LVLAVR at ventricular end‐diastole step wisely decreased to advanced aging, and had a highest F ratio compared with other left chamber volumetric parameters in both genders. LV mass and LA ejection fraction were significantly associated with LVLAVR at ventricular end‐diastole. In contrast, LV mass and LV ejection fraction were significantly coupled with LVLAVR at ventricular end‐systole. This study provides the reference values for LVLAVR from a relatively large number of healthy subjects. LVLAVR may be a sensitive parameter to reflect age‐ and gender‐related change in LV and LA volumes. Further studies should be required to determine its clinical usefulness over traditional echocardiography parameters in various cardiovascular diseases.We hypothesized that left ventricular and left atrial volume ratio (LVLAVR) assessed by three‐dimensional echocardiography (3DE) reflects age‐ and gender‐related change in left chamber size. We aimed to (1) determine the reference values of LVLAVR, (2) investigate their age and gender dependency, and (3) clarify which anthropometric and echocardiography parameters are closely associated with these indices. Both left ventricular (LV) and left atrial (LA) volume curves were obtained using 3DE speckle tracking analytical software, and the LVLAVR curve throughout one cardiac cycle was created, from which LVLAVR at ventricular end‐diastole and at ventricular end‐systole were determined in 313 healthy subjects . The mean values of LVLAVR at ventricular end‐diastole and ventricular end‐systole in male subjects were 5.74 ± 1.54 and 1.37 ± 0.35, respectively. Corresponding values in female subjects were significantly lower  using three‐dimensional echocardiography. We determined age‐ and sex‐specific reference values of LVLAVR at end‐diastole and end‐systole from a relatively large number of healthy subjects. Detailed assessment of LVLAVR clarifies the temporal status of LV−LA coupling at different time points of the cardiac cycle, and thus, would provide further insights for LV−LA coupling. We also hypothesized that this ratio would reflect the temporal status of LV–LA coupling at different phases of the cardiac cycle, and the contribution of other anthropometric and echocardiography parameters for LVLAVR is different at different time points of the cardiac cycle.Accordingly, the aims of this study were to (1) determine the reference values of LVLAVR in healthy subjects, (2) investigate their age and sex dependency, and (3) clarify which anthropometric and echocardiography parameters are closely associated with these indices.22.1Using 3DE database, we retrospectively searched adult healthy Japanese volunteers without hypertension, diabetes, hypercholesterolemia, and cardiovascular disease who underwent 3DE examination. Among 313 subjects who fulfilled eligibility criteria, majority were hospital employees and their relatives, residents, and fellows. Some 3DE datasets used for this study have been used for the previous publications . The depth and sector angle were adjusted to include the entire left ventricle and left atrium with the highest frame rate. 3DE full‐volume datasets were acquired with multibeat acquisition.2.3The image quality of 3DE datasets were evaluated subjectively, considering the completeness of LV and LA border visualization, and categorized as good, fair, poor, and extremely poor. The 3DE analysis for LV and LA volume measurements was performed with the use of a novel 3DE software  by an experienced investigator. Initially, the LV endocardial border was semiautomatically determined after two‐point clicks of the LV apex and center of the mitral valve annulus on the apical four‐chamber, two‐chamber, and long‐axis views extracted from 3DE datasets. The manual adjustment of the endocardial border was performed, when required. Subsequently, the software performed a 3DE speckle tracking analysis throughout one cardiac cycle Figure a. To meaFor the LA view adjustment, the center of the mitral valve and the LA roof was determined on apical four‐chamber and long‐axis views Figure d. After 2.4Both LV and LA volume curve data were exported as a text file. Each curve was interpolated by 100 points during ventricular systole and 100 points during ventricular diastole from one cardiac cycle using interpolation software . Temporal LVLAVR was calculated on 200 sampling points, and finally, LVLAVR curve was generated in each subject. The mean value of LVLAVR from different age groups were separately plotted on 200 points by male and female subjects.2.5The transmitral peak velocities during early (E) and late (A) ventricular diastole were measured on pulsed‐wave Doppler echocardiography. Mitral annular velocities during early ventricular diastole (e’) at both septal and lateral corners of the mitral annulus were measured, and average E/e’ was obtained in each subject.2.6Intraobserver variability was assessed by having the observer to repeat the measurement of LVEDV, LV end‐systolic volume (LVESV), maximal LA volume (LAVmax), minimal LA volume (LAVmin), LVLAVR at ventricular end‐diastole and ventricular end‐systole 2 weeks apart in 25 randomly selected subjects. Interobserver reliability was determined by employing a second observer to perform these measurements in the same 25 subjects. The intra and interobserver variability was calculated as the absolute differences between the corresponding two measurements in percentages of their mean and intraclass correlation (ICC).2.7SD) or median and interquartile interval (25th–75th percentile) based on the data distribution. Categorical data were expressed as numbers or percentages. The subjects were grouped into age decades (from the 3rd decade to ≥7th decade) based on sex. Group comparison between age decades was conducted using the one‐way analysis of variance (ANOVA). Two‐way ANOVA was performed to determine the effect of age and sex group for each echocardiography parameter. Univariable regression analysis was performed to determine the contribution of anthropometric and echocardiographic parameters for LVLAVR at ventricular end‐diastole and LVLAVR at ventricular end‐systole. Variables showing p < .1 were used for multivariable regression analysis with stepwise selection based on Akaike's information criterion. A two‐sided p < .05 was considered statistically significant. All statistical analyses were performed using commercial software .Continuous data were presented as mean ± standard deviation , fair in 131 (41%), poor in 112 (37%), and extremely poor in 26 subjects (8%), respectively. Both LV and LA volume curves could be generated in 280 subjects . The median frame rate of 3DE datasets was 20/s . The mean values of LVLAVR at ventricular end‐diastole and at ventricular end‐systole were 5.48 ± 1.53 and 1.25 ± 0.34, respectively, indicating that the LV volume was more than 5.5 times larger than the LA volume at ventricular end‐diastole, and the LV volume was 1.3 times larger than the LA volume at ventricular end‐systole.3.1The reference values for LV and LA volumes, ejection fraction, LV mass, and LVLAVR at ventricular end‐diastole and ventricular end‐systole are summarized according to age group, and displayed separately by male and female subjects Tables  and 2. A3.2Two‐way ANOVA showed that age group was significantly different for LVLAVR at ventricular end‐diastole, but sex group was not different. With regard to the LVLAVR at ventricular end‐systole, both age and sex groups were significantly different.3.3Table 2; 0.615, p < .001). Multivariable analysis, including age, sex, BSA, HR, SBP, DBP, LV mass, LVEF, and E/e’, showed that age, sex, BSA, HR, LV mass, and LVEF significantly contributed to the LVLAVR at ventricular end‐systole .Multivariable analysis including age, sex, BSA, HR, systolic blood pressure (SBP), diastolic blood pressure (DBP), LV mass, and LAEF, showed that age, sex, BSA, HR, LV mass, and LAEF significantly contributed to the LVLAVR at ventricular end‐diastole  We established the reference values of LVLAVR at ventricular end‐diastole and at ventricular end‐systole; (b) significant age dependency of LVLAVR was observed in both sexes, showing that highest and lowest values were observed in the 3rd and ≥7th decades, respectively; (c) there was also gender dependency, reflecting lower values of LVLAVR at both ventricular end‐diastole and ventricular end‐systole in female subjects than in male subjects; (d) the contribution of echocardiography parameters was different for LVLAVR at ventricular end‐diastole and LVLAVR at ventricular end‐systole, characterizing that LV mass and LA functional parameters were correlated with LVLAVR at ventricular end‐diastole, and LV mass and LV functional parameters were associated with LVLAVR at ventricular end‐systole.n = 19; mean age, 51 years) than younger group , which was in agreement with the results in this study. We expand their findings further using a different imaging modality, 3DE, that is more widely available and semiautomated software that is more user friendly and less time consuming and determined age‐ and sex‐related reference values of LVLAVR in a large number of healthy subjects.3DE provides accurate and reliable cardiac chamber volumes and their function in clinical practice . The other authors report no conflicts.


