true infection from non\u2010respiratory sources collected more than 2\u2009days after admission.2.4The primary outcome was all\u2010cause mortality within 30\u2009days after admission. The secondary outcome was the duration of hospitalization by assessing the number of days alive and outside the hospital within 30\u2009days after hospital admission.2.5U test or unpaired t test for continuous variables.Descriptive analysis was performed. Discrete variables are expressed as number and percentage (%) and continuous variables as either mean\u2009\u00b1\u2009deviation (SD) or median and interquartile range (IQR). Proportions were compared using chi\u2010square test or Fisher's exact test for categorical variables and nonparametric Mann\u2013Whitney P value <0.20 in univariate analysis, biologically relevant potential clinical confounders , and ribavirin treatment were entered into backward stepwise multiple variable Cox regression model to identify factors independently associated with hospital mortality. A lower HR (HR\u2009<\u20091) indicates a lower probability of death.Factors affecting patient survival were analyzed. Time to in\u2010hospital death was defined as the time from hospital admission to date of death within 30\u2009days after admission. Data were censored at either hospital discharge or the date of the final daily record for patients alive and still in the hospital or at 30\u2009days from admission, whichever was first. Univariate and multivariate Cox regression analyses were performed to determine predictive factors of mortality by estimating crude hazard ratio (HR) and adjusted hazard ratio (aHR) and their 95% confidence intervals (CIs). Factors with a P value <0.05 was considered to be statistically significant. All statistical analyses were performed using SPSS Statistics software version 20 .Factors affecting duration of hospitalization were analyzed using time\u2010to\u2010event analyses. Univariate and multivariate Cox regression analyses were performed to identify factors independently associated with the time to hospital discharge alive within 30\u2009days after admission, with patients who were not discharged at day 30 or death before day 30 were considered as right censored at day 30. A lower HR (HR\u2009<\u20091) indicates a lower probability of hospital discharge alive and therefore increased duration of hospitalization. Kaplan\u2013Meier curves were used to illustrate time to hospital death and time to hospital discharge alive. All statistical analyses were two\u2010sided, and a 3A total of 175 adult patients with community\u2010acquired RSV\u2010ARI were included in this study Figure\u00a0. The mea3.1Ninety\u2010nine (56.6%) patients received treatment with oral ribavirin. Of those, 64 (64.6%) received treatment within 24\u2009h after admission, and 89 (89.9%) received treatment within 48\u2009h after admission. The most common dosing regimen prescribed was 600\u2010mg loading, followed by 200\u2009mg three times a day for 7\u2009days. Patients who were likely to receive treatment with ribavirin were patients with chronic lung diseases, severe ARI, and patients who had infiltrates on chest radiograph Table\u00a0. There w3.2P\u2009=\u20090.01) patients had evidence of bacterial infection during hospitalization. Thirty (17.1%) patients had bacterial coinfection, and 18 (10.3%) had bacterial superinfection \u2009<\u200950\u2009ml/min/1.73\u2009mThe average length of hospital stay was 9 (IQR: 6\u201315\u2009days). Patient demographic data and clinical characteristics and associated hospital\u2010free days are shown in Tables 4We found the RSV\u2010ARI patients to be older adults with many coexisting medical conditions. The mortality rate was 7.4%, which is comparable with previously reported mortality rates of 6%\u201313% in patients hospitalized with RSV infection.Disease severity at admission, low eGFR, bacterial infection, and systemic corticosteroids use were associated with increased mortality. Treatment with oral ribavirin was the only factor associated with reduced mortality. Factors previously reported to be associated with mortality in patients hospitalized with RSV infection were advanced age,There is currently no scoring system specifically designed to assess the severity of patients hospitalized with RSV infection. We used IDSA/ATS criteria for severe CAP to define severe ARI due to its good performance for identifying patients at risk for deterioration or escalation of care, ICU admission, and mortality.Bacterial coinfection was reported in 9%\u201330% of patients hospitalized with RSV infection.RSV infection is associated with airway inflammation and increased airway responsiveness and may trigger exacerbation of chronic airway diseases. Wheezing was reported in 33%\u201390% of patients with RSV infection.2 and was found to be an independent predictor of mortality, with a fourfold increased risk of death. Few retrospective studies reported that elevated blood urea level was associated with increase mortality of patients hospitalized with RSV infection.Almost half of patients had an eGFR less than 50\u00a0ml/min/1.73\u00a0mCurrently, the standard of care for the management of RSV infection in adults is mainly limited to supportive care. To our knowledge, the present study is the first to evaluate the effect of oral ribavirin in non\u2010immunocompromised adults with RSV\u2010ARI. Oral ribavirin treatment was associated with a reduction in mortality of non\u2010immunocompromised adults with RSV\u2010ARI. Ribavirin had no effect in the univariate model. This may be explained by indication bias characterized by physicians treating more severe patients with ribavirin. Nevertheless, ribavirin therapy had no effect on duration of hospitalization. The reason for this is suggested to be a consequence of improved survival of more severe patients as a result of their being treated with ribavirin. Similar to the findings in other studies, oral ribavirin appears to be a safe and well\u2010tolerated treatment.The strengths of this study include a homogeneous cohort of adult, non\u2010immunocompromised patients with community\u2010acquired RSV infection with virological confirmation by RT\u2010PCR. A large percentage (56.6%) of patients receiving ribavirin led to well powered to detect differences in treatment efficacy. Moreover, important confounders were carefully adjusted for in multivariate analysis, and there was no missing outcome\u2010related data.This study has some mentionable limitations. First, the study is a retrospective single\u2010center study which is vulnerable to biases and incomplete data. Second, although we took many possible confounding factors into account by adjusting for them, residual confounding cannot be completely excluded. Our cohort comprised mostly older adults with many coexisting medical conditions, so our outcomes might be confounded by different levels of unmeasured patient preference for life\u2010sustaining treatment. Third, initiation for ribavirin treatment could be subject to indication bias since it was not always clear why some patients were given ribavirin and some were not. Furthermore, standardized dosing and duration of ribavirin has not been established in adults, so dosing and duration were decided according to the discretion of the attending physician. Fourth, the reporting of adverse events during ribavirin treatment may be inaccurate.52, severe ARI, systemic corticosteroids, and bacterial infection were identified as independent predictors of mortality, and oral ribavirin treatment may improve survival in these patients. RSV infection in patients hospitalized with ARI should be recognized, and treatment with oral ribavirin should be considered, especially in patients with severe ARI. Randomized controlled trials are warranted to validate our findings.RSV\u2010ARI in adult non\u2010immunocompromised patients may result in significant mortality and health care utilization. Estimated GFR\u2009<\u200950\u2009ml/min/1.73\u2009mPhunsup Wongsurakiat: Conceptualization; data curation; formal analysis; investigation; methodology; project administration; resources; software; supervision; validation; visualization. Siwadol Sunhapanit: Conceptualization; data curation; formal analysis; investigation; methodology; project administration; resources; software; supervision; validation; visualization. Nisa Muangman: Conceptualization; data curation; formal analysis; investigation; methodology; project administration; resources; software; supervision; validation; visualization.This research received no specific grants from any funding agency in the public, commercial, or non\u2010profit sectors.https://publons.com/publon/10.1111/irv.12971.The peer review history for this article is available at Table S1 Infectious Diseases Society of America/American Thoracic Society criteria for defining severe community\u2010acquired pneumoniaTable S2 Demographic, clinical characteristics, and hospital\u2010free days within 30\u2009days of all patients hospitalized with respiratory syncytial virus\u2010associated acute respiratory illnessTable S3 Severity at admission and hospital\u2010free days within 30\u2009days of all patients hospitalized with respiratory syncytial virus\u2010associated acute respiratory illnessTable S4 Bacterial coinfection, bacterial superinfection, treatment and hospital\u2010free days within 30\u2009days of all patients hospitalized with respiratory syncytial virus\u2010associated acute respiratory illnessClick here for additional data file."