Metabolic syndrome (MetS) is a cluster of four major obesity-related risk factors for cardiovascular disease (CVD). Russia has one of the highest CVD mortality in the world, but its association with MetS remains unknown. Also little is known about factors associated with MetS and its components in Russia.Data on 3555 adults aged 18-90 years were collected in a cross-sectional study in 2000. MetS was defined by the International Diabetes Federation (IDF) and National Cholesterol Education Program (NCEP) criteria. Sex-specific associations between the IDF-defined MetS, its components, and life-style, socio-economic factors and laboratory indicators, were analysed using multivariable Poisson regression. Vital status of the study participants was identified by July 2009. Sex-specific associations between MetS and stroke, Coronary Heart Disease (CHD), CVD and all-cause death, were studied by Poisson regression adjusted for age, smoking, alcohol and history of CVDs.After adjustment for all studied factors except BMI, age, serum GGT, C-reactive protein and AST-to-ALT ratio were associated with MetS in both genders. Additionally, MetS was associated with sedentary lifestyle in women and with smoking in men. In the same regression model drinking alcohol 2-4 times a month and consumption of five or more alcohol units at one occasion in men, and drinking alcohol 5 times or more a month in women were inversely associated with MetS. After a 9-year follow-up, MetS was associated with higher risk of death from stroke  and from either stroke or myocardial infarction  in men. No associations between MetS and any of the studied causes of death were observed in women.Factors associated with MetS in both genders were age, GGT, C-reactive protein, and AST-to-ALT ratio. Moderate frequency of alcohol consumption and binge drinking in men and higher leisure time physical activity in women, were inversely associated with MetS.Positive associations between MetS and mortality were only observed for deaths from stroke and either stroke or MI in men. The metabolic syndrome (MetS) is a cluster of four major cardiovascular disease (CVD) risk factors; obesity, insulin resistance (hyperglycemia), arterial hypertension and dyslipidemia where obesity and insulin resistance are the core elements . Other iMetS is associated with increased CVD and all-cause mortality ,4. MoreoThe prevalence of MetS is associated with life-style, demographic, socio-economic, and genetic factors. Age, body mass index, postmenopausal status, diet rich in saturated fats, carbohydrates, and smoking have been positively associated with MetS, while inverse associations have been shown for physical activity, education, income, and alcohol intake ,10-12.Cardiovascular mortality in Russia is about four times higher than in Western Europe and the gap is the largest among middle aged men . AlthougDespite the fact that determinants of MetS and its contribution to mortality in Europe and North America receive much attention by the research community, it remains one of the least studied factors in Russia. In an earlier study we showed that while the prevalence of MetS among Russian women in 2000 was comparable with findings from other European countries, among men it was a half of that .The aim of this study was to further explore the data collected in 2000 by studying socio-demographic and lifestyle correlates of MetS and associations between the MetS and CVD-and all-cause mortality after 9 years of follow-up.The data were obtained from a cross-sectional population-based study conducted in 2000 in Arkhangelsk, Northwest Russia. Detailed information on study design, sampling procedure and data collection is presented elsewhere -19. In bData on education, occupational status, use of medications, history of myocardial infarction (MI), diabetes mellitus, and stroke as well as typical patterns of leisure time physical activity, smoking, frequency and amount of alcohol consumption, frequency of fresh fruits and vegetables intake with no specified time-frames were collected using a 6-page comprehensive questionnaire. Blood pressure (BP) was measured three times. The average of the two last readings was used in the study. Waist circumference (WC) was measured at the umbilical level. Weight and height were measured with subjects in light clothing and without shoes. Venous blood samples were drawn and centrifuged within 15-25 min. Most of the participants fasted prior to testing.Enzymatic colorimetric tests were used to measure TC  and TG . HDL-C was measured by a homogenous enzymatic colorimetric test . All biochemical analyses of serum lipids were performed using a Hitachi 737 analyzer. Gamma-glutamyltransferase (GGT) was measured by an enzymatic colorimetric test . Aspartate-aminotransferase (AST) and alanin-aminotransferase (ALT) were measured photometrically by Hitachi 917 analyzer. Serum C-reactive protein (CRP) was measured by particle-enhanced immunoturbidimetric assay in a Roche Modular P analyzer . Glycated hemoglobin (HBA1c), which reflects the mean glucose level over the preceding 2-3 months, was assessed by Bio-Rad Variant II HPLC system with reagents from Bio-Rad Laboratories .The inter-assay and intra-assay coefficients of variation for all laboratory tests were under 3%.MetS was defined according to the International Diabetes Federation (IDF)  and Nati2, respectively. As the distribution of the liver enzymes and CRP was right-skewed, we used logarithmically transformed values in the regression models.Education was divided into 3 categories: low (primary or secondary school), average  and high (complete university education). As income level was difficult to determine due to high inflation and collapsing economy due to the crisis and default in 1998-99, we used data on self-reported occupational status as a "surrogate" measure for income. Income level was defined according to official data on average salary levels in different sectors of the economy for year 2000 . Five caAltogether 150 individuals had missing data on one or more variables and were excluded from the analyses. The final sample consisted of 3555 individuals (1918 men and 1637 women) aged 18-90 years or 96% of the initial sample.Differences in the distribution of the studied characteristics between genders were studied by Pearson's chi-squared tests and unpaired t-tests for categorical and continuous data, respectively. Gender-specific associations between MetS defined by the IDF criteria, its individual components and socio-demographic, lifestyle and metabolic factors were calculated using Poisson regression with robust variance estimates as recommended by Barros and Hirakata , and areIn July 2009 we collected data on the vital status of all study participants, using the mortality register of the Arkhangelsk Regional Healthcare Department which is based on data from medical death certificates. Causes of death were coded using the International Classification of Diseases, 10th Revision (ICD-10). The study end-points were: death from coronary heart disease (CHD) (I20-25); death from stroke (I60-64); death from either myocardial infarction (MI) or stroke ; CVD death (I00-99); and all-cause death. By July 2009, 200 subjects of the 3555 participants had died and in 97 of the cases (48%) the diagnosis was verified by autopsy. To study associations between MetS in 2000 and mortality by 2009, we used both IDF and NCEP definitions of MetS to increase comparability of the findings with other studies. Gender-specific risk ratios (RR) were calculated by Poisson regression.All analyses were performed using STATA 10 . The study was approved by the Regional Ethical Committee in Norway.Participants' background characteristics and the prevalence of MetS are presented in Table Among men, MetS was positively associated with age, BMI, sedentary lifestyle, GGT and CRP; and inversely associated with income, smoking, frequency and amount of alcohol intake as well as the AST-to-ALT ratio in the crude analysis. After adjustment for all studied factors except BMI, the associations between MetS and income disappeared. Additional adjustment for BMI attenuated most of the associations except the positive association with age, and inverse associations with the AST-to-ALT ratio, frequency and amount of alcohol consumption Table .In women, MetS was positively associated with BMI, age, very low income, sedentary lifestyle, GGT and CRP, and inversely associated with education, unknown income category, smoking, frequency and amount of alcohol consumption as well as AST-to-ALT ratio in crude analysis. After adjustment for all study factors except BMI, the associations between MetS and income, education, smoking and alcohol disappeared. After further adjustment for BMI, only age, sedentary lifestyle, GGT and CRP remained associated with MetS.In the multivariable analysis of the MetS components Table , frequenSerum levels of GGT and CRP in women were positively related to all five metabolic components Table . High seMetS as defined by the IDF criteria was associated with more than 6 times higher risk of death from stroke among men after 9 years of observation in Table , Model 1The risk of cardiovascular death was almost 2.5 times higher both in men and women with MetS Table , Model 1To the best of our knowledge this is the first study in Russia on determinants of MetS and its association with all-cause and cardiovascular mortality. The main findings suggest that frequency of alcohol consumption and amount of alcohol consumed at one drinking episode are important correlates of MetS in Northwest Russia. Age, sedentary lifestyle and liver enzymes were also associated with MetS independently of all other studied factors. Moreover, MetS was associated with increased risk of death from stroke and either stroke or myocardial infarction among men during the 9-year observation period. The study discloses sex-specific adjusted relationships between frequency and volume of alcohol consumption in Russia , but this association disappeared after adjustment. However, smoking was positively associated with dyslipidemia in both genders and inversely with central adiposity in men. These findings are consistent with previous research suggesting that nicotine increases the energy expenditure, reduces the appetite and stimulates the lipolysis, thus decreasing the risk for obesity . On the Increased serum levels of GGT, CRP and low AST-to-ALT ratio turned out to be independently associated with high metabolic risk, similarly to what has been observed in previous research,24-26. TMetS was associated with an increased risk of stroke-, either stroke or MI-, CVD-and all-cause death during the 9 year follow-up. After adjustment for age and other potential confounders, the risk was still more than 3 times higher for a fatal stroke and more than 2 times higher for death from either stroke or MI among men with MetS. The lack of significant associations between MetS and, CVD-, and, particularly, CHD-death in the adjusted analyses, might be due to heterogeneity of these diagnostic groups. The CHD, for example, included not only diagnoses of fatal myocardial infarction (I21-23) which are clinically well-distinguishable, characterized by progressing atherosclerosis and pathogenetically close to relatively homogenous and clinically well-defined group of cerebral strokes (I60-I64), but also such vaguely defined conditions as "other forms of acute or sub-acute ischemia" (I24) and "chronic ischemic heart disease" (I25). The latest evidences from Russia suggest that alcohol is an important factor implicated in the pathophysiology of the former two causes of death, and that some deaths within these subgroups are actually caused by acute alcohol intoxication or alcohThus, as a cluster of four major CVD risk predictors, MetS represents one of the factors contributing to the high cardiovascular mortality in Russia, but it is unlikely that it plays a central role at present. Following the improvements of living conditions during the last decade, the latest state's anti-alcohol initiatives launched in 2006, and the recent increase in life-expectancy , the preAge, GGT and C-reactive protein, and AST-to-ALT ratio were associated with MetS in both men and women. High leisure time physical activity in women and moderate frequency of alcohol consumption and binge drinking in men were inversely associated with MetS. Differences between men and women in alcohol consumption may explain gender variation in the MetS prevalence. MetS increased the risk of death from stroke and from either myocardial infarction or stroke during the 9-year follow-up period in men while no associations with mortality were found in women.The authors declare that they have no competing interests.OS and ON planned the study and were responsible for collection of data. OS and AG performed data analysis. OS drafted the manuscript, which was further elaborated by AG and ON. All authors read and approved the final version of the manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2458/10/582/prepub


