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[ "venous thromboembolism ( vte ) comprising of deep vein thrombosis ( dvt ) and pulmonary embolism ( pe ) can result in significant mortality , morbidity , and healthcare expenditure .", "approximately , one - third of patients with symptomatic vte manifests pe , whereas two - thirds manifest dvt alone .", "both dvt and pe can be clinically silent ( asymptomatic ) and hence not suspected .", "if undiagnosed , asymptomatic vte can lead to chronic venous disease or recurrent vte and long - term debilitating sequelae such as postthrombotic syndrome and chronic thromboembolic pulmonary hypertension .", "vte is not only disabling but also prolongs hospital stay and increases the cost of treatment .", "along with myocardial infarction and arrhythmia ( due to electrolyte imbalance ) , pe is one of the commonest causes of sudden unexplained deaths in hospitalized patients .", "it is estimated that 20 million cases of lower extremity dvt occur in the usa alone .", "the prevailing notion that the incidence of vte in asians is less than that in the western population has been disproved by recent studies .", "the incidence of postoperative dvt in indian patients undergoing major lower limb surgery is as high ( 43.2% and 60% patients in the groups with and without prophylaxis , respectively ) as seen in the western world .", "given the growing burden of vte in india and lack of substantial indian data on characteristics of vte patients , use of diagnostics tools , prophylaxis , treatment options , and clinical outcomes in vte , there was a need to systematically collect such data .", "data on patient characteristics , clinical outcomes , predictors of mortality in acute dvt , management strategies and temporal trends in vte .", "the intent was to collect and provide data that would reflect actual day - to - day clinical practice , rather than results of highly controlled clinical trials with restricted study populations and imposed experimental intervention .", "consecutive medical records of inpatients and outpatients between january 2006 and december 2010 , meeting eligibility criteria ( confirmed diagnosis of acute or acute - on - chronic dvt by doppler ultrasound scan and/or pe by chest computed tomography scan , pulmonary angiography or v / q scan ) were identified and collected from the general medical records and/or radiology departments at each of the three participating hospitals .", "hospital data were used to obtain the total number of patients who were annually registered at the hospital from 2006 to 2010 .", "data were processed and analyzed using sas ( version 9.1 , statistical analysis system ) .", "for the purpose of analysis , acute - on - chronic descriptive statistics were used to present patient characteristics , management strategies , and clinical outcomes of patients .", "annual incidence rates ( 95% ci ) of vte per 100,000 hospital registrations over a period of 5 years were reported for each site .", "fisher 's exact test was used to determine differences in the incidence of acute dvt ( pe ) over the years 20062010 .", "armitage trend test was used to examine the direction ( positive or negative ) of the trend .", "as primary analyses the remaining 41% ( 393/949 ) medical records were not included because they did not satisfy the inclusion criteria .", "data from seven patients were excluded as there was no radiologically confirmed diagnosis of pe .", "a total of 64% ( 352/549 ) patients had acute dvt without pe , 23% ( 124/549 ) had acute dvt with pe , and 13% ( 73/549 ) had pe .", "eighty - seven percent ( 476/549 ) of patients had acute dvt ( pe ) , and 36% ( 197/549 ) had pe ( acute dvt ) [ figure 1 ] .", "overall distribution of venous thromboembolism patients ( n = 549 ) a total of 21% ( 115/549 ) of patients visited the hospitals directly without being referred by a physician .", "venous thromboembolism patients referred from different medical specialties ( n=434 ) the demographic characteristics of the vte patients are mentioned in table 2 .", "demographic characteristics of venous thromboembolism patients ( n=549 ) a total of 182 patients had evidence of one risk factor , 126 had evidence of two risk factors , 70 had evidence of three risk factors and 31 had four or more risk factors recorded .", "patients undergoing orthopedic surgery constituted 22% ( 33/152 ) of all surgical patients [ table 3 ] .", "risk factors for venous thromboembolism based on a review of the available records , 157 patients had a single co - morbidity , 81 had two co - morbidities , 23 had three co - morbidities , and 16 had four or more co - morbidities .", "( myocardial infarction , heart failure , chronic obstructive pulmonary disease , ventilator dependency , sepsis , or pneumonia ) [ table 4 ] .", "co - morbidities in venous thromboembolism patients of the 476 patients with dvt , 2% ( 9 ) had upper extremity dvt , 97% ( 462 ) had lower extremity dvt and the site of dvt was not known in 5 patients .", "a total of 31% ( 143/462 ) patients had dvt in the right limb , 54% ( 249/462 ) in the left limb and 9% ( 41/462 ) in both limbs ( site not known in 29 patients ) .", "of the 462 patients with lower extremity dvt , 61% had proximal dvt , 13% had distal dvt , and 7% had proximal and distal dvt .", "a total of 39% ( 215/549 ) patients were diagnosed with vte during their hospital stay , 54% ( 296/549 ) were admitted to hospital with a diagnosis of vte , and 7% ( 38/549 ) were diagnosed and continued to be managed in the outpatient department [ figure 2 ] .", "place of detection of venous thromboembolism ( n = 549 ) duration of hospitalization after diagnosis of venous thromboembolism a smaller proportion of patients ( 15% ; 81/549 ) was diagnosed with vte during the postoperative period .", "figure 3 shows the proportion of patients with vte at different time points during the postoperative period .", "of those diagnosed beyond 6 weeks , 21% ( 3/14 ) had orthopedic surgery ( hip fracture surgery ) .", "diagnosis of venous thromboembolism during the postoperative period ( n = 81 ) the most common ( 73% ) symptom was swelling of the limb among patients with vte [ table 6 ] .", "symptoms in venous thromboembolism patients in merely 4% of all the patients , dvt was also confirmed by venography .", "pe was confirmed by pulmonary angiography in 27% of all the patients [ table 7 ] ..", "heparin ( low molecular weight heparin [ lmwh]/unfractionated heparin [ ufh ] ) alone , a combination of heparin ( lmwh / ufh ) and oral anticoagulant ( warfarin ) , and fondaparinux sodium alone were recommended to 82% ( 420/515 ) , 13% ( 66/515 ) , and 2% ( 12/515 ) patients , respectively as initial anticoagulation .", "five percent ( 25/515 ) of patients were recommended lmwh alone , and 76% ( 393/515 ) were recommended either warfarin or acenocoumarol alone for long - term anticoagulation .", "the median duration of initial anticoagulation was 5 days while that of long - term anticoagulation was 180 days ( 6 months ) .", "anticoagulants were needed to be stopped because of bleeding in only 2% ( 9/515 ) patients .", "clinical outcomes in patients diagnosed with venous thromboembolism during hospital stay clinical outcomes in patients admitted to hospital with a diagnosis of venous thromboembolism the annual incidence of acute dvt ( pe ) increased from 2006 to 2010 at all the three sites [ figure 4 ] .", "however , a formal site - wise statistical analysis could not be performed to analyse trends in the incidence rates in acute dvt ( pe ) and pe alone as there were zero observations in some instances .", "incidence of acute deep vein thrombosis ( with or without pulmonary embolism ) over a 5 years period ( 20062010 ) at three sites demographic characteristics of venous thromboembolism patients ( n=549 ) a total of 182 patients had evidence of one risk factor , 126 had evidence of two risk factors , 70 had evidence of three risk factors and 31 had four or more risk factors recorded .", "2% ( 9 ) had upper extremity dvt , 97% ( 462 ) had lower extremity dvt and the site of dvt was not known in 5 patients .", "of those diagnosed beyond 6 weeks diagnosis of venous thromboembolism during the postoperative period ( n = 81 ) the most common ( 73% ) symptom was swelling of the limb among patients with vte [ table 6 ] .", "a total of 182 patients had evidence of one risk factor , 126 had evidence of two risk factors , 70 had evidence of three risk factors and 31 had four or more risk factors recorded .", "based on a review of the available records , 157 patients had a single co - morbidity , 81 had two co - morbidities , 23 had three co - morbidities , and 16 had four or more co - morbidities .", "of the 476 patients with dvt , 2% ( 9 ) had upper extremity dvt , 97% ( 462 ) had lower extremity dvt and the site of dvt was not known in 5 patients .", "of those diagnosed beyond 6 weeks diagnosis of venous thromboembolism during the postoperative period ( n = 81 ) the most common ( 73% ) symptom was swelling of the limb among patients with vte [ table 6 ] pe was confirmed by pulmonary angiography in 27% of all the patients [ table 7 ] .", "incidence of acute deep vein thrombosis ( with or without pulmonary embolism ) over a 5 years period ( 20062010 ) at three sites pe was confirmed by pulmonary angiography in 27% of all the patients [ table 7 ] .", "incidence of acute deep vein thrombosis ( with or without pulmonary embolism ) over a 5 years period ( 20062010 ) at three sites to our knowledge , this is the first multicenter , retrospective registry in india involving patients with vte that reflect real - world clinical practice .", "in contrast with the western data in which vte is predominantly a disease of older age , 44% patients in our study were between 40 and 59 years of age while 34% were below 40 years , particularly those with pe .", "in a study from north india , men constituted 70% of our registry , more than those reported from vellore registry ( 48% ) , but similar to those reported in the endorse ( epidemiologic international day for the evaluation of patients at risk for vte in the acute hospital care setting ) study ( 69% ) .", "one of the reasons for this could be significantly high levels of homocysteine ( thrombophilia marker ) in males as compared to females as reported in an indian study .", "fewer indian women use oral contraceptives and postmenopausal hormone replacement therapy , which are known to be risk factors for thrombosis .", "this is supported by the fact that only 1% of women in this registry reported the use of oral contraceptives , and none reported use of hormonal replacement therapy .", "a total of 28% of the overall referrals were from cardiologists .", "the majority ( 82% ) of the referrals were from medical rather than surgical ( 15% ) specialties as against a referral rate of 93% from surgeons at vellore .", "our finding complements that from the endorse study in which 55% of the medical patients at risk of vte had cardiovascular disease .", "majority ( 53% ) of patients in our study had co - morbid cardiovascular disease including diabetes mellitus ; it is possible that these patients visited a cardiologist for their cardiovascular ailment ( s ) and were then referred by the cardiologist to vascular disease specialist ( investigator ) .", "most ( 89% ) of these patients had swelling of the ( lower ) limb .", "it is possible that these patients may not have felt the need to visit a specialist for a symptom like swelling of limb , instead visited their family physician .", "it is very encouraging to know that family physicians suspected dvt in these situations and referred the patient to a specialist .", "patients with a history of vte are about 8 times more likely to develop a new episode during a subsequent high - risk period compared with patients without a history of dvt or pe .", "prior history of dvt was the most ( 34% ) common risk factor in patients who had only dvt , whereas past history of pe , trauma , and immobilization for more than 3 days were the most common risk factors in patients who had only pe .", "our results ( major lower limb surgery as a risk factor in 3% patients ) appear to be consistent with those reported in the endorse study , which reported dvt in 4.4% patients undergoing major lower limb surgery .", "other studies from india have reported a dvt incidence rate ranging from 8% to 20% in major lower limb surgery .", "however , in our study , only 7% of patients had malignancy as a predisposing factor .", "among the malignancies , genitourinary cancer had the highest incidence ( 45% ) .", "hypertension ( 25% ) was the most common co - morbidity followed by diabetes mellitus ( 19% ) in this patient population .", "in addition , obesity ( 11% ) was a common risk factor in dvt complicated by pe .", "our findings support an asian ( korean ) study that demonstrated prevalence of the metabolic syndrome in 48% patients with vte .", "co - morbid neurological disease ( other than stroke ) and ventilator dependency were also commonly found in patients with dvt ( 10% ) and pe ( 11% ) respectively .", "both these conditions immobilize patients for prolonged periods of time , predisposing them to vte .", "venography and pulmonary angiography are the gold standard for diagnosis of dvt and pe respectively .", "in our study , venography was used in just 4% patients and pulmonary angiography in less than one - third of the patients .", "perhaps the relatively high cost of these tests and limited availability of such procedures may be the limiting factors .", "overall , most ( 93% ) patients were managed as inpatients ( 39% diagnosed with vte during hospital stay and 54% admitted to hospital with a diagnosis of vte ) .", "a mean duration of hospitalization of 79 days after diagnosis of vte is supported by published data .", "in selected low - risk patients , outpatient treatment of dvt and pe may be considered .", "this approach was observed in a small proportion ( 7% ) of patients who were managed on an outpatient basis , nearly all ( 97% ) of whom had only dvt .", "the reported prevalence of postsurgical vte in our study ( 15% ) was half of that ( 30% ) reported in vellore registry .", "this could be explained by higher referral rate from surgeons at vellore compared to that of our sites .", "most ( 40% ; 32/81 ) dvt cases were diagnosed between 2 and 6 postoperative weeks , but pe in most cases ( 70% ; 7/10 ) was diagnosed during the first postoperative week .", "we notice that acute dvt complicated by pe was less ( 6% ; 7/124 ) frequently diagnosed during the postoperative period as against 18% ( 64/352 ) and 14% ( 10/73 ) of acute dvt alone and pe alone , respectively .", "the use and duration of anticoagulants in our registry appears to be consistent with the american college of chest physicians treatment guidelines , which recommend at least 5 days of initial anticoagulation with parenteral anticoagulation ( lmwh , fondaparinux , intravenous ufh , or subcutaneous ufh ) and at least 3 months of long - term anticoagulation treatment with vitamin k antagonist .", "bleeding is the most serious complication of anticoagulation treatment and is a major concern for clinicians particularly as the patient 's age advances .", "in this registry , anticoagulant treatment was needed to be stopped because of bleeding in only 2% of the study population .", "the prospective reite registry has reported a rate of 3% for major / fatal bleeds .", "thus , the fear of bleeding complications , which decreases the use of anticoagulant treatment , appears to be minimal .", "dvt complicated by pe ( 60% ) and pe alone ( 75% ) were more frequently shifted to intensive care unit than those who had dvt alone ( 25% ) .", "similar to published data in which hospital readmission rate for vte was 5% for primary and 14% for secondary diagnosis , we report a hospital readmission rate of 6% ; however we do not know the cause for readmission .", "the death rate was 7% among those diagnosed with vte during hospital stay as against a rate of 1% among those who were hospitalized with a diagnosis of vte .", "over 90% of patients treated on an outpatient basis obtained symptomatic relief with treatment .", "in our study , the hospital discharge rate ( 97% ) was more than triple and death rate was a quarter of that reported by pandey et al .", "( hospital discharge rate 31% and death rate 16% ) at a university hospital in delhi .", "our data show a significant increase in acute dvt ( pe ) from 2006 to 2010 .", "this can be explained by the increased awareness of vte in india as well as the advent of better diagnostic modalities , such as duplex ultrasonography becoming more readily available and accepted .", "although there was no significant change in the number of pe cases from 2006 to 2010 , the burden of pe is almost double ( 13% of all vte ) of 7% , rate reported at christian medical college , vellore during a 10-year period from 1996 to 2005 .", "our finding is consistent with a study from north india that reported a 16% incidence of pe in adult medical autopsies .", "this study has the expected limitations of any retrospective review including the availability of complete records for all patients , although a robust review of the data on medical charts was conducted .", "controlling for bias and confounders is difficult as there is no randomization and no blinding .", "follow - up data of patients after hospital discharge were not available .", "in cases of death , further , the clinic charts reviewed in this study included a mix of those from vascular surgery and hematology departments , limiting the generalizability of the study results .", "despite these limitations , this study provides large amount of useful information in a short span of time on patient characteristics , clinical outcomes , management strategies , and temporal trends in vte , based on real world data that reflect actual day - to - day clinical practice over a period of 5 years across three sites in india .", "we believe that this information will serve as a guide in the optimal implementation of vte prophylaxis and treatment , to improve patient outcomes and to decrease the occurrence of vte in india .", "real world data reflecting actual day - to - day clinical practice in vte over a period of 5 years across three sites in india showed that vte is not uncommon in indian patients and that acute dvt was responsible for the substantial burden of vte .", "liesel c. dsilva is and dr .", "sadhna j. joglekar was full - time employee of glaxosmithkline pharmaceuticals limited ." ]

[ "background and aim : there is lack of substantial indian data on venous thromboembolism ( vte ) .", "the aim of this study was to provide real - world information on patient characteristics , management strategies , clinical outcomes , and temporal trends in vte.subjects and methods : multicentre retrospective registry involving 549 medical records of patients with confirmed diagnosis of vte ( deep vein thrombosis [ dvt ] confirmed by doppler ultrasonography ; pulmonary embolism [ pe ] by computed tomography , pulmonary angiography and/or v / q scan ) from 2006 to 2010 at three indian tertiary care hospitals.results:acute dvt without pe , acute dvt with pe , and pe alone were reported in 64% ( 352/549 ) , 23% ( 124/549 ) , and 13% ( 73/549 ) patients , respectively .", "mean age was 47 ( 16 ) years , and 70% were males .", "h / o dvt ( 34% ) , surgery including orthopedic surgery ( 28% ) , trauma ( 16% ) , and immobilization > 3 days ( 14% ) were the most common risk factors for vte .", "hypertension ( 25% ) , diabetes ( 19% ) , and neurological disease ( other than stroke ) ( 8% ) were the most common co - morbidities .", "most ( 94% ) were treated with heparin alone ( 82% ) or fondaparinux ( 2% ) for initial anticoagulation ; low molecular weight heparin alone ( 5% ) or warfarin / acenocoumarol ( 76% ) for long - term anticoagulation .", "anticoagulant treatment was stopped because of bleeding in 2% ( 9/515 ) patients .", "mortality was 7% among patients diagnosed with vte during hospital stay versus 1% in those hospitalized with diagnosed vte .", "the annual incidence of dvt ( pe ) increased from 2006 to 2010.conclusion:acute dvt alone was responsible for the substantial burden of vte in indian patients .", "bleeding was not the limiting factor for anticoagulant treatment in most patients ." ]

[ 9, 10, 12, 21, 39, 40, 43, 45, 51, 53, 67, 72, 90, 109 ]