} +{"text": "For these procedures, convolutional neural networks have proven to be very beneficial in achieving near-optimal accuracy for the automatic classification of SPECT images. (2) Methods: This research addresses the supervised learning-based ideal observer image classification utilizing an RGB-CNN model in heart images to diagnose CAD. For comparison purposes, we employ VGG-16 and DenseNet-121 pre-trained networks that are indulged in an image dataset representing stress and rest mode heart states acquired by SPECT. In experimentally evaluating the method, we explore a wide repertoire of deep learning network setups in conjunction with various robust evaluation and exploitation metrics. Additionally, to overcome the image dataset cardinality restrictions, we take advantage of the data augmentation technique expanding the set into an adequate number. Further evaluation of the model was performed via 10-fold cross-validation to ensure our model\u2019s reliability. (3) Results: The proposed RGB-CNN model achieved an accuracy of 91.86%, while VGG-16 and DenseNet-121 reached 88.54% and 86.11%, respectively. (4) Conclusions: The abovementioned experiments verify that the newly developed deep learning models may be of great assistance in nuclear medicine and clinical decision-making. Recent evidence suggests that coronary artery disease (CAD) is the most common type of cardiovascular disease being the leading cause of mortality worldwide. The percentage of death attributed to CAD is higher compared with other heart diseases. CAD occurs when the blood vessels are narrowed, and blood does not circulate properly around the heart. It is extremely crucial for a patient to be diagnosed early with any form of heart disease, especially CAD, so that the doctor can ensure that the patient will receive the proper medication and treatment ,2.A well-established method in clinical practice for the assessment of CAD is the single-photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI) with technetium-99 m-labeled (99 mTc) perfusion agents. The method is rather advantageous for most cases. This method can offer rest and stress representation of the patient\u2019s heart to identify areas that have myocardial perfusion abnormalities . The mosDL-based solutions are increasingly being used to solve medical image analysis and computer-assisted intervention problems in medical informatics. This is due to their ability to effectively extract patterns and features only from input images, achieving tremendous results. The most significant advantage of such methods lies in the fact that they are adaptable to the specific functionality of medical image analysis. This advantage has been extensively utilized by researchers in the field in adapting DL into a variety of medical diagnostics with minimal implementation and heterogeneous infrastructure harmonization efforts. Additionally, DL provides a pipeline for medical imaging applications such as segmentation, regression, image generation, and representation learning in medical diagnostics . DL is aCAD systems are increasingly utilized in scientific diagnostics and they have an irreplaceable role in the diagnosis of MPI images, as they represent the blood flow of the heart in high contrast . An autoIn particular, Berkaya et al. in sought tOther studies on CAD diagnosis in nuclear medicine are focused on the implementation of the DL methods to categorize polar maps into normal and abnormal. Liu et al. developeApostolopoulos et al. in developeAdditionally, various recent studies demonstrate outstanding achievements regarding explainable artificial intelligence (XAI) implementations, which manage to provide transparency in the case of black-box models . In partAccording to previously conducted studies and the corresponding results, CNNs seem to attain similar accuracy to that of medical experts, and the approaches developed ,10,11. HThe contribution of this research is to propose a CNN model and utilize transfer learning with the purpose of developing a model that can automatically classify SPECT images and predict CAD. For that reason, we have carefully selected metrics, that are reliable and robust such as accuracy, loss, AUC value, and ROC curve . Our extPatient data have been acquired from the Diagnostic Medical Center \u201cDiagnostiko-Iatriki A.E.\u201d in Larisa, Greece by the Nuclear Department and have been retrospectively examined. The study covers a period from 30 March 2012 to 28 February 2017. Over this period, 842 consecutive patients underwent gated-SPECT MPI with 99mTc-tetrofosmin. A hybrid SPECT/CT gamma-camera system was used for MPI imaging. Fifty-six (56) patients were excluded from the dataset due to inconclusive MPI results. Our dataset includes a total of 647 patients, where 262 of them correspond 134 to infarction, 251 to ischemic, and 262 to normal. The images have been extracted with SPECT method and are a visual representation of the heart in rest and stress mode.Two nuclear medicine experts (N. Papandrianos and N. Papathanasiou) were asked to label each instance of the dataset according to their expertise and experience. Both count several years of experience. Labeling had been performed by the experts using solely the MPI scans of each patient. In this way, the model could be directly compared with the human experts. Hence, this study uses the experts\u2019 diagnostic yield as the ground truth and aims to furnish a DL model capable of competing with the human eye and the human expertise. The Ethical Committee approved the study of our institution. The nature of the survey waives the requirement to obtain patients\u2019 informed consent. In In the case of infarction, as depicted in CNNs have become an encouraging type of model for medical image analysis since they do not need manual extraction of features, and instead, they can acquire hierarchical features by processing low-level features into high ones .The first layer in the implementation of CNN is the convolutional layer, which is the core function, where the feature maps are generated. The feature maps are the result of the application of filters to the input image, for the purpose of attaining the pixels that have a positive impact on the output.Following is the pooling layer, which reduces the spatial size by forwarding the necessary data for the optimization of calculation time and the usage of minimum computed resources, during the training. Next, a dropout layer is included, which randomly nullifies neurons on each iteration, to prevent overfitting. Then, flatten layer follows, which transforms multidimensional data into a one-dimension array, for inserting it into a fully connected layer. Lastly, a fully connected layer follows, where each node is connected with the previous node for the calculation of output, with the utilization of the activation function.Concerning the activation functions, we utilize RELU (rectified linear unit) for all convolutional and fully connected layers, which outputs only the values that are positive and nullifies all negative values. The activation function of the output layer is based on the output, where in binary classification problems, the sigmoid function is utilized, where it contains a threshold, and any value higher than the threshold are classified as positive and the rest as negative. In a multiclass classification problem, the softmax function is preferred, which outputs a probability value for each possible label, and the higher probability indicates the predicted label .This paper targets the implementation of an RGB-CNN model, as a prosperous method in nuclear imaging for the classification of SPECT data and utilization of transfer learning. The robust CNN that was applied in our dataset can export highly efficient results. In The steps of our methodology are reported below:Step 1: Loading datasetThe SPECT MPI images were given by a nuclear physician, for the construction of an automatic classification tool. The images are demonstrated in RGB mode, and the corresponding patients underwent stress and rest examination. The dataset includes images of three categories: infarction, ischemia, and normal, and they are labeled \u201c0\u201d, \u201c1\u201d, and \u201c2\u201d respectively.Step 2: Data preparationData normalization: Normalizing data is a common technique in the DL methodology. It is important to rescale the values of pixels and transform them in the range of , so there would be an easier computation process.Data shuffle: To achieve generalizability and avoid bias in our proposed CNN model, it is mandatory to shuffle our data, so the data will be inserted into the model in random order.Data split: The dataset was split into three parts: training, validation, and testing. Each part has a specific percentage of the whole dataset, more specifically, training holds 85% of the total dataset and testing holds the remaining 15%. From the training dataset, 80% is provided for training, whereas 20% of training is supplied for validation .Step 3: TrainingData augmentation: The data augmentation technique is important in DL applications, to increase the number of the existing dataset, especially when the number of training data is small. The techniques that are applied in the current research are: rescale, rotation, range, width shift range, height shift range, shear range, zoom range, horizontal flip, and vertical flip. The aim of this procedure is to achieve generalizability and prevent overfitting, which occurs when the model fits precisely with training data and cannot perform correctly with unseen data ,24.Define CNN architecture and activation functions: For the definition of the best-proposed model, which assures generalizability and robustness, a thorough exploration must be made. The parameters that need to be explored are pixel size, batch size, number of nodes and layers of convolutional layers, and number of nodes of fully connected layers. Furthermore, it is essential to select the proper activation function for the convolutional and dense layers .Train CNN: During the training process, CNN extracts abstract patterns, which are acquired from the produced feature maps with respect to the corresponding output. Furthermore, the back-propagation technique is utilized for the fine-tuning of the model with the adjustment of weights, that have a positive impact on the result, and nullifying the values that do not ,27.Step 4: ValidationThroughout the process of validation, the network has not been fully specified and utilizes a section of training data to extract validation metrics. The purpose of the validation is to minimize the errors, normalize the weights and provide the best results.Step 5: TestingDuring the testing procedure, the best model has been concluded. The goal of testing is to evaluate the results of the model in classifying unknown data and for that reason, we used valid metrics such as precision, recall, sensitivity, specificity, accuracy, loss, and AUC ,16,27.The aim of this research is the development of an efficient CNN that can fully autonomously identify any signs of cardiovascular disease. With the utilization of accurate metrics along with external evaluation and more specifically, 10-fold cross-validation the CNN model will be tested for its accuracy and robustness. Throughout the CNN exploration