The Metabolic syndrome (MetS) is a cardiovascular risk factor of public health significance and of recent has become a topical issue. The prevalence of diabetes mellitus (DM) is on the increase and with this scenario, a possible increase in burden of DM which may be largely attributed to cardiovascular complications is expected. The objective of this report is to determine the prevalence of the MetS and compare gender characteristics in subjects with type 2 DM.Subjects with type 2 DM were recruited from an urban hospital for the study. Clinical data was obtained by interviewing the patients and referring to their Case folders. The anthropometric indices and blood pressure measurements were documented. Laboratory parameters analysed for included total cholesterol, high density and low density cholesterol, triglyceride and glycosylated haemoglobin. Statistical analysis included usage of Student's t test and chi square.963 patients with type 2 DM aged between 35-85 years were recruited for the study. The main outcome measures included the prevalence of the metabolic syndrome and the gender differences of its components. The prevalence of the metabolic syndrome was 86%. The frequency of occurrence of the MetS was similar for men (83%) and women (86%) and increased with age in both sexes. The prevalence of MetS increased from 11% among participants aged 20 through 29 years to 89% in participants aged 70 through 79. In our patients with DM, the commonest occurring and least detected MetS defining parameters are central obesity and elevated triglyceride levels respectively. The components of the MetS that differed significantly in both sexes was HDL-C. The combination of the components of the MetS were comparable in both genders and 5.8% of the subjects with the MetS had all components of the MetS.The prevalence of the MetS in type 2DM is high in both genders and increases with age thus posing a potential high cardiovascular risk in this group of patients. The modifiable risk factors for the MetS should be a focus point in the management of subjects with type 2 DM, The metabolic syndrome (MetS) is a cluster of cardiovascular risk factors that is characterized by obesity, central obesity, insulin resistance, atherogenic dyslipidemia, and hypertension. AlthougThe prevalence of metabolic syndrome increases with increasing glucose intolerance  and withIn Nigeria, DM is an emerging non-communicable health problem as its prevalence is on the increase. The reported prevalence rates of MetS in Nigerians with and without DM are 22% and 59% respectively.Published reports differ in the gender distribution of the MetS. Whilst some researchers report a higher incidence of the MetS in men ,10 than Subjects with type 2 DM were recruited from the General hospital Gbagada and the Lagos state University Teaching hospitals, Lagos for the study. This report is part of a recent study on lipid profile in DM by the author . DetailsLaboratory assessment included obtaining venous blood samples in a fasted state for the determination of components of the lipid panel , blood glucose and glycosylated haemoglobin levels (HBA1c). Serum glucose was measured using glucose-oxidase method and lipid profile by enzymatic-colorimetric method. Ethical approval was obtained from the Ethical committee of both hospitals and informed consent was obtained from the study subjects.The presence of the metabolic syndrome was determined using the new definition. The preA total of 973 patients with diabetes mellitus were recruited for the study. The females and males were 703 and 260 in number respectively.The mean age of the study subjects was 58.6 10.5) years and the female:male ratio was 3:1. Smoking and alcohol histories were documented in 83 (9%) and 208 (21%) of the subjects. Hypertension was a notable feature which was present in 572 (59%) of the subjects. A summary of the clinical parameters of the study subjects is shown in Table 0.5 years2 vs 27 kg/m2 p = 0.0001, 7 vs 6.5, p = 0.03). The mean HBA1c, Low density lipoprotein (LDL-C) and total cholesterol (TCHOL) were also significantly higher in females than males respectively .A comparison of the clinical and biochemical parameters of both sexes showed that the mean BMI and duration of DM of the female subjects were significantly higher than those of the males  were on oral hypoglycaemic agents, 64 (7%) were on insulin and 108 (11%) and 9(1%) respectively were on combination of insulin and OHA and sole dietary management respectively.The total number of the subjects with the metabolic syndrome was 834 thus giving a prevalence rate of 86%. The most prevalent risk factor was abdominal obesity. The proportions of the defining parameters of MetS are shown in Table 2The distribution of the components of the metabolic syndrome is depicted in Figure For two components, the most frequent combinations were central obesity and reduced HDL-C (51.6% in women and 57.5% in men), for three components, the most frequent combinations were central obesity, hypertension and reduced HDL- (42.2% in women and 37.8% in men) and for four components (6.2% in women and 4.5% in men).The proportion of the males with the MetS was comparable to that of the females with the MetS  The mean duration of DM was comparable in both sexes (7.1(6.2) vs 6.5(6.6) p-0.1). The overall prevalence of hypertension was 67% and the proportion of females with it was significantly higher than that of the males. . Smoking and alcohol histories were documented more in males than females and these differences were statistically significant (for smoking 11 (2%) vs 60 (27%) p 0.0000001. alcohol history (71 (12%) vs 105 (47%) p-0.00001)The pattern of lipid abnormalities showed that elevated LDL-C and reduced HDL-C were the commonly documented lipid abnormalities. This is shown in Figure The frequency of occurrence prevalence of the metabolic syndrome increased with age. The proportions of subjects with the metabolic syndrome in each age class is shown in Table 3The age specific distribution of the MetS was comparable in both genders except in ages 70 through 79.9. These results are shown in Figure The proportion of women with the MetS who had elevated blood pressure was significantly higher than men who had same (431 (76% vs 135 (61%), p = 0.01). Females with the metabolic syndrome tended to have higher total cholesterol and LDL-cholesterol than the males with the metabolic syndrome. A comparison of other clinical and biochemical parameters in both genders with the MetS is shown in Table 4The subjects with the metabolic syndrome tended to be older and their mean LDL-C was higher than that of the subjects without the metabolic syndrome. The clinical and biochemical parameters are shown in Table The MetS is a cluster of cardiovascular risk factors including obesity, hypertension and dyslipidaemia that increases the risk of the development of type 2 diabetes mellitus and cardiovascular disease. The risk factors of MetS include obesity, aging, sedentary lifestyle, diabetes mellitus, coronary heart disease and lipodystrophy ,15. It iThere are currently two major definitions for metabolic syndrome and these are provided by the International Diabetes Federation and the The components of the metabolic syndrome vary in their rates of occurrence. The Seychelles study reThe pattern of lipid abnormalities in this study was such that LDL-C although not a component of MetS was the commonest documented lipid abnormality in subjects with the MetS. The occurrence of elevated LDL-C in people with the Mets has been noted to increase the magnitude of the risk for developing coronary artery disease. I reporGender differences were also documented in the occurrence of hypertension in the metabolic syndrome. We report a prevalence rate of hypertension of 67%. This is similar to reports to reports from the Middle East and NigeAlthough each of the components of the metabolic syndrome individually have been identified as risk factors for cardiovascular disease, an individual with three or more components is at particularly high risk. I report a comparable distribution of the components of the MetS in both sexes. A small proportion-5.8% -of our subjects with type 2 DM have all the components of the MetS. This is in contradistinction to the report by Fezeu et al who repoA comparison of biochemical parameters other than those that define the MetS in both sexes showed that subjects with the MetS were significantly older, had higher body mass indices and higher low density cholesterol than those without the MetS.This study has shown the unacceptably high prevalence rate of MetS in both sexes with type 2 DM thus predicting a high disease burden of type 2 DM from possible cardiovascular complications.The authors declare that they have no competing interests.AOO designed the study, participated in data collation, statistical analysis, funding and writing the draft of the manuscript


Although diabetic patients have an increased rate of cardio-vascular events, there is considerable heterogeneity with respect to cardiovascular risk, requiring new approaches to individual cardiovascular risk factor assessment. In this study we used whole body-MR-angiography (WB-MRA) to assess the degree of atherosclerosis in patients with long-standing diabetes and to determine the association between metabolic syndrome (MetS) and atherosclerotic burden.Long standing (≥10 years) type 1 and type 2 diabetic patients  were examined by WB-MRA. Based on the findings in each vessel, we developed an overall score representing the patient's vascular atherosclerotic burden (MRI-score). The score's association with components of the MetS was assessed.2 = 0.24, p = 0.038). Finally, using an established risk algorithm, we found a significant association between MRI-score and 10-year risk for CHD, fatal CHD and stroke.The median MRI-score was 1.18 [range: 1.00-2.41] and MetS was present in 58% of the cohort . Age (p = 0.0002), HDL-cholesterol (p = 0.016), hypertension (p = 0.0008), nephropathy (p = 0.0093), CHD (p = 0.001) and MetS (p = 0.0011) were significantly associated with the score. Adjusted for age and sex, the score was significantly (p = 0.02) higher in diabetics with MetS (1.450 [1.328-1.572]) compared to those without MetS (1.108 [0.966-1.50]). The number of MetS components was associated with a linear increase in the MRI-score (increase in score: 0.09/MetS component; rIn this high-risk diabetic population, WB-MRA revealed large heterogeneity in the degree of systemic atherosclerosis. Presence and number of traits of the MetS are associated with the extent of atherosclerotic burden. These results support the perspective that diabetic patients are a heterogeneous population with increased but varying prevalence of atherosclerosis and risk. Today diabetes mellitus is often classified as a coronary heart disease (CHD) equivalent , which hHence the MetS has become the center of an intensive debate due to different and changing definitions, lack of a unifying pathophysiological concept, disputed predictive value regarding CHD and uncertain specific therapeutic consequences ,15,16. WPreviously we have used whole-body magnetic resonance angiography (WB-MRA) in patients with long-standing type 1 or type 2 diabetes to obtain comprehensive vascular imaging (except coronaries) . In our The original study included 65 patients with type 1 (T1DM) or type 2 (T2DM) diabetes of more than 10 years which was published previously . The par2 to avoid nephrogenic systemic fibrosis (NSF) [Inclusion criteria were diagnosis of type 1 or type 2 diabetes mellitus of >10 years duration. Exclusion criteria were pregnancy, allergic reaction to Gadolinium-chelates and a creatinine clearance <30 ml/min per 1.73 mis (NSF) . CreatinAt the time of inclusion, a number of parameters were registered including age, sex, type and duration of diabetes, smoking history, body mass index (BMI), blood pressure, HbA1c, triglycerides, low density lipoprotein (LDL)-cholesterol, high density lipoprotein (HDL)-cholesterol and creatinine. CHD