[ "there is an epidemic of stroke in low and middle - income countries due to rapidly increasing prevalence of vascular risk factors such as hypertension , diabetes mellitus , dyslipidaemia .", "the need has thus arisen to conduct studies aimed at epidemiologic , genetic and phenotypic characterisation of stroke in sub - saharan africa to provide evidence - based information to confront this menace .", "to this end , it is important that controls selected for comparison with cases are recruited with a high degree of certainty that they indeed do not have stroke or tia to allow for valid comparisons to be made .", "in view of this simple , quick and accurate assessment of symptoms of stroke is needed for epidemiologic studies particularly those of the case control type .", "in 2000 , meschia et al .", "developed the questionnaire for verifying stroke - free status ( qvsfs ) as a method for verifying the stroke - free phenotype in participants of clinical , epidemiological and genetic studies .", "having one or more affirmative answers to any of the questionnaire was associated with finding stroke , tia , or either stroke or tia on medical record review .", "jones et al .", "showed by directly interviewing participants and review of medical records that the qvsfs had a nppv and ppv of 0.96 and 0.71 respectively making the 8-item qvsfs a sensitive and valid tool , and a structured telephone interview format of questionnaire administration still had an excellent sensitivity of 1.0 , specificity of 0.86 , positive predictive value of 0.36 and negative predictive value of 1.0 among participants aged 60 years and above .", "the qvsfs is also reliable with intra - rater and inter - rater agreement of stroke - free status classification of 0.90 and 0.94 respectively .", "the qvsfs is easy to administer as a self - report pencil - and - paper questionnaire or by an interview in person or by telephone and has been translated into spanish by castillo et al .", "for use among hispanic populations .", "two questions in the instrument assess previous diagnosis of either stroke / tia together with six questions about stroke symptoms .", "thus not only is the 8-item qvsfs a useful tool in identifying stroke - free individuals but it could be used to screen for undiagnosed stroke .", "the sensitivity and specificity of having any of the six symptom questions for stroke detection was 0.82 and 0.62 respectively .", "indeed the qvsfs has been successfully used in the recruitment of controls involved genetic studies into ischaemic stroke , to screen for cerebrovascular end points in the carotid revascularisation endarterectomy versus stent trial ( crest ) and in the reasons for geographic and racial differences in stroke ( regards ) study .", "this instrument could have tremendous potential in developing countries where stroke prevalence is increasing , awareness of stroke symptoms low and the confirmation of stroke diagnosis either missed by health workers or constrained by the pervasive lack of neuro - imaging modalities .", "in these low literacy settings the lack of knowledge of stroke symptoms might impact negatively on the performance of stroke symptom questionnaires .", "furthermore there is a lack of specific medical terminology for symptoms of stroke in local dialects across sub - saharan africa .", "the performance of the questionnaire could be enhanced further by the introduction of culturally acceptable pictures of stroke symptoms .", "one of the key comments regarding the 8-item qvsfs questionnaire is that the benchmark for verification of strokes has relied on review of medical records of patients but this approach may be problematic in settings where medical records are kept under less than optimal circumstances and where patients may not always seek health services for ailments from medical facilities but from herbalists , chemical shops and so forth .", "an approach to overcome this limitation would be to examine participants by neurologists or to use a cranial ct scan for verification in a subset of participants .", "this study seeks to validate the 8-item qvsfs at 5 centers in nigeria and ghana which are involved in the on - going nih supported stroke investigative research and educational networks ( siren ) study .", "participants will be recruited from five tertiary referral medical centers in west africa namely the komfo anokye teaching hospital ( kath ) in kumasi , ghana ; the university college hospital ( uch ) , ibadan , nigeria ; federal medical centre ( fmc ) , abeokuta , nigeria ; ahmadu bello university hospital ( abuh ) , zaria , nigeria and aminu kano teaching hospital ( akth ) , kano , nigeria ( fig .", "kumasi where kath is situated is the principal city of the akan tribe in central ghana and serves a population of 4 million .", "uch and fmc situated in ibadan and abeokuta respectively are located in southern nigeria and serve a combined population of 4 million nigerians of predominantly yoruba ethnicity .", "abuh and akth in zaria and kano provide health care services to 15 million nigerians of mainly hausa and fulani descent .", "ethical approval for the study will be sought from the ethics committees of the 5 participating sites .", "the original questionnaire developed by meschia et al .", "will be translated into the local languages ( yoruba southern nigeria , hausa northern nigeria , akan middle & lower belts of ghana ) , pre - tested and back - translated into english language to establish semantic equivalence .", "at each of the study sites , a panel comprising of a neurologist , three to five doctors and nurses , and public health practitioners will translate the questionnaire into the local dialect by consensus .", "the translated versions of the questionnaires in 3 languages are shown in supplementary information section ( s1 ) .", "another version of the questionnaire will be developed where question items 3 to 8 will have line pictures of the neurological symptoms being elicited by the interviewer ( fig .", "participants attending general medicine and neurology out - patient clinic appointments will be approached and enrolled into the study after obtaining informed consent .", "baseline demographic details will be obtained and the questionnaire administered by a medicine resident in the local dialect and the answers recorded as yes , no , or do n't know to each question item .", "the version of the questionnaire without pictures will be administered first followed by the version with pictograms by the same interviewer .", "furthermore , participant awareness of known vascular risk factors such as hypertension , diabetes mellitus , dyslipidaemia , cigarette smoking , excessive alcohol intake , physical inactivity , known heart disorders , family history of stroke will be assessed using 8 questions assessing knowledge of the presence of these specific risk factors .", "after the interview participants will undergo a 3-staged evaluation by a neurologist .", "the first stage will involve a review of the medical records of patients to determine if a previous diagnosis of stroke has ever been made , the duration of stroke diagnosis , whether neuro - imaging information on stroke type is available .", "the second stage entails an examination for presence of hemiparesis , hemi - anesthesia , mono - ocular / binocular visual loss , hemianopsia , receptive or expressive aphasia , and cerebellar deficits .", "the third stage will comprise of an evaluation of a cranial ct scan in a subset of participants .", "this neuro - imaging validation will be performed within 48 h among a subset of subjects ( at least 4 stroke and 4 stroke - free ) per site after this thorough evaluation the neurologist makes a diagnosis which is our gold standard .", "assuming that the standard test has an accuracy of 75% as measured by the area under the roc curve ( auc ) , a sample of 35 cases and 35 controls achieve 82% power to detect an extra accuracy by the proposed test of 15% ( auc = 90% in the proposed test ) using a two - sided test at a significance level of 0.05 .", "the sample size required increases to 80 per group in order to detect a difference of 10% ( auc = 85% in the proposed test ) under the same conditions .", "thus , the sample size of 100 per linguistic category ( akan , yoruba , hausa ) will be sufficient detect an effect size as small as 10% allowing up to 10% false positive rates and control to case ratio of the standard deviation of the responses to be 0.5 as suggested by obuchowski and mcclish .", "given that the 8 items qvsfs is going to be translated into three ( yoruba , hausa , chi ) different languages , we will evaluate the reliability of the translation before it is implemented to predict stroke status using a sample size of 50 consistency and validity of the translation for each language using exploratory factor analysis and cronbach 's alpha .", "patients who score 0/8 will be deemed as stroke free whereas those with any positive score will be deemed as not stroke free according to the 8-item qvsfs .", "sensitivity analysis will be performed where do n't know will be assumed to be = 1 .", "baseline demographic characteristics between patients who are symptom free for stroke and those with stroke will be compared using either chi - squared test ( categorical variables ) or student 's t - test or mann whitney 's u - test for means / medians respectively ( continuous variables ) .", "the sensitivity , specificity , positive predictive value , negative predictive value , positive and negative likelihood ratios as well as the accuracy and reliability of the 8-item qvsfs will be assessed in comparison with the benchmark stroke determination by history and examination by a neurologist .", "furthermore , the performance of the questionnaire will be compared with neuro - imaging results in a small randomly selected subset .", "the sensitivity and specificity of the 6 stroke symptom questions will be determined for stroke diagnosis among patients with stroke .", "the performance of the questionnaire will also be compared with the modified version of the questionnaire with images illustrating the neurological deficits being elicited by items 3 to 6 .", "we will use factor analysis approach to assess and confirm the structure relationship between each item and the qvsfs score overall .", "kappa statistics will be employed to compare inter - rater and intra - rater performance of the tool administered by medicine residents , at each site and also between study sites .", "this neuro - imaging validation will be performed within 48 h among a subset of subjects ( at least 4 stroke and 4 stroke - free ) per site .", "yes = 1 , no = 0 , do n't know = 0 .", "the questionnaire for verifying stroke - free status ( qvsfs ) , developed and validated primarily in english - speaking western world populations , is a method for verifying stroke - free status in participants of clinical , epidemiological and genetic studies .", "however , the performance of this tool in settings where levels of education and awareness of stroke symptoms are low such as sub - saharan africa has not been conducted .", "the tool has tremendous potential for widespread use in regions such as ours where stroke incidence , prevalence and mortality are escalating and questions on the epidemiology and genetic underpinnings of the stroke epidemic remain unresolved .", "we propose to validate qvsfs for ascertainment of stroke - free status of control subjects enrolled in an ongoing stroke epidemiological study in west africa funded by the national institute of health for h3africa .", "the novel aspects of our validation study are : firstly , to carry out this validation study simultaneously at five tertiary hospitals across nigeria and ghana involving participants speaking three different languages ( yoruba , hausa and akan ) .", "the qvsfs will be translated into these languages and administered to participants enrolled from neurology and general clinics in these hospitals .", "secondly , given the low levels of education , the lack of awareness of stroke symptoms , and general paucity of semantically equivalent medical terminology in the local dialects for stroke symptoms in our settings , we will evaluate the performance of the tool with and without pictograms .", "finally , ascertainment of stroke status will be conducted by neurologists across the 5 sites using a combination of structured medical history , neurological examination , review of medical records and neuro - imaging ( gold standard ) compared with previously published studies which relied on medical records review and neurological examination .", "the 8-item qvsfs is a simple , accurate and cheap tool which could have widespread use for ascertaining stroke status in clinical , epidemiological and genetic studies in settings where facilities for stroke confirmation are lacking ." ]

[ "backgroundthe questionnaire for verifying stroke - free status ( qvsfs ) has been validated in western populations as a method for verifying stroke - free status in participants of clinical , epidemiological and genetic studies .", "this instrument has not been validated in low - income settings where populations have limited knowledge of stroke symptoms and literacy levels are low.objectiveto simultaneously validate the 8-item qvsfs in 3 languages spoken in west africa ( yoruba , hausa and akan ) for ascertainment of stroke - free status of control subjects in siren.methodsusing a cross - sectional study design , 100 participants each from the 3 linguistic groups will be consecutively recruited from neurology and general medicine clinics of 5 tertiary referral hospitals in nigeria and ghana .", "ascertainment of stroke status will be determined by neurologists using structured neurological examination , review of case records and neuro - imaging ( gold standard ) .", "the relative performance of qvsfs without and with pictures of stroke symptoms ( pictograms ) will be assessed using sensitivity , specificity , positive predictive value ( ppv ) and negative predictive value ( npv).conclusionthe proposed study will provide valuable data on the performance of the qvsfs in resource - limited settings ." ]

[ 8, 49, 57, 58, 60, 61, 63, 64 ]

[ "cardiovascular diseases account for the highest mortality rate worldwide and are expected to be the major cause of death by 2020 ( 1 ) .", "studies in iran showed that cardiovascular diseases are the most important cause of death and accounted for 42% of all deaths in 2002 ( 2 ) .", "timely diagnosis and proactive measures play a significant role in effective treatment , prevention development of heart damages and the faster recovery of cardiovascular diseases .", "the time it takes to reach a hospital or a coronary care unit ( ccu ) and the time spent for diagnostic and treatment measures are factors influencing the delay or loss of time from the outset of severe cardiac infarction to the beginning of treatment ( 3 ) .", "overall , the mortality rate of severe cardiovascular deaths is 30% , more than half of which occurs before hospitalization ( 3 ) .", "however , with the advancement of the epidemic this social trend reverses and people at lower socio - economic classes become more vulnerable ( 3 ) .", "studies conducted in some developing countries showed that the underprivileged are more susceptible to cardiac arrests compared to affluent people ( 4 ) .", "furthermore , limited accessibility to health services and the inequality in availability of the services furnished by health and treatment systems deprives these people of acceptable and effective treatment ( 5 ) .", "limited and unequal accessibility to health services in iran are one of the controversial issues mentioned in several studies ( 5 - 7 ) .", "in general , one of the most important goals of a health system is to provide public accessibility and equality in receiving health and treatment services .", "as one measure of development , accessibility to health is one of the basic rights of individuals in the society .", "one of the main points in meting out fairness in the health system is that the distribution of health services must not be based on the socio - economic status and incomes of individuals ( 8) .", "inequality in health services in different countries has taken the form of a global challenge affected by various factors , including individual , social , economic and geographical variables ( 9 ) .", "these factors are stronger in developing countries ( 8,10 ) so that distribution of health services resources in developing countries has turned into a fundamental issue .", "therefore , the measurement of fair distribution of health services on top of previous measures has been emphasized by world health organization ( who ) ( 11 ) .", "inequality in distribution of health services is measured by different scales one of the most common is the gini coefficient which is based on the lorenz curve ( 12 ) .", "although multiple measures of inequality have been shown to be highly correlated with each other ( 7,12 ) , the results of several studies are encouraging and confirming the utility of the gini index in quantifying inequalities in health - related subjects .", "thus , the gini index and lorenz curve are commonly used in analyzing the inequality in distribution of health care resources ( 13 - 16 ) .", "since accessibility to intensive healthcare , in particular for cardiovascular conditions , is of utmost importance and since the appropriate distribution of coronary care unit ( ccu ) beds and cardiologists can be taken as a measure , the present study aims to examine the inequality of the geographical distribution of ccu beds and cardiologists in iran using the gini coefficient and the lorenz curve .", "this study conducted useing demographic data from national census in 2012 collected by the statistics center of iran ( sci ) .", "the number of ccu beds and cardiologists in public sector by province in 2012 was obtained from iran ministry of health and medical education .", "in the present study among various possible inequality measures ( such as gini coefficient , decile ratio , robin hood index and atkinson index ) preference was given to the gini coefficient because it has at least three major advantages ( 17 ) .", "first , it is less sensitive to the number of regions and the size of the numerical values in the data material in general .", "third , gini coefficient can be presented visually by means of a lorenz curve ; which provides an effective visualization of the inequalities .", "the lorenz curve compares the distribution of a given variable with the normal distribution ( of same variable ) that represents equality .", "the grater gap between the lorenz curve and diagonal line means the higher inequality .", "in this curve , the x axis represents the cumulative percentage of population and the y axis shows the percentage of the variable which is expressed as the proportion of the cumulative population .", "the 45-degree line is called the equality line because of showing the completely equal distribution ( 5 ) .", "in our study , the x axis represents the cumulative percentage of population of iranian provinces and the y axis shows the cumulative frequency of cardiologists and ccu beds in the iranian provinces .", "the gini coefficient is defined as the division of the area between diagonal line and the lorenz curve ( 14 ) .", "mathematically speaking , g1=1k=1n(xkxk1)(yk+yk1 ) where x represents the cumulative percentage of the population and y represents the cumulative percentage of ccu beds and cardiologists .", "the gini coefficient ranges between 0 and 1 in which , theoretically , 0 represents complete equality and 1 shows complete inequality of the distribution of a given variable .", "in practice , however , a coefficient below 0.2 is considered complete equality , one ranging between 0.2 and 0.3 shows high equality , one ranging between 0.3 and 0.4 indicates inequality ; a coefficient varying between 0.4 and 0.6 indicates high inequality and a coefficient larger than 0.6 represents complete inequality ( 14 ) .", "in this study it is assumed that more cardiologist and ccu beds are associated with more access to cardiovascular health services , so that people in provinces with higher per capital level of cardiologist and ccu beds have more access to cardiovascular health resources / services .", "finally , in order to calculate gini coefficient , the demographic data and also the number of ccu beds and cardiologists by province were entered and analyzed through ms excel software .", "in 2012 , iran had a total population of 75,149,669 with total number of 3665 ccu beds and the total number of 953 cardiologists in public sector .", "the province of tehran had the largest percentage of ccu beds ( 23.7% ) and cardiologists ( 17% ) .", "there were respectively 4.8 and 1.3 ccu beds and cardiologists across the nation per 100,000 individuals .", "table 1 shows the number of cardiologists and ccu beds per 100,000 individuals and the number of cardiologists per 10 ccu beds by province in 2012 .", "the lorenz curves for the ccu beds and cardiologists are illustrated in figures 1 and2 .", "the gini coefficients obtained for ccu beds and cardiologists were 0.129 and 0.045 , respectively .", "the findings showed that the national mean number of ccu beds for a population of 100,000 is 4.88 , which 23 ( out of a total of 31 ) provinces are below the national mean .", "however , the obtained gini coefficients prove statically adequate equality for the geographical distribution of ccu beds across iran .", "a previous study showed that the province of yazd enjoys the most equal distribution of ccu beds on one hand , and the province of ilam suffers from the least equal distribution of ccu beds ( 16 ) .", "a study on distribution of active hospital bed in iran , reported the gini coefficient for active bed 0.08 and active beds for a population of 10,000 people in 2006 9.2 , while the province of yazd had maximum , and the province of lorestan the minimum beds per population ( 18 ) .", "another study conducted in 2002 using morris imbalance coefficient , showed the province of yazd stands at the highest rank in terms of the number of hospital beds , and the province of semnan ranks the highest in terms of the number of health centers ( 19 ) .", "a study conducted in the netherlands on the distribution of ccu beds in 24 university hospitals for the period 2004 - 2006 reported gini coefficients of 0.638 , 0.569 and 0.569 , which reflected unequal distribution ( 20 ) .", "a study conducted at 2006 reflects equal distribution of non - cardiac intensive care beds in iran .", "the numbers of icu , post icu and nicu beds per 100,000 individuals in iran reported 5.3 , 0.4 and 1.6 , respectively and the gini coefficient for icu , post icu and nicu beds 0.17 , 0.15 and 0.23 ( 14 ) .", "another study conducted at 2011 showed high degree of inequality in the distribution of kidney transplant beds in iran .", "the province of tehran had more than half of the beds installed in its hospitals while 17 provinces had no kidney transplant beds at all ( 5 ) .", "in south africa , there were 4,168 icu beds counted in 2005 of which 86% were installed in three provinces .", "the proportion of bed varied greatly in different provinces of this country , from 1:20,000 to 1:80,000 ( 21 ) .", "the distribution of secondary and tertiary health services in the palestine is also reported to be unequal , mostly concentrated in the downtown .", "in the gaza strip and in the eastern strip the proportions of iu beds per 1,000 were 1.4 and 1.2 , respectively ( 22 ) .", "in another study in the u.s.a the trend of gini coefficient during 1970 - 1997 was used to measure the distribution of hospital beds .", "the northern states have been reported to enjoy an equal distribution of hospital beds ( 15 ) .", "lorenz curve of ccu beds in 2012 lorenz curve of cardiologists in 2012 the present study findings showed that the mean number of cardiologists per 100,000 individuals is 1.27 .", "also , the mean number of cardiologists per 10 ccu is 2.6 which 13 provinces are below the national mean ( out of a total of 31 provinces ) .", "the obtained gini coefficient ( 0.045 ) proves statically adequate equality in the geographical distribution of cardiologists across iran .", "a study conducted on the distribution of specialist physicians in iran at 2010 showed that the numbers of total specialists per 10,000 individuals and per 10 active beds in the country were 1.7 and 1.9 , respectively and the gini coefficient of distribution of total specialists reported 0.052 ( 18 ) .", "the gini coefficient was used in a study at 2000 to measure the resource distribution in mental health services in the us , showing the gini coefficient for psychologists as 0.13 ( 15 ) .", "in another study in japan gini coefficient was used to measure equality in geographical distribution of orthopedic services ; findings showed the orthopedist per 100,000 individuals was 4.3 and the gini coefficient reported 0.36 ( 23 ) .", "the low gini coefficients obtained in this study suggest that the health system in iran has been relatively successful in establishing a fair geographical distribution of coronary care services , which can be attributed to the implementation of the fair national health services distribution strategic plan .", "iran is the first east mediterranean country to implement this strategic health plan as its fourth development plan and through iran s 20-year vision plan in the health services department ( 24 ) .", "furthermore , in a 1992 comprehensive program , the health services classification system was developed in order to avoid unnecessary parallel activities , create fairness in the distribution of inpatient health services , make accessible the health services to all people across the country , reduce the number of unused beds and develop a health services classification system on the basis of different specialties and their respective stations by province .", "variables such as patient admission , population , mean hospital stay length , national divisions , available facilities and the geographical situation ( in terms of route and accessibility ) were determining factors in locating health centers ( 24,25 ) for instance , the maximum accessibility time to a ccu bed is set at 30 minutes .", "therefore , if the temporal distance of a province to the next level of numerical reference shows a time length longer than 30 minutes , the calculated beds , which may even be below the installation basis , would belong to that province and would not be transferred ( 26 ) .", "reports show that in the 2006 - 2007 687 ccu beds were installed in iran , indicating the iranian health system approach to promote health and create the conditions for the fair accessibility of health systems to all citizens ( 27 ) .", "our study descriptive statistics showed a skewed distribution of ccu beds in iran , so that the capital tehran , accommodating one sixth of the total population of iran , owns one fourth of total ccu beds in iran .", "in a similar study by ameryoun et al .", "on the non - cardiac intensive care beds in tehran the ratios of all non - cardiac intensive care beds were almost two times higher than other provinces ( 14 ) .", "also , in another study by tofighi et al .", "on the distribution of specialists , tehran owns 23% of all specialists across the country ( 18 ) .", "however , a study conducted in 2002 ( 19 ) showed that by morris measure , the health centers in tehran do not constitute a balanced distribution , burdened with problems such as traffic jams and other problems rampant in metropolitan cities , causing delays and waste of time from the beginning of acute myocardial infarction symptoms to the initiation of treatment ( accessibility to the ccu bed ) .", "furthermore , problems such as overcrowded hospitals in tehran , a drop in quality and quantity of health services , inadequacy of services on one hand and waste of funds for the provinces and finally a drop in public health on the other hand are other problems plaguing megacities .", "therefore , health policy makers should emphasize decentralization in tehran and identify extra health facilities in different cities so that a balanced allocation of resources may be achieved .", "fair geographical distribution of health services would lead to efficient and cost - effective health system .", "while existing classificatory models in iran focus on structural development , the number of beds and a model of providing health services , few studies have concentrated on the distribution by area , classification and defining areas on the basis of optimal distribution of health services ( 26 ) .", "therefore , current study may provide a foundation for large - scale planning for the health systems in order to remove the inequality in the distribution of health services .", "further research and surveys are strongly recommended to acquire more information and monitor the fairness of distribution of different health systems nationally and across provinces .", "the aforementioned results represent an initial empirical approximation , the validity of which is limited for the following reasons .", "first , counting the number of cardiologists and ccu beds is not an appropriate way to measure extant cardiovascular care and access to it ( a more sufficient reliable measure in iran is not available yet ) .", "second , the methodology used to measure inequality is not perfect and biased with limitations in measuring inequality ; for example , utilizing the gini coefficient showed that there is no significant inequality in the distribution of pubic cardiovascular health services in iran , though , primary information on the distribution of beds and cardiologists showed that about one - fourth of the ccu beds are existed in tehran , where one - sixth of the total population of iran is living .", "such interpretations are helpful for providing an approximation of existing distributions and can show some limitations of using inequality measures .", "despite the fact that the present study is one of the few studies conducted on the geographical distribution of one health services ( cardiovascular health services ) in iran , selecting only two factors ( the number of beds and physicians in the distribution of facilities ) and administering only one measure ( the gini coefficient ) may be considered as the limitations of this study .", "also , because of the unavailability of private sector and province - specific data , the research did not consider the private sector capacity and could not produce detailed provincial results , which are hoped to be overcome in future studies .", "measuring equality in distribution of private sector resources or all the private and public resources together could have extremely different results .", "using gini measure showed that there is no significant inequality in the distribution of pubic cardiovascular health services in iran .", "nevertheless , our descriptive statistics showed that there is a skewness in distribution of pubic cardiovascular health services in iran .", "moreover , even the equal distribution of cardiovascular health facilities such as ccu beds , does not mean they are sufficiently provided in iran ." ]