We aimed to test whether negative emotion regulation difficulties and self‐compassion mediate the relationship between early maladaptive schemas (EMSs) and symptoms of psychopathology and life satisfaction.Data were collected from 296 adults , whose age ranged from 17 to 52 years. The mediating roles of self‐compassion and negative emotion regulation were examined via Hayes’ procedure (PROCESS) for multiple mediation.Negative emotion regulation was the only mediator to psychopathological symptoms, with no additional role for self‐compassion, whereas self‐compassion mediated only to life satisfaction, with no additional role for negative emotion regulation.The results provide evidence for unique mediating roles of negative emotion regulation and self‐compassion, depending on the outcome variable. That helps to understand how problems that may be identified in terms of positive and negative domains are related to EMSs, and allows to put forward potential strategies within the frame of schema therapy. The sample consisted of 117 (39.5%) males and 179 (60.5%) females between the ages of 17 and 52 (2.2completely untrue of me) to 6 (describes me perfectly). The YSQ‐S3 has acceptable levels of overall reliability and validity, and for Turkish adolescents and adults specifically  to α = 0.81  to α = 0.90 (Disconnection/Rejection), with a total scale α coefficient of 0.96.The Young Schema Questionnaire—Short Form 3  to asses problems regarding (negative) emotion regulation. The DERS yields a total score as well as five subscores reflecting nonacceptance of emotional responses, difficulty in engaging in the goal‐directed behavior, impulse control difficulties, lack of emotional awareness, limited access to emotion regulation strategies, and lack of emotional clarity, for which higher scores indicate more emotion regulation difficulties. The Turkish translation of the DERS revealed acceptable reliability and validity  to α = 0.90 (Impulse). In the present study, α coefficients of the subscales were found to be ranging from α = 0.69 (Awareness) to α = 0.90 (Strategies) for the subscales to α = 0.92 for the whole scale.The DERS  to evaluate self‐compassion. The SCS yields total score and six subscale‐scores reflecting three positive subscales , and three negative subscales . The internal consistency of the original scale was found to be α = 0.92, and the test–retest reliability was found to be 0.93 for the original scale. The Turkish translation and adaptation of the SCS reported internal consistencies ranging from α = 0.69 (Self‐judgement) to α = 0.85  to α = 0.85 (Self‐judgement).The SCS Neff,  is a 26‐not at all, 4 = extremely). The checklist covers nine symptom dimensions, that is, Somatization, Obsession‐Compulsion, Interpersonal Sensitivity, Depression, Anxiety, Hostility, Phobic Anxiety, Paranoid Ideation, and Psychoticism, reflecting three global indices . The internal consistencies of the dimensions of the original scale were found to range from α = 0.71 (Psychoticism) to α = 0.85 (Depression). The test–retest reliability of the subscales was found to range from 0.68 (Somatization) to 0.91  to α = 0.92 (Depression).The Brief Symptom Inventory . The scale yields a total score, for which scores between 0 and 20 indicate the level of dissatisfaction , whereas scores above 20 indicate the level of satisfaction . The internal consistency of the original scale was found to be α = 0.87, whereas the test–retest reliability correlation was found to be 0.82 . After giving online consent to participate, participants filled out an online survey consisting of the scales mentioned above. After the completion of the survey, the participants were debriefed about the study and thanked for participation. This procedure was approved by the Applied Ethics Research Center of Middle East Technical University in Ankara, Turkey.2.4p < 0.05 was adopted for all statistical tests. Additional analyses were done with only the total score on positive subscales of the SCS, as the inclusion of the negative scales has been criticized (see above).Analyses were performed using IBM SPSS Statistics for Windows, Version 23.0  via Hayes’  PROCESS 3Descriptive statistics of, and correlations between, gender, age, psychopathological symptoms , self‐compassion , difficulties negative emotion regulation , life satisfaction , and scores with regard to the D/R, IA, OD, IL, and O/I domains are reported in Table Subsequently, multivariate mediation models were run to test the effects of D/R score on psychopathological symptoms through DERS and SCS. In the case of significant correlations between gender or age and variables in the mediation model, we included the respective variable  in the mediation model.3.1F = 72.62, p < 0.001, MSE = 555.54, r2 = 0.50, demonstrating that EMS‐D/R domain, SCS, and DERS together explained 50% of the variance in psychopathological symptoms when age was included as a covariate. The bootstrapping analysis with 5,000 resamples for indirect effects revealed a significant total indirect effect . Confirming our hypothesis, this indicates that SCS and DERS together mediated the relationship between schema domains and symptoms of psychopathology.The first mediation model included D/R as the independent variable, BSI as the dependent variable, the two mediators , and all of the possible covariates . In line with the suggestions by Hayes , nonsigna1 = –0.66, p < 0.001) and higher levels of DERS , the last being related to higher levels of psychopathological symptoms . Only DERS had a significant mediating effect on the relation between the D/R schema domain and symptoms of psychopathology . SCS did not contribute to the indirect effect , the D/R score had a significant direct effect  on symptoms of psychopathology  = 16.95, p < 0.001, MSE = 36.90, r2 = 0.23, indicating D/R, SCS, and DERS together explaining 23% of the variance in satisfaction with life when controlling for age and gender. The bootstrapping analysis with 5,000 resamples for indirect effects revealed a significant total indirect effect . However, DERS did not have a significant mediating effect in the relationship between D/R and life satisfaction, whereas SCS was significant as mediator  and a direct positive effect on DERS . SCS had a positive direct effect on satisfaction with life , whereas DERS did not . The total effect of D/R on life satisfaction was significant , whereas the direct effect was not . Thus, as hypothesized, the D/R domain was negatively associated with life satisfaction, and DERS and SCS together mediated the relationship between the D/R domain and life satisfaction.More specifically, results of our Figure  model re3.3Taking into consideration recent concerns regarding the use of the SCS total score  expressed by Muris et al. , we furt3.4F = 71.93, p < 0.001, MSE = 558.20, r2 = 0.50, revealed that the D/R still had a direct negative effect on positive components of SCS , however, the coefficient was considerably smaller than the coefficient in the first model , depicted in Figure b1 = 0.06, p > 0.05).As depicted in Figure F4,29 = 71.93,a2b2 = 0.45, p < 0.05). SCS did not contribute to the indirect effect beyond DERS. Different from the original results, investigation of pairwise contrasts of the indirect effects of the mediators revealed that the specific indirect effects differed significantly from each other (p < 0.05).The bootstrapping analysis with 5,000 resamples for indirect effects revealed a significant total indirect effect Table . In term3.5F = 16.27, p < 0.001, MSE = 37.24, r2 = 0.22, revealed results similar to the second model , although considerably smaller than the model depicted in Figure a1 = –0.68, p < 0.001). Positive dimensions of SCS had a stronger positive direct effect on satisfaction with life  compared with the original model , whereas results of DERS (b2) did not change. Different from the original model, both direct (c) and indirect (c1) effects of the D/R on life satisfaction were significant (c).The fourth multivariate mediation model, F5,90 = 16.2a1b1 + a2b2 = –0.06, SE = 0.02, 95% BCa CI ). Similar to the original model, only self‐compassion  had a significant mediating effect between D/R and satisfaction with life (Table The bootstrapping analysis with 5,000 resamples for indirect effects revealed a significant total indirect effect (4Mental health comprises the presence of positive emotions and the ability to regulate negative emotions Keyes, ; both poFirst of all, as predicted, results of an initial correlation analysis revealed that, of all schema domains (Young et al., A possible explanation for these findings might be found in the differential effects of positive and negative emotions and strategies. That is, psychopathological symptoms are associated with the presence of negative affect, and emotion dysregulation signals a failure to regulate negative emotions (Fassbinder et al., Our findings underline the need for a better understanding of the difference and overlap between negative emotion regulation and self‐compassion; the literature provides no consensus about the question whether self‐compassion is an emotion regulation technique or a complimentary strategy (Diedrich et al., Next to that, our findings support the idea that addressing EMSs only regarding psychopathological symptoms and negative emotions limits its treatment potential. That is, in improving coping with EMSs it, may be recommended to focus both on enhancing positive emotions, and on decreasing negative emotions. The term emotion dysregulation is often used to describe problems with regulating negative emotions. Positive emotions and the disability to attain them are often overlooked; a disability to create positive emotional states is generally not labeled as emotion dysregulation. Self‐compassion appears to be important for the presence of easily overlooked positive affect. However, whereas the connection between schema therapy and dysregulation of negative emotions has been studied extensively (Dadomo et al., Some limitations should be kept in mind when interpreting the results of the present study. First, the sample is nonclinical, which means that the conclusions from the present study may not be generalizable to clinical populations. Second, the cross‐sectional design prohibits inferring time‐dependent relationships. Third, the results do not imply causation between the variables; the mediating roles of difficulties in negative emotion regulation and self‐compassion need experimental confirmation. Fourth, when looking at the results about life satisfaction, the effect sizes were small. One possible reason for this might be that the instrument used only assesses part of the life satisfaction construct. Including direct indicators of positive affect might result in stronger effect sizes and more reliable conclusions in future research.5To conclude, we demonstrated that the D/R domain remains the most important EMS domain regarding psychopathological symptoms and life satisfaction. Also, self‐compassion mediates the relationship between EMSs of the D/R EMSs and life satisfaction, with no additional role for negative emotion dysregulation, whereas negative emotion dysregulation mediates the relationship between D/R EMSs and psychopathological symptoms, with no additional contribution of self‐compassion. These conclusions remain when taking into account only positive components of self‐compassion. This indicates that self‐compassion and negative emotion regulation represent complementary concepts, each playing a unique role in different aspects of mental health.