status was assessed, defined as documented history of myocardial infarction, stenosis of >50% on coronary angiogram, coronary intervention or bypass grafting. All patients received the whole body MRI in the Department of Radiology within 3 months after recording the above mentioned parameters.2) was used instead of waist circumference. MetS was diagnosed when in addition to diabetes two or more of these traits were present.The MetS was identified according to the definition of the American Heart Association and the National Heart, Lung, and Blood Institute (AHA/NHBLI) : triglyc® .MR imaging studies were performed as described previously on a 1.5 T and 3 T whole body MR system  equipped with 32 receiver channels . Twelve First a time-of-flight (TOF)-MR angiogram of the cerebral arteries with a spatial resolution of 0.7 × 0.5 × 0.7 mm was acquired. Then 3D-Gd-MR-angiography of the carotids , the abdominal aorta , the thighs , the calves and pedal arteries  was obtained. The same scanning parameters and spatial resolutions were used at 1.5 T and 3 T. A time-resolved CE-sequence of the lower calf and pedal arteries  was performed after repositioning the patient in order to compensate for a shortened range of table movement in the Magnetom Trio and to increase diagnostic accuracy.The MR exams of the diabetic group were evaluated by two experienced radiologists who were blinded to all clinical information, in a consensus reading. The cases were presented in groups of five cases per reading session in randomized order over a time period of four weeks. MRA data sets were evaluated by multiplanar reformats (MPR) and small volume maximum intensity projections (thin MIP) for detection of stenosis as well as volume-rendering (INSPACE) for detection of anatomic variants. There were 22 segments analyzed and all but the abdominal aorta and circle of Willis were bilateral . They inAs previously published we have created a new scoring system for the degree of atherosclerotic disease burden found in the diabetic patients, entitled the "vessel score" . The vesContinuous variables were described with mean ± standard deviation or median and range. Chi-squared tests were used to test for simple associations between dichotomous variables. Correlation between continuous variables was tested with the Spearman rank correlation. Differences between the mean were tested with a t-test. A general linear model (GLM) was used to test for associations between the score and other variables after adjustment for age and sex. A p-value of <0.05 indicated significance. SAS 9.1 was used for statistical evaluation.Fifty nine patients  with long standing  type 1 (n = 19) or type 2 (n = 40) diabetes were examined by MRA .MetS was present in 58% (n = 34) of the patients  with no sex difference. Patients without MetS were considerably younger (56 ± 16 yr vs. 69 ± 8 yr). All patients with the MetS had hypertension or anti-hypertensive medication due to diagnosed hypertension, 26 had high triglycerides, 22 had low HDL-cholesterol and 14 patients had a BMI >30 kg/m2 = 0.24, p = 0.038 adjusted for age and sex, figure Patients with MetS had a higher mean score than those without MetS . This association remained significant (p = 0.02) after adjustment for age and sex. Furthermore, we found a dose-response relationship between the number of MetS components and the MRA-score  risk engine . ConsistDuring the last 10 years the classification of diabetes as a CHD equivalent has helped to improve standards of diabetes care by underlining the importance of cardiovascular risk factor management . HoweverDespite the general high risk of the population with an average diabetes duration of 20.7 years and additional cardiovascular risk factors in many patients, we found very pronounced differences in the degree of atherosclerotic burden. The WB-MRA based score ranged from 1.00 to 2.41 with a median of 1.18. More than one third of the population (n = 22) had a score value of 1.00, indicating that these patients had no atherosclerotic changes or at most wall irregularities in all scanned vessels. In contrast, all patients with a score above 2.0 (n = 5) had at least 3 completely occluded vessels and several other stenotic lesions. These results are in line with the perspective of diabetic patients as a heterogeneous population with increased but variable prevalence of atherosclerosis and cardiovascular events ,26.In our study population a high score was significantly associated with age, HDL-cholesterol, MetS and CHD status. The number of components of the MetS was associated with a linear increase in the MRI-score. Furthermore, consistent with previous reports evaluating MRI-based atherosclerosis scores ,28, a hiDespite significant progress in recent years with respect to risk factor modification particularly through the use of lipid lowering agents and drugs targeting the renin-angiotensin system , severalThere are several limitations to our study. First the prognostic significance of the detected vascular lesions is uncertain, due to the lack of follow up data. The association with the UKPDS risk calculations also must be interpreted with caution since the risk engine is not validated for a diabetes duration of >20 years and has an uncertain validity for patients with established cardiovascular disease, although only patients with acute cardiovascular disease were excluded in the original UPKDS study . FurtherIn conclusion our results contribute further evidence to the perspective of diabetic patients as a heterogeneous population with increased but varying prevalence of cardiovascular disease and risk. In our study, presence of the Metabolic Syndrome and the number of its traits helped to identify those patients with the largest atherosclerotic burden. Further research is needed to improve the characterization of risk in diabetic patients and to adapt the treatment guidelines to different risk classes.The authors declare that they have no competing interests.HMF recruited study participants, collected patient history, performed data analysis, and drafted the manuscript. SW and SOS performed MRA data analysis and participated in designing the study, and critically revising the manuscript. RS performed the statistical analysis. MR participated in designing the study and revising the manuscript. KGP participated in designing the study, data analysis, performing the statistical analysis, and drafting the manuscript. All authors read and approved the final manuscript.


This Finnish population-based study, mean age 46 years, evaluates the association of high-sensitivity C-reactive protein (hs-CRP), interleukin-1 receptor antagonist (IL-1Ra), andadiponectin with the NCEP and IDF definitions of metabolicsyndrome (MetS). Adiponectin levels were higher, hs-CRP and IL-1Ralevels lower in subjects without MetS compared to subjects withMetS. If MetS was present according to both IDF and NCEP criteria,BMI, waist, triglycerides, hs-CRP, and IL-1Ra were significantlyhigher compared to subjects who had MetS according to either onlyIDF or only NCEP criteria. The hs-CRP, IL-1Ra, and adiponectin linearlycorrelated with the number of the components of MetS according toboth definitions. Decreased levels of adiponectin and increasedlevels of hs-CRP and IL-1Ra are tightly associated with thecomponents of MetS. Individuals who had MetS according to bothcriteria had the most adverse changes in cardiovascular riskfactors. Metabolic syndrome (MetS) means a clustering of multiple cardiovascular risk factors in an individual. Several definitions of this syndrome have been presented. The first definition was given by the World Health Organization (WHO) in 1999. Theprimary aim of this definition was to identify individuals with high risk for cardiovascular disease (CVD) [The National Cholesterol Education Program (NCEP) Adult Treatment Panel III introduced a new definition for the MetS in 2001 [ociation . The purociation , 5. It iAdipose tissue has also shown to be an active endocrine organ secreting many hormones and mediators regulating glucose metabolism and the risk of CVD. One of these hormones is adiponectin that has been found to be decreased in individuals with obesity, the MetS, and type-2 diabetes , 7. AdipObesity is an inflammatory condition which may lead to chronic activation of the innate immune system, which in turn could cause a progressive impairment of glucose tolerance and lead to diabetes or CVD , 10. In criteria . Based ocriteria , 20.Interleukin-1 receptorantagonist (IL-1Ra), a naturally occurring antagonist of the proinflammatory cytokines IL- process , and it  process . IL-1Rary state . Thus, lNo previous studies have been published on the role of hs-CRP, IL-1Ra, and adiponectin in relation to different definitions of the MetS in the same population. The aim of the present study was to evaluate the inflammatory differences and associations between the inflammatory markers and adiponectin with the MetS according to the NCEP and the IDF definitions.Thestudy population consisted of middle-aged Caucasian subjects Altogether 923 of 1294 subjects  100 methods . Glucose concentration was measured by automated colorimetric method. Serumcholesterol and triglycerides were measured from fresh serum samples withenzymatic colorimeter methods . Serum HDL cholesterol was measured using the same methods afterthe precipitation of low-density cholesterol and very low-density lipoprotein cholesterol byphosphotungstic acid and magnesium.Serum adiponectin was determinedwith an enzyme immunoassay . Plasma concentration of IL-1Ra was measured withhigh-sensitivity assay kits from R&D Systems. hs-CRP wasmeasured with an Immulite analyzer and a DPC high-sensitivity CRP assay(hs-CRP). Adiponectin, hs-CRP, and IL-1Ra were measured in 2002 at thesame time. Before this measurement, the samples werefrozen andstored atIn this study, we used the quantitative insulin sensitivitycheck index (QUICKI) as a marker of insulin sensitivity. It is an alternativemethod to measure insulin sensitivity in large population studies and wascalculated as follows: QUICKI = 1/(log FPI + log FBG), where FPI = fastingplasma insulin level expressed as mU/l, and FBG = fasting plasma glucose levelexpressed as mg/dL .The results are expressed as meanropriate . Theagrf κ>0.80 .Altogether 923 of 1294 invited subjects  compared to subjects who had the MetS according to only one definition. Furthermore, the only-IDF definition group of the MetS had higher levels of hs-CRP and IL-1Ra compared tothe group with only-NCEP definition, probably due to abdominalobesity as the central criterion for the syndrome. The same strongerrelationship with the IDF definition compared to the NCEP was found in Chinespopulation with hs-CRP . SubjectExcess adipose tissue can contribute to inflammation inseveral ways. First, ectopic fat storage induces lipotoxicity promotingintracellular inflammatory response or altered adipokine production . Second,Our study confirmedthat levels of adiponectin, hs-CRP, and IL-1Ra were similarly and linearlycorrelated with the number of components of the MetS according to the IDF andNCEP definitions in both genders. Similar results have been reported previouslywith respect to levels of hs-CRP ,34, 35 The prevalence of the MetS was  Finland. The preThe strength of our study is that it includes asubstantial number of subjects selected from 5 different age groups without anyexclusion criteria in the same town. Therefore, we could reliably compare thecorrelations of IL-1Ra with hs-CRP and adiponectin in the same studypopulation, which is fairly homogeneous regarding age, BMI, andorigin. We could demonstrate that IL-Ra is correlated with Mets similarly as hs-CRPand adiponectin. The limitation of our study is that we measured totaladiponectin, but not the high molecular weight (HMW) multimer of adiponectin,which has been shown to be a better marker for the MetS than is the totaladiponectin level ,45.Weconclude that decreased levels of adiponectin and increased levels of hs-CRP and IL-1Ra possibly reflect the same phenomenon, and correlate linearly with the number of the components of the MetS according to the IDF and NCEP definitions. The levels of inflammatory markers (hs-CRP and IL-1Ra) are higher among patients with MetS defined only by the IDF definition compared to the only NCEP defined ones. More longitudinal follow-up studies are needed to investigate whether or not these new markers of the MetS increase the predictive power with respect to future risk of type-2diabetes and CVD in different populations.