[ "background : timely access to cardiovascular health services is necessary to prevent heart damages .", "the present study examined inequality in geographical distribution of cardiovascular health services in iran .", "methods : present study is a cross - sectional study conducted using demographic data from all iranian provinces ( 31 provinces ) from 2012 census by the statistics center of iran ( sci ) .", "the gini coefficients of ccu beds \n and cardiologists were used to assess equality in access to cardiovascular health services in iran .", "ms excel \n software was used to calculate gini coefficients .", "results : the proportions of ccu bed and cardiologist per 100,000 population were 4.88 and 1.27 , respectively ; also the gini coefficients were 0.129 and 0.045 , respectively .", "conclusion : descriptive statistics showed a skewness in distribution of pubic cardiovascular health services in iran , though gini coefficient revealed no significant inequality .", "however , equal distribution of ccu beds and cardiovascular specialists does not mean they are sufficiently available in iran ." ]

[ 18, 19, 33, 34, 40, 60, 83, 90 ]

[ "results of a liquid culturing system ( bd bactec mgit 960 system ; bd diagnostics , sparks , md , us ) ( for details , see the technical appendix ) showed that all 5 beijing and 5 eai genotype strains were susceptible to isoniazid ( inh ) , rifampin ( rif ) , moxifloxacin ( mxf ) , and amikacin ( amk ) .", "mics were determined by using the agar proportion method ( 11 ) , which showed that ranges were small for the beijing and eai genotype strains : inh , 0.0620.125 mg / l ; rif , 0.1251 mg / l ; mxf , 0.1250.5 mg / l ; and amk , 0.52 mg / l .", "we determined the mutation frequencies of the beijing and eai genotype strains by using previously defined critical drug concentrations of 1 mg / l for inh , rif , and mxf and 5 mg / l for amk ( 11,12 ) ( for details , see the technical appendix ) .", "the mutation frequencies of the beijing and eai genotype strains were similar for inh , mxf , and amk , but they were significantly different for rif ( 1.6 10 to 5.4 10 for beijing strains vs. 6.3 10 to 3.8 10 for eai strains ; p = 0.003 , unpaired mann - whitney test ) ( table 1 ; figure 1 ) .", "because rifamycin drugs are widely used to treat tb , the difference in the mutation frequencies of beijing and eai genotype strains for rif is a major finding .", "frequency of rifampin ( rif)-resistant mutants in mycobacterium tuberculosis beijing and east - african / indian ( eai ) genotype strains ( 5 strains each ) originating from vietnam .", "statistical analysis was performed by using an unpaired mann - whitney test .", "for beijing genotype strains , the increase in mutation frequency during exposure to rif could be due to described missense mutations in the mut genes ( 13 ) .", "such mutations in the mut genes can change the dna repair mechanism ; as a consequence , the frequency of resistant mutant formation might increase .", "however , a direct correlation between the occurrence of particular mutations in mut genes and altered mutation frequency has not been proven .", "furthermore , werngren and hoffner ( 14 ) found an equal mutation frequency for beijing ( 3.6 10 ) and non - beijing ( 4.4 10 ) genotypes .", "a possible explanation for the discrepancy in findings might be the concentration of rif used in the subculture plates .", "in our study , the critical concentration of 1 mg / l rif was used ( 11 ) , whereas werngren and hoffner used a concentration of 2 mg / l rif .", "in addition , werngren and hoffner compared the beijing and non - beijing genotypes of several genotype families , whereas we compared beijing and eai genotype strains that were selected from the same tuberculosis - endemic area and during the same period .", "we determined the time - kill kinetics of rif toward 2 strains with significantly different mutation frequencies : beijing-1585 ( 3.7 10 [ 3.0 10 and 4.3 10 , duplicates ] ) and eai-1627 ( 3.5 10 [ 2.8 10 and 4.1 10 , duplicates ] ) .", "cultures with low and high densities of beijing-1585 and eai-1627 were investigated as described ( 15 ) .", "rif showed strong time- and concentration - dependent activity toward low - density cultures of the 2 strains ( figure 2 ) .", "low concentrations of rif were needed to achieve > 99% mycobacterial killing ; differences between beijing-1585 and eai-1627 were minor ( table 2 ) .", "however , to achieve 100% killing , especially for beijing-1585 , rif concentrations had to be increased substantially ( table 2 ) .", "compared with the low - density culture for beijing-1585 , a substantial increase in rif concentrations was needed to achieve 100% killing of the high - density culture ( table 2 ) .", "this finding may be relevant in the clinical context because high - density mycobacteria populations are expected to exist in infected tissues of tb patients .", "concentration- and time - dependent bactericidal effect of rifampin ( rif ) toward low - density cultures of mycobacterium tuberculosis be-1585 ( 5.1 10 cfu / ml ) ( a ) and m. tuberculosis eai-1627 ( 6.8 10 cfu / ml ) ( b ) .", "after 1 , 3 , or 6 days of exposure , subcultures were performed on solid media to count cfus .", "* accurate cfu counting could not be performed because complete outgrowth of mycobacteria occurred on the sixth day of rif exposure , leading to aggregation .", "* cultures were exposed to rif at 2-fold increasing concentrations for 6 days at 37c ; at indicated time - points , subcultures were performed on solid media for counting .", "low , low - density culture ; high , high - density culture ; nd , not determined .", "rif - resistant mutants did not emerge in low - density cultures of beijing-1585 and eai-1627 .", "however , rif - resistant mutants were selected at relatively high numbers from high - density beijing-1585 cultures compared with high - density eai-1627 cultures .", "in beijing-1585 cultures , exposure to rif concentrations of 232 mg / l selected resistant mutants only ; this was not observed in eai-1627 cultures .", "analysis of rif - resistant beijing mutants showed the following altered rpob gene sequences : cacgac ( h526d ) , cactac ( h526y ) , and tcgttg ( s531l ) , as assessed by using the genotype mtbdrplus ( hain lifescience , nehren , germany ) assay ( for details , see the technical appendix ) .", "for 3 of the 4 anti - tb drugs , the difference in the range of mutant prevention concentrations for the beijing and eai genotype strains was small : inh , 128256 mg / l ; rif , 2561,024 mg / l ; and mxf , 28 mg / l .", "we showed that the currently used anti - tb drug susceptibility assays do not discriminate between the in vitro susceptibility , as determined by the methods used in this study , of the m. tuberculosis beijing and eai genotype strains .", "we also showed that the determination of mutation frequencies might be more informative than results of anti - tb drug susceptibility assays .", "for rif , mutation frequencies in beijing genotype strains were high compared with those in eai genotype strains , and the selection of rif - resistant mutants among beijing strains , but not eai strains , occurred within a wide range of rif concentrations .", "in addition , the killing capacity of rif toward the beijing genotype is dependent on the density of mycobacteria : high concentrations of rif are required to achieve 100% killing of high - density beijing genotype populations but not of high - density eai genotype populations .", "these in vitro characteristics might contribute to the less favorable treatment outcome of beijing genotype tb infections and their significant association with drug resistance .", "our findings demonstrate the need for anti - tb drug treatments that will prevent resistance among m. tuberculosis beijing genotype tb cases , and they suggest that the development of genotype - specific tb therapy might be justified .", "detailed methods for liquid culturing system ( bd bactec mgit 960 system ; bd diagnostics , sparks , md , us ) used to show drug susceptibility of mycobacterium tuberculosis beijing and east - african / indian genotype strains ." ]

[ "to determine differences in the ability of mycobacterium tuberculosis strains to withstand antituberculosis drug treatment , we compared the activity of antituberculosis drugs against susceptible beijing and east - african / indian genotype m. tuberculosis strains .", "beijing genotype strains showed high rates of mutation within a wide range of drug concentrations , possibly explaining this genotype s association with multidrug - resistant tuberculosis ." ]

[ 5, 33, 35 ]