Orostachys japonicus in a human pancreatic cancer cell line, PANC‐1. An ethyl acetate fraction containing quercetin, kaempferol, and flavonol glycosides from O. japonicus (OJE) exhibited significant anticancer activity against the PANC‐1. OJE activated caspase‐3, caspase‐8, and caspase‐9, leading to the induction of both intrinsic and extrinsic apoptosis pathways. It also inhibited cyclin D1, cyclin B1, and cyclin‐dependent kinase 4, representing cell cycle arrest at both G1/S and G2/M phases. In addition, OJE phosphorylated MAPKs such as p38, JNK, and ERK, which are important upstream signaling factors in apoptosis and arrest of cell cycle inducing system. In conclusion, OJE effectively exerted antipancreatic cancer activity via induction of apoptosis directed by both intrinsic and extrinsic pathways and arrest of cell cycle regulated at both G1/S and G2/M stages, which is activated by MAPKs, p38, JNK, and ERK.Targeted therapy at the molecular level is important for pancreatic cancer treatment. This study looked over the anticancer activity of  MTS assay was carried out similarly as described previously  was executed as described in earlier report  and propidium iodide (PI) staining using an Annexin V‐FITC Apoptosis Detection Kit (BD Biosciences) according to the manufacturer's protocol. Apoptosis assay was accomplished using FACSCalibur flow cytometer (Becton Dickinson) as reported previously  according to the manufacturer's protocol. Cell cycle analysis was conducted similarly as performed previously  protein assay (Pierce). Protein samples were separated on 10%–15% SDS–polyacrylamide gels through electrophoresis (Bio‐Rad) and transferred onto a polyvinylidene difluoride (PVDF) membrane. The membrane was incubated for 2 hr at room temperature with 1:5,000 dilutions of the secondary antibody (horseradish peroxidase‐conjugated goat anti‐rabbit IgG) and washed in phosphate‐buffered saline with Tween‐20 (PBST) thrice. Finally, protein concentration was measured using enhanced chemiluminescence (ECL) detection kits.The cells were mixed with different concentrations of OJE and harvested using a cell scraper and then resuspended on ice for 30 min, followed by removal of cell debris by centrifugation at 10,000 2.9Statistical analysis was performed as used in the previous study , such as kaempferol‐3‐rhamnoside (afzelin), kaempferol‐3‐glucoside , quercetin‐3‐rhamnoside (quercitrin), and quercetin‐3‐glucoside  for 12, 24, and 48 hr. The effect of treatment with OJE on the proliferation of PANC‐1 cells was measured using the MTS assay. OJE significantly inhibited the proliferation of PANC‐1 cells in a concentration‐dependent manner Figure .3.3To examine whether the antipancreatic cancer effects of OJE were due to the induction of apoptosis, PANC‐1 cells were treated with OJE and apoptotic cells were observed by staining with DAPI and annexin V/PI. The results of DAPI staining demonstrated that OJE induced apoptosis of PANC‐1 cells in a dose‐related manner, indicated by chromatin condensation and nuclear fragmentation in several PANC‐1 cells Figure .In flow cytometry results, the lower left quadrants in Figure 3.4Activation of caspases in cancer cells is closely associated with apoptosis. Hence, we determined whether OJE activated caspases in PANC‐1 cells. Western blotting showed that OJE effectively activated procaspases; decreased the levels of procaspase‐3, procaspase‐8, and procaspase‐9; and increased the levels of cleaved caspase‐3, cleaved caspase‐9, and cytochrome c in a concentration‐dependent manner, compared to the control in PANC‐1 cells Figure a,b. On t3.5The cell cycle distribution of PANC‐1 cells was analyzed by flow cytometry. As exhibited in Figure 3.6We performed Western blotting to analyze the level of MAPK, which is known to affect upstream signaling pathways. As shown in Figure 450) value of 50 μg/ml  inhibited the growth of PANC‐1 cells and displayed an inhibition concentration . In our study, PANC‐1 cells treated with OJE raised the levels of cleaved caspase‐3 and cleaved caspase‐9, indicating the intrinsic apoptosis pathway, and lowered the level of procaspase‐8 in a dose‐related manner, indicating extrinsic apoptosis Figure . ActivatBecause cancer involves abnormal cell growth and proliferation, arrest of cell cycle is another effective marker of anticancer activity .


Preventing type 2 diabetes (T2DM) is one of the biggest health challenges currently facing the UK, with the NHS spending £14 billion each year on treating the disease and associated symptoms.The aim of this study was to determine the public’s awareness about the symptoms, risk factors and lifestyle choices, commonly associated with T2DM. This study also aimed to determine whether the level of awareness varies if the questions are asked in different languages, primarily those spoken by ethnic minorities.This was a cross sectional, multisite study conducted in London, UK, involving 399 participants, who were non-diabetic, aged between 25 and 74 years old and living in one of four selected London boroughs. Descriptive statistics, Chi square and Fisher’s Exact Tests were used to highlight and summarise the key findings of this study.n = 399/1683) for the English questionnaire was achieved. Overall, 59.4% (n = 237/399) of the cohort were able to identify a minimum of three T2DM symptoms and thus, were considered to have adequate or good awareness. Whereas, 60.6% (n = 242/399) were able to identify a minimum of six T2DM risk factors and were considered to have adequate or good awareness. More participants could correctly identify that obesity was a risk factor of T2DM when they were asked the question in their spoken language, rather than English (p < 0.01). When participants were asked about their current lifestyle choices, there were high levels of inactivity, smoking and alcohol consumption reported.A response rate of 23.7%  contains supplementary material, which is available to authorized users. Over the past decade, the number of individuals with diabetes has risen by 59.8% in the United Kingdom (UK) and currently there are over 4 million individuals living with the condition. By 2025, this number is anticipated to rise to 5 million . At presDiabetes is a condition characterised by either an absence of, or resistance to insulin, an endogenous protein that is responsible primarily for controlling blood sugar levels. Type 1 diabetes mellitus is prevalent in younger populations with an inability to produce insulin from the pancreas, the organ responsible for insulin secretion and blood sugar regulation. Type 2 diabetes mellitus (T2DM) refers to the latter mechanism whereby despite insulin production, the body’s response is diminished, and adequate control of blood sugar is not achieved. Without appropriate diagnosis and treatment, diabetes increases the risk of serious complications such as coronary heart disease and stroke.This study was conducted in four London boroughs. According to national statistics, 40% of individuals residing in London are categorised as high risk for developing T2DM because of their ethnicity . In a ren = 92) did not understand the term diabetes, with 20% (n = 64) unable to suggest a single preventative measure . For this study it was recommended to use a minimum sample size of 385 participants based on the total population of adults aged 25–74 across the boroughs where recruitment for the study took place [Members of the public were selected using convenience sampling. Approximately 1.17 million individuals reside within the four selected London boroughs ; therefook place .To meet the inclusion criteria, participants must be aged between 25 and 74 years, have no previous diagnosis of diabetes and must live in one of the selected London boroughs. Recent literature has recommended a broader age range be applied to adolescence in the UK from 10 to 24 years of age . This stParticipants were provided with an information sheet to read that accompanied the questionnaire. Completion of the questionnaire signified implied consent on the part of the participants. The information sheet outlined the research aims and objectives and provided information regarding the questionnaire content, confidentiality, the right to participate or withdraw, as well as the contact details for the research team. Participants completed the questionnaires with the researchers administering the questions following provision of the information sheet. Initially, all documents were printed in English and the completed questionnaires were collected immediately with most participants completing the questionnaire in 15–20 min. On a separate occasion, the researcher based in Ealing revisited the borough and asked eligible participants who could communicate in Hindi, Punjabi or Urdu to complete the same questionnaire in their preferred language. Similarly to the recruitment phase in the other boroughs, participants were approached in shopping centres, bus stops and the train station in Ealing to complete the questionnaire. All questionnaires were collected immediately after completion, by the researcher. None of the questionnaires were incomplete, hence all questionnaires were considered for data analysis.Data collection was performed using a paper-based questionnaire which consisted of 54 questions  for face and content validation. Face validity included asking participants whether questions were clear and easy to complete. Content validity focused on completion of the questionnaire to determine whether suitable findings could be deduced from the questionnaire outcomes. Findings from the pilot study suggested that no changes were necessary. The individuals involved in the pilot study were excluded from the study to avoid any type of bias.Data was tabulated and analysed using Microsoft Excel. Descriptive statistics were used to determine particular key outcomes of study including: levels of awareness/knowledge with respect to symptoms and risk factors in T2DM, variation in knowledge based on lifestyle e.g. participant weight as well as variation in levels of awareness of T2DM across ethnicities. A Chi-Square Test was performed to evaluate differences in knowledge in relation to participants’ weight and physical activity. Additionally, a Fisher’s Exact Test was used to determine whether demographics or the language used to answer the questionnaire impacted individuals’ awareness about T2DM .p < 0.05.The level of statistical significance was set at n = 399/1683) was achieved for the English questionnaire. This sample size meets the minimum sample size required by the power calculation. Charateristic details of the cohort are presented in Table A response rate of 23.7% n = 399/683 was an = 273/399) and 65.2% (n = 260/399) respectively, could recognise that increased thirst and polyuria were both symptoms of T2DM; however, only 45.6% (n = 182/399), 48.9% (n = 195/399) and 57.6% (n = 230/399) of the cohort respectively could