The metabolic syndrome (MetS) is associated with the presence of low grade inflammation. Our aim was to analyze the inter-relations between each of the components of the metabolic syndrome (MetS) and four inflammatory markers, namely high sensitivity C-reactive protein (hs-CRP), the erythrocyte sedimentation rate, the concentration of fibrinogen and the white blood cell count.We have analyzed data collected between September 2002 and June 2009 in the Tel-Aviv medical center inflammation survey (TAMCIS). We recruited both apparently healthy individuals and individuals presenting with atherothrombotic risk factors. All participants were enrolled during their routine annual health check-up and gave their written informed consent. This is a cross sectional study in which we have fitted linear regression models using inflammatory markers as the dependant variables and adjust them according to the different components of the MetS and multiple other confounders.Included were 12,072 individuals of whom there were 7,760 men at a mean (S.D.) age of 44 (11) years, and 4,312 women aged 44 (11) years. A significant correlation was noted between most components of the MetS and all inflammatory markers, the most significant one being with hs-CRP. In the multi-adjusted regression analysis, waist was the factor that best explained the variability of hs-CRP, in both women and men. It also remained a significant variable for the other inflammatory markers.From amongst the various components of the MetS, waist circumference appears to exert the most influence upon the presence and intensity of the micro-inflammatory response. The metabolic syndrome (MetS) is associated with the presence of a low grade sub-clinical inflammatory process, so called micro-inflammation -7. The rIn order to evaluate the contribution of the MetS components  to the micro-inflammatory process, this cross sectional study has analyzed the strength of the association between each MetS component and four established inflammatory markers. The relative influence of the components of the MetS on these inflammatory markers may be of clinical significance aiding in the establishment of clinical guidelines for health care providers as well to public health policy makers.In the present study we analyzed the data collected at the Tel-Aviv Medical Center Inflammation Survey (TAMCIS), a registered data bank of the Israeli Ministry of Justice -20. ThisBlood samples were drawn in the morning hours, after a 12-h overnight fast. The WBCC and differential were performed using the Coulter STKS  electronic analyzer, while fibrinogen concentrations were determined by the method of Clauss and a SyThe results of the routine health check-up were evaluated by employing certain definitions of the various atherothrombotic risk factors. Diabetes mellitus was defined as a fasting blood glucose level of ≥ 126 mg/dl (7 mmol/L) or treatment with insulin or oral hypoglycemic medications. Hypertension was defined as displaying with blood pressure of ≥ 140/90 mmHg in two separate measurements or the intake of anti-hypertensive medications. Dyslipidemia was defined as the low density lipoprotein cholesterol (LDL-C) or non- high density lipoprotein cholesterol (non-HDL-C) concentrations, for individuals displaying elevated triglyceride concentrations of ≥ 200 mg/dl (2.26 mmol/l) above the recommended levels, according to the risk profile defined by the updated adult treatment panel III (ATP III) recommendations, or the All data was summarized and displayed as mean ± standard deviation (SD) for the continuous variables and as number of patients plus the percentage in each group for categorical variables. Since hs-CRP, ESR and the triglyceride concentrations display irregular distributions, we used a logarithmic transformation which converted the distributions to normal ones for all statistical procedures. Therefore, all results of hs-CRP, ESR or triglyceride concentrations are expressed as back transformed geometrical means and standard deviations. The One-Way Kolmogorov-Smirnov test was used to assess the distributions. For all categorical variables the Chi-Square statistic was used to assess the statistical significance between the two genders. Pearson partial correlations for confounding variables were used to evaluate the age adjusted association between the various components of the MetS and the inflammatory variables. In order to assess and compare the contribution of the different components of the MetS to the variability of the various inflammatory variables, we used linear regression models. The inflammatory variables were the dependent variables and the different components of the MetS, as well as other potential confounders, were the covariates. The confounders included age, history of proven atherothrombotic disease , smoking status, alcohol consumption, level of physical activity and medication with potential influence on the inflammatory markers and/or the metabolic components such as angiotensin converting enzyme (ACE) inhibitors, angiotensin II receptor blockers, statins, fibrates and aspirin, as well as hormone replacement therapy or oral contraceptives in females. In an attempt to adjust for the association between the inflammatory variables (mainly hs-CRP) and obesity, we repeated the correlations and the linear regression models with additional adjustment for BMI. All above analyses were considered significant at p < 0.05 (two tailed). The statistical package for the Social Sciences (SPSS) was used to perform all statistical evaluation .We have presently analyzed a total of 7,760 men at a mean (S.D.) age of 44 11) years (range 18-83) and 4,312 women aged 44 (11) years (range 18-77). The frequencies of the different components per each participant are described in Table 1 years (The present analysis has shown that amongst the various components of the MetS, waist circumference is the component that most significantly influences the micro-inflammatory response. Invariably, Waist and BMI are used inter-changeably in the definition of the metabolic syndrome and there is in fact a strong association between them. Due to this association, adjusting for waist and BMI together causes problematic co-linearity. However, it must be noted that waist circumference still remained the most significant predictor of the inflammatory response even after additional adjustment for BMI. There is a known association between the MetS and the presence of micro-inflammation -34 but tThe prevalence of the MetS in our cohort was relatively low. In fact only 9.6% of women and 11.7% of men had three MetS components or more. One possible explanation for this is the fact that this study was performed in a group of relatively healthy individuals. However, this population could represent those individuals that are still not affected by the results of long standing atherosclerotic disease and might therefore benefit from preventive interventions. In addition, it should be stressed that we did not limit ourselves to individuals with an established diagnosis of MetS. We wanted to discover the relationship between the presence of micro-inflammation and changes in each individual component of the MetS, even in individuals without defined MetS. Theoretically, our findings can be used to support the recent report by Arnlov et al  that havIn conclusion, a clarification of the relationship between each MetS component and the intensity of the micro-inflammatory response may be of clinical relevance. Such a clarification might help to highlight the importance of targeted interventions such as weight reduction, a measure previously proved to be clearly beneficial ,41.The authors declare that they have no competing interests.OR and AS have participated in the design of the study, performed the statistical analyses and drafted the paper. SB and IS conceived the study, participated in its design and coordination and helped to draft and review the manuscript. TF, TC and OKB helped in the data organization and retrieval, English editing and final draft preparation. All of the authors have read and approved the final manuscript.