[ "the need for magnetic resonance imaging ( mri ) in patients with an implanted pacemaker or implantable cardioverter - defibrillator ( icd ) is a growing clinical issue .", "it is estimated that as many as 75% of active cardiac device recipients will become indicated for mri .", "currently , the vast majority of such devices are contraindicated for use with an mri .", "in european heart rhythm association survey , published recently for non - mri - certified icds ( 0.51.5 t field strength ) , the totally subcutaneous icd ( s - icd ) system , an implantable defibrillator with no leads that touch the heart , has recently been demonstrated to be a safe and effective defibrillator option for patients at risk for sudden cardiac death .", "it provides shock therapy and post - shock pacing therapy , but no long - term bradycardia pacing .", "although it has been shown as an alternative to the standard transvenous icd , its compatibility with mri remains unclear .", "various types of clinical mri systems currently use a superconductive magnet that creates a static magnetic field strength , typically 1.5 or 3 t. the use of mri with most pacemakers and icds is considered a contraindication due to potential hazards , including heating of the electrode that resides in or on the heart , damage to myocardium , elevation of pacing thresholds , unintended induction of ventricular tachycardia ( vt ) or ventricular fibrillation ( vf ) , pacing inhibition , permanent device malfunction , and distortion of the mri scan .", "recently , mr - conditional.", "mr - conditional indicates a lack of known hazards in a specified mri environment with specified conditions of use .", "due to the variety of mri scanners and scanning protocols , it is not practical to test even a single device under all conditions .", "hence , mr - conditional labelling dictates that the device is safe for use under certain scanning conditions , as well as how the cardiac device should be programmed before an exposure to the magnetic field in a mri scanner .", "the literature , although limited , provides some guidance for imaging patients with implanted pacemakers or icds that do not have mr - conditional labelling .", "this single - centre prospective non - controlled study describes the first use of mri in patients with an implanted s - icd .", "patients with implanted s - icd systems ( boston scientific sqrx model 1010 and q - trak model 3010 ) were enrolled for mri testing over a period of 18 months .", "the s - icd system implanted in this patient cohort was composed of a can implanted in a left mid - lateral pocket and a para - sternal subcutaneous electrode .", "the s - icd is currently not certified for use with an mri ; therefore , the ethics committee of homolka hospital , prague , czech republic approved our clinical study .", "patients with newly implanted s - icd systems ( < 6 weeks ) were excluded , and none of the patients had any intravascular leads .", "the patients were randomized for either a cardiac , brain , cervical , or lumbar spinal scan .", "one of the subjects underwent an additional knee examination , due to reported chronic pain .", "a total of 15 patients were enrolled into this study ( 12 males and three females , aged 2283 years , mean 53 years .", "subjects in our cohort ( table 1 ) underwent a total of 22 mri scans between 6 june 2012 and 24 december 2013 .", "in total , five brain scans , three cardiac scans , 12 lumbar scans , one knee , and one cervical spine scan were conducted ( table 2 ) .", "however , in one patient a minor disc protrusion was found , in other mri revealed stenosis of intervertebral foramen which was causing radicular pain of the nerve root l4 and based on this examination the patient was referred to ct - navigated periradicular therapy .", "table 1summary of patient anatomical data and scan locations , along with noted clinical eventsidagesexbmidgef , % indication for s - icdheating0164f20.5hcmp / vfs85secondary preventionnone0283m30.0post - mi / smvts post - catheter ablation/35secondary prevention ( post - transvenous icd extraction)none0331m25.3arvc / d / smvts68secondary preventionin - tolerable re - scanned0458m23.6post - mi / post - cabg30primary preventionnone0577m25.5post - mi30primary preventionnone0663m27.0post - mi30primary preventionnone0768m23.7post - mi / vfs / vts60secondary prevention post - transvenous icd extraction / svc occlusiontolerable0822m29.4brugada sy / vfs68secondary preventionin - tolerable re - scanned0959m27.1dcmp / vfs / post - mitral valve surgery/60secondary prev./post - transvenous icd extractionnone1041f24.6arvc / d70primary preventionnone1123f21.5lqts / vf60secondary preventionnone1266m36.9post - mi / vf / post - cabg50secondary prevention / post - repeat transvenous icd extractiontolerable1348m22.9dcmp(non - compaction)/vfs35secondary preventionnone1470m29systolic dysfunction of lv35primary preventionnone1526m33brugada sy65primary preventionnonehcmp , hypertrophic cardiomyopathy ; smvt , sustained monomorphic ventricular tachycardia ; mi , myocardial infarction ; arvc , arrhythmogenic right ventricular cardiomyopathy ; cabg , coronary artery by - pass graft ; lqts , long qt syndrom .", "table 2parmeters of s - icd and patient sensation during individual mri scansscan # idbody partheating sensationsshock zone ( b.p.m.)condit .", "shock zone ( b.p.m.", ")bat % episode num.101brainnone2302101001202brainnone240220861303l spinein - tolerable240220831403brainnone240220831504brainnone220190691605l spinenone220210541706l spinenone240220681807l spinetolerable240220582908l spinein - tolerablenananana1008brainnonenananana1108l spinenone2302108411209heartnone2402208911310l spinenone2301807911410heartnonenananana1511heartnone2301909711612l spinetolerable2001709721712l spinenone2001709421813c spinenone23019010041913l spinenone23019010042014l spinenone2301908612115kneenone25021010012215l spinenone2502101001s - icd parameters acquired prior- and post - mri were without any change , therefore only one value is presented.indices : na , not available ; l spine , lumbar spine ; c spine , cervical spine .", "summary of patient anatomical data and scan locations , along with noted clinical events hcmp , hypertrophic cardiomyopathy ; smvt , sustained monomorphic ventricular tachycardia ; mi , myocardial infarction ; arvc , arrhythmogenic right ventricular cardiomyopathy ; cabg , coronary artery by - pass graft ; lqts , long qt syndrom .", "parmeters of s - icd and patient sensation during individual mri scans s - icd parameters acquired prior- and post - mri were without any change , therefore only one value is presented .", "indices : na , not available ; l spine , lumbar spine ; c spine , cervical spine .", "studies were performed using a siemens avanto 1.5 t mri scanner ( vb17 software , quantum gradient coils ) .", "all scans were run in normal operating mode , which is limited to 2 w / kg whole body averaged specific absorption rate ( sar ) .", "clinically relevant mri sequences were used for evaluation ( see table 3 ) .", "table 3types of pulse sequences typically used for imaging of respective anatomical areasscan locationscan sequencesflairdwiflashfsehastesestirtruefispbrainxxxxheartxxxxcervical spinexxkneexxxxlumbar spinexxflair , fluid attenuated inversion recovery ; dwi , diffusion weighted imaging ; flash , fast low angle shot ; fse , fast spin echo ; haste , half acquisition single - shot turbo spin echo ; se , spin echo ; stir , short tau inversion recovery ; truefisp , true fast imaging with steady - state precession.fse sequence caused heating in subjects with a thermistor probe during lumbar spine examination ( see the text for details ) .", "types of pulse sequences typically used for imaging of respective anatomical areas flair , fluid attenuated inversion recovery ; dwi , diffusion weighted imaging ; flash , fast low angle shot ; fse , fast spin echo ; haste , half acquisition single - shot turbo spin echo ; se , spin echo ; stir , short tau inversion recovery ; truefisp , true fast imaging with steady - state precession .", "fse sequence caused heating in subjects with a thermistor probe during lumbar spine examination ( see the text for details ) .", "patients were asked to report immediately any pain , torqueing movement , or heating sensation in the area of the pocket or the electrode by pressing an emergency bulb .", "furthermore , all patients were questioned immediately following the mri procedure to ascertain any discomfort in the vicinity of the can or electrode .", "pulse oximetry and standard lead electrocardiogram ( ecg ) if discomfort occurred , the patient was asked if the scan could be repeated at a later time using a revised scan sequence or the subject was again randomized for another anatomical area .", "since none of the components of the s - icd system are on or in the heart , heating near or around however , heating near the electrode or can with the s - icd system may still cause serious patient discomfort .", "therefore , along with education of subjects , each patient was instrumented by taping an oesophageal temperature probe ( beta - therm model g22k7mcd8 ) on the skin over the mid - lateral implant site to record any temperature excursions that might be correlated to patient symptoms of heating / discomfort near the pocket .", "to minimize the risk of inappropriate therapy , the s - icd system was programmed to therapy each s - icd system was evaluated prior to and immediately after the scan to verify proper functioning , including interrogation , sensing , and battery voltage .", "after the completion of the mri , long - term regular clinical follow - up and checking of the device were performed .", "since none of the components of the s - icd system are on or in the heart , heating near or around the electrode can not harm the myocardium .", "however , heating near the electrode or can with the s - icd system may still cause serious patient discomfort .", "after the completion of the mri , the s - icd system was reprogrammed to original settings .", "long - term regular clinical follow - up and checking of the device were performed .", "no anomalies were noted via pulse oximetry or ecg during the scans for any of the patients .", "eleven of 15 patients reported no sensation or pain from heating of the can , two of 15 patients reported feeling some heating , and two patients reported intolerable heating ( see table 2 ) .", "in patients with intolerable heating , the scan was halted within seconds and changed to a scan of the brain , which proceeded without incident .", "patient reports of heating in the vicinity of the can occurred only during lumbar scans with a thermistor probe ; no such reports occurred during scans of the brain , cardiac area , cervical spine , or without the probe .", "in two cases where heating in the vicinity of the can was reported by the patient , the scan sequence was altered to reduce the intensity of radiofrequency ( rf ) field exposure by reducing the turbo factor ( e.g.", "from 21 to 7 ) , increasing the repetition time ( e.g.", "to > 4000 ms ) , and reducing the flip angle ( e.g.from 170 to 120 ) .", "the target values were chosen arbitrarily to maintain image contrast ( flip angle ) and keep scan time at reasonable limits ( turbo factor and repetition time ) .", "less heating was noted by patients after these modifications to the scan parameters were made .", "03 ) was observed to have a skin lesion , appearing to be a circular rash or ulcer on the surface of the skin over the can , approximately 35 mm in diameter .", "the cause of this skin anomaly is not known ; it was later noted to have fully healed at a follow - up 10 days after the scan .", "to ascertain the effect of heating due to the instrumented thermistor catheter , the two patients who experienced the heating ( examinations 9 and 16 , see table 2 ) were rescanned several weeks later without the thermistor catheter in place ( examinations 11 and 17 ) .", "first , modified sequence ( with even lower amount of energy deposited in the tissue ) was used , which caused no heating .", "as no sensation was reported by the subjects , they were asked to report even a minimal discomfort , and the lumbar scans were performed using the same settings that resulted in heating with the thermistor catheter in place in the first imaging session .", "the results of the rescans revealed that no heating was felt by the patients when the thermistor catheter was absent .", "there were no noted changes to battery voltage , ability to detect the qrs signal or stored diagnostic data .", "pacing thresholds can not be assessed by the s - icd system , so this was not evaluated .", "none of the patients reported any pulling or twisting of the can or pain from heating of the s - icd electrode .", "for scans of the brain , lumbar spine , knee , and cervical spine , no effect from image artefact was noted in the anatomical area of interest .", "however , for scans of the cardiac area , image artefact was noted to interfere with the ability to see parts of the left ventricle , though the right ventricle of the heart was unaffected and could be imaged usefully .", "this was due to the can and not the electrode ( see figure 1 ) , modifications to the protocol for the lumbar spine resulted in a lower signal - to - noise ratio ; however , the images remain in diagnostic quality ( see figure 2 ) .", "figure 1kinetic study in four - chamber view : the systolic ( a and c ) and diastolic ( b and d ) images of cine sequences , four - chamber view .", "the steady - state free precession ( ssfp ) sequence ( a and b ) shows more artefacts .", "in ssfp kinetic study , an inflow of dark blood from the left pulmonary veins was seen .", "it could be caused by s - icd but also by metallic ring in mitral annulus .", "the spoiled gradient echo ( gre ) sequence ( c and d ) is better , but an artefact at the lateral wall is obvious .", "figure 2lumbar spine imaging with icd : low sar t2 fse sequence ( upper image ) compared with normal t2 fse in the same subject ( lower image , for the scanning parameters see the discussion section ) .", "kinetic study in four - chamber view : the systolic ( a and c ) and diastolic ( b and d ) images of cine sequences , four - chamber view .", "lumbar spine imaging with icd : low sar t2 fse sequence ( upper image ) compared with normal t2 fse in the same subject ( lower image , for the scanning parameters see the discussion section ) .", "lumbar spine imaging with icd : low sar t2 fse sequence ( upper image ) compared with normal t2 fse in the same subject ( lower image , there are several reports in the current literature about mr - conditional pacemakers from several companies , but very limited reports about mr - conditional icds .", "biotronik announced in late 2011 release of their first mr - compatible icd device and defibrillator leads pro mri , but in the conditions of use excluded scanning of the torso and focused more on the extremities examination .", "in european heart rhythm association survey , 60% of centres did not implant any mri - certified icds , 34.3% implanted < 10 icd devices , and only 5.6% implanted 10 and more icds ; one - fifth of responders stated that mri - certified icds should be implanted in all patients but lack of reimbursement was indicated as a possible obstacle to implant more mri - certified pacemakers / icds by 47.1% of responding centres .", "none of the components of the s - icd system are on or in the heart .", "the s - icd depends less upon being in direct contact with the myocardium to function and instead uses far - field sensing and stimulation to provide the shock and post - shock pacing therapy .", "as a consequence , unlike transvenous systems heating near or around the electrode can not harm the myocardium , which could present with possible safety consequences such as an elevation in pacing thresholds or scarring of the myocardium , but it may still cause serious patient discomfort .", "because the s - icd is larger than modern transvenous icd 's , there may be more potential for the can to experience heating due to the magnetic gradient or rf field .", "we report results from what we believe is the first experience of mri scanning in patients with an implanted s - icd and in various anatomical areas .", "overall , mri was performed safely in all patients , which is in contrast to the current literature with mri imaging in patients with electrical - active devices which are not mri - conditional .", "in our study , the primary clinically significant event attributable to the mri scan was the occurrence of heating in the area of the pocket in the four patients that underwent lumbar scans .", "it was not known if this was due to the s - icd can itself or an artefact of the thermistor catheter used to measure skin temperature over the pocket .", "this required a revision of our protocol , which was to re - scan two of the patients who complained of heating .", "re - scanning of these patients without the thermistor probe resulted in no complaints of heating , so it is assumed that the thermistor catheter itself heated during the lumbar scans and caused the discomfort .", "as further evidence , all the heating complaints occurred during rf - intensive scan sequences ( namely fast spin echo ) with the temperature probe located axially near the centre of the bore , where rf fields are the highest .", "the thermistor catheter is constructed of insulated conductive cables connected to electrodes and should couple to the rf fields efficiently , causing heating at the electrodes and pain or damage on the surface of the skin where the probe was placed over the s - icd can .", "if the heating was due to the s - icd can itself , it would more likely occur during gradient - intensive scan sequences ( which can generate eddy currents on can surfaces and internal components ) and at locations in the bore where there are high gradient fields , such as near the bore edges .", "however , when the patient was scanned with gradient - intensive scan sequences ( e.g.", "flair dwi ) and with the s - icd system in high gradient field locations in the bore ( e.g.", "such as during a brain scan ) , patients did not detect any heating or discomfort .", "in addition , the subcutaneous lead , which was not instrumented with a thermistor catheter , never resulted in any heating sensation noted by the patient , even when exactly the same sequence that resulted in heating in the first session was used .", "the use of mri - compatible temperature monitors such as fibre optic temperature probes would have provided better confirmation of possible skin temperature elevation and would not have been affected by the rf fields .", "for cardiac imaging , the main problem to solve is metallic artefact , especially on the gradient - echo sequences .", "like in research performed by nazarian et al .", ", several scan protocols were used to see if any yielded different effects or reduced the qualitative extent of artefact .", "gradient mode was changed from normal to whisper , resulting in slower ramping of the field and therefore diminishing the changes of the magnetic field in time .", "artefacts when present were limited to blurring of the left ventricle during cardiac scans and most yielded clinically useful information .", "standard interrogation of the s - icd revealed no adverse effects upon the functioning of the system .", "while no adverse effects upon the post - scan s - icd device function were noted , not all possible scanning protocols were tested .", "it should be noted that , four of the s - icd 's were exposed to repeat mri scans without adverse effects to device function .", "in addition , because the s - icd does not provide long - term bradycardia pacing , it is assumed that pacemaker - dependent patients would not be implanted with this system .", "the inhibition of the pacemaker function during the scanning sequence and possible pacing threshold changes are a unique concern in patients implanted with transvenous icds .", "this study included only 15 patients and 22 scans done on the same 1.5 t mri scanner .", "thus , even these preliminary results should only be applied to 1.5 t mri scanners ( similarly as reported in the present literature for other implantable devices ) .", "device functionality was tested immediately after the scan but not for long - term effects .", "in addition , not all device functions were tested although the s - icd system does have a beeper / interrogation warning if battery levels or memory irregularities occur .", "however , patients were scheduled for regular check - up and no defect of the device was observed in following 725 months ( mean observation time 18 months ) .", "delayed enhancement mri for determining cardiac scarring was also not tested .", "also , there are other anatomical areas that were not evaluated , such as shoulder and knees .", "while more data are required to support a claim of mri - conditional , this study is the study to demonstrate the feasibility of exposing s - icd patients to mri using the scanning and monitor protocol described , with some precautionary measures including : ( i ) programming the device therapy off ; ( ii ) limiting the sar to 2.0 w / kg ; ( iii ) continuous monitoring of the patients pulse oximetry and ecg by qualified personnel and especially for any feelings of heating ; ( iv ) evaluate device function post scan ; ( v ) availability of full resuscitation facilities at the mri site .", "given the variables of different mri scanners , the decision to perform mri on patients with an implanted s - icd system should be balanced against the potential risks .", "in our study , the only heating was very likely introduced by not fully mri - compatible thermometer probe ; subjects rescanned without the probe did not report any abnormalities during the scan of any body area listed ( brain , cervical and lumbar spine , heart , and knee ) .", "this study was supported by iga mz r nt12094/2011 , research project charles university in prague , prvouk p34 and unce 204010/2012 .", "funding to pay the open access publication charges for this article was provided by iga mz r nt12094/2011 ." ]

[ "aimsour aim was to evaluate the potential for safely imaging patients with a new type of implantable cardioverter - defibrillator called the subcutaneous implantable cardioverter - defibrillator ( s - icd ) in a 1.5 t magnetic resonance imaging ( mri ) scanner .", "with the increasing number of patients with cardiac implantable devices who are indicated for mri \n , there is a growing need for establishing mri compatibility of cardiac implantable devices.methods and resultspatients with implanted s - icd systems underwent one or more types of anatomical mri scans .", "the s - icd was programmed off and patients were monitored throughout the imaging procedure .", "device function was evaluated pre- and post - scan .", "patients were asked to report immediately any pain , torqueing movement , or heating sensation in the area of the pocket or electrode .", "fifteen patients underwent a total of 22 examinations at 1.5 t. scans included brain , spine , knee , and heart .", "two patients were re - scanned due to complaints of heating over the can during lumbar scans , which was caused by a thermistor probe placed on the skin to measure skin temperature .", "all the remaining scans occurred without incident .", "no evidence of device malfunction was observed.conclusionthis study is the first to domonstrate the feasibility of exposing s - icd patients to mri using the scanning and monitoring protocol described .", "more data are required to support s - icd as a mri conditional device ." ]

[ 0, 6, 21, 50, 60, 84, 86, 90, 107, 114 ]