correctly identify that weight loss, blurred vision and lethargy were other common symptoms.Most participants, 68.4% (n = 237/399) of the participants could correctly identify at least three out of five common T2DM symptoms, with 91 patients  and 146 patients  demonstrating adequate and good levels of awareness of T2DM symptoms respectively. The results were stratified according to gender, age, ethnicity, highest level of education and exposure to medical information (Table n = 47/221) or good (n = 101/221) awareness of T2DM symptoms compared to males , (p < 0.01). Poor level of awareness was more prominent in patients who had not received any medical information (n = 117/ 237) compared to those who had been exposed to medical information (n = 50/162) (p < 0.01)  identified being overweight, and 83.2% (n = 332/399) identified obesity as potential risk factors that could increase the likelihood of a T2DM diagnosis, whereas fewer participants, 38.3% (n = 153/399) and 49.6% (n = 198/399) respectively, could identify that smoking and alcohol consumption were modifiable risk factors associated with T2DM. Only 14.3% (n = 57/399) of the cohort were aware that mental health conditions, such as depression and schizophrenia were risk factors for T2DM  of the cohort could correctly identify at least six out of twelve risk factors; with 11.8% (n = 47/399) having adequate awareness and 48.8% (n = 195/399) having good awareness of T2DM risk factors.Most of the cohort, 86.7% (8.3% n = 53/399 ann = 118/222) or good (n = 31/222) awareness of T2DM risk factors compared to males  (p < 0.01).The results were stratified according to gender, age, ethnicity, highest level of education and exposure to medical information Table . No statn = 109/ 237) compared to those who had been exposed to medical information (n = 52/162) (p < 0.01)  reported that they exercised on a regular basis. Walking, gardening and housework were defined as non-vigorous activities in the questionnaire; whereas running, cycling, swimming and weightlifting were defined as vigorous activities. Only 41.9% (n = 125/298) of those who exercised, reported that their activities were vigorous. Only 15.1% (n = 45/298) of the participants were meeting the current exercise recommendations outlined by the Department of Health [Most of the cohort, 74.7%  in awareness of risk factors between participants indicating high level of physical activity compared to those with low level of physical activity; the classification of physical activity level was based on the recommendations outlined by the Department of Health [A Chi-Square test was performed to examine potential differences in participants’ awareness based on physical activity. The results indicated a significant difference  reported that they either currently smoked or had smoked previously, with the modal number of cigarettes smoked per day being 10–19. In terms of alcohol consumption, 50.6% (n = 202/399) of the cohort reported that they regularly consumed alcohol, with one quarter of the cohort 25.1% (n = 100/399) reporting that they drank at least twice a week.Participants were asked about their smoking history and current alcohol consumption. Almost half of the cohort, 42.3% (n = 349/399), reported that they snacked between meals and 45.5% (n = 159/349) opted for crisps, chocolate bars or biscuits as their preferred snack. Fewer participants, 15.1% (n = 53/349) opted for fruit or nuts. Participants were also asked about their consumption of desserts. Most participants, 81.0% (n = 323/399), reported eating at least one dessert per week; however, 19.2% (n = 62/323) reported eating a minimum of five desserts each week. Furthermore, when asked about their sugary drink consumption, 64.1% (n = 256/399) reported drinking a minimum of one sugary drink per day.Participants were also asked to recall information about their diet during a typical week. With regards to snacking, most participants, 87.5% (n = 109/399) were aware that a typical male should consume 2500 kcal per day whereas 34.1% (n = 136/399) were aware that a typical female should consume 2000 kcal per day. Participants that answered incorrectly were more likely to overestimate the recommended daily calorie intake rather than underestimate it.To determine participants awareness of dietary requirements and calorie consumption, they were asked “What is the recommended daily calorie intake for men and women?”. Overall, 27.3% (n = 31/399) could identify the images representing overweight individuals; whereas, most participants, 77.4% (n = 309/399), could identify the images representing the extreme scale of obesity . None of the participants could identify the early stages of obesity  as obese, but few 23% (n = 92/399) identified them as being overweight (BMI 25–29.9 kg/m2).Using a validated pictorial tool, participants were shown images of overweight and obese individuals . Few parn = 358/399), were unable to calculate their BMI whilst only 58.6% (n = 234/399) knew their height and slightly more, 62.5% (n = 250/399), knew their current weight.Participants were asked to provide their weight, height and BMI measurements. Most participants, 89.7% (p = 0.43) between the weight categories.Additionally, a Chi-Square test was performed to examine potential differences in participants’ awareness based on their weight. The calculation compared participants with a normal weight (BMI = 18.5–24.9) to those who were considered overweight or obese (BMI ≥25). There was no statistically significant variation in awareness (Participants were asked 20 subsequent questions about T2DM which were adapted from the Starr County Diabetes Education Study  and the n = 113/221) had an adequate awareness about T2DM, compared to males . In addition, more participants aged between 24 and 29 years (n = 134/286) had an adequate or good awareness about T2DM, compared to participants who were aged between 50 and 74 years . Also, more individuals who had studied at college or university (n = 149/308) had an adequate or good awareness about T2DM, compared to individuals who reported their highest level of education to be primary or secondary school .The results were stratified according to gender, age, ethnicity, highest level of education and exposure to medical information Table . No statn = 88/159) had an adequate or good awareness about T2DM, compared to individuals who had not received any previous information .Finally, more individuals who had been exposed to medical information about T2DM (n = 162/399), had received information about T2DM previously. Of those who had received information, 48.7% (n = 79/162) reported that the information was provided in a leaflet format; however, 60.5% (n = 98/162) would prefer to receive this information from healthcare professionals (HCPs).Participants were asked several further questions about T2DM information. Less than half of the cohort, 40.6% (n = 31/63) whereas the Urdu and Punjabi questionnaires had similar response rates of 43.7% (n = 31/71) and 43.2% (n = 32/74) respectively. Demographic details of the cohort are presented in Table For the second part of this study, individuals living in Ealing were approached and asked to complete the questionnaire in Hindi, Punjabi or Urdu, depending upon their main spoken language. Variable response rates were achieved. The Hindi questionnaire had a response rate of 49.2% . However, there was no statistically significant difference observed with other options/statements listed as risk factors or to assess general awareness in the survey when participants were asked in English or their main spoken language.The questionnaire results were further analysed and it was observed that participant awareness about obesity as a risk factor of T2DM changed when asked in different languages. More participants could correctly identify that obesity was a risk factor for T2DM when asked in Punjabi, Hindi or Urdu, compared to when they were asked in English  of participants identifying not exercising as a risk factor for T2DM, only 15.1% (n = 45/298) of those who exercised met the guideline recommendations. However, those who met the exercise recommendations had higher level of awareness of T2DM risk factors (p < 0.01). Additionally, 55.4% (n = 221/399) of the cohort reported between 0 and 20 min of activity per week. This finding is concordant with a national US survey that identified that high levels of awareness of the role of exercise in reducing the risk for T2DM does not necessarily correlate with increased exercise engagement in both high-risk and diagnosed diabetic patients [Discrepancies between patient reported awareness and behaviour were observed during the study particularly with respect to physical activity. The current exercise guidelines from the Department of Health recommend that individuals should participate in 75 min of vigorous activity or 150 min of non-vigorous activity each week . Howeverpatients . NeverthStratification of results according to participant demographics revealed no statistically significant associations between age, ethnicity, educational level and T2DM awareness. However, females and those who had received information about T2DM previously had a greater awareness of T2DM symptoms and risk factors. The latter finding is supported by results from a meta-analysis which concluded that lifestyle education could reduce the 1-year incidence of T2DM by 50%, thus emphasizing the importance of providing information for T2DM prevention .Of those who had received information about T2DM previously, most reported that it had been supplied in a leaflet format. However, 60.5% of the cohort would prefer to receive this information verbally from a HCP. A systematic review which determined the effectiveness and value of written information among patients with long term conditions, reached a similar conclusion . The revFindings from this study revealed that T2DM awareness was not influenced by language. This may have been due to the small sample size used in the second part of this study. Although the findings were not statistically significant, it is important to consider spoken languages, particularly in multi-cultural cities, like London. Offering medical information in different languages ensures that key health messages are distributed throughout the population.This study has several strengths and limitations. Firstly, it was conducted prior to the launch of the NHS Diabetes Prevention Programme (DPP) . EventuaThus, this study provides an insight into the current levels of awareness about T2DM and may provide a helpful baseline for the NHS DPP. Once the programme has finished, this study could be repeated to determine whether T2DM awareness has improved.n = 399/1683) of those asked to take part completing the questionnaire. Finally, the data collected was quantitative based on options provided in the data collection tool regarding symptoms and risks awareness, hence the results