process, experiments were conducted with various values for the following parameters: pixel size, batch size, number of nodes and layers of convolutional layers, and number of nodes of fully connected layers . The proIn this research study, the problem we seek to address is the automatic classification of obstructive CAD images, with three possible outputs: infarction, ischemic, and normal. To that end, various architectures of CNN, which are commonly used for classifying images correctly ,27,28,29\u00ae Core\u2122 i9-9980HK CPU 2.40GHz, (2) GPU: NVIDIA Quadro RTX 3000, (3) Ram: 32 GB, (4) System operating type: 64-bit operating system and x64-based processor.The developed algorithm was run in Google Colab ,30 runtiTo find the best architecture for the provided dataset, a thorough exploration was conducted. On that basis, we examined different values for pixel sizes , batch sizes , number of nodes for convolutional layers and nodes for dense layers . Additionally, we examined various epochs (400 up to 800), whereas we kept a fixed drop rate value of 0.2 for all simulations, as this value provides adequate results.To properly assess the results, certain robust metrics were selected, such as accuracy, loss, AUC, ROC curve, precision, recall, sensitivity, and specificity. More specifically, accuracy is the ratio between several correct predictions to a total number of predictions. Loss dictates the error in classifying images by calculating the gradients between predicted and real outputs. The AUC value is the numerical demonstration of a model to differentiate an image within the possible output and its value ranges between 0 and 1, where 1 is the ideal, ROC curve is the visual representation of the classifier\u2019s performance. Regarding precision is the ratio between correctly classified positive samples to the total number labeled as positive, where recall is the percentage of correctly classified samples. Sensitivity evaluates the model\u2019s capability by calculating the percentage of the positive samples, that were predicted correctly, whereas specificity computes the percentage of negative samples ,11,27.With respect to the initial default values for the performed exploration process, these are the following: 250 \u00d7 250 for pixel size, 16 for batch size, 16-32-64-128 for convolutional layers, and 128-128 for dense layers, as well as 400 epochs. Firstly, various batch sizes were examined by keeping the rest of the values fixed, to find the best batch size. Afterwards, we examined different pixel sizes, while having kept fixed values for convolutional and dense layers, considering that 32 is the best batch size. In In the following step, different convolutional layers were examined, in order to configure to the best combination. In The last step deals with the selection of the best number of nodes for the dense layers. Therefore, different numbers of nodes were examined, and the produced results are visually depicted in At this point, various architectures were explored for our RGB model, and each combination was executed for at least 10 runs so that a robust and reliable model was finally conducted. The ultimate architecture of RGB is 300 \u00d7 300 for pixel size, 32 for batch size, 16-32-64-128 for convolutional layers, and 128-128 for dense layers. We can see in In addition to the procedure, which is followed for the determination of the RGB model, we also utilized a powerful method, commonly used in imaging problems, which is called transfer learning. A model is previously trained in various classification problems and can perform adequately in related tasks and has great generalizability skills . In our DenseNet-121\u2019s best architecture consists of 250 \u00d7 250 for pixel size, 32 for batch size, 0.2 drop rate, 400 epochs, 12 true trainable layers, global average pooling, and 2 fully connected layers with 32 nodes each. In In In In To implement robust and reliable models, we utilized the 10-fold cross-validation technique in order to further evaluate the performance of our model . This meFor comparative analysis, In this study, three CNN models were examined to differentiate between infarction, ischemic and normal perfusion in SPECT-MPI images; in stress and rest mode. The first DL-based model, the RGB-CNN, was built from scratch, comprising four convolutional layers and two dense layers. VGG-16 was the second model applied, which is acknowledged for image classification tasks and was designed using fourteen layers, to prevent overfitting. The third model is DenseNet-121, which was implemented with twelve layers for the same purpose. Transfer learning was applied to the last two models, as a widely used and robust technique for image classification. The provided dataset consists of 647 images, where the data are heterogeneous, which is an important factor in terms of generalizability. Since the dataset is considered rather small, the data augmentation method was employed to increase the size. Furthermore, the dataset was split into three parts, training, validation, and testing, to evaluate our model in data, with known outputs, through the validation dataset, and unseen data, with the utilization of the testing dataset. Additionally, a 10-fold cross-validation was performed, and the results demonstrated great stability and reliability for our models.Nuclear experts also performed visual classification of the models achieving supervised learning with known output. It should be highlighted that we conducted an in-depth exploration process where various combinations concerning different image sizes, batch sizes, and convolutional and dense layers were examined, to conclude the best architecture of the DL models, for the corresponding dataset. Concerning the selection of batch size, we investigated different values for batch sizes between 8 and 64, following the reported literature ,32. The The distinction of results and the improvement of metrics, during the experiment, is a promising fact for the model\u2019s capabilities. In this direction, certain metrics, which are robust and reliable, were employed to evaluate models\u2019 stability and performance. These are accuracy, loss, AUC, ROC curve, precision, recall, sensitivity, and specificity and were applied in all three models. The results demonstrated that all three models can achieve high accuracy and minimize loss, even for a small dataset, which is a key factor for attaining reliability. VGG-16 and RGB-CNN performed better against DenseNet-121, achieving an accuracy of 93.33%, 88.54%, and 86.11%, respectively. These results ensure reliability and that fine-tuning a model is both important and effective. It turns out that the proposed RGB-CNN model and other robust and widely recognizable models can perform equally well.Due to their generalizability and reliability, as proven through k-fold cross-validation, the proposed models can be deployed by nuclear experts on any SPECT-MPI images, without any further adjustments, extracting sufficient results. However, there are some limitations in this work, that need to be considered and further addressed in the future. Firstly, only SPECT images were used as input to the proposed models, since CNNs can perform directly to images. Secondly, the size of our dataset is limited for CNN classifiers, so we had to increase it by adding more images to feed our models, thus extracting more abstract feature maps to further optimize our approach. Despite the existence of these limitations, the proposed models are capable to perform satisfactorily and operate adequately in unknown data.Some of the clinical implications that emerge from the employment of the proposed methodology in medical imaging include the invaluable support towards an instant and automatic clinical diagnosis of SPECT MPI images that could prevent patients from possible undesirable heart conditions, such as infarction. The DL-based approach could potentially serve as a crucial assisting tool for medical experts in their effort to (i) evaluate and further diagnose correctly SPECT MPI images of patients suffering from angina, or known coronary artery disease, and (ii) instantly deliver proper treatment suggestions. The integration of the proposed RGB-CNN model in the clinical everyday practice constitutes a challenge in the medical imaging domain, provided that its enhanced performance is also validated on larger datasets.A notable aspect that has been reported in the present studies is explainable artificial intelligence (XAI). Even though CNNs can extract spectacular results, it remains unclear how CNN models arrive at a specific output resulting in certain decisions. CNNs are considered black boxes, as they do not provide any evidence of their conclusions and thus, we depend mostly on the extracted metrics to fully trust their output. CNNs accept images as input, compute some calculations with the help of hidden layers, and produce an output in the form of a percentage of a prediction. Therefore, scientists and medical experts have the belief that CNNs perform with bias and therefore, they are skeptical about CNNs trustworthiness, especially in the medical domain, where each decision is crucial for the patient\u2019s health. Considering this persistent disbelief of their abilities and trustworthiness, explainable artificial systems have been developed in order to provide interpretability and understanding of the internal computation of CNNs. In future studies, our aim is to thoroughly explore and further develop XAI systems. In view of the abovementioned considerations, XAI is a realm that needs to be explored to a greater extent in the future, especially for medical diagnosis, where the predicted output of the proposed models has such an essential role .To sum up, our three-class classification models are capable of performing pleasingly and distinguishing images between infarction, ischemic and normal cases, with the utilization of 10-fold cross-validation, transfer learning, and data augmentation. All three models can be an integral tool to assist with the automatic diagnosis of coronary artery disease and can be clinically deployed with the help of a user interface (UI) platform.DL has demonstrated that it can perform autonomously and assist in the healthcare domain ,35. More"} +{"text": "Nearly fully dense (over 99.5%) and crack-free SLM-fabricated TiB2/AlZnMgCu composite samples were obtained and its microstructure and mechanical