[ "treatment with statins is highly effective in primary and secondary cardiovascular disease prevention , but their use can be associated with a variety of adverse effects , mainly affecting the muscles and liver .", "the most frequent symptom is myalgia , which occurs in 1015% of patients treated with statins .", "in primary prevention , up to 25.4% of patients stop taking statins by 6 months after the beginning of treatment .", "for patients who can not tolerate statin therapy , statins inhibit the rate - limiting step in cholesterol synthesis through acting on the key enzyme 3-hydroxy-3-methylglutaryl coenzyme a ( hmgcoa ) reductase .", "besides inhibiting the synthesis of cholesterol , biosynthesis of coenzyme q10 is also reduced , since coenzyme q10 is an intermediate in the mevalonate pathway .", "statins were shown to reduce serum / plasma levels of coenzyme q10 by 1654% and coenzyme q10 supplementation was reported to increase the levels of coenzyme q10 in plasma .", "coenzyme q10 , also known as ubiquinone , is localized in cellular membranes and participates in electron transport , and during oxidative phosphorylation in mitochondria , protects against oxidative stress and regenerates active forms of the antioxidant vitamin e .", "deficiency of coenzyme q10 affects oxidative phosphorylation and mitochondrial adenosine triphosphate ( atp ) production , and consequently impairs muscle energy metabolism .", "therefore , a deficiency of coenzyme q10 is the most probable mechanism of statin - related myopathy [ 79 ] .", "if the proposed mechanism of statin - related muscle pain is at least partially correct , coenzyme q10 supplementation seems a logical step in its reduction .", "several previous studies have reported conflicting results regarding decrease of statin - related muscle pain by coenzyme q10 supplementation in different study populations [ 6,1113 ] .", "therefore , the aim of the present study was to test whether coenzyme q10 supplementation could decrease mild - to - moderate statin - associated muscle pain .", "the specifics of the chosen group represent one of the most frequent clinical scenarios in statin - related adverse effects .", "fifty patients of both sexes , aged between 40 and 65 years , with statin - related muscle pain were recruited in this study .", "important inclusion criteria were the use of a statin for more than 6 months and the presence of statin - associated muscular symptoms for at least 6 months .", "in all enrolled patients , before the inclusion to the study , all possible efforts to decrease symptoms and to identify possible association with statin use were made as follows : gradual decreases of statin dose , de - challenge and re - challenge of statin treatment , and switch to another statin .", "where other possible identifiable causes of myopathy were suspected , patients were not eligible for enrollment .", "also , patients with serious medical conditions or any other specific disease ( e.g.", ", hepatic , vascular , renal , or endocrine ) or coagulopathy were excluded .", "a neurologist and an orthopedist also excluded possible neurological and orthopedic reasons for muscle pain before the inclusion to the study .", "this was a double - blind , placebo - controlled study with balanced randomization ( 1:1 ) .", "an independent pharmacist , who was not clinically involved in the study , packed containers with either placebo or q10 ( mgc company , japan ) and numbered them according to a simple randomization procedure ( computerized random numbers ) .", "the substances , placebo or q10 , were in the form of tablets identical in appearance , packed in the same white , opaque containers .", "the key to the content of each numbered container was stored in the safe deposit box of the pharmacist .", "each participant was assigned an order number and received the corresponding prepacked container according to the simple randomization procedure .", "the allocation sequence obtained was concealed in a sealed envelope from the researchers enrolling and assessing participants .", "the control group ( n=25 ) received placebo , and the q10 group ( n=25 ) received coenzyme q10 supplementation over a period of 30 days .", "the patients were recruited at the department of vascular diseases , university of ljubljana medical center .", "they reported myopathic symptoms consisting of muscle pain per se or accompanied by other symptoms , such as muscle weakness , muscle fatigue , or both .", "a definition of mild - to - moderate muscle symptoms was used , representing the pain severity score ( pss ) or pain interference score ( pis ) of 26 .", "the study protocol was approved by the national medical ethics committee of slovenia and informed consent was obtained from all the patients .", "enrolled patients were assessed in 2 separate visits : at the beginning and at the end of the study ( i.e.", ", day 0 and day 30 of the study ) .", "on the first visit , a clinical examination of each subject was performed and each subject completed a brief pain inventory ( bpi ) questionnaire for evaluation of myopathic symptoms before intervention .", "the questionnaire consisted of 2 parts : a pain severity score ( pss ) , calculated by averaging scores of the 4 pain intensity categories and a pain interference score ( pis ) , computed by averaging values of the 7 interference items from the questionnaire .", "a blood sample was also obtained for the following laboratory analyses : fasting plasma lipid profile ( total cholesterol , low - density lipoprotein ( ldl ) cholesterol , and triglycerides ) , creatine kinase ( ck ) concentration , and liver function enzymes ( transaminases and gamma - glutamyl transpeptidase ) .", "patients were then randomly assigned to receive either coenzyme q10 supplementation ( a daily supplement consisting of 50 mg of water - soluble coenzyme q10 twice daily ) or placebo twice daily for 30 days .", "their assigned statin therapy was continued during the course of the study .", "on the second visit after completion of supplementation therapy , myopathic symptoms were re - evaluated with the bpi questionnaire and another blood sample was obtained for the above - listed laboratory analyses .", "intragroup differences in q10 and placebo groups from the beginning to the end of the supplementation period were assessed by the paired t test .", "intergroup comparisons of relative changes ( before / after study ) between q10 and placebo group were assessed by the t test .", "power analysis for the difference between the placebo and the q10 groups for the pain severity score ( pss ) and pain interference score ( pis ) was conducted .", "parameters needed for the power analysis the difference between groups and standard deviations were estimated from the sample .", "a power of 99.1% and 98.5% was achieved when pis and pss , respectively , were used as a response .", "all statistical analyses were performed using graph pad prism 5.0 and spss 15.0 software .", "power analysis for the difference between the placebo and the q10 groups for the pain severity score ( pss ) and pain interference score ( pis ) parameters needed for the power analysis the difference between groups and standard deviations were estimated from the sample .", "fifty patients were enrolled in the study , of whom 25 received coenzyme q10 and 25 received placebo .", "nineteen patients received statin therapy in secondary prevention and 31 in primary prevention .", "in patients who received statin in secondary prevention , intensive dose reduction was not performed and statin discontinuation lasted for a short time ( not more than for 2 weeks ) .", "patient characteristics at inclusion in the study are summarized in table 1 and did not differ between groups .", "the distribution of types of statin among the patients was as follows : 22 patients received rosuvastatin 1020 mg daily , 20 patients received atorvastatin ( 10 patients 40 mg daily , and 10 patients 1020 mg daily ) , 4 patients received simvastatin 1020 mg daily , 3 patients received fluvastatin 80 mg daily , and 1 patient received lovastatin 20 mg daily .", "at inclusion in the study , the intensity of myopathic pain , measured as the pain severity score ( pss ) , was similar in both groups ( placebo and q10 group ) .", "intragroup comparison showed that after 30 days of intervention , the intensity of myopathic pain in the q10 group was significantly reduced , from 3.90.4 to 2.90.4 ( p<0.001 ) , but there was no significant change in myopathic pain intensity in the placebo group ( figure 1a ) .", "when comparing the percentage of change between the groups ( intergroup comparison ) , we found that the intensity of myopathic pain was significantly reduced after 30 days of intervention in the q10 group compared to the placebo group ( 33.15.7% and 0.46.3% , respectively ; both p<0.05 ) .", "interference of pain with daily activities was measured as the pain interference score ( pis ) .", "at inclusion in the study , intragroup comparison showed that after q10 intervention , pis was significantly reduced , from 4.00.4 to 2.60.4 ( p<0.001 ) .", "in the placebo group , the pis did not change significantly ( figure 1b ) .", "when comparing the percentage of change between the groups ( intergroup comparison ) , we found that the intensity of myopathic pain was significantly reduced after 30 days of intervention in the q10 group compared to the placebo group ( 40.37.0% and 11.510.2% , respectively ; both p<0.05 ) .", "the results of the biochemical analyses made at the beginning and at the end of the study are presented in table 2 .", "there were no differences in liver and muscle enzymes or cholesterol levels in the q10 or placebo groups during the course of the study ( intragroup comparison ) ( table 2 ) .", "in the present study , the possible beneficial effects of coenzyme q10 supplementation on mild - to - moderate statin - related muscle symptoms were studied , since this is one of the most frequent reasons for statin therapy withdrawal .", "we found that supplementation with coenzyme q10 ( 50 mg twice daily for 30 days ) reduced muscle pain and produced less interference by pain with daily life activities .", "overall , coenzyme q10 supplementation decreased statin - related muscle symptoms in 75% of patients .", "we observed no significant effects of coenzyme q10 supplementation on liver and muscle enzymes , which were within normal ranges during the course of the study in both treatment groups .", "also , cholesterol levels did not change significantly from the beginning to the end of the study .", "the observed beneficial effects of coenzyme q10 supplementation could lead to better statin treatment compliance .", "the present study was designed as a double - blind , randomized , placebo - controlled trial to evaluate the possible beneficial effect of coenzyme q10 supplementation ( 50 mg twice daily for 30 days ) on statin - associated muscle pain .", "a 30-day period was chosen because data in the literature indicate that the effect should reveal itself within that period .", "in its absence , extended supplementation is not recommended .", "using the standardized and simple brief pain inventory ( bpi ) questionnaire , consisting of a pain severity score ( pss ) and a pain interference score ( pis ) , we found that after 30 days with coenzyme q10 supplementation , muscle pain and the interference of pain with daily life activities in the mild - to - moderate symptom group were significantly reduced from the beginning to the end of the study ( from 3.90.4 to 2.90.4 and from 4.00.4 to 2.60.4 , respectively , both p<0.001 ) .", "the relative values of pss and pis significantly decreased in the q10 group compared to placebo group ( 33.1 and 40.3% , respectively ; both p<0.05 ) , showing the effectiveness of q10 .", "coenzyme q10 supplementation did not affect liver and muscle enzymes , which were in the normal ranges in both groups during the course of the study .", "according to the guidelines , all patients included in our study had myalgia muscle pain per se that could also be accompanied with other muscular symptoms such as muscle weakness , muscle fatigue , or both .", "the levels of all cholesterols did not differ significantly before and after intervention in separate groups .", "conflicting results of coenzyme q10 supplementation on statin - induced muscle pain were observed in previous studies .", "the beneficial effects of coenzyme q10 were confirmed in 2 studies , but not in others .", "reported that coenzyme q10 supplementation at a 200-mg daily dose ( twice that used in our study ) for 12 weeks did not improve myalgia in patients receiving simvastatin ( in a dosage of 1040 mg daily ) .", "in that study , the myalgia score was assessed by a visual analogue scale , which is known to be less accurate than the more complex brief pain inventory ( bpi ) questionnaire used in our study , and this could be the reason for the negative result observed .", "similar results were observed in a study by bookstaver et al .", ", in which coenzyme q10 was supplemented in a dosage of 120 mg daily for 3 months .", "it is also interesting that the intervals of observation were longer in both of these 2 studies compared to the present study .", "on the other hand , the most similar regimen to ours was in the study by caso et al .", ", in which the same dosage of coenzyme q10 was prescribed ( 100 mg daily ) and the bpi questionnaire was used to assess pain severity and pain interference with daily activities .", "also , the duration of supplementation was the same .", "like our results , a decrease in both parameters was observed after 30 days of coenzyme q10 supplementation , but its major limitation was not being placebo - controlled .", "from that point of view , the results obtained in the present study have greater value and confirm the beneficial effect of coenzyme q10 supplementation .", "a recent study by fedacko et al .", "showed that coenzyme q10 supplementation decreased symptoms of statin - associated myopathy , intensity of muscle pain , muscle weakness , muscle cramps , and muscle tiredness .", "considering all data from the above - mentioned studies together , we believe that the conflicting results show a complex relation between statin - related muscle symptoms and coenzyme q10 supplementation , probably due to the many confounding factors that influence the efficacy of coenzyme q10 supplementation .", "the limitation of the present study was the relatively small number of patients involved , which consequently limits extensive generalization of the results obtained .", "the main reason for the relatively small population group lay in the strict inclusion criteria , which ensured recruiting only patients with real statin - related muscular symptoms , who were highly motivated and informed , and consequently an accurate estimate of the intervention efficacy could be obtained .", "specifically , over - subjective estimation of statin - associated muscular symptoms is a well - known problem , which could importantly affect the results and conclusions .", "undoubtedly , further studies enrolling larger numbers of participants are warranted to address this problem .", "importantly , patients with mild - to - moderate muscular symptoms were included , which is probably the most frequent clinical scenario in patients with statin - related symptoms .", "furthermore , it is important to note that it was placebo - controlled and used widely accessible , relatively objective standardized questionnaires , allowing for great comparability .", "on the other hand , we do not know whether the proposed therapy is effective in all patients with statin - associated symptoms , but according to our data , it should be effective in the mild - to - moderate statin - associated symptoms group .", "the present study was patient - oriented and designed to focus on clinical effects of coenzyme q10 supplementation in statin - induced muscle symptoms , and not its mechanistic background .", "therefore , the concentration of coenzyme q10 in plasma or muscles and possible mechanistic background ( e.g.", ", anti - inflammatory and anti - oxidative ) were not addressed in this study .", "the present study revealed that by simple coenzyme q10 supplementation of the regular statin treatment , associated muscle pain in the mild - to - moderate symptoms group could be significantly reduced .", "consequently , it may lead to lower interference with daily activities and higher compliance with statin treatment .", "these observations mean a better quality of life , besides adequate cardiovascular protection , which is the primary goal of statin therapy .", "the results of the present study are very promising , but require further testing in larger clinical trials , mainly to allow them to be generalized ." ]

[ "backgroundstatin use is frequently associated with muscle - related symptoms .", "coenzyme q10 supplementation has yielded conflicting results in decreasing statin myopathy .", "herein , we tested whether coenzyme q10 supplementation could decrease statin - associated muscular pain in a specific group of patients with mild - to - moderate muscle symptoms.material/methodsfifty patients treated with statins and reporting muscle pain were recruited .", "the q10 group ( n=25 ) received coenzyme q10 supplementation over a period of 30 days ( 50 mg twice daily ) , and the control group ( n=25 ) received placebo .", "the brief pain inventory ( bpi ) questionnaire was used and blood testing was performed at inclusion in the study and after 30 days of supplementation.resultsthe intensity of muscle pain , measured as the pain severity score ( pss ) , in the q10 group was reduced from 3.90.4 to 2.90.4 ( p<0.001 ) .", "the pain interference score ( pis ) after q10 supplementation was reduced from 4.00.4 to 2.60.4 ( p<0.001 ) .", "in the placebo group , pss and pis \n did not change .", "coenzyme q10 supplementation decreased statin - related muscle symptoms in 75% of patients .", "the relative values of pss and pis significantly decreased ( 33.1% and 40.3% , respectively ) in the q10 group compared to placebo group ( both p<0.05 ) .", "from baseline , no differences in liver and muscle enzymes or cholesterol values were found.conclusionsthe present results show that coenzyme q10 supplementation ( 50 mg twice daily ) effectively reduced statin - related mild - to - moderate muscular symptoms , causing lower interference of statin - related muscular symptoms with daily activities ." ]

[ 15, 26, 52, 53, 61, 62, 68, 69, 70, 87, 99 ]