would have benefited from further qualitative research to explore trends of awareness in more details.This study had an acceptable sample size across the 4 included boroughs; however, the convenience sampling methods used to recruit participants may have been a limitation, as the researchers were only able to recruit participants in public places; therefore, home-bound individuals or those who did not use public transport were not accurately represented. Compared to London population, the sample size of the study can be considered small (given the low response rate) which might limit the generalisability of the results across all boroughs in London. Also, participants were asked to self-report information about their lifestyles. This method of data collection relies on an individual being able to accurately recall information and thus, could be influenced by cognitive decline or memory recall issues . The parMore than half of the participants in this study demonstrated adequate or good knowledge and awareness about the symptoms, risk factors and lifestyle choices, commonly associated with T2DM. However, some gaps in awareness still exist among the remaining proportion of participants. The existing evidence suggests that T2DM prevention interventions can be beneficial; however, future prevention strategies must be tailored according to the needs of the local population, and should aim to raise awareness about the condition. Given the role of awareness in disease prevention, it would be valuable to investigate public awareness of other long-term conditions as well. Finally, this study showed that T2DM awareness was not influenced by language; however, further research involving a larger cohort is required.Additional file 1:FINAL Project diabetes questionnaire – BMC. (DOCX 251 kb)


Knowledge of caregivers’ burden and fatigue before and after patients’ treatment for locally advanced head and neck cancer is scarce. Therefore, we aimed to explore caregivers’ fatigue and burden in relation to patients’ fatigue, distress, and quality of life.For caregivers, burden and fatigue were assessed. For patients, fatigue severity, distress, and health-related quality of life (HRQoL) were assessed. Measurements were conducted prior to treatment, 1 week, and 3 months after chemoradiotherapy.Caregivers’ burden and fatigue followed patients’ high peak in distress, fatigue, and diminished HRQoL as a consequence of treatment. Caregivers’ baseline fatigue was a predictor for fatigue after chemoradiotherapy. Female spouses with higher baseline levels of fatigue and burden and caring for patients with lower levels of HRQoL seem risk factors for burden after chemoradiotherapy.Attention should be paid to caregivers’ burden and fatigue before starting patients’ intense treatment with chemoradiotherapy, as both burden and fatigue before starting treatment may contribute to burden and fatigue after chemoradiotherapy. Every year, globally, 650,000 patients are diagnosed with head and neck cancer. The most common type of head and neck cancer is head and neck squamous cell carcinoma (HNSCC) which is associated with tobacco and alcohol abuse. Furthermore, in oropharyngeal cancer, part of the tumors are caused by the human papillomavirus (HPV). Patients with HPV-positive tumors have a favorable prognosis when compared to patients with HPV-negative tumors . StandarConsidering the aforementioned aspects, social support from patients’ informal caregivers is indispensible during and after treatment. Badr and colleagues found that patients with head and neck cancer and their caregiver cope with distress as a couple . ConsequThis prospective, observational pilot study had two exploratory aims. First, we wanted to explore the course of caregivers’ burden and fatigue in relation to patients’ fatigue, distress, and HRQoL before and after chemoradiotherapy. An important number of caregivers of head and neck cancer patients’ report needing help themselves . TherefoThis prospective, observational pilot study was conducted between 2011 and 2013 at the Radboud University Medical Center in the Netherlands. Eligible for participation were patients older than 18 years with LAHNC and who were scheduled for treatment with chemoradiotherapy with curative intent  and their informal caregivers. Patients and caregivers had to be able to give informed consent and read and write in Dutch. Patients receiving the chemoradiotherapy as primary treatment were treated with concomitant chemoradiotherapy during 5.5 weeks. They received accelerated radiotherapy. Patients who were treated with concomitant chemoradiotherapy as postoperative therapy were treated with a conventional chemoradiotherapy schedule and received treatment for 7 weeks. In oropharyngeal cancer patients, HPV positivity was determined by the use of immunohistochemical determination of p16. In case p16 was positive, PCR for HPV was performed. If also the PCR was positive, we identified the patient as HPV positive.The local medical ethical committee gave permission for the study. The attending oncologist (CH) and/or nurse practitioner (CO) informed the couples during their first visit to the outpatient clinic. If both patient and caregiver gave their informed consent, they were included. The attending oncologist or nurse practitioner extracted the treatment characteristics from the patient’s medical record, including HPV status, postoperative chemoradiotherapy (yes/no), and duration of treatment (weeks). Participants were asked to complete self-report questionnaires at three time points: (T0) prior to start chemoradiotherapy, (T1) 1 week after ending chemoradiotherapy, and (T2) 3 months after the end of chemoradiotherapy. Completing the paper and pencil questionnaire took between 45 and 60 min.A general questionnaire assessed caregivers’ and patients’ demographic characteristics, including gender, age, nationality, education, and employment.α = .74).Caregivers’ burden was assessed by the Self-Perceived Pressure from Informal Care questionnaire (SPPIC) which is a Dutch, validated questionnaire . It measα = 0.82–0.90) [Patients completed the Hospital Anxiety and Depression Scale (HADS) , which i82–0.90) .α = 0.84) [α = 0.72–0.95) [The EORTC QLQ-C30 (version 3.0) is a well-validated questionnaire to assess HRQoL.  It consi = 0.84) . We deci = 0.84) . Additio72–0.95) .α = 0.88) [For caregivers and patients, the severity of fatigue was assessed by the validated subscale fatigue severity of the Checklist Individual Strength (CIS). The 8-item subscale is scored on a 7-point Likert scale. The final score ranges from 8 to 56. Higher scores indicating more fatigue . A cutof = 0.88) .t tests  or the Mann-Whitney U test  were used. For categorical variables, chi square tests or Fisher’s exact test were performed. Characteristics of dyads who dropped out during the study were compared with the dyads who completed all the measurements. This was performed for age, gender, marital status, level of education, patients’ and caregivers’ baseline fatigue, caregivers’ baseline burden, and patients’ HRQoL and distress.Analyses were performed using Statistical Package for the Social Sciences software version 20 . When the data of the patient and/or the caregiver were incomplete at any time point, the dyad was excluded for analyses. For sample characteristics, descriptive statistics were used. For continuous variables, Student’s R2 and Beta weights were used for interpretation of the model. The assumptions of linearity, constant error variance, and normality were determined by performing residual analysis. Statistical significance was determined based on a two-sided alpha of 0.05.For our first exploratory aim, general linear model repeated measure analysis was performed to determine caregivers’ course of burden, using mean SPPIC scores on all measurement time points T0, T1, and T2). For determining caregivers’ and patients’ course of fatigue, mean fatigue severity scores on all measurement time points  were used. Additionally, the same analyses were performed to determine caregivers’ fatigue in relation to patients’ fatigue, using mean scores on all the measurement time points . To explore the association between patients’ distress and caregivers’ burden and distress, Pearson correlations were performed. For our second exploratory aim, we designed an exploratory model, which is shown in Fig. , and T2.n = 4); patient had caregivers, but no principal one (n = 2); dyad was not recruited by accident (n = 1); or reasons were unclear (n = 1). After inclusion, three dyads withdrew from participation for unclear reasons and one patient passed away. The mean recruitment rate was three dyads every month. For analyses, complete data of 56 dyads was available for T0, 49 dyads for T1 , and 45 dyads for T2 , incomplete data n = 1). Baseline characteristics are given in Table n = 11) and those who completed all assessments at all time points (n = 45), except for baseline burden, which was significantly lower in the group who dropped out (mean rank 16.6) compared to the group who completed all measurements . Patients who dropped out (n = 11) showed no significant differences compared to the patients who completed all measurements (n = 45), except for baseline HRQoL, which was significantly higher in the group of patients who dropped out (mean rank 37.6) compared to the patients who completed all measurements . At T0, patients’ health-related functioning was significantly better, and disease-related symptoms were significantly less when compared with data of the EORTC manual reference values (stages III/IV head and neck cancer) [In total, 68 patients were eligible. Eight dyads decided not to participate. Reasons not to participate were that participating was perceived too burdensome  . Details one n = ; dyad wap = 0.006) and showed a peak at T1. At T2 after chemoradiotherapy, burden was significantly lower when compared to burden at T0 and T1 .Caregivers’ mean scores on burden and the distribution of the level of burden are given in Table p = 0.029).Caregivers’ mean scores on fatigue and the proportion of severely fatigued caregivers are shown in Table p = 0.079; T1: mean rank 27.2 versus 23.6, p = 0.578; T2: mean rank 32.2 versus 21.9, p = 0.093) and fatigue .There was no statistically significant difference for caregiver found between groups for HPV positivity on all three time points for burden  and decreased significantly from T1 to T2 (p < 0.001). Patients’ levels of fatigue were significantly higher at T2 compared to T0 (p = 0.026). Patients’ distress changed over time (p = 0.012) and showed a peak at T1. Distress increased between T0 and T1 (p = 0.02), and decreased again between T1 and T2 (p = 0.03), down to baseline levels. There was no difference in distress at T0 and T2. Patients’ HRQoL decreased from T0 to T1 (p < 0.001) and recovered from T1 to T2 (p < 0.001), up to baseline levels. Moreover, a clinically relevant