To report clinical efficacy and toxicity of fractionated CyberKnife radiosurgery for the treatment of hilar lung tumors.Patients presenting with primary and metastatic hilar lung tumors, treated using the CyberKnife system with Synchrony fiducial tracking technology, were retrospectively reviewed. Hilar location was defined as abutting or invading a mainstem bronchus. Fiducial markers were implanted by conventional bronchoscopy within or adjacent to tumors to serve as targeting references. A prescribed dose of 30 to 40 Gy to the gross tumor volume (GTV) was delivered in 5 fractions. Clinical examination and PET/CT imaging were performed at 3 to 6-month follow-up intervals.Twenty patients were accrued over a 4 year period. Three had primary hilar lung tumors and 17 had hilar lung metastases. The median GTV was 73 cc (range 23-324 cc). The median dose to the GTV was 35 Gy , delivered in 5 fractions over 5 to 8 days . The resulting mean maximum point doses delivered to the esophagus and mainstem bronchus were 25 Gy  and 42 Gy , respectively. Of the 17 evaluable patients with 3 - 6 month follow-up, 4 patients had a partial response and 13 patients had stable disease. AAT t a median follow-up of 10 months, the 1-year Kaplan-Meier local control and overall survival estimates were 63% and 54%, respectively. Toxicities included one patient experiencing grade II radiation esophagitis and one patient experiencing grade III radiation pneumonitis. One patient with gross endobronchial tumor within the mainstem bronchus developed a bronchial fistula and died after receiving a maximum bronchus dose of 49 Gy.CyberKnife radiosurgery is an effective palliative treatment option for hilar lung tumors, but local control is poor at one year. Maximum point doses to critical structures may be used as a guide for limiting toxicities. Preliminary results suggest that dose escalation alone is unlikely to enhance the therapeutic ratio of hilar lung tumors and novel approaches, such as further defining the patient population or employing the use of radiation sensitizers, should be investigated. Patients presenting with inoperable lung tumors are generally treated with conventionally fractionated radiotherapy. To improve local control and survival, researchers in the past decade have explored various means of delivering high doses of radiation in shorter intervals . Lung tu® System  has been successfully employed at Georgetown University Hospital since early 2002 to treat stationary extracranial tumors [The CyberKnifel tumors . With thl tumors ,20. HereThis retrospective review of an established departmental treatment policy was approved by the Georgetown University institutional review board. Consecutively treated patients between October 2005 and October 2009 with pathologically confirmed inoperable primary hilar lung cancers or hilar lung metastases were reviewed. A tumor was considered a "hilar lung tumor" if it abutted or invaded the mainstem bronchus. Baseline studies included PET/CT imaging with iodinated IV contrast as clinically feasible.Tracking based on translational and rotational target information requires the use of a minimum of 3 non-collinear fiducials to be visible on the orthogonal images of the CyberKnife x-ray targeting system. Three to five gold fiducials measuring 0.8-1 mm in diameter by 3-7 mm in length  were placed in or near the tumors via bronchoscopy as previously described .Fine-cut 1.25 mm) treatment planning CT's were obtained following fiducial placement during a full inhalation breath hold with the patient in the supine treatment position. Gross tumor volumes (GTV) were contoured utilizing mediastinal windows. A treatment plan was generated using the TPS 5.2.1 non-isocentric, inverse-planning algorithm with tissue density heterogeneity corrections for lung based on an effective depth correction. The radiation dose was divided into 5 equal fractions of 6 to 8 Gy, prescribed to an isodose line that covered at least 95% of the planning treatment volume (PTV = GTV). Guidelines for dose limits to critical central thoracic structures are provided in Table .25 mm trPatients were treated in the supine position with their arms at their sides. A form-fitting vest containing 3 red light-emitting surface markers was attached to the surface of the patient's anterior torso in the region of maximum chest and upper abdominal respiratory excursion. These markers projected to an adjustable camera array in the treatment room. Precise patient positioning was accomplished utilizing the automated patient positioning system. The internal fiducials were located using orthogonal x-ray images acquired with ceiling-mounted diagnostic x-ray sources and corresponding amorphous silicon image detectors secured to the floor on either side of the patient.Prior to initiating treatment, an adaptive correlation model was created between the fiducial positions as periodically imaged by the x-ray targeting system and the light-emitting markers as continuously imaged by the camera array. During treatment delivery the tumor position was tracked using the live camera array signal and correlation model, and the linear accelerator was moved by the robotic arm in real time to maintain alignment with the tumor. Fiducials were imaged prior to the delivery of every third beam for treatment verification and to update the correlation model.Patients were followed with physical examination and PET/CT imaging at 3 to 6 month intervals. Local tumor recurrence was defined as progression of the treated tumor on PET/CT imaging. Biopsies were obtained when clinically indicated. Early treatment response was defined by the Response Evaluation Criteria in Solid Tumors (RECIST) Committee . ToxicitStatistical analysis was performed with the MedCalc 11.1 statistical package. The follow-up duration was defined as the time from the date of completion of treatment to the last date of follow-up or the date of death. Actuarial local control and overall survival were calculated using the Kaplan-Meier method.Twenty consecutive patients (10 men and 10 women) were treated over a 4-year period Table . Three pTreatment plans were composed of hundreds of pencil beams delivered using a single 20 to 40-mm diameter collimator . Radiation was delivered in 5 equal fractions of 6 to 8 Gy each to a median prescription isodose line of 76% . The median dose delivered to the prescription isodose line over an average of 6 days  was 35 Gy . The resulting mean maximum point doses delivered to the esophagus and mainstem bronchus were 25 Gy  and 42 Gy , respectively.All patients underwent clinical follow-up, and 14 patients reported symptomatic relief within 1 month of treatment and 2 patients reported relief by 4 months. Of the 17 patients with early radiographic follow-up, 4 patients experienced partial responses and 13 patients had stable disease at 3 - 6 months. There was no local disease progression within the 6-month follow-up interval. Furthermore, 13 patients with serial PET/CT imaging exhibited early declines in the maximum standardized uptake values  and a high maximum esophageal point dose approaching the limit of 40 Gy. A second patient with severe COPD and progressing metastatic NSCLC developed dyspnea and an infiltrate on CT corresponding to the high dose treatment volume 8 months following CyberKnife treatment (40 Gy). He required temporary supplemental oxygen and his symptoms resolved with conservative treatment over a 4 day hospital stay. Finally, a patient with advanced mesothelioma developed a mainstem bronchus fistula 7 months following treatment and died  and the mainstem bronchus received a maximum point dose of 49 Gy.Strict maximum point dose constraints were maintained for normal tissues. Immediately following treatment, mild brief fatigue was reported by the majority of patients. Acute Grade II esophagitis, requiring brief hospitalization for IV hydration, was observed in 1 patient with renal cell carcinoma presenting with a relatively large GTV (182 cmd Figure . He was Continuous tracking of respiratory tumor motion and precise beam alignment throughout treatment permits greater dose conformality to the tumor contour and a sharp dose gradient ,24. We oPrior to proceeding with our institutional study of CyberKnife radiosurgery for hilar lung tumors, maturing data of others suggested that critical central thoracic structures tolerate high-dose hypofractionated radiation poorly . In a phDespite the short survival of treated patients and the aggressive radiation doses used, local control at 1 year was a disappointing 63%. However, in light of dose limiting major bronchus, lung, and esophageal toxicity, further dose escalation beyond 40 Gy is not a feasible approach to improve local control in hilar tumors with a significant endobronchial component. Additional clinical trials that exclude patients with gross mainstem endobronchial disease will be necessary to define the appropriate patient characteristics and doses. Alternatively, this study provides support for investigation of novel radiation sensitizers to enhance the therapeutic ratio of hilar lung tumor radiosurgery.Hilar lung tumor patients may be treated with frameless stereotactic radiosurgery, resulting in encouraging early clinical responses, acceptable acute toxicity and reliable palliation. However, local control at 1 year remains poor despite aggressive radiation doses and life threatening late toxicity has been reported, especially for tumors with a significant endobronchial component. We propose additional clinical investigation optimizing patient selection and consideration of novel combination treatments with radiation sensitizing drugs.MAX: maximum standardized uptake value;CT: computed tomography; GTV: gross tumor volume; GY: Gray; NSCLC: non-small cell lung cancer; PET: positron emission tomography; PTV: planning treatment volume; and SUVBC is an Accuray clinical consultant. EA is paid by Accuray to give lectures.KU participated in data collection, data analysis and manuscript drafting and manuscript revision. AJ participated in data collection, data analysis and manuscript revision. EO participated in data collection, data analysis and manuscript revision. SS created tables and figures and participated in data analysis and manuscript revision. XY participated in treatment planning, data collection and data analysis. SV participated in data collection, data analysis and manuscript revision. DS participated in data analysis and manuscript revision. KWH participated in treatment planning, data analysis and manuscript revision. SC prepared the manuscript for submission, participated in treatment planning, data collection, data analysis and manuscript revision. AD participated in data analysis and manuscript revision. EA participated in treatment planning, data collection, data analysis and manuscript revision. BC drafted the manuscript, participated in treatment planning, data collection and data analysis. All authors have read and approved the final manuscript.