[ "most adults with autoimmune diabetes non - insulin - requiring at diagnosis become so within 36 years ( 1 , 2 ) .", "the optimal treatment for this second largest group of patients with diabetes is still unknown ( 37 ) .", "adult patients with autoimmune diabetes usually have larger remaining -cell mass at diagnosis and many develop -cell destruction more slowly .", "latent autoimmune diabetes in adults ( lada ) is therefore a suitable group for evaluating new therapies in autoimmune diabetes and may also serve as a model for intervention in classical type 1 diabetes ( 3 , 4 , 69 ) .", "the incidence of autoimmune diabetes is about equal in almost all age groups ( 10 , 11 ) .", "abrupt onset , often with ketoacidosis , is most frequent during childhood , a more modest onset is more frequent in adolescents and younger adults , and among adults and elders a slowly progressive onset , termed lada , is frequent ( 3 , 4 , 11 , 12 ) .", "classical type 1 diabetes and lada patients often have normal c - peptide levels at diagnosis , but further progressive decline occurs after onset , and insulin dependency occurs almost inevitably ( 3 , 4 , 8 , 9 , 13 ) .", "most trials in early type 1 diabetes have been performed in children , whose remaining -cell mass is limited , and short - term evaluation of intervention may be difficult also due to not infrequently occurring remission periods ( 14 , 15 ) .", "no therapy has yet been demonstrated to promote long - term insulin independency ( 3 , 5 , 7 , 16 ) .", "rodent studies have demonstrated potential positive effects of insulin treatment ( 17 , 18 ) .", "a pilot study of small doses of insulin versus sulphonylurea ( su ) to ten ica - positive patients with slowly progressive -cell failure favoured insulin for the preservation of c - peptide ( 19 ) .", "c - peptide is the outcome measure of choice of -cell function in trials of autoimmune diabetes ( 20 ) .", "even modest preservation of -cell function has been demonstrated to have positive effects on the frequency of hypoglycaemic events , and on the prevalence of retinopathy ( 21 ) .", "to investigate the effect of early insulin treatment in lada patients , for 3 years , on residual -cell function and metabolic control , compared with a group initially treated with diet and/or oral hypoglycaemic agents ( oha ) .", "adults , aged 30 years , diagnosed with diabetes in lund and kronoberg counties in southern sweden , non - insulin - requiring at diagnosis and positive to at least one of gadabs and/or icas were eligible for participation .", "two thirds had to be excluded due to mental conditions or severe physical illness , but also unwillingness to risk the early start of insulin injections .", "the majority of the patients were randomised into two groups , in blocks of eight , by pre - prepared closed envelopes kept at the two hospital policlinics .", "however complete strict randomisation was not possible , as some patients refused randomisation to possible insulin treatment before it was unavoidable .", "there were 20 patients in the intervention group ( i ) , treated with insulin from baseline , starting with 26 units intermediate - acting insulin at night ; and 17 patients in the control group ( c ) who received regular treatment with dietoha , mostly metformin , and some su ( 5/17 ; 30% ) .", "for both the groups , goals for glucose levels were in accordance with general guidelines ( fasting plasma glucose ( fpg ) 4.57 , preprandial pg 57 and postprandial decisions to increase treatment in doses , number of doses and addition of ohas or insulin were at the discretion of the treating physician .", "if two doses / day of intermediate - acting insulin or mix - insulin were not satisfactory , doses of direct or rapid - acting insulin before meals were added , resulting in 14 doses / day .", "glucagon - stimulation tests were performed at baseline and after 12 , 24 and 36 months during annual policlinic visits at the two research clinics .", "after an overnight fast , c - peptide was determined before and 6 min after i.v .", "c - peptide was analysed by commercial ria ( md315 , euro - diagnostica ab , malm , sweden ) , total variation ( sum of intra - and inter - assay variations ) 7% , reference range 0.251.0 c - peptide level , to reflect a preserved normal -cell function , was arbitrarily set at 0.5 nmol / l .", "icas were analysed with immunofluorescence assay , with detection limit 9 jdf - u , sensitivity 100% and specificity 88% .", "gadabs were analysed with radioimmuno - precipitation with lower reference limit at an index of 0.08 , corresponding to 21 who - u / ml , sensitivity 70% and specificity 100% .", "all analyses were standardised according to the diabetes antibody standardization program ( 25 , 26 ) .", "metabolic control was assessed by hbalc ( mono - s ) , and values were converted to dcct standard ( 27 ) .", "regarding the metabolic syndrome , complete information was available regarding only body mass index ( bmi ) and prevalence of hypertension , defined as blood pressure > 140/80 mmhg at the baseline visit , or taking antihypertensive medication .", "all subjects provided informed consent .", "analyses were carried out according to intention - to - treat .", "for comparisons between the groups , student 's t - test , or fisher 's exact test and the mann c - peptide and hbalc at baseline and after 12 , 24 , and 36 months were analysed with repeated measures anova using time as covariate ; for three - group analyses , anova with bonferroni correction was performed where appropriate .", "risk factors and relations were analysed in several models with simple , multiple , linear and logistic regressions ( forward stepwise , wald ) .", "spss software , version 17.0 ( chicago , il , usa ) , was used .", "for the baseline characteristics of the groups , see table 1 .", "there were no significant gender differences in the whole study , except that in the control group there were only men with hypertension ( p=0.03 ) .", "most subjects were overweight since both the i and c groups had mean bmi27 kg / m .", "median duration of diabetes at inclusion in the study was 5.0 ( quartiles 3.09.0 ) months .", "in both the groups , 90% of the patients , 18/20 in i and 15/17 in c , completed 36 months of follow - up .", "the conventionally treated ( c ) , 30% ( 5/17 ) started insulin treatment due to clinical necessity within 6612182430 months .", "for the levels of glucagon - stimulated c - peptide , see table 2 and fig .", "c - peptide levels were unchanged for four patients , increased by mean 0.73 ( 0.5 ) nmol / l for six and declined in all others after 36 months .", "mean glucagon - stimulated c - peptide decreased significantly in both the groups during the 36 months ( p<0.0001 ) .", "there was a significant time trend for the decrease in c - peptide of 0.17 nmol / l per year ( p=0.03 ) over 36 months without any significant difference between the groups .", "in repeated measures , anova with time as covariate , that analyses the changes in c - peptide over time with the levels at baseline taken into account , no differences could be found regarding mean - stimulated c - peptide at any time point , although with the mann whitney u test the difference in c - peptide at baseline ( cp0 ) was significant , p=0.03 .", "there were large variations in c - peptide levels between different individuals , at all time points , within both the groups ( p<0.0001 ) , explaining all the variation between them ( fig .", "cp0 explained 43% of level of c - peptide at 36 months ( cp36 ) , r 0.43 ( p<0.0001 ) .", "furthermore , age was the only other factor that had a weak and non - significant influence on cp36 , explaining about 5% of cp36 , r 0.049 ( p=0.2 ) .", "gender , baseline or end - of - study values of bmi , titres of gadab or ica , hbalc or diabetes duration before the study start did not influence c - peptide at end - of - study .", "it was 86% ( 13/15 ) in c , and 61% ( 11/18 ) in i ( p=0.13 ) .", "the odds ratio ( or ) for having a cp36 0.5 nmol / l was 2.4 for every increase in cp0 with 0.10 nmol / l ( p=0.02 ) , and 1.06 for each increase in baseline age by 1 year ( p=0.03 ) .", "if corrected for cp0 and age , the two factors found to have any influence on cp36 , the insulin treated had a non - significant or of 2.5 ( 0.04184 ) of having a cp36 of 0.5 the results of levels of fasting c - peptide ( fcp ) , when comparing the two treatment groups ( data not shown ) , were in accordance with the described results of stimulated c - peptide .", "among the controls , the level of hbalc had increased significantly at 36 months from 7.0 ( 1.3)% to 7.5 ( 1.5)% ( p=0.006 ) ( fig .", ", there was no significant difference between hbalc at baseline , 7.3 ( 1.3)% , and after 36 months , 7.2 ( 0.7)% ( p=0.6 ) ( fig .2 ) .", "for the levels of hbalc at baseline and during follow - up , see table 2 and fig .", "the differences between the groups in absolute levels of hbalc were not significant either at baseline or after 12 , 24 or 36 months .", "the levels of hbalc were not influenced by age , gender , bmi , antibody prevalences or titres or c - peptide levels .", "at baseline , prevalences of gadab were 94% , ica 67% , 72% had both antibodies , 22% gadab only and 6% only ica , with no significant differences between the two treatment groups .", "of the 32 patients whose ia-2a status was known , 7 ( 22% ) were positive , all of them were also positive to gadab and all but one was positive to ica , meaning that 75% of all were positive to at least two antibodies .", "at baseline , mean indexes of gadab were 0.78 ( 0.39 ) in i , 0.78 ( 0.48 ) in c ( ns ) and mean ica titres were 29.4 ( 40 ) in i , 72.4 ( 119 ) jdf - u in c ( ns ) .", "at baseline , there were no significant differences in the prevalences of any of the three antibodies between the two treatment groups or between genders , different ages , duration of diabetes before study start or levels of bmi or hbalc .", "neither were there any significant differences between the groups in titres of gadab or ica after 12 , 24 or 36 months .", "the titres of gadab or ica were not related to patient age , gender , bmi , diabetes duration , treatment or hbalc at baseline or during the follow - up .", "c - peptide at baseline or 36 months was not influenced by baseline titre of gadab , ica or ia-2a .", "no episodes of major hypoglycaemia were reported for any of the patients , and only a few minor ones .", "mean weight at baseline was 77.4 ( 14.5 , range 57.8110 ) kg in group i , and 83.0 ( 17.8 , range 50.8117 ) kg in group c ( ns ) ; at end - of - study 79.3 ( 12.4 , 57.7101 ) kg in i , 82.3 ( 14.8 , range 50.4115 ) kg in c ( ns ) .", "mean weight change during the study was 2.5 ( 4.8 , range 8.8 to + 9.3 ) kg in i ; 1.0 ( 10.5 , range 27.3 to + 16.4 ) kg in c ( ns ) .", "for the three groups , those treated with insulin from baseline , those never treated with insulin and those who were originally treated with dietoha , but had to start insulin treatment during the study , the influences of age , bmi , hbalc , diabetes duration before study start or antibody titres were analysed , with no significant findings except for the influence of cp0 on cp36 .", "the tests for all the relevant parameters were also carried out with the 37 patients divided into groups of ever- versus never - insulin treated ( during the study ) , again with no significant results ( p=0.120.87 ) , apart from the significant influence of cp0 on cp36 ( p<0.0001 ) .", "few prospective intervention studies have been conducted in lada patients and there is still no general agreement on the best treatment aimed to preserve -cell function ( 57 , 16 ) .", "there has not been any general consensus definition of lada , which complicates comparisons and pooling of results .", "the most common denominators are adult age , positivity to at least one pancreatic autoantibody , and non - insulin dependency at diagnosis ( 4 ) .", "age , bmi , duration of diabetes and of insulin independency , which of the antibodies that were analysed , gadab titres and the expression of the essential outcome variable c - peptide vary ( 2 , 4 , 5 , 2830 ) .", "a cochrane review also noted the heterogeneity between studies , and the conclusion about early insulin treatment was uncertain ( 5 ) .", "our study included patients aged 30 years , non - insulin dependent at the times of diagnosis and inclusion and positive to at least one pancreatic autoantibody , for 75% two antibodies , thereby fulfilling the main criteria for lada ( 4 ) .", "the results of the study indicated that none of the baseline parameters , except initial c - peptide level , significantly influenced the outcome , eliminating the importance of several criteria in comparisons with other studies .", "in other studies , patients aged > 65 years have often been excluded , but lada exists also in these older age groups ( 11 ) .", "the decline in residual -cell function was progressive for the majority of our lada patients , as is usual in autoimmune diabetes ( 4 , 8 , 13 , 16 ) .", "we observed great variation in the rates and magnitudes of -cell loss between patients and between different time periods during the study , with no consistent patterns .", "mechanisms such as more step - wise losses due to , for instance , partial remissions might explain this ( 15 ) .", "the decline in c - peptide was irrespective of age , gender , bmi , antibody titres , hbalc or treatment modality .", "the lack of influence of bmi , age , diabetes duration and baseline hbalc on disease progression was also seen in a non - interventional observation study of lada that followed 13 ab - positive patients by stimulated c - peptide for 2 years ( 16 ) .", "similar to ukpds , we found no association between gadab levels and disease progress ( 31 ) , in contrast to observational studies that described this ( 30 , 32 ) .", "we could not , in a number of regression analyses , define any other factor besides cp0 that significantly influenced the level of cp36 .", "the significance of initial c - peptide level was also demonstrated in a large swedish study of new - onset 1534 year olds and in the tokyo intervention study ( 28 , 33 ) .", "the length of our study may explain that some patients with initially higher levels of c - peptide , overrepresented in the control group , by 36 months had not yet lost enough -cell function to be clinically insulin dependent .", "some antibody - positive patients were described to take up to 12 years to become insulin dependent , but practically all eventually did ( 34 ) .", "a significant beneficial effect of early insulin treatment on the preservation of -cell function could not be demonstrated , but level of hbalc after 36 months was better preserved in the insulin treated , in keeping with observations by chaillous et al .", "incidentally , the shape of the curve of the development of hbalc levels over time for the conventionally treated group in our study had a likeness to that observed in the ukpds ( 35 ) .", "our study , as most prospective intervention studies of lada , was not large .", "the tokyo study , with 60 patients , found a preference for insulin treatment versus su , possibly due to the differences in treatment , but longer duration of diabetes , up to 5 years without insulin before inclusion , rendering a selection of patients with better endogenous insulin production from the start , would have excluded those who progressed earlier to insulin dependence , so the trial population differed from ours ( 28 ) .", "baseline level of c - peptide was an important independent predictor of the ability to preserve a sufficient amount of c - peptide over time , just as in our study .", "many reports end with a general recommendation of insulin treatment in lada , but the evidence has not been compelling , as concluded by the 2007 cochrane review , which scrutinised seven insulin intervention studies in lada , two insulin versus su , the rest insulin alone versus different combinations of insulin+oha ( 5 ) .", "ukpds recorded hbalc , weight and treatment , randomised to insulin versus su , and found that 60% of the su treated were insulin dependent after 2 years ( 36 ) .", "one conclusion was that su might promote insulin dependency and apart from not recommending su the cochrane review found no preference for any special type of treatment for the lada group ( 5 ) .", "in our study after 3 years , 65% of the conventionally treated patients were not yet treated with insulin .", "in contrast to both ukpds and the tokyo study , only 30% of our control patients were treated with su , which could be of importance for -cell function .", "in another study , of 54 patients in four groups , the insulin treated , all with low fcp , 0.3 nmol , received either insulin alone or combined with rosiglitazone ( rgz ) , and the oha treated , all with fcp > 0.3 to our knowledge , this study is the first prospective controlled european intervention study of treatment in lada .", "differences in defining the lada population regarding age , diabetes duration before start of intervention , antibody prevalences and gadab titres , bmi and , not least , baseline levels of c - peptide , if available , have contributed to difficulties in interpreting and comparing the results of the few existing lada intervention studies ( 4 , 5 , 28 , 29 , 37 ) .", "in this study , none of these factors , except baseline level of c - peptide , significantly affected the outcome .", "the similar findings also seen in trials of classical type 1 diabetes and of prevention of autoimmune diabetes in high - risk individuals substantiate the observation of the influence of initial level of c - peptide on outcome level ( 38 , 39 ) .", "we also saw a non - significant or favouring insulin treatment for preservation of -cell function , indicating the possibility that a larger study population and/or a longer period of follow - up might demonstrate significant preference for early insulin treatment also regarding -cell function .", "this study indicated that early insulin treatment in lada patients lead to better preservation of level of metabolic control , and that it was safe and well tolerated .", "the decline in c - peptide was progressive irrespective of age , gender , bmi , hbalc levels and antibody titres .", "only baseline level of c - peptide significantly influenced c - peptide level after 3 years .", "m landin - olsson has received a part - time professorship sponsored by novo - nordisk scandinavia .", "the other authors have no dualities of interest in relation to this article .", "the work was financed by the healthcare regions of skane and kronoberg , southern sweden ; lund university funding of clinical research ( alf ) ; and the swedish council of medical research ." ]

[ "objectivesthe optimal treatment of latent autoimmune diabetes in adults ( lada ) is not established .", "we explored whether early insulin treatment , which has shown beneficial effects in rodents and in human pilot studies , would result in better preservation of -cell function or metabolic control , compared with conventional treatment.subjects and methodsglucagon - stimulated c - peptide and hbalc were evaluated at baseline and after 12 , 24 and 36 months in 37 patients recently diagnosed with diabetes , aged 30 years , non - insulin - requiring and gadab and/or ica positive .", "twenty patients received early insulin and 17 received conventional treatment ( dietoral hypoglycaemic agents ( oha ) , metformin , some and/or sulfonylurea ) and insulin when necessary.resultslevel of metabolic control , hbalc , was preserved in the early insulin treated , while it significantly deteriorated in the conventionally treated .", "there was no significant difference between the groups in c - peptide after 12 , 24 or 36 months , or in the decline of c - peptide .", "only baseline c - peptide predicted a c - peptide of 0.5 nmol / l at 36 months .", "gender , body mass index , antibody titres or hbalc did not influence the levels of c - peptide or hbalc at baseline or end - of - study , or the decline in c - peptide .", "among the dietoha - treated \n , 5/17 ( 30% ) developed insulin dependency during the follow - up .", "no major hypoglycaemic events occurred.conclusionsearly insulin treatment in lada leads to better preservation of metabolic control and was safe .", "superior preservation of c - peptide could not be significantly demonstrated \n .", "only baseline level of c - peptide significantly influenced c - peptide level after 3 years .", "further studies exploring the best treatment in lada are warranted ." ]

[ 13, 14, 18, 44, 48, 51, 55, 63, 67, 87, 98, 102, 104 ]

[ "anemia is a global health problem and an independent risk factor for increased morbidity and mortality in various groups of patients , especially in patients with chronic diseases and in the elderly .", "low levels of 25-hydroxyvitamin d ( 25ohd ) are also highly prevalent among these patients .", "recent epidemiological evidence suggests that circulating 25ohd is inversely associated with hemoglobin ( hb ) levels [ 415 ] .", "the risk of anemia is highest at deficient 25ohd levels ( i.e.", ", < 30 nmol / l ) and lowest at 25ohd levels of 50 to 125 nmol / l [ 4 , 6 , 15 ] .", "in chronic kidney disease ( ckd ) patients , some nonrandomized intervention studies could already show that intravenous administration of activated vitamin d ( 1,25-dihydroxyvitamin d3 = 1,25(oh)2d3 ) is associated with an increase in hb levels within 12 months of treatment and a reduced need for erythropoietin ( epo ) [ 16 , 17 ] .", "moreover , intravenous 1,25(oh)2d3 administration was associated with a decreased weekly epo dose of 50% .", "regarding hb levels , similar results have been obtained in hemodialysis patients with oral alfacalcidol ( 1-vitamin d3 ) after 8 weeks and also after 12 and 18 months of treatment .", "in hemodialysis patients , high - dose oral vitamin d2 ( 50,000 iu monthly ) was associated with dose - reductions in erythropoiesis - stimulating agents ( esa ) , while hb concentrations remained unchanged [ 21 , 22 ] .", "in children with ckd stage 5 and 25ohd levels < 75 nmol / l , 12 weeks of vitamin d2 treatment in conjunction with 1,25(oh)2d3 was associated with a significantly reduced dose of esa required to treat the children .", "in anemic patients with preserved kidney function , however , one single intramuscular bolus of 600,000 iu vitamin d3 did not influence hb levels .", "nevertheless , it is noteworthy that in general populations the effect of high - dose bolus administration of vitamin d on clinical outcomes has been questioned .", "the purpose of the present study was to determine the effect of a daily vitamin d3 supplement on hb levels in a group of hypertensive patients with preserved kidney function and inadequate 25ohd levels .", "this is a secondary analysis of the styrian vitamin d hypertension trial of a postspecified endpoint .", "the study was a randomized , double - blind , placebo - controlled , single - center trial which took place at the outpatient clinic at the division of endocrinology and metabolism , medical university of graz , austria .", "the study was registered at eudract ( number 2009 - 018125 - 70 ) and clinicaltrials.gov ( nct02136771 ) .", "the study was approved by the ethics committee of the medical university of graz , austria .", "two hundred study participants ( 106 men and 94 women ) were recruited from the clinics of the department of cardiology and the department of internal medicine , division of endocrinology and metabolism , medical university of graz , austria , from june 2011 to august 2014 .", "eligible study participants were adults aged 18 years or older with a serum 25ohd concentration below 75 nmol / l and arterial hypertension .", "pregnant or lactating women were excluded as well as patients with hypercalcemia ( serum calcium > 2.65 mmol / l ) , regular vitamin d intake > 880 iu per day during the last four weeks before the study , estimated glomerular filtration rate ( egfr ) < 15 ml / min per 1.73 m , drug intake as part of another clinical study , acute coronary syndrome or cerebrovascular event in the previous two weeks , 24-hour systolic bp > 160 mm hg or < 120 mm hg , 24-hour diastolic bp > 100 mm hg , change in hypertensive treatment ( drugs or lifestyle ) in the previous four weeks or planned changes in antihypertensive treatment during the study , any disease with an estimated life expectancy of < 1 year , any clinically significant acute disease requiring drug treatment , and chemotherapy or radiation therapy .", "eligible study participants were randomly allocated to receive 2800 iu ( 70 g ) cholecalciferol as seven oily drops per day ( oleovit d3 , fresenius kabi austria , graz , austria ) or a matching placebo for eight weeks .", "the dose of 2,800 iu vitamin d per day was chosen because a rule of thumb suggests that vitamin d supplementation of 1,000 iu increases 25ohd levels by approximately 25 nmol / l .", "given that a commonly used normal range of 25ohd is 75 to 150 nmol / l we conclude that a supplementation of 2,800 iu daily may be sufficient to increase the 25ohd level of most study participants to target ranges without causing supraphysiological 25ohd levels .", "one hundred patients were assigned to the intervention group and 100 patients to the control group .", "randomization was performed by web - based software ( http://www.randomizer.at/ ) with a permuted block randomization ( block size of 10 and stratification according to sex ) .", "the primary outcome measures were hb levels and anemia .", "in accordance with earlier classifications [ 4 , 6 , 29 ] , hb concentrations < 12.5 g / dl were considered as anemic , which corresponded to the average threshold value of the world health organization gender - based definition ( < 13.0 g / dl in men and < 12.0 g / dl in women ) .", "blood sampling was performed in the morning between 7 and 11 am after an overnight fast .", "all blood samples were either measured at least four hours after blood collection or immediately stored at 20c until analysis .", "measurement of 25ohd was performed by chemiluminescence assay ( ids - isys 25-hydroxyvitamin d assay ; immunodiagnostic systems ltd .", ", boldon , uk ) on an ids - isys multidiscipline automated analyzer .", "all hematological parameters were measured on a sysmex xe-5000 automated hematology analyzer ( sysmex america , inc .", ", the measurements of other biochemical parameters have been described elsewhere .", "in accordance with published data [ 31 , 32 ] we categorized 25ohd levels < 30 nmol / l as deficient , 3049.9 nmol / l as insufficient , and 50 to 74.9 nmol / l as borderline .", "change from baseline data is shown as means and 95% confidence interval ( ci ) .", "we used the mcnemar test and fisher 's exact test , respectively , to assess differences in anemic status within and between groups .", "the unpaired t - test or chi - squared test ancova with adjustments for baseline values was used to test for differences in the outcome variables between the vitamin d and the placebo group at the follow - up visit .", "analyses were performed using spss version 21.0 ( spss , inc .", ", chicago , il , usa ) .", "baseline characteristics of the study participants are shown in table 1 .", "in both groups , mean hb values were clearly above the anemia threshold of 12.5 g / dl .", "at baseline , the proportion of anemia in the vitamin d and placebo groups was 9.0% and 4.0% , respectively ( p = 0.152 ) .", "regarding 25ohd levels , 6.0% of the vitamin d group and 9.0% of the placebo group had deficient levels .", "the proportion of insufficient 25ohd levels was 27.0% and 36.0% , respectively .", "in the remaining 67.0% and 55.0% , the vitamin d status was classified as borderline .", "circulating 25ohd increased on average by 35.4 nmo / l ( 95% ci : 31.2 to 39.6 nmol / l ) in the treatment group and 8.1 nmol / l ( 95% ci : 4.6 to 11.7 moreover , vitamin d treatment did not influence anemic status significantly ( p > 0.999 ) .", "in detail , the percentage of anemic subjects remained constant in the vitamin d group ( p > 0.999 ) and increased only slightly in the placebo group ( p > 0.999 ) ( figure 1 ) .", "vitamin d treatment had no effect on hb levels and other hematological parameters in anemic patients ( see table s1 in supplementary material available online at http://dx.doi.org/10.1155/2016/6836402 ) .", "moreover , there was no vitamin d effect on hb levels and other hematological parameters in the group of subjects with initial 25ohd levels < 30 nmol / l ( table s2 ) .", "there was , however , a significant vitamin d effect on pth levels , with suppressed pth levels in the vitamin d group ( table 2 ) .", "this study showed that a daily vitamin d supplement of 2800 iu for 8 weeks had no effect on hb levels or anemia risk in hypertensive patients with 25ohd levels in addition , compared with previous interventional studies we were able to include a large number of patients .", "moreover , the daily vitamin d dose was sufficient to increase in - study 25ohd levels on average clearly above 75 this value is recommended by many endocrinologists and vitamin d researchers as the lower target level for various clinical outcomes [ 33 , 34 ] .", "second , the study duration of 8 weeks was relatively short , given that the half - life of red blood cells in circulation is 3 months .", "third , we have no data on circulating levels of 1,25(oh)2d , which is the active , hormonal form of vitamin d. generally , evidence is increasing that 1,25(oh)2d can stimulate erythropoiesis in red blood cell precursor cells by increasing epo sensitivity .", "furthermore , 1,25(oh)2d can upregulate proliferation of hematopoietic progenitor cells [ 35 , 36 ] .", "nevertheless , our findings with plain vitamin d in patients with preserved kidney function do not support the beneficial impact on hb levels of earlier studies with activated vitamin d in ckd patients [ 16 , 17 ] .", "it is , however , noteworthy that in ckd patients the prevalence of anemia is high and circulating 1,25(oh)2d levels are low .", "moreover , a recent meta - analysis of randomized controlled trials has demonstrated that , after administration of vitamin d or activated vitamin d , the increase in circulating 1,25(oh)2d tends to be much higher in ckd patients than in non - ckd patients .", "in our study , a vitamin d - induced increase in circulating 1,25(oh)2d levels may have been blunted by the suppressed pth levels , and this may have contributed , at least in part , to the null effect on hb levels .", "in the present study , moreover , it was a surprising finding that all 13 anemic patients had initial 25ohd levels > 50 nmol / l .", "generally , epidemiological evidence suggests that circulating 25ohd levels are inversely associated with hb levels and anemia risk [ 4 , 6 ] .", "a recent meta - analysis of retrospective observational studies showed that , compared with individuals with adequate 25ohd levels , low 25ohd levels were associated with an odds ratio for anemia of 2.25 ( 95% ci : 1.473.44 ) .", "the cut - off for low 25ohd levels was 50 nmol / l in 5 out of the 7 included studies and 75 nmol / l in the remaining 2 studies .", "only individuals without chronic diseases were included in that meta - analysis .", "however , two large studies in patients with cardiovascular disease [ 4 , 6 ] indicate that hb levels are only significantly affected if circulating 25ohd levels are in the deficiency range .", "also of note is the fact that observational studies have shown circulating 1,25(oh)2d to be a better predictor of anemia than circulating 25ohd [ 4 , 5 , 39 ] .", "altogether , data indicate that especially anemic patients with deficient 25ohd levels and low circulating 1,25(oh)2d levels may benefit from improved vitamin d status .", "in conclusion , our data demonstrate that a daily vitamin d supplement of 2800 iu for 8 weeks does not increase hb levels in nonanemic hypertensive patients with 25ohd levels" ]