decrease in HRQoL was observed from T0 to T1 , and this was restored from T1 to T2 .Patients’ mean scores on fatigue, distress, and global health are shown in Table F = 5.245 (1.81); p = 0.025). Fatigue peaked for both patients and caregivers at T1 ; p < 0.001). Patients’ fatigue was lower at baseline but increased significantly faster (F = 9.233 (1.81); p = 0.003).Comparing the course of caregivers’ fatigue to patients’ fatigue, patients were significantly more fatigued than their caregivers . At T1, caregivers’ burden was significantly correlated to patients’ distress and HRQoL . At T2, burden was significantly correlated to patients’ distress and HRQoL at T2 .At baseline, caregivers’ burden was significantly correlated to patients’ fatigue, distress, and HRQoL . Patients’ fatigue at T0 was significantly correlated to distress and HRQoL at T0 , T1 , and T2 .At baseline, caregivers’ fatigue was significantly correlated to patients fatigue at T0 . Caregivers’ fatigue on T0, T1, and T2 was significantly correlated at all time points .Patients’ distress was significantly correlated to their HRQoL at T0, T1, and T2 (p = 0.012). Burden and fatigue at baseline contributed most to burden 3 months after chemoradiotherapy (13% of the 27%), followed by gender, patients’ global HRQoL at T1, and relation to the patient. Age and the change in global HRQoL between T1 and T0 contributed less.Table p < 0.01). Caregivers’ care-related characteristics  at baseline contributed most to the explained variance of fatigue scores 3 months after chemoradiotherapy (29% of 34%).Thirty-four percent of the variance in fatigue scores was explained by the independent variables. Caregivers’ fatigue at baseline contributed significantly to caregivers’ fatigue on T2 (This prospective, observational pilot study of patients with LAHNC and their caregivers is one of the few studies to focus on the course of burden and fatigue of caregivers in relation to patients fatigue, distress, and global HRQoL. It contributes to the existing knowledge about risk factors for burden and fatigue in caregivers of patients short after patients’ end of treatment with chemoradiotherapy.This study adds valuable knowledge for the identification of caregivers at risk for burden when patients have finished chemoradiotherapy. Female spouses with higher baseline levels of burden and fatigue, and caring for patients with lower levels of global HRQoL seem at higher risk for burden after the end of the intensive treatment of chemoradiotherapy. Adelman and colleagues describe risk factors for caregiver burden, which resemble our findings, such as female sex and cohabitation with the care recipient . They deThis study adds valuable knowledge to the literature about the course of caregiver burden. The available data of caregivers’ course of burden during and after treatment is limited and mostly regarding caregivers’ burden during treatment. Nightingale and colleagues reported an increase in burden during radio- and/or chemotherapy, which remained high up to the end of treatment . Badr anA main risk factor for caregivers’ severe fatigue after patients finish chemoradiation is baseline fatigue. Fatigue is considered an important determinant for general health, and levels of fatigue were higher among caregivers when compared to the general working population , 39. AddAlthough this study adds valuable knowledge, limitations should be considered. The predefined model for these exploratory analyses, based on clinical observations and supported by theory, contained a large number of predictors in a small sample size. Nevertheless, the exploratory model offers a direction for future studies with a larger sample size to identify caregivers at risk for burden and fatigue . FurtherIn conclusion, burden of caregivers of LAHNC patients receiving chemoradiotherapy is determined by multiple variables and follows patients’ peak in distress, fatigue, and diminished HRQoL. Female, spousal caregivers who are burdened and fatigued at baseline are important to identify before a patient starts treatment in order to prevent burden after patients’ ending of chemoradiotherapy. Where burden seems to be determined by multiple aspects, caregivers’ fatigue after patients’ curative treatment for LAHNC seems predominantly caused by caregivers’ fatigue at baseline. Fatigue is an important problem to identify, since it is an important determinant of a person’s general health and ability to participate in society. Lastly, problems as a consequence of patients’ treatment for LAHNC are likely to influence both the well-being of caregivers and patients. Therefore, it seems justified to involve both patients and caregivers when designing interventions addressing the aforementioned issues.


Anemia is frequent among patients with traumatic brain injury (TBI) and is associated with an increased risk of poor outcome. The optimal hemoglobin concentration to trigger red blood cell (RBC) transfusion in patients with TBI is not clearly defined.All eligible consecutive adult patients admitted to the intensive care unit (ICU) with moderate or severe TBI were randomized to a “restrictive” (hemoglobin transfusion threshold of 7 g/dL), or a “liberal” (threshold 9 g/dL) transfusion strategy. The transfusion strategy was continued for up to 14 days or until ICU discharge. The primary outcome was the mean difference in hemoglobin between groups. Secondary outcomes included transfusion requirements, intracranial pressure management, cerebral hemodynamics, length of stay, mortality and 6-month neurological outcome.p < 0.01) in the restrictive and liberal groups, respectively. Fewer RBC units were administered in the restrictive than in the liberal group . There was negative correlation  between hemoglobin concentration and middle cerebral artery flow velocity as evaluated by transcranial Doppler ultrasound and the incidence of post-traumatic vasospasm was significantly lower in the liberal strategy group . Hospital mortality was higher in the restrictive than in the liberal group  and the liberal group tended to have a better neurological status at 6 months (p = 0.06).A total of 44 patients were randomized, 21 patients to the liberal group and 23 to the restrictive group. There were no baseline differences between the groups. The mean hemoglobin concentrations during the 14-day period were 8.4 ± 1.0 and 9.3 ± 1.3  contains supplementary material, which is available to authorized users. Anemia is common in patients admitted to the intensive care unit (ICU) and is present on admission in 63% of patients. Blood transfusion has traditionally been used to restore hemoglobin concentrations in these patients. Overall, 37% of ICU patients receive at least one blood transfusion during the ICU stay, with a median of five units of packed red blood cells (RBCs) . In patiAnemia may impair cerebral oxygenation in patients with TBI, especially when hemoglobin concentration is less than 9 g/dL, and blood transfusion may increase cerebral oxygen delivery and potentially reduce the risk of tissue hypoxia . NeverthTwo randomized clinical trials have evaluated different transfusion thresholds in patients with TBI. A post hoc analysis of the Transfusion Requirements In Critical Care (TRICC) study evaluated 67 patients with moderate-to-severe TBI who were included in the original cohort of 838 critically ill patients who had a hemoglobin concentration lower than 9.0 g/dL within 72 h of ICU admission. There were no significant reductions in mortality with a blood transfusion threshold of 10 g/dL compared to a threshold of 7 g/dL . RecentlTransfusion practices in the setting of acute TBI are highly variable, depending on physician specialty and disease severity , 7. We tTransfusion Requirements After Head Trauma  was an open-label, parallel, feasibility, randomized controlled trial that was conducted at two ICUs in the Hospital das Clínicas of São Paulo University. The study was conducted in accordance with the amended Declaration of Helsinki. Local institutional review boards approved the protocol  and written informed consent was obtained from all the patients or their surrogates.Patients were considered eligible if they were older than 18 years; were admitted to the ICU with moderate or severe TBI  score ≤ 12 at hospital admission); and had a hemoglobin concentration less than 9 g/dL within 7 days from hospital admission. Exclusion criteria included patients who had a GCS of 3, with dilated pupils bilaterally; had previous known neurological sequelae; were pregnant; were Jehovah's witnesses; had hemorrhagic shock at randomization; were moribund.Enrolled patients were randomized in a 1:1 ratio to the restrictive or the liberal arm in random permuted blocks. None of the investigators or ICU staff members was aware of the randomization list prior to group allocation, or of the block numbers or block sizes, at any time. The randomization was performed using an automated third-party Internet-based service  in order to maintain allocation concealment. Given the nature of the intervention, the ICU staff could not be blinded to the treatment assignments. Patients were followed for 6 months after hospital discharge.Hemoglobin concentrations were assessed at least daily and patients were randomized to the liberal or restrictive blood transfusion strategy when their hemoglobin concentration was less than 9 g/dL. In the liberal group, patients were transfused if the hemoglobin concentration was less than 9 g/dL and in the restrictive group, if their hemoglobin concentration was less than 7 g/dL. Patients were given single units of cross-matched, pre-storage non-leuko-reduced RBCs. After every RBC transfusion, hemoglobin concentrations were checked one hour after transfusion and a single unit of RBCs was provided if the hemoglobin concentrations were lower than 9 g/dL or 7g/dL in the liberal or in the restrictive groups, respectively. The transfusion strategy was respected for 14 days or until death or ICU discharge, whichever came first. All other interventions, including transfusion before ICU admission or during surgery, were at the discretion of the attending team and were not influenced by the trial investigators.The primary outcome was the difference in mean hemoglobin concentration between the liberal and restrictive groups during the 14 days after hospital admission. Secondary outcomes included the number of transfused patients; the number of RBC packs transfused; ICU mortality; hospital mortality; mortality at 6 months after hospital discharge; adverse events; presence of elevated intracranial pressure (ICP) and intensity of intracranial hypertension treatment ; cerebraA TCD examination was performed every 48 h and mean cerebral arterial velocities, pulsatility indexes and Lindegaard indexes were measured. Post-traumatic vasospasm was defined as a middle cerebral velocity greater than 120 cm/sec in one vascular territory