properties were investigated. It is found that the laser absorption rate of powder is improved by introducing micron-sizedTiB2 particles, then the energy density required for SLM forming can be reduced, and the densification can finally be improved. Some crystalline TiB2 formed a coherent relationship with the matrix, while some broken TiB2 particles did not, however, MgZn2 and Al3 can perform as intermediate phases to connect these non-coherent surfaces to aluminum matrix. All these factors lead to an increase in strength of the composite. The SLM-fabricated micron-sized TiB2/AlZnMgCu composite finally shows a very high ultimate tensile strength of ~646 MPa and yield strength of ~623 MPa, which are higher than many other aluminum composites fabricated by SLM, while maintaining a relatively good ductility of ~4.5%. The fracture of TiB2/AlZnMgCu composite is occurred along the TiB2 particles and the bottom of the molten pool. This is due to the concentration of stress from the sharp tip of TiB2 particles and the coarse precipitated phase at the bottom of the molten pool. The results show that TiB2 plays a positive role in AlZnMgCu alloys fabricated by SLM, but finer TiB2 particles should be studied.In this paper, micron-sized TiB In recent years, modern advanced industrial equipment, such as aviation, aerospace, electric power, petrochemical, shipbuilding and so on, is developing towards the direction of complex structure and high performance ,2. The r2CuMg) precipitate at a cooling rate of more than 500 \u00b0C/h, thus obtaining better aging hardening effect during subsequent heat treatment TiB2 // (\u2212111) [110]Al and OR2: (\u2212110\u22121) [11\u221220]TiB2 // (002) [110]Al, respectively, as also reported by [2 particles and Al matrix are well combined.orted by ,32,41, i2 and aluminum matrix are established to further analyze the interface binding, as shown in F), and the calculation Formula (2) [Crystal structure models of interface between TiBmula (2) is as fo2, which have the same structure and similar lattice spacing. The atomic spacing mismatch of the most close-packed and nearly close-packed directions are calculated to be 6.2% and 9.8%, respectively, showing a good coherent relationship. Al3 has the same grain structure as aluminum matrix, but the lattice spacing is slightly larger. In the same crystal plane pair with TiB2, the atomic spacing mismatch of the most close-packed and nearly close-packed directions are calculated to be 4.4% and 4.5%, respectively, showing an excellent coherent relationship, as represented in 3 has a better interface binding with TiB2 than aluminum matrix dose, so it is more likely to cause enrichment of Sc and Zr elements around TiB2.2 and Sc, Zr element interact with each other and act synergistically in Al matrix composites. On the one hand, it is beneficial to the interface bonding between the reinforcement phase and the matrix, and enhance the strength of the composite material. On the other hand, the evenly distributed precipitation phase Al3 will be reduced, and the effect of precipitation strengthening will be weaken. These results indicate that there are new considerations in the composition design and strengthening mechanism of Sc, Zr micro-alloyed aluminum matrix composites reinforced with TiB2 formed by SLM.This phenomenon indicates that TiB2/AlZnMgCu composites after heat treatment with the same process have similar changes: after heat treatment, the tensile strength and yield strength of AlZnMgCu alloys increase about 131 MPa and 155 MPa, respectively, and elongation decreases by about 10.7%. The tensile strength and yield strength of TiB2/AlZnMgCu composites increase about 136 MPa and 159 MPa, respectively, and elongation decreases by about 8.5%. The reason for this is that the heat treatment process is mainly regulated by precipitation of Al3 and MgZn2 phases, and the addition of micron-sized TiB2 particles has little effect on the heat treatment process. However, the addition of micron-sized TiB2 particles improve the mechanical properties. By comparing the mechanical properties of as-printed TiB2/AlZnMgCu composites and as-printed AlZnMgCu alloys, the tensile strength has increased by about 7.5%, the yield strength has hardly increased, and the elongation after fracture has decreased by about 19.4%. The properties of heat-treated states are similar, where the tensile strength has increased by about 6.6%, the yield strength has increased by about 3% and the elongation after fracture has decreased by about 15.1%. The heat-treated TiB2/AlZnMgCu composite samples obtained by SLM have extremely high strength, where the ultimate tensile strength is about 646.7 MPa and the yield strength is about 623 MPa. In addition, plasticity was preserved, as its elongation after fracture is about 4.5%. Its comprehensive mechanical properties exceed most of the SLM forming aluminum composites reported so far [d so far ,45,46,472/AlZnMgCu composite is shown in 2 particles separated from the matrix could be found. The fracture morphology shows that the fracture of micron-sized TiB2/AlZnMgCu composite formed by SLM occurs at pores, defects and the interface between the TiB2 particles and Al matrix.The fracture morphology of as-printed micron-sized TiB2/AlZnMgCu composite. After tensile deformation, the crack passes through the columnar and equiaxed grain regions completely. Moreover, there are TiB2 particles and grooves left by debonding of TiB2 particles near the fracture. The observation above indicates that the sharp tip of TiB2 will cause concentration of stress, which leads to crack propagation.The tensile plates were sliced vertically and horizontally, and the microstructure of the side of the fracture were observed by SEM after being grinded and polished; the results are shown in 2/AlZnMgCu composite samples were sliced along the vertical direction, and the comparison results with the as-printed state are shown in 2 particles and grooves left by TiB2 particles after debonding also exist in the crack passing through the sample in heat treatment state. The difference is that the crack has a tendency to proceed along the equiaxial fine grain zone, which is the bottom of the molten pool. A possible reason for this is that the large precipitated phase at the bottom of the molten pool, as analyzed in 2/AlZnMgCu composite specimens, the crack generally expands along the equiaxed grain zone and the interface between TiB2 and the matrix.Heat-treated TiB2/AlZnMgCu composites fabricated by SLM are investigated. The differences of micron-sized TiB2/AlZnMgCu composite and AlZnMgCu alloy samples in terms of macroscopic defects, microstructure, interface, mechanical properties and fracture behavior are compared between the as-printed and heat-treated samples. The main conclusions are as follows:2/AlZnMgCu composite with good surface quality and high densification of 99.76% have been successfully prepared by SLM. Micron-sized TiB2 particles are distributed uniformly in the matrix. The addition of TiB2 leads to an increase of densification, but has little influence on the microstructure, phase composition and heat-treatment process.The crack-free micron-sized TiB2 particle surface has a good interface with the aluminum matrix and the interface is clean and smooth, with no other intermediate phase. A large number of alloy-elements are enriched near the irregular surface of these broken TiB2, for relatively high surface free energy, similar to grain boundaries. Due to the poor interfacial bonding between these parts of the surface and the aluminum matrix, the Mg (Zn1.5Cu0.5) phase can form as the interphase to bond the matrix. The reason for this is that its lattice parameter at a specific crystal plane is between the TiB2 and aluminum matrix.The complete micron-sized TiB2 particles has a beneficial effect on the mechanical properties of AlZnMgCu samples, and the increase is about 6%. The main reason for the increase is the increase of densification due to the increase of the powder laser absorption rate. In contrast, due to the introduction of brittle ceramic particles and its stress concentration effect, the ductility has decreases by about 15%. The ultimate tensile strength and yield strength of the composite are about 646 MPa and 623 MPa, respectively. Moreover, the composite has some plasticity and elongation after fracture, which is about 4.5%.The addition of micron-sized TiB2/AlZnMgCu composite is due to the stress concentration of the sharp tips of TiB2. In addition, the large particles precipitated after heat treatment are mainly concentrated in the fine grain zone at the bottom of the molten pool, and these coarse precipitated phases can also easily cause propagation of cracks.The fracture of the micron-sized TiBIn this paper, the micron-sized TiB2 particles by the external method do have a positive effect, such as improving the densification and slightly improving the mechanical properties. However, there is space for further improvement. The reason for this is that the micron-sized TiB2 particles introduced by the external method are too large to achieve the effect of fine grain strengthening, and the effect of Orowan strengthening and load bearing is also minimal due to insufficient additions. Besides, most of the particles added are irregular in shape, which may cause stress concentration. Therefore, the use of nano-sized particles TiB2 should be the focus of subsequent experiments, and the synergistic effect of TiB2 and Sc, Zr micro-alloyed Al matrix composites can also be further studied.To sum up, the introduction of micron-sized TiB"} +{"text": "II complex was synthesized by reacting 5-methyl-3-pyrazolamine and copper(II) acetate in water under ambient conditions. Di\u00adethano\u00adlamine was added to facilitate carbon dioxide adsorption, creating an alkaline environment. Structural analysis revealed that the complex crystallizes in the P21/c space group of the monoclinic crystal system, with the central copper(II) atom in a square-planar coordination environment N2O2. Co-crystallized water mol\u00adecules are present, forming O\u2014H\u22efO hydrogen bonds with the CuII mononuclear complex. Hirshfeld surface analysis highlighted the importance of various inter\u00adactions, including H\u22efO/O\u22efH, H\u22efC/C\u22efH, and H\u22efN/N\u22efH, in providing crystal structure packing.A mononuclear square-planar Cu II complex of (5-methyl-1H-pyrazol-3-yl)carbamate, [Cu(C5H6N3O2)2]\u00b74H2O, was synthesized using a one-pot reaction from 5-methyl-3-pyrazolamine and copper(II) acetate in water under ambient conditions. The adsorption of carbon dioxide from air was facilitated by the addition of di\u00adethano\u00adlamine to the reaction mixture. While di\u00adethano\u00adlamine is not a component of the final product, it plays a pivotal role in the reaction by creating an alkaline environment, thereby enabling the adsorption of atmos\u00adpheric carbon dioxide. The central copper(II) atom is in an (N2O2) square-planar coordination environment formed by two N atoms and two O atoms of two equivalent (5-methyl-1H-pyrazol-3-yl)carbamate ligands. Additionally, there are co-crystallized water mol\u00adecules within the crystal structure of this compound. These co-crystallized water mol\u00adecules are linked to the CuII mononuclear complex by O\u2014H\u22efO hydrogen bonds. According to Hirshfeld surface analysis, the most frequently observed weak inter\u00admolecular inter\u00adactions are H\u22efO/O\u22efH (33.6%), H\u22efC/C\u22efH (11.3%) and H\u22efN/N\u22efH (9.0%) contacts.A mononuclear square-planar Cu Co-crysII ion displays a square-planar coordination environment (N2O2) formed by two nitro\u00adgen atoms of pyrazole rings and two oxygen atoms of carboxyl\u00adate group of (5-methyl-1H-pyrazol-3-yl)carbamate ligands. The Cu1\u2014N1 distances are 1.931\u2005(2)\u2005\u00c5 while the Cu1\u2013O1 distances are shorter and account to 1.9140\u2005(17)\u2005\u00c5. The O1\u2013Cu1\u2013O1i and N1\u2014Cu1\u2014N1i bond angles are 180\u00b0, which is typical for a square-planar arrangement -to-plane distance of 0.182\u2005(3)\u2005\u00c5.The Cunt Fig.\u00a01. At the 2] units form layers with Cu1 centres lying in the ab plane. The plane-normal-to-plane-normal angle between the horizontal N1\u2014O1\u2014N1i\u2014O1i planes of two adjacent layers is 74.762\u2005(2)\u00b0.In the crystal structure, monomeric mol\u00adecular complexes. Geometric parameters for inter\u00admolecular hydrogen bonds are given in Table\u00a02All the components of the structure are associated s Figs. 2, 3 \u25b8. \u03c0\u20132] neutral complexes. The plane-to-plane distance for these \u03c0\u2013\u03c0 contacts is 3.324\u2005(3)\u2005\u00c5 with the plane-to-plane shift being 1.498\u2005(5)\u2005\u00c5. It is also worth noting very weak C\u2014H\u22ef\u03c0 contacts between two contiguous [Cu(5-MeHpzCarb)2] units with a carbon-atom-to-plane distance of 3.586\u2005(4)\u2005\u00c5.Inter\u00adestingly, four water mol\u00adecules and the carboxyl group form a five-membered supra\u00admolecular ring Fig.\u00a03. In addi4.Crystal Explorer 21.5 software to 1.1041 (blue) a.u. There are eight red spots on the dnorm surface . Visualizations were performed using a red\u2013white\u2013blue colour scheme, where red highlights shorter contacts, white is used for contacts around vdW separation, and blue depicts longer contacts. The red spots on the 3D dnorm Hirshfeld surfaces indicate the direction and strength of the inter\u00admolecular E\u2014H\u22efO hydrogen bonds , as well as weak C\u2014H\u22efO and C\u2014H\u22ef\u03c0 contacts. The overall two-dimensional fingerprint plots for the selected inter\u00adactions are shown in Fig.\u00a04b.The Hirshfeld surface analysis was performed and the associated two-dimensional fingerprint plots were generated using ce Fig.\u00a04a. VisuaThe most significant contributions to the overall crystal packing are from H\u22efH (32.2%), H\u22efO/O\u22efH (33.6%), H\u22efC/C\u22efH (11.3%), H\u22efN/N\u22efH (9.0%) and C\u22efN/N\u22efC (4.1%) inter\u00adactions. The H\u22efO/O\u22efH contacts form a pair of spikes on the sides of the corresponding two-dimensional plot, which are indicative of strong inter\u00admolecular inter\u00adactions between atoms. At the same time, the H\u22efN/N\u22efH and H\u22efC/C\u22efH contacts form less pronounced spikes, indicating that these inter\u00adactions are weaker.5.et al., 20162(CO2)2 moiety [four-coordinated copper atom with an N2O2 coordination environment] were found. Most similar to the title compound, complexes forming a four-coordinated N2O2 coordination environment, are trans-bis\u00ad\u00adbis\u00adcopper(II) copper(II) bis\u00adcopper(II) dicopper(II) , copper(II) acetate and di\u00adethano\u00adlamine were mixed together, and dissolved in water. After 3 days, clear, light-violet crystals were collected by filtration, dried for less than a minute, and then placed under crystallographic oil for further measurements.5-Methyl-3-pyrazolamine \u2014H, Cp\u2014H and Ow\u2014H groups were positioned geometrically and refined as riding atoms, with C\u2014H = 0.95\u2005\u00c5 and Uiso(H) = 1.2Ueq(C) for Cp\u2014H groups, N\u2014H = 0.88\u2005\u00c5 and Uiso(H) = 1.2Ueq(N) for N\u2014H groups and O\u2014H = 0.87\u2005\u00c5 and Uiso(H) = 1.5Ueq(O) for Ow\u2014H groups. Methyl H atoms were positioned geometrically and were allowed to ride on C atoms and rotate around the C\u2014C bond, with C\u2014H = 0.98\u2005\u00c5 and Uiso(H) = 1.5Ueq(C) for the CH3 groups.Crystal data, data collection and structure refinement details are summarized in Table\u00a0310.1107/S2056989023008575/tx2076sup1.cifCrystal structure: contains datablock(s) I. DOI: 10.1107/S2056989023008575/tx2076Isup2.hklStructure factors: contains datablock(s) I. DOI: 2298123CCDC reference: crystallographic information; 3D view; checkCIF reportAdditional supporting information:"} +{"text": "The transcriptomic analysis predicts that the pre-basophil population includes previously-defined basophil progenitor (BaP)-like cells in terms of gene expression profile. Pre-basophils are highly proliferative and respond better to non-IgE stimuli but less to antigen plus IgE stimulation than do mature basophils. Although pre-basophils usually remain in the bone marrow, they emerge in helminth-infected tissues, probably through IL-3-mediated inhibition of their retention in the bone marrow. Thus, the present study identifies pre-basophils that bridge the gap between pre-BMPs and mature basophils during basophil ontogeny.Basophils are the rarest granulocytes and are recognized as critical cells for type 2 immune responses. However, their differentiation pathway remains to be fully elucidated. Here, we assess the ontogenetic trajectory of basophils by single-cell RNA sequence analysis. Combined with flow cytometric and functional analyses, we identify c-Kit hi pre-basophils downstream of pre-basophil and mast cell progenitors (pre-BMPs) but upstream of mature basophils and this population includes basophil progenitors (BaPs).Single cell sequencing can be used to better characterize immune cell progenitors. Here the authors characterize CLEC12A They have several similarities with tissue-resident mast cells, including the expression of the high-affinity IgE receptor (Fc\u03b5RI) on their cell surface and the prompt release of granule contents (degranulation) upon cross-linking of Fc\u03b5RI. Therefore, basophils had mistakenly been regarded as blood-circulating surrogates of mast cells. However, the development of analytical tools for basophils, such as basophil-deficient mice9. Unipotent basophil progenitors (BaPs) are identified in 2005 and defined as Lineage (Lin)\u2212cKit\u2212CD34+Fc\u03b5RI\u03b1+ cells10 or Lin\u2212cKit\u2212CD34+CD200R3+ cells11. As BaPs can be generated in vitro from granulocyte-macrophage progenitors (GMPs), they are considered as down-stream of GMPs. Further studies identified bi-potential basophil and mast cell common progenitors in the bone marrow (pre-BMPs [Lin-Sca-1-cKit+CD34+Fc\u03b5RI\u03b1+ Fc\u03b3RII/IIIhi cells] and pro-BMPs [Lin\u2212Sca-1\u2212cKit+CD34+E-cadherin+Fc\u03b3RII/IIIhi cells])13. In addition, bi-potential basophil and mast cell common progenitor cells (BMCPs) have been identified also in the spleen10, even though later study has suggested that BMCPs can only differentiate into mast cells14. Thus, basophils differentiate from hematopoietic stem cells (HSCs) via GMPs, bi-potential basophil and mast cell progenitors and uni-potent basophil progenitors9.Basophils terminally differentiate within the bone marrow in contrast to mast cells, and several progenitor populations have been reported to differentiate into mature basophils17. This was also the case in basophils, and dynamic gene expression changes from HSCs to basophils have been reported in mice and humans22. Findings from single-cell transcriptomes indicate that basophil differentiation trajectory is coupled with erythrocyte/megakaryocyte differentiation rather than neutrophil or monocyte differentiation. Indeed, several reports showed the presence of oligo-potent basophil and erythrocyte/megakaryocyte progenitors in mice and humans23. Thus, single-cell transcriptomes have shown differentiation pathways from HSCs to BaPs. Nevertheless, the continuous differentiation trajectory from progenitors to mature basophils remains to be fully defined, and it is uncertain whether intermediate populations exist between progenitors and mature basophils along the basophil ontogeny.Recent advancements in the single-cell RNA sequencing (scRNA-seq) technology have challenged the classical view of hematopoietic cell differentiation, including the stepwise model of the hematopoietic differentiation tree. A series of single-cell transcriptomic analyses have provided a detailed snapshot of hematopoietic cell differentiation landscape, which indicates that hematopoietic cell differentiation is a rather continuous process in that oligo-potent progenitors differentiate into each respective cell lineageIn this work, we define the basophil differentiation trajectory by conducting highly sensitive scRNA-seq analysis of basophils in mice and identify pre-basophils located between pre-BMPs and mature basophils during basophil ontogeny.24. To determine the culture condition optimal for the generation of BMBAs, we cultured mouse bone marrow cells with different concentrations of IL-3, ranging from 0 to 100\u2009ng/mL, for 7 days. The frequency of CD200R3+c-Kit\u2212 basophils in the culture increased up to ~60% as the IL-3 concentration went up to 0.3\u2009ng/mL compared to Fc\u03b5RI\u03b1loCD49bhi BMBAs in flow cytometric analysis and higher Itga2 (encoding CD49b) expression than did BMBA1 , in which 4811 genes were upregulated in BMBA1 while 571 genes were upregulated in BMBA2/3 and Itga2 (encoding CD49b), respectively, for the use of discriminating two subpopulations of BMBAs in the following experiments. Indeed, the flow cytometric analysis using monoclonal antibodies specific to those proteins demonstrated that Fc\u03b5RI\u03b1hiCD49blo and Fc\u03b5RI\u03b1loCD49bhi BMBAs nearly correspond to CLEC12AhiCD9lo and CLEC12AloCD9hi BMBAs, respectively analysis of cells present in the IL-3 culture of bone marrow cells. Seurat clustering analysis of scRNA-seq data sets identified 11 clusters of cells and 2 clusters of Clec12alo basophils (Baso2 and Baso3) were abundant in the bone marrow and much fewer in the spleen Fig.