With conventional radiation technique alone, it is difficult to deliver radical treatment (≥ 60 Gy) to gliomas that are close to critical structures without incurring the risk of late radiation induced complications. Temozolomide-related improvements in high-grade glioma survival have placed a higher premium on optimal radiation therapy delivery. We investigated the safety and efficacy of utilizing highly conformal and precise CyberKnife radiotherapy to enhance conventional radiotherapy in the treatment of high grade glioma.® image-guided radiosurgical system. The majority of patients (88%) received concurrent and/or adjuvant Temozolmide.Between January 2002 and January 2009, 24 patients with good performance status and high-grade gliomas in close proximity to critical structures  were treated with the CyberKnife. All patients received conventional radiation therapy following tumor resection, with a median dose of 50 Gy (range: 40 - 50.4 Gy). Subsequently, an additional dose of 10 Gy was delivered in 5 successive 2 Gy daily fractions utilizing the CyberKnifeDuring CyberKnife treatments, the mean number of radiation beams utilized was 173 and the mean number of verification images was 58. Among the 24 patients, the mean clinical treatment volume was 174 cc, the mean prescription isodose line was 73% and the mean percent target coverage was 94%. At a median follow-up of 23 months for the glioblastoma multiforme cohort, the median survival was 18 months and the two-year survival rate was 37%. At a median follow-up of 63 months for the anaplastic glioma cohort, the median survival has not been reached and the 4-year survival rate was 71%. There have been no severe late complications referable to this radiation regimen in these patients.We utilized fractionated CyberKnife radiotherapy as an adjunct to conventional radiation to improve the targeting accuracy of high-grade glioma radiation treatment. This technique was safe, effective and allowed for optimal dose-delivery in our patients. The value of image-guided radiation therapy for the treatment of high-grade gliomas deserves further study. High-grade gliomas are generally aggressive tumors with poor prognosis . They tePresently, it is our clinical practice to treat high-grade glioma patients with maximum safe surgery followed by 6 weeks of chemoradiation . It has been generally feasible with conventional radiation technique to deliver such "full dose" treatment while respecting institutional peritumoral critical structure maximum point dose tolerances Table . However®, a commercially available frameless image-guided radiosurgery system , was installed at Georgetown University Hospital in late 2001. Standard components include a light weight linear accelerator, a robotic manipulator and an automated x-ray image-guided computer targeting system. Generally, the treatment planning system with input from the user selects hundreds of small non-isocentric circular radiation beams to deliver a highly conformal radiation treatment with steep dose gradients to a defined target in order to spare normal tissues [The CyberKnife tissues ,18. SubsPatients with newly diagnosed resected unifocal high-grade gliomas (WHO Grade III and VI) in close proximity (<1 cm) to critical structures Table  were evaThe extent of surgical resection was documented as total tumor resection or subtotal tumor resection following review of operative reports and post operative MRI imaging Table . SalvagePatients were placed in the supine treatment position with their heads resting on a standard support. A custom thermoplastic mask was crafted. Thin-sliced (1.25 mm) high-resolution CT images were obtained through the cranium for conventional and CyberKnife treatment planning. Treatment planning MRI imaging was completed selectively to enhance target and critical structure delineation when clinically indicated. Target volumes and critical structures were contoured by team neurosurgeons. Treatment volumes were generous including the contrast enhancing tumor volume when present and the surgical defect with a 3 cm margin. Critical structures in close proximity to the target volume were not excluded from the treatment volume during conventional radiation treatment. Forty to 50.4 Gy was delivered in 1.8 to 2.0 Gy fractions 5 days a week for a total of 4 to 5 1/2 weeks. Treatment was delivered using linear accelerators with nominal energies ≥ 6 MV. Intensity modulated radiation therapy (IMRT) technique was not permitted.® radiosurgical system for cranial tumors have been described in detail [® radiosurgical system. An inverse planning method with non-isocenteric technique was used. The treating physician and physicist input the specific treatment criteria, limiting the maximum dose to critical structures  describes the uniformity of dose within a treated target volume, and is directly calculated from the prescription isodose line chosen to cover the margin of the tumor:HI = Maximum dose/prescription doseThe new conformity index (NCI) as formulated by Paddick , and modPTC = The percentage of the target volume covered by the prescription isodose line.Image-guided radiosurgery was employed to eliminate the need for stereotactic frame fixation. Using computed tomography planning, target volume locations were related to cranial landmarks. With the assumption that the target position is fixed within the cranium, cranial tracking allows for anatomy based tracking relatively independent of patient's daily setup. Position verification was validated every third beam during treatment using paired, orthogonal, x-ray images ,24.Patients received concurrent and/or adjuvant chemotherapy at the discretion of their medical oncologist. Typically, patients were administered Temozolomide with concurrent radiation at a dose of 75 mg/m2/d, given 7 d/wk from the first day of conventional irradiation until the last day of CyberKnife treatment. After a 4-week break, patients generally received 6 cycles or more of adjuvant Temozolomide on a 5-day schedule of 150 to 200 mg per square meter every 28 days.Clinical evaluation and MRI imaging were performed at 3-6 month intervals following CyberKnife treatment for 5 years. Evaluation frequency beyond 5 years was determined by the medical oncologist. Throughout the follow-up period, a multidisciplinary team of neurosurgeons, radiation oncologists, medical oncologist and radiologists reviewed outcomes at a weekly central nervous system tumor board. Toxicity was scored according to the National Cancer Institute Common Terminology Criteria for Adverse Events, Version 3.0 The follow-up duration was defined as the time from the date of surgery to the last date of follow-up for surviving patients or to the date of death. Actuarial survival and local control was calculated using the Kaplan-Meier method.Twenty four consecutive eligible patients were treated over a seven year period extending from January 2002 to January 2009 . Upon completion of conventional treatment, an additional dose of 10 Gy was delivered in five successive 2 Gy daily fractions utilizing the CyberKnifeThe median follow-up was 23 months  for glioblastoma multiforme patients and 63 months  for anaplastic glioma patients Table . No patiUltimately, 16 patients experienced local progression during follow-up Table . SalvageHigh grade gliomas adjacent to critical structures are difficult to treat with conventional radiation therapy technique alone . When ir® radiosurgical system has several advantages over conventional radiation delivery systems. Since hundreds of non-isocentric treatment beams are available, the CyberKnife is capable of delivering a highly conformal treatment [In this study, we utilized the highly conformal and accurate fractionated CyberKnife radiotherapy to enhance conventional radiotherapy and investigated the safety and efficacy of this technique. The CyberKnifereatment ,18. Cranreatment -31. FurtThis is the first study to evaluates CyberKnife enhanced conventionally fractionated radiation therapy and chemotherapy for high-grade gliomas. Twenty-four patients were treated with encouraging 2 year and 4 year overall survival rates of 37% and 71% for the glioblastoma multiforme and anaplastic glioma cohorts, respectively. There were no severe late toxicities attributed to this technique using conventional total radiation doses of approximately 60 Gy. Our results demonstrate the feasibility, tolerability and efficacy of delivering CyberKnife enhanced conventionally fractionated radiation therapy and chemotherapy. Unfortunately, local progression remains the predominant pattern of failure for these patients despite optimal radiation treatment and chemotherapy Figure . NonetheBC is an Accuray clinical consultant.EO participated in data collection, data analysis and manuscript preparation. BC participated in drafting the manuscript, treatment planning, data collection and data analysis. KE participated in data collection, data analysis and manuscript revision. XY participated in treatment planning, data collection and data analysis. SL participated in treatment planning, data collection and data analysis. SS created tables and figures and participated in data analysis and manuscript revision. HH participated in data collection, data analysis and manuscript revision. JK participated in data collection, data analysis and manuscript revision. HP created tables and figures and participated in data analysis and manuscript revision. AE participated in data collection, data analysis and manuscript revision. CK participated in treatment planning, data analysis and manuscript revision. KM participated in treatment planning, data analysis and manuscript revision. DS participated in data analysis and manuscript revision. WJ participated in treatment planning, data analysis and manuscript revision. SC participated in drafting the manuscript, treatment planning, data collection and data analysis. All authors have read and approved the final manuscript.


The C—S—N—C torsion angle is −80.6 (6)°. The chlorobenzoyl ring is disordered and was refined using a split model [occupancy ratio 0.537 (3):0.463 (3)]. In the crystal, molecules are linked by pairs of N—H⋯O(S) hydrogen bonds, forming inversion dimers.In the title compound, C N-(aryl)-amides, see: Gowda et al. (2000N-(substitutedbenzoyl)-arylsulfonamides, see: Gowda et al.  Åb = 8.1963 (7) Åc = 18.397 (3) Åβ = 131.77 (1)°V = 2820.4 (7) Å3Z = 8Kα radiationMo −1μ = 0.42 mmT = 293 K0.48 × 0.20 × 0.16 mmOxford Diffraction Xcalibur diffractometer with a Sapphire CCD detectorCrysAlis RED; Oxford Diffraction, 2009Tmin = 0.822, Tmax = 0.935Absorption correction: multi-scan (5253 measured reflections2432 independent reflectionsI > 2σ(I)1623 reflections with Rint = 0.033R[F2 > 2σ(F2)] = 0.071wR(F2) = 0.115S = 1.162432 reflections216 parameters15 restraintsH-atom parameters constrainedmax = 0.30 e Å−3Δρmin = −0.31 e Å−3ΔρCrysAlis CCD  used to solve structure: SHELXS97  I, global. DOI: 10.1107/S1600536812015681/nc2273Isup2.hklStructure factors: contains datablock(s) I. DOI: 10.1107/S1600536812015681/nc2273Isup3.cmlSupplementary material file. DOI:  crystallographic information; 3D view; checkCIF reportAdditional supplementary materials:


Rapid scientific and technological advances have allowed for a more detailed understanding of the relevance of intestinal microbiota, and the entire body-wide microbiome, to human health and well-being. Rodent studies have provided suggestive evidence that probiotics (e.g. lactobacillus and bifidobacteria) can influence behavior. More importantly, emerging clinical studies indicate that the administration of beneficial microbes, via supplementation and/or fecal microbial transplant (FMT), can influence end-points related to mood state , brain function , and mental outlook . However, despite the advances in the area of gastro-biological psychiatry, it becomes clear that there remains an urgent need to explore the value of beneficial microbes in controlled clinical investigations. With the history explored in this series, it is fair to ask if we are now on the cusp of major clinical breakthroughs, or are we merely in the quicksand of Autointoxication II? Though the first two parts of this series, we have attempted to provide a historical and contextual approach to the more direct lines of contemporary evidence as it relates to gut microbiota, its intentional manipulation, and mental health. Here in part III we will discuss more specific research related to the direct experimental and clinical effects of probiotics in the context of stress, neurophysiology, behavior and mental outlook. The emerging studies clearly show that we are in the midst of a very exciting time within gastro-biological psychiatry. Still, as we conclude our series, it becomes evident that there many unanswered questions and an urgent need for expanded clinical investigations.More clinically relevant information related to behavior is provided by animal studies involving interactions between stress, dietary habits and alterations to the normal homeostasis of gut microbiota (i.e. dysbiosis rather than germ-free). The term dysbiosis is often erroneously attributed to Metchnikoff, however, both eubiosis  and dysbiosis  were already in popular use decades before Metchnikoff gained fame. Physician Elliot E. Furney used the terms together in his 1890 book related to plant, animal and human resiliency . In animBifidobacterium longum NCC3001  prevented the anxiety-like behavior associated with gut inflammation in animals with an intact vagus nerve, but it did not have this anxiolytic effect if the vagotomy was performed after chronic low-grade inflammation. Remarkably, the reduction in anxiety-like behavior after probiotic administration was not associated with any detectable reduction in gut inflammation per se[Lactobacillus rhamnosus also showed that administration to healthy animals in stressful situations reduced anxiety and depression-like behaviors in the elevated plus maze (EPM) and forced swim tests. These behavioral changes were linked to alterations in the gamma-aminobutyric acid (GABA) system of the brain in the probiotic group, yet the changes in behavior and brain chemistry were largely extinguished with vagotomy [More directly, however, the anxious-like behavior of dysbiosis invoked by small amounts of gut pathogens is associated with increased markers of activation within limbic structures of the brain  . Intestion per se. In othevagotomy .Lactobacillus hilgardii fermentation has been shown to have clinical value in anxiety reduction [Bifidobacterium longum normalized anxiety-like behavior and hippocampal BDNF levels among animals when the parasite Trichuris muris was introduced orally – the behavioral benefits were once again independent of inflammatory cytokines [As we argued almost a decade ago regarding depression and the gut-brain axis, some species of intestinal microbes can make significant contributions to the prodcution of GABA and other neurotransmitters in vivo . The exteduction . As for eduction . This suytokines .Salmonella enteritides exposure vs. other natural foods. In particular, a switch from the standard chow to banana powder decreased mortality from 96% to 6% over one month post-infection [As described in Part I, Lloyd Arnold reported in the 1920-30s that dietary context can influence intestinal-pathogen-induced symptoms and mortality. Remarkably, he found that the standard stock rodent chow, one that they had been using for years in his lab to raise mice, was associated with the highest mortality in mice upon nfection . For Arnnfection . When confection . From thbenefit to the host. The same is true of antimicrobial administration – clearly, antimicrobial agents can cause massive shifts in gut microbiota, yet here again the oral administration of these agents to mice (anxious BALB/c strain) caused a decrease in anxiety-like behavior. Such was not the case when the antimicrobial agents were delivered by injection, nor were there any behavioral changes when the agents were delivered orally to germ-free mice [Of course, this research also exposes the short-comings of the term dysbiosis, in that a shift from ‘normal’ homeostasis of intestinal microbiota  might actually confer ree mice . As mentree mice .E. coli Nissle 1917) is more effective at reducing experimental intestinal inflammation and markers of intestinal permeability vs. either one alone. In particular, this combination of probiotic and antibiotic significantly reduced the expression of matrix metalloproteinase 9 (MMP-9) [It is unlikely that antibiotics are a long-term solution to depression; however, the recently reported success of minocycline in depression  can no l (MMP-9) , a salie (MMP-9) , meanwhi (MMP-9) ,26, and  (MMP-9) -29. Sinc (MMP-9) , researc (MMP-9) .Lactobacillus reuteri vs. control) prior to experimental colorectal distension in rats. Remarkably, live probiotic prevented the physiological signs of visceral pain (marked bradycardia) that was otherwise evident in the control group. The researchers found the same effect whether or not the L. reuteri was alive, heat or radiation-killed, indicating that even structural components of probiotics can play a role in visceral sensitivity. This reduction in cardio-autonomic response in the animals was noted even at the highest level of distention pressure (80mm Hg), and the resiliency was accompanied by an inhibitory effect on discharge of colonic afferent nerve fibers in the probiotic groups [Bifidobacterium infantis 35624 can reduce visceral pain behaviors in both normosensitive and hypersensitive-anxious rat strains during colorectal distention [Bifidobacterium infantis can normalize sensitivity to colorectal distention in a rat model of post-inflammatory colonic hypersensitivity [Bifidobacterium lactis CNCM I-2494 in a fermented dairy matrix has been shown to reduce visceral hypersensitivity when colorectal distention occurred in the context of psychological stress. This study also showed that the probiotic reduced intestinal permeability and blood endotoxin levels. It is noteworthy that the antinociceptive effect of the fermented dairy product (inclusive of the aforementioned bifidobacterium strain plus Lactococcus lactis and two yogurt starters L. bulgaricus and S. thermophilus) was more effective than an equivalent dose of Bifidobacterium lactis CNCM I-2494 alone [Some of the more intriguing animal studies in recent years have involved the efficacy of probiotics in the reduction of visceral pain, including that related to colorectal distention. One study involved 9 days of probiotic supplementation  by colorectal distention – however, L. farciminis administration significantly reduced Fos expression in these areas during colorectal distention [Lactobacillus paracasei NCC2461 prevented this antibiotic-induced visceral sensitivity [L. paracasei did not restore normal lactobacilli levels overall, indicating that a major influence on gut microbial genera is not required for therapeutic efficacy via probiotics.stention . Finallysitivity . Importain sensitive people the brain is profoundly influenced by afferent impulses coming from a distended, underactive or unduly active bowel’ – certainly modern day interoseptive sensitivity in anxiety and pain-related conditions would support this notion [Although these are preliminary animal studies, one cannot help but to reconsider the influential voice of intestinal toxemia’s most vehement critic. Recall from Part I that Alvarez, who focused his attention on Freudian-inspired conditions - ‘hysterical’ bloating and ‘neurosis of the abdominal wall’ as he called them - claimed that personal  sensitivity to distention was at the heart of the gastrointestinal complaints in many of those with neurasthenia. Alvarez turned out to be correct in proposing a psycho-mechanical theory, his 1919 assertion  that ‘ins notion ,40. HoweConsider the separate research on methane producing microbes within the intestines; these microbes have been consistently linked to constipation -43, and A primary focus among the scientists and clinicians of the autointoxication era was on gut-derived putrefactive chemicals and their burden on the brain and elsewhere. As autointoxication faded away, Alvarez and others dismissed the notion that, except under rare circumstances, these chemicals could be absorbed and/or retained at any appreciable levels such that they could influence health. Although the modern gut-to-brain scientific focus has shifted to LPS and inflammatory cytokines, even the classic putrefactive chemicals  and some of the gut-derived and liver metabolized/conjugated structures  continue to be linked to systemic cellular damage and neuropsychiatric disorders -52. In pAlthough the association between cardiovascular disease and kidney disease is clearly significant, uremic toxins are presenting themselves as independent predictors of CVD risk, even at surprisingly mild levels of kidney disease. Recent studies show that even mild increases in serum p-cresylsulfate (0.7mg/L) are associated with coronary artery disease , and expIn animals, uremic chemicals can influence neurotransmitter levels in the brain, and emerging studies suggest they may have divergent effects on behavior depending on the level of production – in other words, too little or too much of these gut-derived chemicals may influence behavior . Isatin,Lactobacillus plantarum C29, isolated from the traditional Asian food kimchi, can increase hippocampal brain derived neurotrophic factor (BDNF) [L. acidophilus (vs. placebo) reduced immobility and observations of post-swim fatigue – these effects of L. acidophilus were in tandem with reductions in brain measurements of oxidative stress and serum measurements of the inflammatory cytokine TNFα [Bifidobacterium animalis 01, isolated from centarians, decreased oxidative stress burden and brain monoamine oxidase activity, thereby potentially increasing neurotransmitter levels between synapses [Meanwhile, other lines of experimental research continue to highlight the utility of probiotics in the prevention of intestinal permeability , reductir (BDNF) . Numerour (BDNF) . In exper (BDNF) ,76,77. Iine TNFα . Recentlsynapses .The influence of probiotics as a means to attenuate substance P release may also play a relevant role within the gut-brain connection. Experimental alterations to the normal gut microbiota can increase substance P release in the nervous system and promote behaviors reflective of anxiety . Indeed,Lactobacillus plantarum has been shown to secrete bioactive extracellular proteins capable of interacting with and modulating dendritic cells [C. jejuni as previously described) continue to be demoinstrated [Researchers have begun to explore the crosstalk biomarkers through which microbiota and host communicate. For example, ic cells . The secnstrated . As resenstrated , it is bnstrated . The rolnstrated .Bifidobacterium animalis subsp. lactis 420 to these animals reversed the bacterial translocation, its associated adipose tissue inflammation and metabolic disturbances indicative of diabetes [L. farciminis can reduce the effects of this vicious cycle in an animal model of acute stress [In a study which takes us back to the previously described work of Fenton Turck in 1916 , a Frencdiabetes . Of coure stress . Specifie stress . The resMycobacterium vaccae took note of its unexpected improvement in quality of life scores. Although it did not alter cancer survival times, benefits in favor of M. vaccae injections included aspects of cognition, vitality, and emotional health. [M. vaccae is widely distributed in nature, including soil and water, and it begs the question to what extent is the withdrawal from contact with nature and its non-pathogenic microbes a factor in mental health? As mentioned, it has been recognized for over a century that lactobacilli can be found in garden soil and on plant foods [M. vaccae can beneficially influence brain serotonergic activity under stress, and live M. vaccae added to the mice diet improves behavioral displays of anxiety and cognitive functioning [Recently there has been, once again, a suggestion that it might be possible to vaccinate against depression . Specifi health.  