associated with a Lindegaard Index greater than 3 , 10.3) and non-convulsive status epilepticus.An adverse event was defined as the occurrence of any of the following: septic shock , acute rIn our institution only selected patients are monitored using an ICP monitor. Instead, most patients with TBI are monitored by serial clinical examination, TCD and brain computed tomography (CT), based on previously published protocols , 15. In Neurological status was evaluated using the Glasgow Outcome Scale (GOS)  at hospiThe sample size was calculated to detect a mean difference in hemoglobin concentration between the liberal and the restrictive groups of 1.2 g/dL, assuming a mean hemoglobin concentration of 8.2 g/dL in the restrictive group and a hemoglobin concentration of 9.4 g/dL in the liberal group, with a standard deviation of 1.2 g/dL in both groups, based on previous trials . Thus, et test or the Wilcoxon-Mann-Whitney test, accordingly. Categorical variables were presented as absolute and relative frequencies and compared using the χ2 or Fisher’s exact test, as appropriate. Secondary outcomes were considered exploratory and no multiple test correction was implemented. All tests were two-tailed and statistical significance was assumed with a p value less than 0.05. The statistical analysis was performed using the SPSS software .Analyses were based on the modified intention-to-treat population, excluding patients whose consent was later withdrawn and excluding randomization errors. Repeated measures general linear modeling was performed to assess the overall effect of group allocation on daily mean hemoglobin during the ICU stay (interaction between the transfusion strategy and time). No imputations for missing data were performed. For continuous variables, skewness and kurtosis values were used to assess normality of the data distribution and distributional graphical methods were used. Continuous variables were analyzed as mean ± standard deviation or as median and quartiles (25th–75th) and compared by Student’s p = 0.09); more midline deviation ≥ 5 mm on brain CT (16 (70%) vs. 10 (48%); p = 0.14); and more patients received blood transfusions before randomization (15 (65%) vs. 9 (43%); p = 0.14), compared to the liberal group . Thus, 44 patients were included in the final analysis, with 21 in the liberal group and 23 in the restrictive group , giving a mean difference of 0.9 ± 0.2 g/dL (Table p < 0.01) . The post-hoc analysis revealed that the difference between the groups in daily mean hemoglobin was statistically significant from day 5 up to day 14.The mean hemoglobin concentration during the first 14 days after hospital admission was 9.3 ± 1.3 g/dL in the liberal group and 8.4 ± 1.0 g/dL in the restrictive group . In the other patient, the attending physician refused to give a transfusion one day after randomization, despite a hemoglobin concentration lower than 9 g/dL.p = 0.02). All 21 patients in the liberal group were transfused, compared with 13 (57%) patients in the restrictive group, with a mean of 3.1 ± 1.6 vs. 1.5 ± 1.7 units per patient, respectively (p < 0.01)  g/dL and 6.8 (6.6–7.9) g/dL in the liberal and restrictive groups, respectively p = 0.0. All 21 p = 0.86) , there was no difference in the total number of interventions between the liberal and restrictive groups.The interventions aiming at controlling intracranial hypertension are shown in Additional file r = − 0.265, p < 0.01) between the hemoglobin concentration and middle cerebral artery flow velocity. The incidence of post-traumatic vasospasm was significantly lower in the liberal group . There were no statistically significant differences in pulsatility indexes (PI) between groups.The mean values of the TCD analysis from the first 14 days after ICU admission are shown in Additional file n = 1 patient (5%) vs. n = 7 patients (30%), respectively; p = 0.048). There was no significant difference between groups in GOS outcomes at hospital discharge. At 6 months, nine patients had died, two in the liberal group and seven in the restrictive group. The liberal group tended to have a better neurological status, as evaluated by the GOS (p = 0.06). Furthermore, among the living patients, 62% vs. 44% had a favorable GOS in the liberal and restrictive groups, respectively , similar to the results of Robertson et al. , but thiSeveral limitations should be noted. First, this was a pilot trial, aimed at evaluating the feasibility of a randomized clinical trial comparing liberal and restrictive blood transfusion strategies in patients with moderate and severe TBI. Therefore, the secondary outcome analysis should be considered exploratory. Nevertheless, our results are in line with previous experimental, physiological and observational data and point toward superiority of the liberal transfusion strategy , 19, 20.The trial reached feasibility criteria. The restrictive group had lower hemoglobin concentrations and received fewer RBC transfusions. Hospital mortality was lower and neurological status at 6 months favored the liberal group. Given the observed difference in outcome, a phase-II study is warranted.Additional file 1:Table S1. Adverse events. Table S2. Interventions for intracranial hypertension control during the ICU stay. Table S3. Transcranial Doppler. Table S4. Patients’ comorbidities. (DOCX 25 kb)


Increased oxidative stress in cerebral mitochondria may follow exposure to the systemic hypobaric hypoxia associated with residing at higher altitudes. Because mitochondrial dysfunction is implicated in bipolar disorder (BD) pathophysiology, this may impact the cerebral bioenergetics in BD. In this study, we evaluated the cerebral bioenergetics of BD and healthy control (HC) subjects at two sites, located at sea level and at moderate altitude.n = 22) and Salt Lake City . Levels of phosphocreatine, β nucleoside triphosphate (βNTP), inorganic phosphate, and pH over total phosphate (TP) were measured using phosphorus‐31 magnetic resonance spectroscopy in the following brain regions: anterior cingulate cortex and posterior occipital cortex, as well as bilateral prefrontal and occipitoparietal (OP) white matter (WM).Forty‐three veterans with BD and 33 HC veterans were recruited in Boston (A significant main effect of site was found in βNTP/TP (Boston > SLC) and phosphocreatine/TP (Boston < SLC) in most cortical and WM regions, and inorganic phosphate/TP (Boston < SLC) in OP regions. A main effect analysis of BD diagnosis demonstrated a lower pH in posterior occipital cortex and right OP WM and a lower βNTP/TP in right prefrontal WM in BD subjects, compared to HC subjects.The study showed that there were cerebral bioenergetic differences in both BD and HC veteran participants at two different sites, which may be partly explained by altitude difference. Future studies are needed to replicate these results in order to elucidate the dysfunctional mitochondrial changes that occur in response to hypobaric hypoxia. Rates of suicide are increased in higher‐altitude regions of the USA as well as other countries.A growing body of literature has suggested that oxidative stress due to mitochondrial dysfunction may be a central pathophysiology of bipolar disorder (BD).2) becomes lower. For example, at 4700 feet, the altitude of Salt Lake City (SLC), the atmospheric pressure is around 646 mmHg (compared to 760 mmHg at sea level).As altitude increases, the partial pressure of oxygen in the inspired air (PiO31P‐MRS) has been used to assess the phosphate‐bearing metabolites in the regions with both gray and white matter. We compared the cortical intracellular pH, PCr, inorganic phosphate (Pi), β‐nucleic triphosphate , and pH in the subjects recruited at the cities with moderate elevated altitude and near sea level .In this study, we hypothesized that the cerebral bioenergetic profiles including PCr and adenosine triphosphate (ATP), as well as intracellular pH, would be altered in both BD and healthy control (HC) subjects in environments with markedly different altitudes, which may identify a vulnerability of individuals with BD in elevated altitude. Phosphorus‐31 magnetic resonance spectroscopy . See Table Seventy‐six subjects completed participation across our two study sites  was used for phosphorus metabolite data acquisition at each site. Proton decoupled 31P spectroscopic imaging data were acquired using a 3‐D magnetic resonance spectroscopy imaging pulse sequence (3‐D MRSI) with the following parameters: field of view (FOV), 20 × 20 × 20 cm3; volume of interest, 20 × 20 × 10 cm3; receiver bandwidth = 2.5 kHz; repetition time (TR)/echo time (TE) = 3000/2.3 ms; flip angle = 90°; average number = 16; vector size = 1024; and matrix scan size = 8 × 8 × 8. To facilitate voxel placement, high‐resolution T1‐weighted images (M1) were acquired using a 3‐D magnetization‐prepared rapid gradient echo acquisition (MPRAGE) pulse sequence with the following parameters: TR/TE/inversion time (TI) = 2000/3.37/1100 ms; flip angle = 8°; FOV = 256 × 192 × 224 mm3; 256 × 192 × 224 matrix size; 1 × 1 × 1 mm3 spatial resolution; and bandwidth = 300 Hz/pixel. The anterior–posterior line was identified on the midsagittal images acquired by MPRAGE pulse sequence. In addition, due to the high concentration of water in the brain relative to high‐energy phosphates, suboptimal single‐channel proton coil sensitivity within 31P/1H dual‐tuned coils is common, reducing structural image quality. Especially in the frontal lobe regions, the dual‐tuned coil's signal‐to‐noise ratio and image contrast were poorer than those acquired using the 12‐channel phased‐array proton head coil. The reduced image contrast in the brain region of interest (ROI) hampers partial voxel volume correction because of less accurate tissue segmentation. Furthermore, tissue‐specific data analysis requires the alignment of the 3‐D MRSI grids at the desired ROI across multiple subjects. Low signal‐to‐noise ratio and poor image contrast reduce the normalization accuracy between T1‐weighted image and standard image. To improve the accuracy of normalization and tissue segmentation, additional 3‐D high‐resolution MPRAGE images (M2) were acquired using a proton‐only 12‐channel phased‐array head coil .Neuroimaging data were acquired using Siemens 3 Tesla whole body MRI systems  at University of Utah and McLean Hospital. A 31P/1H dual‐tuned head coil were registered into M2 images of the same brain. The affine transformation matrix (TM1‐ > M2) from M1 to M2 was inverted and then TM2‐ > M1 (the inverted TM1‐ > M2) was applied onto M2 to obtain registered M1 (M1*) in the M1 subject‐native space. Third, the normalization of the M1* image into the MNI template space was performed to achieve a warping field map using the FNIRT tool of FSL . The inverse warping field image is used to map the voxel center determined in the first step from MNI space to subject native space. Finally, according to the property of MRSI grid