[ "epidemiological evidence suggests that circulating 25-hydroxyvitamin d ( 25ohd ) levels are inversely associated with hemoglobin ( hb ) levels and anemia risk .", "we evaluated whether vitamin d supplementation improves hb levels and reduces anemia risk in hypertensive patients .", "two hundred patients with 25ohd levels < 75 nmol / l who attended the styrian vitamin d hypertension trial were included , of whom 188 completed the trial .", "patients randomly received 2800 iu vitamin d3 daily or a matching placebo for eight weeks .", "initially , the prevalence of anemic status ( hb levels < 12.5 g / dl ) and deficient 25ohd levels ( < 30 \n nmol / l ) was 6.5% and 7.5% , respectively .", "all anemic patients had 25ohd levels > 50 nmol / l . \n the mean ( 95% confidence interval ) vitamin d effect on hb levels was 0.04 ( 0.14 to 0.22 ) g / dl ( p = 0.661 ) .", "moreover , vitamin d treatment did not influence anemic status significantly ( p > 0.999 ) .", "likewise , vitamin d had no significant effect on hb levels in the subgroups of anemic patients or in patients with initial 25ohd levels < 30 nmol / l . in conclusion , \n a daily vitamin d supplement of 2800 iu for eight weeks did not improve hb levels or anemic status in hypertensive patients .", "future trials should focus on anemic patients with deficient 25ohd levels ( e.g.", ", < 30 nmol / l ) .", "this trial is registered with clinicaltrials.gov [ nct02136771 ] ." ]

[ 9, 12, 13, 40, 42, 45, 50, 60, 62, 67 ]