Of cours health. . It is nnt foods . Recent nt foods . Very prctioning . These sL. rhamnosus IMC 501 and L. paracasei IMC 502 minimized the systemic oxidative stress, lipid peroxidation in particular, associated with intense physical activity [L. casei, L. plantarum, B. brevis) in the treatment of SIBO, indeed the pilot study (n = 50) showed a more favorable response to probiotic treatment vs. the metronidazol control [Human research continues to accumulate in the area of probiotics and oxidative stress. A 6-week study involving patients with type 2 diabetes showed that probiotic yogurt administration improved fasting blood glucose as well as systemic antioxidant enzyme activity and total antioxidant status . In a onactivity . Given tactivity , the res control .Bifidobacterium lactis CNCM I-2494, L. bulgaricus and L. lactis) vs. non-fermented dairy vs. no beverage for one month. The fMRI was conducted during an emotional reactivity task . Based on blood flow assessments during the task, the probiotic group showed diminished activity in the mid/posterior insula vs. the control groups [There has also been intriguing preliminary research involving probiotic administration and changes in the brain activity as measured via functional magnetic resonance imaging (fMRI). In a double-blind, controlled study, 45 healthy women (age 18–50) consumed either a probiotic yogurt , should they confer benefit, could be considered a probiotic blend of sorts. Infusion of fecal microbiota from healthy donors has recently been reported to improve insulin sensitivity in individuals with metabolic syndrome, [Enterobacter cloacae B29 was eradicated from an obese adult, and remarkably, the induction of obesity, inflammation and serum endotoxemia when that same strain was introduced to gnotobiotic mice [L. reuteri ATCC55730 showed that the strain reduced mucosal inflammatory cytokine production after it was administered as a rectal enema for 8 weeks [Finally, although not probiotics yndrome,  and neuryndrome, . Workingtic mice . The enc 8 weeks .While some researchers continue to search for specific probiotic strains as transfer candidates, others are examining the use of cocktails of pathogen-free microbes derived from the entire commensal range . ExperimLactobacillus casei fermented beverage compared to the placebo group [Lactobacillus casei probiotic vs. placebo. At the conclusion of the 8-week study, depression scores remained unchanged between the groups, however there were significant improvements in anxiety as measured via the Beck Anxiety Inventory vs. placebo [The first formal investigation of the potential psychological benefits of strictly defined probiotic supplementation in humans involved 132 otherwise healthy adults; those who had more depressive symptoms at baseline had significant improvement in mood scores after taking a probiotic bo group . A separ placebo .Lactobacillus helveticus and Bifidobacterium longum combination probiotic which was orally administered for one month in a placebo-controlled study. Using a variety of validated anxiety, stress, and depression scales, researchers reported significant improvements in day-to-day depression, anger, anxiety, as well as lower levels of the stress hormone cortisol among otherwise healthy adults taking a daily probiotic supplement vs. placebo. In addition, an experimental arm of this study also confirmed that the probiotic added to the chow of rats did indeed decrease behaviors indicative of anxiety [Lactobacillus helveticus and Bifidobacterium longum vs. controls , and among this low cortisol sub-group the overall benefits in anxiety and depression were pronounced over time [bifidobacteria levels [Even more recently, French researchers evaluated a  anxiety . Moreovever time . Finallya levels .The essential deficiencies in academic medical history derive from its commitment to the “great man, great discoveries” view of medical history and of medical progress…those who labour long at such gathering are prone to mistake their miscellany of accumulations for real knowledge and deep understanding’ [may play a role in mental health – was correct.Looking back at the first three decades of the 20th century is an experience, for the modern scientist interested in the gut-microbiome-brain connection, akin to an anthropological archeologist discovering an ancient civilization. Superficially, the historical markings are dominated, as they often are in medicine, by the myopic and biased view toward the so-called ‘great/infamous men, great/infamous discoveries and claims’. Medical historians focus on heroes and anti-heroes in the fights against ignorance and disease. Yet the complete chronicles are never as simple as Lane vs. Alvarez. Psychiatrist and medical historian Iago Galdston warned against losing context and understanding with such chronicles - ‘tanding’ . Siftinga triumph of ignorance over science’. Yet, as the French physiologist Claude Bernard wrote, “That which we know is a great hindrance to our learning that which is yet unknown to us”. By the year 2000 we “knew” intestinal toxemia and friendly microbes for mental health to be exclusively a medical folly, one associated with charlatans and so-called colon cleansers.Related concerns of intestinal permeability, SIBO, hypochlorhydria, carbohydrate intolerance, endotoxins, modernity and dietary matters, gut microbe vaccines, the oral administration of lactic acid bacteria, colonic microbiota transfer, and qualitative/quantitative changes to the intestinal microbiota were all discussed as being relevant to mental health and cognition. For a variety of reasons, not the least of which included lack of human evidence and broad claims that autointoxication was the exclusive root of all neuropsychiatric disorders, these discussions disappeared from mental health publications. One cannot say that the disappearance of autointoxication was driven exclusively by the emergence of evidence-based medicine because in many cases it would be supplanted by unverifiable Freudian psychoanalytic viewpoints. Still, clinicians pleaded for more than studies in rodents, rabbits and monkeys – they needed convincing human research so that medicine could be practiced not by hypothesis - and yet none would be forthcoming. Unwarranted colectomies and unfounded marketing promissory notes for good health via friendly microbes would obscure legitimate research pathways that might have otherwise been followed with vigor. They also created a superficial and simplified medical history based on great or infamous men. Over time, autointoxication would become known only for these surgical and marketing extremes, ultimately becoming a medical outcast – or, as it was written just prior to our hypotheses papers, ‘L. bulgaricus as a fountain of youth, or colon cleansers as a solution to all the potential ills of what may indeed be a type of intestinal ‘toxemia’. However, modern historical reviews that stick exclusively to the redundant and superficial narrative of “autointoxication was the arena of charlatans, it was wrong and disproven by Alvarez” contribute little, and indeed provide a disservice to the medical minds that were on a rational path. Of course, reminders of the dangers of practicing medicine by hypothesis alone have their place. However, it may be time to re-write some of the history books or at least qualify them; the legacy of Lane and Cotton should not negate that of those who found that a high fat diet and stress increased intestinal permeability and bacterial translocation, or those who reported successful outcomes with simple fecal transplantation. Why should the legacy of those who instilled fears into healthy adults regarding autointoxication, as a means to sell pseudoscientific contraptions, obscure that of rational physicians who saw some legitimacy to intestinal toxemia as relevant to unhealthy populations? It is fairly obvious many of those physicians rationally discussing intestinal toxemia a century ago were confronted with unhealthy patients  that would today be classified with elaborate diagnostic criteria and codes.All of this contemporary work, as described above, forces us to have a fresh look at the inner dialogue within the historical intestinal toxemia publications. Obviously the modern advances are not a validation of colectomy, These results suggest that neuroticism is involved in the pathophysiology of IBS’ [we will learn to understand the experiences of man in terms of multidirectional relations, and with a simultaneity that is free of the naiveté and artificiality of straight line sequential causality…when we have come to such an understanding, psychosomatic medicine will be truly holistic. But then, may I whisper it softly, it will no longer be psychosomatic medicine. It will be medicine such as Hippocrates could comprehend, and Paracelsus might celebrate – a keen reflection on the interrelations of Microcosm and Macrocosm’ [Top-down, psychosomatic-oriented theorists  continue of IBS’ . These scrocosm’ .human GABA system, are not synthetic benzodiazepines; as discussed throughout this paper, orally administered microbes are much more likely to converge with lifestyle variables within the gut lumen.With all our modern advances, we once again arrive at a place of theory, albeit slightly more sound in its support. In order to truly advance from the days of Metchnikoff we must expand the bench and rodent work and bring it into the clinical investigative setting, and not to do so, of course, for the purpose of yet more anecdote. The undoing of intestinal toxemia and the idea of probiotics for brain health was not Alvarez, it wasn’t the charlatans and the high colonics, nor was it for the want of more rodent and laboratory studies - its undoing was the lack of convincing controlled clinical work. It seems remarkable, given the supporting scientific rationale, that there has been so little in the way of clinical research. At this point, as highlighted throughout this series, we already have extensive experimental research from which to guide probiotic strain selection for clinical experimentation – e.g. strains that can lower LPS burden; strains that lower oxidative stress, and systemic inflammatory cytokines; strains that have a beneficial influence on stress resiliency; strains that can influence neurotransmitter precursor levels via amino acids and neuronal membrane structure via fatty acids; strains that can attenuate intestinal permeability; strains that can lower uremic toxin burden. It may take decades to further elucidate the divergent ways in which these and other specific probiotic strains may interact, alone and in combination with each other, to influence markers relevant to animal models of depression and/or anxiety. This critical work should, of course, continue. However, the mouse models will always be lacking the clinically-relevant context of mood-related diet, physical activity, environmental toxin exposure and other variables within lifestyle medicine. Probiotics, even if they do influence the human mood, cognition and fatigue. The results from these early studies, in concert with what is now a fairly robust body of experimental research, would suggest that we have now passed the time in which clinical investigations should be approached with vigor. Moreover, the work of Michaël Messaoudi [This presents a quandary for experimental researchers examining the use of probiotics in the behavior of animals as a means to inform clinical utility. Since environmental enrichment factors are known to interact with psychological stress and diet, both of which interact with gut microbiota, a near-endless combination of animal housing and dietary variables related to microbes must be investigated - from running wheels, tunnel positioning, wood, plastic and soil materials -123. To essaoudi ,114 and M. vaccae added to the dietary of animals – as a soil-derived organism, M. vaccae can easily find its way onto plant foods. It seems the links between traditional dietary patterns, mental health and microbiota, are far more complex than generally appreciated. We simply cannot view the gut-brain-microbiota axis as isolated from diet, the context of its macro and micronutrient as well as phytochemical composition. This fact underscores the potential futility of probiotic administration to a sedentary individual with depression that may be co-consuming a fast-food style diet with the addition of pharmaceuticals and/or dietary chemicals  that are otherwise capable of altering the intestinal microbiota [The strain specific focus is clearly justifiable in the scientific examination of a particular probiotic preparation or commercial ‘functional food’ for mental health. Research not only shows that heat-killed bacteria may have strain-specific benefit, the research also indicates that there are broad and divergent effects of lactic acid bacteria in their interaction with the immune system . If we icrobiota . These aIn the real-world of mental healthcare provider and patient, one that occurs in a holistic setting involving lifestyle factors, the odds of a single strain of probiotic bacterium providing clinically meaningful and long-lasting benefit, not simply statistically significant differences vs. placebo, could not be estimated to be high. Yet, probiotic experiments with rodents, just as they did in the day of Metchnikoff  , generatPLoS One, Japanese researchers showed that a strain of Bifidobacterium animalis can increase longevity in mice via its influence on gut polyamine production [emerge from phase I of translational medicine? Will all of this work become another clinically meaningless forgotten city in the future, one destined to once again be explained away by conflicts over toilet training? If there is a future role of probiotics in cognitive and mental health, one relevant for clinicians, and one that can only be proven or disproven by human intervention studies, it is almost certainly as our group hypothesized it to be – an adjuvant to well-established first-line care.Today, in the new era of Autointoxication II, what is old is new again – preliminary non-clinical research efforts, based on metagenomics and microbiome projects, are commercially co-opted to support a financially lucrative probiotic business wherein unsubstantiated claims abound . Metchnioduction . In 2012oduction ; meanwhioduction . It seemACB and EMS have no competing interests. ACL has received consulting fees from Genuine Health, Toronto, Canada.ACB, ACL and EMS contributed equal time and effort in the investigation, research and drafting of this manuscript. All authors read and approved the final manuscript.