re‐shifting with an additional linear phase application in the k‐space domain, all MRSI grids were aligned with respect to the ROI center in the subject‐native space.In the present study, multiple ROI selections, including anterior cingulate cortex (ACC), posterior cingulate cortex (POC), bilateral prefrontal white matter (WM), and occipitoparietal (OP) WM, are shown in Figure 31P spectra were preprocessed using a MATLAB‐based application . The 3‐D MRSI matrix was interpolated to 16 × 16 × 16 and a 75% Hamming filter was applied to reduce signal contamination in neighboring voxels. Spectra from the desired ROI location within the aligned MRSI grid were extracted and then apodized with 2‐Hz Lorentzian line broadening before Fast Fournier Transform. The zero‐ and first‐order phase corrections were performed on all spectra. The signal intensity of each metabolite was obtained using the Advanced Method for Accurate, Robust and Efficient Spectral Fitting of MRS data with use of prior knowledge (AMARES) fitting algorithm within the software application jMRUI 6.0.All * images were segmented into gray matter (GM), WM, and cerebrospinal fluid (CSF) using FSL. Brain tissue images were extracted by removing the outer skull and scalp surfaces using the Brain Extraction Tool of FSL. Finally, the FAST/FIRST tool was utilized to calculate the segmented tissue percentage in the ROI. Coregistration between the spectroscopic ROI and the segmented image was performed with a user‐developed MATLAB program.To evaluate the influence of brain tissue components within the ROI, the M131P‐MRS scans at both sites. Five healthy subjects living in SLC traveled to Boston, and were scanned at both sites within a 24‐h period in order to assess and establish quality control. The results indicated that upper range of within‐subject coefficient of variation (COV) was 14.7%, which belongs to desirable levels of COV.The comparability of spectral data across the two study sites has been validated using phantoms as reported in an earlier publication.stata 15 . Fisher's exact and one‐way analysis of variance (ANOVA) tests were employed to compare the composition of sex and the means of continuous variables in demographic and clinical information among the four groups. As there was a significant difference in age among the groups (P = 0.014), this difference has been taken into consideration in further analyses. In addition, the composition of CSF in the ACC voxel was significantly different across the groups  was used to assess the altitude (place), the diagnosis, and their interaction effects on the 31P‐MRS metabolites, including covariates. Due to a small sample size for HC subjects in Boston, the 95% confidence interval (CI) of P‐value was estimated using a non‐parametric random permutation test with 5000 iterations of ancova tests. After ancova was applied, adjusted prediction of mean value with 95%CI was estimated by observation information matrix models using maximum likelihood. Correlation analyses between two continuous variables were conducted using Pearson's correlation. A P‐value < 0.05 was regarded as statistically significant. Then, the Benjamini–Hochberg procedure of false discovery rate was used to reduce false positive rates arising from multiple comparison issues of the mean comparison of the metabolites in all the voxels.Statistical analyses were conducted using ps Table . Since CF > 5.19, P < 0.003), mostly driven by the differences between BD and HC. Within BD subjects, there were no significant differences in terms of MADRS, YMRS, and number of items in lifetime CSSRS suicide behavior between the patients from the two sites . BD subjects in SLC had greater suicidal ideation intensity ratings than those in Boston . History of alcohol use of the subjects is presented in Tables Detailed demographic information and clinical characteristics are presented in Table F > 11.83, P < 0.001) and PCr/TP  in both the ACC and the POC, and Pi/TP  in the POC. In predicted estimation of mean value adjusted by diagnosis and/or covariates, the subjects living in SLC had 7.66% and 6.02% higher PCr levels within ACC and POC, respectively, whereas 19.0% and 22.7% lower βNTP levels (a proxy measure of adenosine triphosphate in the brain) of ACC and POC were found in the subjects from SLC compared to those from Boston. The predicted Pi of POC was 14.8% higher in the subjects from SLC. A lower pH within POC in BD subjects was also observed relative to HC subjects as a main‐effects analysis of diagnosis . Upper limits of 95%CI for all the P‐values of ancova tests were estimated below 0.05. Detailed comparisons of 31P‐MRS results in ACC and POC are presented in Table In the regions of gray matter, a main effects analysis identified site effects in βNTP/TP  by 17.5%–23.1% in predicted value and higher PCr/TP  by 4.67%–6.06% were observed in the subjects from SLC relative to those from Boston across the regions. In right prefrontal WM, both altitude and diagnosis effects were found in βNTP/TP . Like POC, higher ratios of Pi/TP  by 12.6% and 7.79%  were observed in bilateral OP WM of the subjects from SLC relative to those from Boston, whereas lower pH of right OP WM  only was observed in the subjects with BD relative to those in the HC group. Upper limits of 95%CI for all the P‐values of ancova tests were estimated below 0.05 except PCr level of left prefrontal WM. However, the PCr/TP ratio in the left prefrontal, and PCr/TP and Pi/TP ratios for the right OP WM regions between the sites and βNTP/TP in right prefrontal WM between diagnosis did not remain significant after multiple comparison correction. Detailed comparisons of 31P‐MRS results in the regions of WM are presented in Table In the regions of WM, the differences of βNTP/TP and PCr/TP by site were similar to those within the ACC and POC. Aside from right prefrontal WM, lower βNTP/TP  relative to in Boston, near sea level . We also found that decreased βNTP levels in right prefrontal WM were affected by both site and BD. In addition, there were increased Pi levels within the POC in the subjects from SLC and decreased pH values of occipital lobe in the subjects with BD. In line with the previous literature regarding suicide rates in the USA, BD subjects from SLC showed higher suicidal ideation intensity rating than those from Boston.The present results are, to the best of our knowledge, the first report of a study intended to explore As hypothesized, altitude differences between the sites may have led to mild hypobaric hypoxic stress on the brains of the SLC residents. However, if the current results represent the long‐term, chronic adaptation in brain mitochondrial functioning to altitude‐associated hypobaric hypoxia, our hypotheses should fulfill the following assumption. We assumed that mild hypobaric hypoxia in the elevation of about 1.5 km would be enough to provide altitude‐related changes in the human brain. Clearly, mountain sickness, active acclimatization response, and declining cognitive functions are not observed in the subjects living in SLC.31P‐MRS.Although differences in altitude may be responsible for the current findings, other confounding factors may also be important. For example, low consumption of alcohol was observed in Utah relative to in Massachusetts.Hypobaric hypoxia as a consequence of elevated altitude could be connected to an increased risk for suicide and depression through two molecular pathways.In light of altered cerebral bioenergetics in BD, Kato and coworkers reported indicating that decreased levels of PCr in the frontal lobes might be associated with the pathophysiology of BD.31P‐MRS study with adolescents with BD.In the WM of the right frontal lobe, both altitude and diagnosis effects in the levels of βATP were found. This was similar to the findings from a in vitro experiments, it was reported that HIF‐2β had a high affinity for promoter areas of brain and muscle isoforms of CK enzyme as well as creatine (Cr) transporter genes, which suggested indirect evidence that HIF‐1 may serve as a transcriptional factor for genes involved in Cr metabolism.Altered levels of cerebral high‐energy phosphate compounds were supposed to be elucidated by the following molecular mechanisms. First, hypoxia inducible factor (HIF) may play a certain role in a molecular pathway for increasing PCr under hypoxia. HIF is a key molecule helping the cells to survive in a hypoxic environment.31P‐MRS and lateralization depending on mood states.31P‐MRS, like proton MRS, the composition of GM and WM has not been considered in this study.The current study has several limitations. The number of healthy subjects assessed in Boston was relatively small, which weakens the statistical power. Also, the inclusion of both euthymic and depressive BD patients might have affected the results. There have been a few reports regarding the differences in bioenergetic profile measured by This is the first study examining the effects of geographic area, and specifically altitude of residence, on the pathophysiology of BD. While our findings are difficult to interpret in isolation, they fit into a model of mitochondrial dysfunction in BD when considered in the context of what is known about hypoxia, suicide, and mood disorders. For example, it has been reported that patients with hypoxic chronic medical conditions are at increased risk for suicide, and that this risk increases with altitude.The results of the present study are also consistent with the published evidence that increased suicide rates are associated with mountainous areas of the USA, an association that, notably, has been replicated by investigators working in multiple other countries,No authors have any conflicts of interest to report.All authors contributed to and approved this version of the manuscript. J.H. conducted the statistical analyses and wrote the manuscript. C.R. and D.S. recruited participants for the study, conducted clinical assessments and study measures, and contributed to the writing of the manuscript. X.S., Y‐H.S., and C.Z. acquired and processed the magnetic resonance spectroscopy imaging data. R.V. facilitated the acquisition of magnetic resonance spectroscopy data at the Brockton site. D.Y‐T., D.K., and D.Ö. served as coinvestigators and clinicians on the project. T‐S.K. contributed to study design. P.F.R. and L.E.D. were principal investigators of the study and provided oversight for all study staff, and direction for the collection, analysis, and interpretation of all data.Table S1. Exploratory mean comparisons of repeated measurements (five subjects) from phosphorus‐31 magnetic resonance spectroscopy for the reliability of the scans between sitesTable S2. Tissue‐composition comparisons in each voxel among the groupsTable S3. Self‐reporting total years of alcohol drinking in lifetimeTable S4. Self‐reporting days of alcohol drinking in a week during the last 6 monthsClick here for additional data file.