[ "following a clinically predictable progression pattern , advanced prostate cancer ( pca ) metastasizes to distant organs , with a striking predisposition for bone .", "despite a decreasing overall mortality rate for pca patients , the development of effective treatments has been hindered , in part , by the lack of cell lines and/or xenograft models that accurately recapitulate the complex metastatic microenvironment .", "without appropriate models to reflect the disease , mechanistic studies to accurately elucidate the players involved in pca progression in bone have been difficult to implement , impeding the development of clinically effective therapeutics targeted to bone metastases .", "some of the more commonly used pca cell lines ( e.g.", ", pc-3 and du-145 ) offer convenience to investigators because they adhere well to tissue culture plastic and therefore are amenable to high throughput screening of drug libraries .", "however , these same cell lines , when inoculated in bone , generate a largely osteolytic response , in contrast to the predominantly osteoblastic nature of the native human disease .", "to more accurately model the disease , we have employed the lncap cell line progression series ( lncap , c4 , c4 - 2 , and c4 - 2b ) , with c4 - 2b cells forming osseous lesions in bone .", "however , we and other investigators continue to search for pca cell models with greater fidelity to the disease that will foster the translation of preclinical findings into the clinic , particularly to satisfy the need to identify new treatments that will eradicate pca metastases growing in bone .", "to address the need for the highest - possible fidelity in pca cell sources , patient - derived xenograft ( pdx ) models have been established for the preclinical investigation of various aspects of pca biology including angiogenesis , identification of castrate - resistant stem - like cells , and effect of anti - androgen therapies .", "pdx models are generated when tumor tissue from the patient is surgically resected and engrafted directly into immunocompromised mice .", "tumors are subsequently maintained solely in vivo via mouse - to - mouse passage , requiring both careful monitoring of the tumor burden and labor intensive animal transfers .", "through serial passaging in mice and the absence of any in vitro manipulation , pdx tumors remain biologically stable , preserving much of the molecular , genetic , and histological features as well as heterogeneity of the original tumor .", "however , given the high costs of animal maintenance , lengthy latency period following engraftment , variable engraftment rates , and rare access to patient tissue specimens , pdx in vivo models are generally not yet widely employed in cancer research .", "most notably , given the poor viability exhibited when grown in vitro under standard tissue culture conditions , it is extremely challenging to culture pdx bone metastatic pca cells for any brief ex vivo manipulation needed to conduct controlled mechanistic studies in vivo .", "mirroring the in vitro behavior of pdx prostate tumors , pca cell lines belonging to the lncap series also adhere poorly to two - dimensional ( 2d ) tissue culture surfaces , precluding them from use in standard drug screening platforms .", "to circumvent this problem , our laboratory recently demonstrated the feasibility of using three - dimensional ( 3d ) hyaluronan ( ha)-based hydrogel systems to support the growth and viability of these pca cell lines for mechanistic studies and drug testing .", "while the commonly employed human tumor spheroid model is an alternative to culturing these poorly adherent cells , hydrogel encapsulation provides the means to fully recapitulate the tumor microenvironment with precise , tunable control over architectural and mechanical cues and/or critical cell specifically , as a ubiquitous component of the bone marrow where bone metastatic pca cells reside , ha plays an active role in regulating several biological processes , including tumorigenesis , strongly justifying its use as an extracellular matrix analogue for culturing bone metastatic tumor cells in vitro .", "on the basis of the suitability of ha - based hydrogel systems for the culture of pca cell lines , we hypothesized that these systems would similarly support the viability of pdx pca cells in vitro .", "hence , in the present study , we developed a novel protocol to encapsulate pdx pca cells within 3d ha - based hydrogels and examined tumor cell morphology , viability , proliferative capacity and phenotype .", "we also tested the potential of this 3d pdx pca model as a diagnostic platform for evaluating rapid patient - specific drug response , a significant advance toward achieving a more personalized therapeutic regimen .", "phenol red - free dulbecco s modified eagle medium / nutrient mixture f-12 ( dmem / f-12 ) , t - medium , penicillin / streptomycin , trypsin - edta , l - glutamine , live / dead viability / cytotoxicity kit , and quant - it picogreen dsdna assay kit were obtained from life technologies ( grand island , ny ) .", "fetal bovine serum ( fbs ) phosphate buffered saline ( pbs ) was obtained from lonza ( walkersville , md ) .", "thiol - modified ha ( ha - sh , glycosil , average mw = 240 kda , degree of thiolation = 1 mol / mg ha - sh ) and poly(ethylene glycol)-diacrylate ( peg - da , extralink , average mw = 3350 da ) were obtained from biotime inc .", "this ha - sh / peg - da hydrogel system previously has been characterized extensively .", "dmso , l - cysteine , and papain papaya latex were obtained from sigma - aldrich ( st .louis , mo ) .", "primary antibodies used were human - specific anti - nuclei antibody from millipore ( mab1281 , billerica , ma ) , anti - androgen receptor from santa cruz biotechnology ( sc-816 , dallas , tx ) , anti - cleaved caspase-3 from cell signaling technology ( nb11089717 , danver , ma ) , and anti - ki-67 from novus biologicals ( # 9664s , littleton , co ) .", "sylgard 184 poly(dimethylsiloxane ) ( pdms ) elastomer kit was from dow corning ( midland , mi ) .", "mda pca 183 and mda pca 118b cells were routinely maintained as subcutaneous tumors in cb-17 scid mice ( charles river ) .", "all experiments for the propagation of pdx tumors in mice were conducted under iacuc approval from the university of texas md anderson cancer center .", "the mda pca 183 xenograft was derived from androgen - dependent prostate carcinoma , whereas the mda pca 118b was derived from androgen receptor - negative castrate - resistant prostate carcinoma .", "for this study , mda pca 183 and mda pca 118b pdxs of passage 12 and 8 respectively , were used .", "on the day of harvest , tumor specimens were removed immediately , rinsed six times with pbs , minced with a scalpel blade , and digested with accumax enzymatic solution for 15 min at 37 c .", "the enzyme solution was inactivated with fbs , the resultant tumor slurry was filtered through a 70 m cell strainer , and the filtrate was centrifuged .", "the supernatant was removed , the resulting cell pellet was resuspended , and a cell count was performed .", "custom - made pdms molds were made by mixing sylgard 184 elastomer and cross - linker 10:1 ( v / v ) according to manufacturer s instructions .", "the liquid silicone solution was centrifuged at 4 c/3000 rpm/5 min to remove bubbles and poured into a square aluminum frame with a 1.5 mm - thick spacer .", "an x-660 automated co2 laser cutter ( universal laser systems , scottsdale , az ) was used at 2.5% speed and 60% power to cut the slabs into 24 60 mm rectangles with multiple 6 mm diameter cylindrical cavities .", "the resultant molds were steam - autoclaved before each use and were sealed onto sterile glass slides before being employed as molds for hydrogel fabrication .", "each cylindrical cavity could hold approximately 50 l of hydrogel .", "prior to pdx tumor culture , ha - sh and peg - da were solubilized at 10 and 20 mg / ml , respectively , in degassed water per the manufacturer s instructions .", "the solutions were mixed at 4:1 ( v / v ) ratio , 35 l of the combined solution was placed in each cavity of the silicone molds , and the mixture was allowed to cross - link for 1 h at 37 c .", "the bottom layer of acellular hydrogel served as a cushion layer to prevent cell clusters from settling out of the cell hydrogel construct during culture .", "following tumor harvest , were plated on 6-well plates at densities determined to yield hydrogel constructs with 150,000 and 300,000 encapsulated mda pca 183 and mda pca 118b cells respectively , per construct .", "mda pca 183 and mda pca 118b cells were cultured in dmem / f-12 supplemented with 10% and 30% ( v / v ) fbs , respectively , in the presence of 100 u / ml of penicillin and 100 g / ml of streptomycin .", "tumor cells then were incubated at 37 c with 5% co2 for 2 days , after which tumor cell aggregates that formed in suspension from all wells were collected into sterile 15 ml tubes and gently centrifuged .", "supernatant was removed from each tube , and the remaining cell pellets were resuspended in complete dmem / f-12 medium , combined , and split into microcentrifuge tubes and centrifuged again .", "notably , as these cells form clusters in suspension , we could not perform cell counts immediately prior to encapsulation .", "instead , cell counting for the preparation of hydrogel constructs was performed at the step of 2d culture in 6-well plates ( immediately after the tumors were dissociated ) .", "the resulting cell pellets then were resuspended in solutions of ha - sh and peg - da ( 4:1 v / v ) as described above , and 25 l of the cell - hydrogel suspension was immediately pipetted into each mold cavity , over the 35 l cushion layer of cross - linked ha - sh / peg - da .", "seeded hydrogels were returned to the incubator for 45 min , then immersed in cell culture medium and incubated overnight .", "the following day , each mold cavity was scored with a 26-gauge needle , cell - hydrogel constructs were transferred into 24-well plates and submerged in culture medium .", "the c4 - 2b bone metastatic pca cell line was maintained in t - medium containing 5% fbs ( v / v ) and 2 mm l - glutamine in the presence of 100 u / ml of penicillin and 100 g / ml of streptomycin .", "for the docetaxel drug study , 50,000 cells were encapsulated within ha - sh / peg - da as described above for the pdx tumors .", "a lower cell density was used for the cell line because high - density culture was associated with poor cell viability ( data not shown ) .", "cell - hydrogel constructs ( n = 3 ) were maintained for 2 days before treatment with docetaxel for 3 days .", "docetaxel was diluted in dimethyl sulfoxide ( dmso ) such that the final concentration of dmso was 1% ( v / v ) in complete medium across all drug concentrations .", "morphology of the cells encapsulated within the hydrogel was monitored by differential interference contrast microscopy at days 1 , 3 , 5 , and 7 postencapsulation using a nikon eclipse te300 inverted microscope and nis elements software ( nikon instruments , melville , ny ) .", "fluorescently labeled samples were imaged using a nikon a1-rsi confocal microscope and images processed using the nikon nis - elements ar software ( nikon instruments , melville , ny ) .", "cell viability was assessed using the live / dead viability / cytotoxicity kit as per the manufacturer s instructions .", "briefly , cell - hydrogel constructs at the designated time - points were incubated in 2 m calcein - am and 4 m ethidium homodimer-1 in pbs for 30 min at 37 c before confocal imaging .", "cell - hydrogel constructs ( n = 3 or 4 ) were collected into individual microcentrifuge tubes at the designated time - points , flash - frozen using liquid nitrogen , and stored at 80 c .", "frozen samples then were lyophilized overnight and digested in pbe buffer ( 0.10 m na2hpo4 and 0.010 m na2edta in demineralized water at ph 6.5 ) containing 125 g / ml papain in the presence of 14.5 mm l - cysteine at 65 c overnight .", "the digested samples then were sonicated using a probe sonicator , and the liquid supernatant was assayed using the quant - it picogreen dsdna quantification assay as per the manufacturer s instructions .", "excitation and emission wavelengths of 485 and 528 nm , respectively , were used to measure the fluorescence ( flx800 fluorescence microplate reader ; biotek instruments ) .", "cell - hydrogel constructs were washed with pbs and fixed with 4% ( v / v ) paraformaldehyde for 10 min at room temperature .", "after fixation , constructs were washed with pbs and stored at 4 c until staining .", "constructs were immersed in 0.2% ( v / v ) triton x-100 for 5 min at room temperature to permeabilize cells , then blocked with 500 l of 3% ( w / v ) bsa and 0.2% triton x-100 in pbs at 4 c overnight .", "all antibodies were diluted at 1:200 in 3% bsa and 0.2% triton - x-100 in pbs .", "antibody staining was performed using 200 l of the mixed solution to each sample , which were placed on a rocking platform shaker at 4 c overnight .", "samples were washed with pbs before adding fluorophore - labeled secondary antibodies directed against the appropriate host .", "secondary antibodies were diluted 1:500 in 3% bsa and 0.2% triton - x-100 in pbs , and 200 l of that solution was added to each sample .", "dapi ( 5 g / ml ) was added to each sample at room temperature for 5 min .", "when phalloidin was used , it was diluted 1:20 in pbs , and 100 l of that mixture was added to each sample for 15 min .", "in initial experiments , following tumor digestion , we encapsulated the entire pdx cell population directly into hydrogels .", "when we did so , a large number of dead cells was transferred to the hydrogels as observed after 1 day in 3d culture ( data not shown ) .", "these dead cells likely were generated during the tumor harvest and digestion , and also contain mouse - derived cells that die immediately within the hydrogels .", "as the presence of high numbers of dead cells would complicate any biochemical assays that were envisioned , we sought to develop an alternative procedure designed to encapsulate cells with high viability ( figure 1a ) .", "( a ) mda pca 183 and mda pca 118b pdx tumors ( indicated by red arrows ) that were grown subcutaneously in scid mice were harvested , then mechanically and enzymatically digested .", "the tumor slurry was subsequently plated onto 6-well plates and cultured for 2 days during which the majority of mouse - derived cells ( red ) attached .", "the resulting tumor aggregates that formed ( blue ) then were encapsulated within ha - sh / peg - da hydrogels and cultured for up to 14 days .", "( b ) dissociated tumor cells plated on tissue culture plastic for 2 days formed multicellular clusters in suspension with other cell types adhering to the plastic surface .", "( c ) mixture of dapi - stained ( blue ) cells within tumoroids and adherent cells after 2 days in culture .", "scale bars = 100 m .", "in optimizing the culture conditions for the pdx pca cells , we observed that most of the mda pca 183 and mda pca 118b pca cells that had undergone mechanical and enzymatic digestion and been plated onto 6-well plates formed multicellular aggregates in suspension after 2 days in culture , presumably reflecting their characteristic poor adherence onto tissue culture plastic ( figure 1b ) .", "additionally , during this period , we noted that a population of cells in the tumor slurry ( shown in red in figure 1a ) adhered to the tissue culture plastic surface .", "leveraging this phenomenon , we collected the aggregates in suspension ( leaving behind the adherent cells ) and found that the process of gentle centrifugation resulted in the removal of dead cells .", "given that the mda pca 183 and mda pca 118b tumors were grown as subcutaneous tumors in mice , they carry along with them a subpopulation of mouse - derived cells in addition to the human pca cells .", "indeed , we found that among the poorly adherent pca cells that formed multicellular aggregates in suspension after 2 days on tissue culture plastic , the cells that had adhered stained positive for vimentin ( figure 1c ) .", "henceforth , we employed this pre - encapsulation 2d culture method , which not only removes dead cells , but also enriches the pdx tumor population via the depletion of mesenchymal cells .", "a summary of the process used to form 3d pdx tumoroids within the ha - sh / peg - da hydrogel is illustrated in figure 1a .", "in the first week after encapsulation , mda pca 183 cells were maintained as large tumoroids with most having diameters between 60100 m .", "mda pca 118b cells were maintained as smaller tumoroids , typically smaller than 60 m in diameter ( figure 2a and supplementary figure 1 ) .", "cells in tumoroids were in close contact in multicellular clusters , observed via staining with phalloidin for f - actin ( figure 2b ) .", "to demonstrate that human pca cells comprise the 3d pdx tumoroids , we stained the encapsulated cells for epithelial cell adhesion molecule ( epcam ) , an established marker for epithelial cells .", "as expected , both the mda pca 183 and mda pca 118b 3d pdx tumoroids stained positive for epcam ( figure 2c ) , indicating that the tumoroids form from self - sorting epithelial cells despite the presence of mesenchymal cells in the original xenograft tumors .", "additionally , we also confirmed this by probing for the human - specific anti - nuclei antibody and found that the majority of cells within the tumoroids stained positive ( data not shown ) , indicating that the 3d pdx tumoroids form from largely human cells .", "next , we asked if the pca cells in tumoroids retained their androgen receptor activation status .", "probing specifically for the androgen receptor , we found that while the androgen receptor was mainly localized in the nucleus of cells in the mda pca 183 tumoroids , nuclear localization of the receptor was not observed in the mda pca 118b cells as would be expected in vivo .", "generation of pdx tumoroids encapsulated within 3d ha - sh / peg - da hydrogels .", "( a ) mda pca 183 and mda pca 118b cells remained as multicellular tumoroids post - encapsulation , over 1 week in culture .", "cells were stained with dapi ( blue ) or phalloidin ( green ) ; a merged image is shown on the right panel .", "( c ) hydrogel - encapsulated mda pca 183 and mda pca 118b cells were stained with dapi ( blue ) , and with antibodies against epcam ( green ) and the androgen receptor ( red ) .", "while the mda pca 183 cells exhibited nuclear localization of the androgen receptor ( indicated by yellow arrows ) , the mda pca 118b cells stained negative for nuclear localization of the androgen receptor .", "encapsulation of the nonadherent tumoroids into ha - sh / peg - da hydrogels maintained cell cell contacts for at least 2 weeks in culture .", "given that these pdx pca tumors exhibit poor viability in vitro on 2d , we next investigated whether the encapsulated pdx tumoroids remained viable within the hydrogels over time using the live / dead viability / cytotoxicity assay .", "as shown in figure 3 , cells in both the mda pca 183 and mda pca 118b tumoroids were predominantly viable at days 1 , 5 , and 14 .", "remarkably , pdx cells had the highest survival when they had formed large clusters with other cells .", "dead or dying cells in each hydrogel were observed to be one of two types : either single cells that had not aggregated with other cells to form multicellular clusters or cells on the periphery of each cluster ( particularly prominent in figure 3b , day 14 ) .", "beyond viability , to establish if the 3d pdx tumoroids demonstrate tumor growth characteristics necessary for the model to serve as a drug - testing platform , particularly for drug candidates that target actively dividing cells , we monitored their growth over 1 week in culture , using dna content as a surrogate measure of cellularity .", "notably , the overall cellularity of the mda pca 118b constructs was lower than that of the mda pca 183 because the mda pca 118b cells formed smaller clusters , therefore the retrieval of cells for hydrogel encapsulation was less efficient than from the mda pca 183 cultures .", "this is apparent from the finding that even though a higher theoretical seeding density ( 150,000 and 300,000 cells per construct for mda pca 183 and 118b , respectively ) was employed for the mda pca 118b constructs , the average initial dna content of the mda pca 118b constructs still was lower than that of the mda pca 183 constructs ( day 1 , figure 4a ) .", "in analyzing the cellularity of the 3d pdx constructs over time , while dna content remained constant with no significant difference over time for the mda pca 183 tumoroids , there was a significant decrease in cellularity for the mda pca 118b from day 1 to 5 , after which an increase in cellularity was observed ( figure 4a ) .", "probing the 3d pdx tumoroids for ki-67 and cleaved caspase-3 , markers of proliferation and apoptosis , respectively , we found that differences in the proportion of proliferative and apoptotic cells at day 5 in culture was not apparent for either mda pca 183 or 118b ( figure 4b , c ) .", "panels in ( a ) and ( b ) show mda pca 183 and 118b after 1 , 5 , and 14 days in culture , respectively .", "cells were stained with calcein - am ( green , left panel ) or ethidium homodimer-1 ( red , middle panel ) .", "( a ) average cellularity of the 3d mda pca 183 and 118b constructs over 1 week in culture .", "upper panel of ( b ) and ( c ) shows the mda pca 183 and mda 118b tumoroids , respectively , stained with dapi ( left panel , blue ) and antibodies against ki-67 ( middle panel , red ) .", "lower panel of ( b ) and ( c ) shows the mda pca 183 and mda pca 118b tumoroids , respectively , stained with dapi ( left panel , blue ) and antibodies against cleaved caspase-3 ( middle panel , red ) the right panel shows a merged image where green indicates f - actin .", "having demonstrated that the encapsulated 3d pdx tumoroids are ( 1 ) made up of viable pca cells , ( 2 ) maintain in vivo - like androgen receptor distribution , and ( 3 ) are proliferative in the hydrogels , we next determined the suitability of this in vitro platform for drug testing of primary pca cells .", "given the inherent differences in origin between the mda pca 118b and mda pca 183 pdx models , we hypothesized that they would demonstrate a differential sensitivity to chemotherapeutic drugs .", "to test this hypothesis , we exposed the 3d mda pca 183 and mda pca 118b tumoroids to docetaxel , currently part of the first line regimen to treat patients with castrate - resistant metastatic pca .", "surprisingly , we found that not only was there no overall difference in docetaxel sensitivity between the 3d mda pca 183 and mda pca 118b tumoroids , no significant reduction in cell number was detected within the range of docetaxel concentrations tested for either 3d tumoroid systems ( figure 5a ) .", "to confirm these findings , we performed the live / dead viability / cytotoxicity assay and found that cells were largely viable even at the highest docetaxel concentration ( figure 5b ) .", "additionally , there were no apparent differences in the proportion of apoptotic cells as indicated by cleaved caspase-3 staining at the various docetaxel concentrations tested ( supplementary figure 2 ) .", "to demonstrate that the lack of cell - kill was cell source - dependent , we similarly exposed hydrogel - encapsulated cells from a bone metastatic prostate cancer cell line , c4 - 2b , to docetaxel .", "interestingly , a significant decrease in cellularity was already apparent between 1 and 10 nm ( figure 5a , b ) .", "this finding was corroborated by an observed increase in the proportion of ethidium homodimer-1-stained cells with increasing concentration of docetaxel ( figure 5b ) .", "notably , given that viable c4 - 2b cells were present at 10,000 nm as observed by calcein - am staining , it is likely that the decrease in the proportion of calcein - am - stained c4 - 2b cells due to drug cytotoxicity could not be clearly discerned when compared to controls .", "we also showed that the pdx cells were readily killed with 1 m sodium azide ; thus , it was likely not an issue of drug accessing the pca cells ( data not shown ) .", "( a ) average cellularity of 3d mda pca 183 and 118b constructs after exposure to increasing docetaxel concentrations , compared to the c4 - 2b cell line , also hydrogel - encapsulated .", "c4 - 2b cells exhibited significantly lower resistance to docetaxel as compared to both pdxs ( p < 0.05 ) .", "( b ) viability of cells after exposure to 0 , 10 , or 10,000 nm docetaxel , assessed by calcein - am staining ( green , left panels ) and ethidium homodimer-1 ( red , middle panels ) .", "in this study , we assessed a 3d ha - based hydrogel system for the culture of primary pdx bone metastatic pca tumors , well - known to exhibit poor viability when cultured on tissue culture plastic in vitro .", "given the ubiquity of ha in the bone marrow extracellular matrix and our previous studies that demonstrated the feasibility of using 3d ha - based hydrogels to culture poorly adherent bone metastatic pca cell lines , we hypothesized that these biologically active hydrogels would serve as excellent matrices to support the long - term culture of primary pdx pca tumor tissue in vitro .", "the inability of bone metastatic pca cells , whether derived from cell lines or primary pdx tumor tissue , to grow in 2d culture is an established phenomenon that indicates the lack of critical components from the bone microenvironment upon which these highly adapted cells depend .", "in optimizing the culture conditions for the 3d pdx pca cells , we found that the cancer cells failed to adhere to tissue culture plastic , as was expected .", "instead , these cells aggregated to form multicellular aggregates in suspension , where the formation of cell cell contact is a likely mechanism employed by the pca cells to adapt to the loss of native cell - matrix interactions .", "indeed , as proposed by shen and kramer , cancer cells are capable of undergoing synoikis , a term that was used to describe the avoidance of apoptosis by relying on intercellular adhesions in the absence of cell matrix interactions .", "focusing specifically on squamous cell carcinoma cells , the authors demonstrated that e - cadherin - mediated cell cell contact resulted in the generation of compensatory survival signaling via the epidermal growth factor receptor .", "interestingly , a similar observation was made by a landmark report by kondo et al .", "cell interactions were necessary for the survival of primary patient - derived colorectal cancer cells in suspension culture .", "in optimizing the culture method for the primary pdx pca cells , we leveraged the ability of the cancer cells to spontaneously aggregate to form multicellular clusters in suspension as a means to reduce the presence of contaminant cells such as dead cells , including those that were originally from the tumor tissue itself ( in regions of necrosis ) and those that were generated during the process of tumor digestion .", "we found that the application of gentle centrifugation to retrieve the pca aggregates in suspension after 2 days on tissue culture plastic was an effective method to separate the pca cells from dead cells in suspension prior to encapsulation within the hydrogel .", "given that the pdx pca cells were maintained in mice prior to harvest , the cancer cells were also likely contaminated with mouse - derived cells ( such as blood cells , endothelial cells , or fibroblasts ) , which consequently introduces a source of heterogeneity and complicates downstream biochemical studies .", "furthermore , considering the importance of the tumor microenvironment in influencing tumor behavior , the presence of mouse - derived stroma may confound studies evaluating species - specific stroma - targeting drug candidates , hence making it a major hindrance in current pdx tumor models .", "indeed , while the pca cells formed aggregates in suspension , a population of cells was consistently observed to adhere to the tissue culture plastic surface .", "for example , in mda pca 183 cultures , we found that the adherent cells expressed vimentin and originated from mouse tissue ( figure 1c ) .", "while further characterization is necessary to determine the actual yield of the cancer cells , these results , in conjunction with the observation that epcam , an epithelial cell marker , was near - ubiquitously expressed in all of the hydrogel - encapsulated pdx clusters ( figure 2c ) , highly suggest that the pre - encapsulation 2d culture serves as a desirable selective method to generate viable and enriched pdx pca cells in 3d .", "in this study , we optimized the culture of pdx pca cells in vitro , which to our knowledge is unprecedented .", "while robust growth was limited by a balance between proliferation and apoptosis , viability of the hydrogel - encapsulated pca cells was notably well maintained even up to 14 days in culture ( figure 3 ) .", "ten to 20% of cells within the 3d pdx tumoroids stained positive for ki-67 at day 5 in culture ( figure 4b , c ) , indicating that a subset of cells was still progressing through the cell cycle .", "comparing the proportion of proliferative cells within the 3d mda pca 118b pdx tumoroids to their in vivo counterparts , we found that our estimate of ki-67-positive cells is well within the range of that in vivo .", "we are currently modifying the ha - based hydrogel to study the effects of ecm moieties and other cell types on the growth behavior of the pdx pca tumoroids in 3d culture .", "with the shift in focus from traditional chemotherapy to biologically targeted approaches based on a mechanistic understanding of pca biology , preservation of salient features of the original tumor is a critical criterion in evaluating the success of this culture system as a drug - testing platform .", "to this end the androgen receptor is an important modulator for prostate growth and currently the primary therapeutic target in pca .", "additionally , this nuclear receptor regulates psa expression , which is used clinically as a biochemical marker to track the progression of pca and response to therapy .", "predominantly cytoplasmic in the absence of ligands , ligand binding to the androgen receptor results in conformational changes , nuclear translocation of the ligand - bound receptor , and transcriptional activity .", "mirroring the in vivo tumor , detection of nuclear androgen receptor in the 3d mda pca 183 tumoroids indicates that the ha - sh / peg - da hydrogel system is capable of maintaining critical androgen receptor signaling in these androgen - dependent cells .", "similarly , nuclear androgen receptor was not observed in the 3d mda pca 118b tumoroids as would be expected in in vivo , indicating that these 3d pdx models may have utility as drug - testing platforms evaluating androgen receptor - targeting agents currently under intense clinical investigation .", "drug discovery and screening has historically relied on cancer cell lines , which have generated a wealth of knowledge in cancer biology .", "however , the dichotomy in drug efficacy between preclinical and clinical testing is increasingly apparent , primarily attributed to the genetic and epigenetic changes that accrue when cells acclimatize to the in vitro culture environment in extended periods of cell culture .", "indeed , gillet et al .", "evaluated the multidrug resistance transcriptome of six cancer types and found no correlation between clinical samples and established cell lines , underscoring the need for new in vitro cancer models and primary tumor models .", "hypothesizing that inherent differences exist between traditional pca cell lines and pdx pca tumors , we evaluated the response of the 3d pdx pca tumoroids ( mda pca 183 and 118b ) to docetaxel and compared their response to the c4 - 2b bone metastatic prostate cancer cell line .", "docetaxel is a microtubule stabilizer and is currently part of the first - line standard treatment for metastatic castrate - resistant pca .", "we found that despite the differences between the mda pca 183 and 118b cells in patient origin , their overall drug sensitivity to docetaxel was similar .", "given that both pdx - derived cultures showed a low number of proliferating cells and that docetaxel targets actively dividing cells , it thus was unsurprising that both demonstrated similar resistance to the drug in 3d culture .", "however , interestingly , the 3d pdx pca cells exhibited a significantly higher resistance to the drug as compared to the c4 - 2b cells .", "it is unlikely that the increased resistance is due to impaired diffusion of the drug into the hydrogel since it demonstrated clear efficacy against the hydrogel - encapsulated c4 - 2b cells .", "while results from this drug study are promising , studies are ongoing to establish clinical relevance and understand the mechanisms underlying this difference .", "with the increasing awareness that irreversible biological changes occur when conventional cell lines are established in vitro , beyond prostate cancer , there is general shift toward the use of pdx tumor models for cancer research .", "however , their utility depends on the ability to manipulate the tumor cells ex vivo prior to implantation .", "given the alterations in biological properties associated with 2d culture , a few groups have taken steps to optimize methods to reliably grow primary tumor cells in 3d .", "one such example is in colorectal cancer , where it has been shown that primary colorectal cancer cells can be cultured as 3d spheroids or colospheres in vitro , enabling the manipulation of the cancer cells before engraftment in vivo for controlled studies .", "in our current study , we demonstrate for the first time that primary bone metastatic pca cells can similarly be cultured in vitro with the use of a 3d ha - based hydrogel system .", "lastly , this 3d pdx model may ultimately be adapted to a rapid and high throughput platform for assessing drug efficacy , rational drug combinations , and development of predictive biomarkers for novel targeted therapies , while reducing the need for low throughput animal hosts .", "as an example , we showed here that 3d pdx pca cells exhibited an increased resistance to docetaxel as compared to a standard cell line commonly used in pca research .", "ultimately , it is envisioned that the use of 3d pdx models may greatly accelerate the advancement of novel drug candidates together with predictive biomarkers that enable patient selection when translated into early phase clinical trials .", "on the basis of previous success culturing bone metastatic pca cell lines using 3d ha - based hydrogels , we demonstrate for the first time that never in 2d pdx pca tumors can be cultured in vitro and maintained for at least 2 weeks .", "the resulting hydrogel - encapsulated 3d pdx tumoroids retained viability , proliferative capacity , and the androgen receptor expression , indicating that this novel 3d pdx model may serve as a valuable platform for drug development .", "while it has yet to be tested , this system promises the possibility of culturing tumor tissue directly from the patient for rapid drug screening , thereby eliminating the middle mouse and its associated problems , a major leap toward personalized medicine ." ]

[ "the lack of effective \n therapies for bone metastatic prostate cancer \n ( pca ) underscores the need for accurate models of the disease to enable \n the discovery of new therapeutic targets and to test drug sensitivities \n of individual tumors .", "to this end , \n the patient - derived xenograft ( pdx ) \n pca model using immunocompromised mice was established to model the \n disease with greater fidelity than is possible with currently employed \n cell lines grown on tissue culture plastic .", "however , poorly adherent \n pdx tumor cells exhibit low viability in standard culture , making \n it difficult to manipulate these cells for subsequent controlled mechanistic \n studies .", "to overcome this challenge , we encapsulated pdx tumor cells \n within a three - dimensional hyaluronan - based hydrogel and demonstrated \n that the hydrogel maintains pdx cell viability with continued native \n androgen receptor expression .", "furthermore , a differential sensitivity \n to docetaxel , a chemotherapeutic drug , was observed as compared to \n a traditional pca cell line .", "these findings underscore the potential \n impact of this novel 3d pdx pca model as a diagnostic platform for \n rapid drug evaluation and ultimately push personalized medicine toward \n clinical reality ." ]

[ 7, 15, 19, 132, 133, 141, 163, 177 ]

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