\u00a0. Consisteen Fig.\u00a0. In lineion Fig.\u00a0.26 (GEO accession number: GSE140802) and identified 1 cluster of Fcer1a+Kit+Cd34+ pre-BMP-like cells, 2 clusters of Clec12ahi basophils (Baso1 and Baso2) and 3 clusters of Clec12alo basophils enrichment analysis showed that GO terms associated with cell proliferation, such as \u201cnuclear division\u201d, \u201cchromosome segregation\u201d, and \u201cDNA replication\u201d were enriched in CLEC12Ails Fig.\u00a0, in accolo mature basophils showed higher levels of CD63 expression (an indicator of degranulation) and IL-4 production than did CLEC12Ahi pre-basophils is a widely studied helminth in mouse models of human hookworm infection. They enter host animals through the skin and migrate to the lungs and finally to the intestine. After worms have passed through the lungs, basophils accumulate in the lungs and\u00a0are crucial for the suppression of exaggerated lung inflammation and repair of damaged lung tissue28. On day 7 post Nb-infection, we detected CLEC12Ahi pre-basophils, in addition to CLEC12Alo mature basophils, in the spleen, blood and even lungs in mice resulted in the appearance of CLEC12Ahi pre-basophils in the peripheral blood and upstream of CLEC12AloCD9hi mature basophils in mice. The transcriptomic analysis predicted that the pre-basophil population include previously-defined basophil-progenitor (BaP)-like cells in terms of the gene expression profile.Advancements of scRNA-seq technology have enabled us to understand the differentiation trajectory of various hematopoietic cell lineages and revisited the classical view of hematopoietic cell differentiation. In the present study, we took advantage of this technology combined with flow cytometric and functional analyses and succeeded in the identification of CLEC12A33. Besides the proliferative capacity, pre-basophils were found to display immune responsiveness distinct from that of mature basophils. As expected from their location at the earlier differentiation stage, pre-basophils were less activated in response to IgE-mediated stimulation than did mature ones, even though they express higher levels of Fc\u03b5RI on the cell surface. Intriguingly, however, pre-basophils responded more vigorously than mature ones to IgE-independent stimulation such as IL-3 and IL-33 in terms of IL-4 secretion. Of note, pre-basophils accumulating in the Nb-infected lungs showed IL-4 expression comparable to that of mature basophils, suggesting their possible contribution to Th2 immunity against Nb infection. The transcriptomic analysis in the present study identified that IL-3-stimulated pre-basophils display higher expression of Il13 and Il10 compared to mature basophils. Considering that IL-10 and IL-13 dampen tissue damage in the lungs during Nb infection35, pre-basophils may exert regulatory functions in Nb-infected tissues. Interestingly, Rodriguez Gomez et al. reported the emergence of Fc\u03b5RI++ basophils in the spleen of colitis model mice where Fc\u03b5RI++ basophils produced significantly higher amounts of IL-4 and IL-6 in response to IL-3 than did Fc\u03b5RI+ basophils36. These characteristics of Fc\u03b5RI++ basophils are consistent with those of pre-basophils identified in the present study. Basophil-derived IL-4 and IL-6 were shown to dampen inflammation in the colon36, suggesting the possible contribution of Fc\u03b5RI++ pre-basophils to the regulation of colitis.We found that pre-basophils in the bone marrow are highly proliferative in contrast to mature basophils. This is also the case in pre-basophils accumulating in Nb-infected peripheral tissues. Even though the frequency of pre-basophils is much less than that of mature ones in the infected tissues, we assume that their proliferation and differentiation to mature basophils as well as their continuous accumulation in the infected tissues enable the efficient expansion of basophils for the protection against parasitic infection, as in the case of bacterial infections that induce the emergence of immature neutrophils in peripheral tissues37. Under homeostatic conditions, CXCL12-expressing stromal cells retain CXCR4-expressing neutrophils in the bone marrow whereas inflammatory cues such as G-CSF promote the egress of neutrophils, including immature ones, by down-regulating the surface expression of CXCR4, leading to the emergence of immature neutrophils in the circulation37. Although CXCR4 on basophils has been reported to be involved in the migration toward the inflamed skin and secondary lymphoid organs39, its function in the basophil egress from the bone marrow remained unexplored. In the present study, we demonstrated that the inhibition of CXCR4 by AMD3100 promotes the egress of pre-basophils from the bone marrow. Furthermore, the ex vivo stimulation with IL-3 reduced the expression of CXCR4 on pre-basophils, suggesting the possibility that the systemic upregulation of IL-3 leads to the egress of pre-basophils from the bone marrow. A similar mechanism may operate during Nb infection to promote the emergence of pre-basophils in peripheral tissues.The interaction of CXCR4 and its ligand CXCL12 regulates the physiological distribution of HSCs and neutrophils-CLEC12Ahi pre-basophils that are located downstream of pre-BMPs and upstream of mature basophils in the basophil ontogeny. Pre-basophils display the proliferative capacity and activation property distinct from those of mature basophils. While pre-basophils are retained in the bone marrow under homeostatic conditions, they appear in peripheral tissues during helminth infection and display proliferative and activating properties. Taken together, the present study identified pre-basophils that bridge the gap between pre-BMPs and mature basophils along the basophil differentiation pathway in mice. Human basophils have been shown to express CLEC12A40 and therefore further studies are warranted to identify the human counterpart of mouse pre-basophils.In conclusion, we identified c-KitMcpt8GFP transgenic C57BL/6 mice (B6-Tg(Mcpt8-GFP)HKar) were developed in our laboratory4. IL-4 reporter G4 (Il4GFP/+) C57BL/6 mice (B6.129P2-Il4tm1.1Wep) were provided by Dr William E Paul41. CD45.1 congenic C57BL/6 mice (B6.SJL-PtprcaPepcb/BoyJ) were purchased from the Jackson Laboratory. In most of the experiments except for Supplementary Fig.\u00a02 Inhalation. All animal studies were approved by the Institutional Animal Care and Use Committee of Tokyo Medical and Dental University (No. A2022-023C).C57BL/6\u2009J (C57BL/6\u2009JmsSlc) and BALB/c (BALB/cCrSlc) mice were purchased from Japan SLC. The following antibodies were purchased from BioLegend: biotinylated anti-B220 , anti-CD3\u03b5 , anti-CD4 , anti-CD8a , anti-CD19 , anti-CD49b , anti-Gr-1 , and anti-TER-119 ; FITC-conjugated anti-CD49b , anti-Fc\u03b5RI\u03b1 , and anti-CD45 ; Alexa Fluor 488-conjugated anti-CD45.2 ; PE-conjugated anti-CD34 , anti-CD63 , anti-CLEC12A , anti-CXCR4 , rat IgG2a, \u03ba Isotype Ctrl and rat IgG2b,\u03ba Isotype Ctrl ; PE-Cy7-conjugated anti-CD49b and anti-CD200R3 ; APC-conjugated anti-CD200R3 , anti-Sca-1 and anti-CLEC12A ; APC/Cy7-conjugated anti-CD16/32 ; APC/Fire750-conjugated anti-CD9 ; Pacific Blue-conjugated anti-c-Kit and anti-CD45.1 ; BV421-conjugated anti-CD34 and anti-CD45 ; BV510-conjugated anti-Fc\u03b5RI\u03b1 ; BV605-conjugated anti-c-Kit ; BV711-conjugated anti-CXCR4 ; BV786-conjugated anti-IL-7R\u03b1 ; PerCP/Cy5.5-conjugated anti-TER119 . BD OptiBuild BV711-conjugated anti-CD49b was purchased from BD Biosciences. FITC-conjugated Streptavidin was purchased from Thermo Fisher Scientific. TNP-specific IgE antibody was prepared in our laboratory.Cell culture was performed in complete RPMI supplemented with 10% FBS (Sigma), 2mM L-glutamine , 1\u2009mM sodium pyruvate , 0.055\u2009mM 2-mercaptoethanol (Gibco), 100\u2009U/mL penicillin/streptomycin , and 0.1\u2009mM MEM non-essential amino acids solution ). Bone marrow-derived basophils (BMBAs) were generated by culturing bone marrow cells in the presence of varying concentrations of mouse IL-3 (0\u2013100\u2009ng/mL: BioLegend) for 7 d. For most of the experiments except for Supplementary Fig.\u00a0Single cell suspensions were prepared from the bone marrow and spleen, followed by red blood cell (RBC) lysis by using RBC Lysis Buffer (BioLegend) for 5\u2009min. For the flow cytometric analysis of peripheral blood, leukocytes from the heparinized blood sample were isolated from the interphase of 25% and 65% Percoll PLUS (cytiva) after gradient centrifugation. For the flow cytometric analysis of lung and skin samples, tissues were minced by razors and dissociated by using gentleMACS dissociator (Miltenyi Biotec) and Lung Dissociation Kit or Multi Tissue Dissociation Kit 1 . Cells were stained with the indicated antibodies after treatment with normal rat serum (Merck Millipore) and TrueStain FcX PLUS to prevent non-specific binding. Stained cells were analyzed with FACSLyric (BD Biosciences) and FlowJo software ver 10.8.1 (BD Biosciences) or sorted with FACS AriaIII (BD Biosciences). For ex vivo EdU uptake assay, cells collected from the bone marrow or lung were cultured for 2\u2009h with 10 \u03bcM EdU (5-ethynyl-2\u2032-deoxyuridine). After culture, EdU staining was performed by using Click-iT Plus EdU flow cytometry assay kits according to the manufacturer\u2019s protocol.Cytospin samples of sort-purified basophils were stained with May-Gr\u00fcnwald and Giemsa stain .Mcpt8GFP transgenic mice and depleted of lineage-positive cells by using biotinylated lineage antibodies and EasySep Mouse Streptavidin RapidSpheres Isolation Kit . GFP-positive cells were sort-purified from lineage-negative cells. Basophils isolated from 5 mice were pooled to generate scRNA-seq data. For scRNA-seq in Fig.\u00a0+cKit- cells by cell sorting. Basophils isolated from 5 mice were pooled to generate scRNA-seq data.For scRNA-seq in Fig.\u00a042 for cDNA and hashtag library amplification. Briefly, BD Rhapsody beads were subjected to TdT and RNase H reactions, followed by second-strand synthesis and 1st round of whole-transcriptome amplification (WTA). cDNA product was purified by 0.65\u00d7 AmPure XP beads , and Hashtag product was isolated from unbounded fraction by adding additional 0.7\u00d7 AmPure XP beads . cDNA and hashtag libraries were then subjected to 2nd round of WTA and 2nd round of hashtag-amplification, respectively, followed by purification by AmPure XP beads. Illumina cDNA libraries were constructed from amplified cDNA libraries by using NEBNext Ultra II FS library prep kit for Illumina .Single cell suspensions were reacted with 2.5\u2009\u03bcg/mL of Totalseq anti-mouse Hashtag-A antibodies [BioLegend, clone: M1/42, 30-F11, dilution 1:400; Hashtag antibody A0301 , A0302 , and A0306 are used for scRNA-seq in Fig.\u00a043 in R software 3.6.3, gene expression libraries were aligned to mouse Ensemble RNA by Bowtie2-2.4.244, and count matrices were generated using the modified python script of BD Rhapsody workflow. Valid cell barcodes were identified as cell barcodes above the inflection threshold of knee-plot of total read counts of each cell barcode identified by the DropletUtils package45. Each sample origin and doublets were identified based on fold-change of the normalized read counts of Hashtag antibodies. To subtract the background read counts of each gene caused by RNA diffusion during the lysis step within the BD Rhapsody cartridge and reverse transcription, distribution-based error correction (DBEC) was performed42. The resultant dataset was mainly analyzed using R software package Seurat v4.0.446 in R 4.1.0. As quality control, doublets were filtered out. The log-normalized gene counts were calculated using NormalizeData function and highly variable genes were defined by FindVariableFeatures function . To mitigate the effect of cell cycle heterogeneity and the difference in read counts, cell cycle scores were calculated using CellCycleScoring function. Read counts and the difference between the G2M and S phase scores were regressed out by the ScaleData function. Principal component analysis was performed on the variable genes, and principal components with their p value\u2009<\u20090.05 calculated by the jackstraw method, were subjected to cell clustering with an Illumina Novaseq 6000 S4 Reagent Kit v1.0 (200 cycles) or NovaSeq 6000 S4 Reagent Kit v1.5 (200 cycles) (read1 67 base-pair and read2 155 base-pair) . Pair-end Fastq files of TAS-Seq and BD WTA kit data were processed as follows. After adapter removal and quality filtering by Cutadapt-2.1051. In bulk RNA-seq analysis in Supplementary Fig.\u00a042. In Fig.\u00a051. In Supplementary Fig.\u00a051. Sequencing was performed by using an Ion Hi-Q Chef kit , an Ion PI v3 Chip kit , and an Ion Proton Sequencer (Thermo Fisher Scientific) according to the manufacturer\u2019s instructions.In bulk RNA-seq analysis in Fig.\u00a052. GO enrichment analysis was performed by the R software package clusterProfiler v4.0.547.Adapter trimming and quality filtering of sequencing data were performed by using Cutadpat-v3.4. The filtered reads were mapped to reference RNA (GRCm38 release-101) using Bowtie2-2.4.2, and read number of each gene were counted. Normalization of count data and DE analyses were performed by utilizing the R software package TCC v.1.32.04 cells) sort-purified from the bone marrow of CD45.2+ C57BL/6\u2009J wild-type mice, together with unsorted CD45.1+ BM cells (0.3\u2009\u00d7\u2009106 cells), were intravenously injected into 9-Gy X-ray irradiated CD45.1 congenic mice. One day later, the bone marrow cells were isolated and subjected to flow cytometric analysis. In this experiment, CD34+ cells were not excluded from CLEC12Ahi basophils.Pre-basophils and mature basophils or control PBS. Single cell suspensions were prepared from the spleen, and peripheral blood 1\u2009h after treatment and subjected to flow-cytometric analysis.For the treatment of IL-3 complexes, 10\u2009\u03bcg of recombinant IL-3 (BioLegend) was mixed with 5\u2009\u03bcg of anti-IL-3 antibody to form an IL-3 complexNippostrongylus brasiliensis (Nb). For the primary Nb infection model, mice were injected with 500 L3 in the tail base, and the infected lungs, spleen, bone marrow, and peripheral blood were collected at 3, 5 or 7 days-post infection. For the secondary Nb infection model, infected mice were injected with 500 L3 in the flank 18 days after the first infection. Two days after the secondary Nb infection, the bone marrow and skin at the inoculation site were harvested.Mice were subcutaneously infected once or twice with third-stage larvae (L3) of 4 cells) were separately cultured for 1 or 2 days in the absence of IL-3, followed by flow cytometric analysis. In Fig.\u00a04 cells) were incubated with TNP-conjugated ovalbumin (TNP-OVA: 10\u2009ng/mL) or control OVA (10\u2009ng/mL) at 37\u2009\u00b0C for 1\u2009h or 6\u2009h. In Fig.\u00a04 cells) were isolated from the bone marrow of non-sensitized mice and stimulated with the following reagents at 37\u2009\u00b0C for 6\u2009h: IL-3 (BioLegend: 10\u2009ng/mL), IL-18 (BioLegend: 10\u2009ng/mL), IL-33 (BioLegend: 10\u2009ng/mL), LPS (Sigma: 100\u2009ng/mL). The concentration of IL-4 in culture supernatants was measured by using ELISA MAX Standard Set Mouse IL-4 .For ex vivo cell culture experiments in Fig.\u00a0t test. Comparisons among multiple groups were performed using one-way or two-way analysis of variance (ANOVA) with post hoc Tukey\u2019s HSD test. A P value\u2009<\u20090.05 was considered statistically significant.Statistical analyses were conducted by using GraphPad Prism (ver 7.0.3) or R software (ver 4.1.0). Results were displayed as means\u2009\u00b1\u2009SEM. Comparisons between two groups were performed using unpaired Student\u2019s Further information on research design is available in the\u00a0Supplementary InformationPeer Review FileReporting Summary"} +{"text": "Patients in psychotic relapse may exhibit violent behavior towards objects, themselves or others. These behaviors, although usually unconscious, are a common reason for hospitalization and a source of rejection and stigmatization by family and society.The objective of this study was to evaluate the presence of aggressive behavior in relapsed inpatients with schizophrenia in the F psychiatry department at the Razi Hospital in Tunisia.This was a descriptive, cross-sectional study of fifty male patients hospitalized for a psychotic relapse who were na\u00efve or discontinuing treatment for at least two months. Patients were assessed using a semi-structured questionnaire and the Overt Aggression Scale (OAS).The age of the patients included ranged from 17 to 65 years, with an average of 36.4\u00b111.51 years. More than half of the patients were without occupation . For personnal history : Seven patients (14%) had attempted suicide ; Eight patients (16%) showed evidence of self-harm ; Thirteen patients (26%) had a history of arrests of which eleven (22%) were incarcerated.The OAS score ranged from to 0 to 35 with a mean at 9.7+/- 10.3. Twenty-seven patients were aggressive (54%).Preventive strategies should focus more on predicting the aggressive potential of patients with schizophrenia and its socio-professional implication. Perhaps when using a less holistic approach to the disease and when approaching aggressive behavior as a symptom in its own right, we will be able to find other alternative options.None Declared"} +{"text": "Archery exercise exerts a rehabilitative effect on patients with paraplegia and might potentially serve as complementary physiotherapy for patients with Parkinson's disease. This study aimed to examine the rehabilitative effects of an archery intervention. A randomized controlled trial of a 12-week intervention was performed in patients with idiopathic Parkinson's disease. Thirty-one of the 39 eligible patients recruited from a medical center in Taiwan participated in the trial, of whom 16 were in the experimental group practicing archery exercises and 15 were in the control group at the beginning; twenty-nine completed the whole process. The Purdue pegboard test (PPT), the Unified Parkinson's Disease Rating Scale I to III (UPDRS I to III), physical fitness test, and timed up and go test (TUG) were used to assess the intervention effects of archery exercise. U tests were medium to large, indicating that the archery intervention exerted promising effects on improving hand flexibility and finger dexterity, activity functions in motor movement, lower extremity muscular strength, and gait and balance ability. Compared to the control group, the outcome differences between the posthoc and baseline tests in PPT, UPDRS I to III, lower extremity muscular strength, and TUG in the experimental group did show positive changes and their effect sizes examined from Mann\u2013Whitney Traditional archery exercise was suggested to have a rehabilitative effect for mild to moderate Parkinson's disease and could be a form of physiotherapy. Nevertheless, studies with larger sample sizes and extended intervention periods are needed to ascertain the long-term effects of archery exercise. Parkinson's disease (PD) is the second most prevalent neurodegenerative disorder after Alzheimer's disease, and its onset often occurs in the elderly. The estimated global burden of PD has increased from 2.5\u2009million in 1990 to 6.1\u2009million in 2016 and 9.4\u2009million in 2020, and the age-standardized prevalence rates have increased by 21.7% . The symMotor symptoms affect the functional mobility, balance, and gait of patients with PD, which affect many activities of daily living. Pharmacological and neurosurgical treatment of PD may not exert optimal effects on reversing the deteriorating extremity function and mobility of patients with PD , 5; moreThe use of complementary and alternative medicine and physiotherapy has been recommended as adjuvant strategies to improve motor function, functional mobility, and balance. Tremor and impaired finger dexterity are recognized as early symptoms in patients with PD, and reductions in their amplitude and/or frequency are treatment targets. However, whether complementary approaches are beneficial for improving PD functions is still a highly debated issue , and aloIn addition to the usual exercise interventions described above, Qigong , 30, TaiArchery is a static sport with a stable sequence of movements throughout the shot. The movements include standing in a proper position with postural stability, pushing the bow, drawing the bow string with a three-finger hook, sighting the target, relaxing the flexor group muscles of the forearm, and actively contracting the extensors to release the arrow \u201340. An aA randomized controlled trial of a 12-week archery training course was designed to improve the impairments associated with Parkinson's disease (PD). The clinical diagnosis of PD was based on the UK Brain Bank Criteria and deten\u2009=\u200920) and the control group (n\u2009=\u200919). During the pretest task for collecting baseline data, four of the participants in each group withdrew. During and after the 12-week course, one participant in the archery exercise intervention group withdrew and one participant in the control group was unable to complete the post-test task. After receiving approval from the Research Ethics Committee of China Medical University and Hospital (CRREC-106-083 AR-1), we started this study on December 7, 2017. Initially, 59 volunteers were recruited; and among the volunteers, 16 were unable to fully participate in the trial, and one already participated in another study. Therefore, 39 participants provided written informed consent, and a random assignment approach was then applied to allocate them into the experimental group , advanced shooting (2nd stage), and integrative practice (3rd) were arranged in the first three weeks, the next four weeks, and the final five weeks, respectively. Each archery practice lasted for two hours and was held once a week in the Student Activity Center of the China Medical University next to its affiliated hospital. Before starting the archery practices, sitting posture exercises for warming up and stretching the upper extremities and finger skeletal muscles using elastic bands were led by coaches for approximately 15\u2009minutes. For participant safety, a physical therapist was assigned to accompany them and observe their ongoing activities to avoid injury. Each participant was provided an elastic band and encouraged to practice the upper extremity and finger stretching actions at home to improve their archery skills. A telephone interview was conducted once a month to provide care and support to participants.Participants in the control group received standard care. The care included a face-to-face personal interview educating them on how to stretch the upper extremities (UE) and finger skeletal muscles and self-care in daily living activities by delivering a pamphlet.The primary outcome measure was tests of UE impairment and activity using the Purdue pegboard test (PPT). The test involves two abilities: gross movements of arms, hands, and fingers and fine motor extremity ability, through which finger dexterity and arm and hand coordination are assessed. Participants were asked to place as many pegs as they can and the number was recorded when time elapsed. The related information on PPT and its execution could be reached in elsewhere \u201345. The U test was used to compare the continuous variables' distributions. The Wilcoxon signed-rank test and Mann\u2013Whitney U test were used to examine the differences between the post-test and pretest in the outcome measures within and between groups, respectively. The effect size statistic was also provided, where a value less than 0.3 indicates a small effect, 0.3 to 0.5 indicates a medium effect, and greater than 0.5 indicates a large effect [The statistical analyses in this study were conducted using SPSS 25.0 for Windows. The chi-square and Fisher's exact tests were used to compare the discrete variables' distributions between the experimental and control groups; the Mann\u2013Whitney e effect .At baseline (before implementing the archery intervention), equal distributions of sociodemographic characteristics and factors that may be associated with PD progression were observed between the experimental and control groups . The mea\u03b7 values were greater than 0.5, showing large effects . The mean values of the differences in the secondary outcomes, namely, UPDRS I to III, extremity flexibility (upper and lower), lower extremity muscular strength, cardio endurance, and TUG test, also showed significant positive improvements with large effects. All differences in outcomes between the post-test and baseline within the control group were insignificant, although most of the differences suggested that their corresponding functions tended to regress. Significant differences with medium to large effects in the differences between the post-test and baseline in the outcomes of PPT, UPDRS I to III, lower extremity muscle strength, and TUG tests between the experimental and control groups were observed , suggesting that the archery intervention exerted promising effects on improving hand flexibility and finger dexterity, activity functions in motor movement, lower extremity muscular strength, and gait and balance abilities.During the intervention, two subjects discontinued participation, and finally, 15 subjects in the experimental group and 14 subjects in the control group completed the post-test outcomes. The potential effects of this archery intervention on improving the physical functions of participants with PD are shown in U tests to obtain more information on the effects of this archery intervention on each secondary outcome assessed using the UPDRS subscales (I to III). As shown in P=0.022) from the increased depression score (mean\u2009\u00b1\u2009SD: 0.11\u2009\u00b1\u20091.72) of the control group, and the effect size was medium (\u03b7\u2009=\u20090.426). Among UPDRS II items, the severity in the function of handwriting was significantly decreased to a greater extent in the experimental group (mean\u2009\u00b1\u2009SD: \u22120.43\u2009\u00b1\u20090.70) than in the control group (mean\u2009\u00b1\u2009SD: \u22120.07\u2009\u00b1\u20090.48) (P=0.045), and the effect size was medium (\u03b7\u2009=\u20090.372); improvements in the functions of turning in bed and facial expressions were observed in the experimental group, but the functions in the control group were worse; both between-group differences were significant , where the effect size for turning in bed was large (\u03b7\u2009=\u20090.551) and for facial expression was medium (\u03b7\u2009=\u20090.388). Among the UPDRS III items, the severity of right upper extremity, finger taps of the left hand, and left leg agility were significantly decreased in the experimental group but increased in the control group, and these between-group differences were significant . The results also found a large effect for left leg agility (\u03b7\u2009=\u20090.584) and medium effects for the right upper extremity (\u03b7\u2009=\u20090.396) and for the left-hand finger taps (\u03b7\u2009=\u20090.414).The between-group differences in the outcomes between the post-test and baseline were analyzed using Mann\u2013Whitney During the archery intervention, no adverse events occurred, indicating that performing archery exercise while in a sitting posture is a safe intervention for patients with Parkinson's disease. Based on the results of the present study, archery exercise exerted a positive effect in improving several motor functions of patients with mild to moderate PD. One of the study strengths is the randomized controlled design and stratification of patients by PD disease stage (Hoehn and Yahr stages 1 to 4) to control for the confounding effects of unequal distribution of disease severity between the experimental and control groups on the intervention outcomes. The results in Tables Archery was one of the first sports introduced in the medical treatment of paraplegics and tetraplegics and was documented to be an ideal remedial exercise for training muscle groups of the arm, shoulder, and trunk muscles mainly used in archery . To our The electrical activity of the muscle groups involved in the archery exercise was monitored using electromyography in an experimental study and reveAs patients with PD expressed many ambitions in pursuing success in shooting at the target point while performing the archery intervention in our study, this 12-week intervention of practicing archery actions along with using elastic bands to repeatedly activate their fingers, arm, trunk, and leg muscles helped patients with PD alleviate their symptoms, stabilize their gait and balance, and improve their extremity functions. These improvements were documented in the results of the present study, in which significantly greater differences in the post- and pretest numbers of placed nails (the changes of the primary outcomes of the three PPT tests) were observed between the experimental group and the control group see , indicatThe differences in outcomes indicated a significant increase in the lower extremity muscle strength, as assessed using physical fitness tests, and a significant decrease in the time required to complete the TUG test before and after the test in the experimental group compared to those in the control group see , which aIn the archery intervention, the use of an elastic band at home by the PD participants to practice the actions involved in the archery classes may have a potential influence on the positive effects of this archery intervention. With the advantage of using a random clinical trial design, this study suggested that traditional archery exercise exerts positive effects on ameliorating a depressed mood and improving the motor functions of arms, hands, and legs and finger dexterity in patients with PD, such as hand writing, turning in bed, decreased rigidity of the right upper extremity, tapping movement of the left fingers, and agility of the left leg in particular. The strength of leg muscles and the gait and balance were also significantly improved. Nevertheless, due to the small number of eligible participants with PD and the short period of intervention (3\u2009months) in this study, these conclusions should be interpreted with caution. Further studies using an RCT design that recruit more participants are needed to achieve sufficient statistical power, and the time of the intervention should be increased to ascertain the long-term effects of the traditional archery exercise." \ No newline at end of file