APOE-e4 dose for the genetic disclosure process of the Alzheimer’s Prevention Initiative Generation Study, a prevention trial in cognitively unimpaired APOE-e4/e4 homozygote individuals.With the onset of prevention trials for individuals at high risk for Alzheimer disease, there is increasing need for accurate risk prediction to inform study design and enrollment, but available risk estimates are limited. We developed risk estimates for the incidence of mild cognitive impairment (MCI) or dementia among cognitively unimpaired individuals by n = 5,073, 158 APOE-e4/e4), the Rotterdam Study , the Framingham Heart Study , and the Sacramento Area Latino Study on Aging (SALSA) . We computed stratified cumulative incidence curves by age  and APOE-e4 dose, adjusting for the competing risk of mortality, and determined risk of MCI and/or dementia by genotype and baseline age. We also used subdistribution hazard regression to model relative hazard based on age, APOE genotype, sex, education, family history of dementia, vascular risk, subjective memory concerns, and baseline cognitive performance. The four cohorts varied considerably in age, education, ethnicity/race, and APOE-e4 allele frequency. Overall, cumulative incidence was uniformly higher in NACC than in the population-based cohorts. Among APOE-e4/e4 individuals, 5-y cumulative incidence was as follows: in the 60–64-y age stratum, it ranged from 0% to 5.88% in the three population-based cohorts versus 23.06% in NACC; in the 65–69-y age stratum, from 9.42% to 10.39% versus 34.62%; and in the 70–75-y age stratum, from 18.64% to 33.33% versus 38.34%. Five-year incidence of dementia was negligible except for APOE-e4/e4 individuals and those over 70 y. Lifetime incidence (to age 80–85 y) of MCI or dementia for the APOE-e4/e4 individuals in the long-term Framingham and Rotterdam cohorts was 34.69%–38.45% at age 60–64 y, 30.76%–40.26% at 65–69 y, and 33.3%–35.17% at 70–75 y. Confidence limits for these estimates are often wide, particularly for APOE-e4/e4 individuals and for the dementia outcome at 5 y. In regression models, APOE-e4 dose and age both consistently increased risk, as did lower education, subjective memory concerns, poorer baseline cognitive performance, and family history of dementia. We discuss several limitations of the study, including the small numbers of APOE-e4/e4 individuals, missing data and differential dropout, limited ethnic and racial diversity, and differences in definitions of exposure and outcome variables.We included cognitively unimpaired individuals aged 60–75 y, consistent with Generation Study eligibility criteria, from the National Alzheimer’s Coordinating Center (NACC)  is associated with increased risk and earlier onset age of Alzheimer disease dementia, and the 1%–2% of the population who carry two copies of this variant (APOE-e4/e4) are at especially increased risk.Having one copy of the e4 variant of the APOE-e4/e4 are being targeted for special prevention strategies.For this reason, individuals with Accurate risk estimates allow potential participants in prevention trials to compare the risk of developing Alzheimer disease dementia to any risk associated with the preventive intervention itself.Such estimates also help those planning trials decide how many participants they need.APOE-e4/e4 will develop Alzheimer disease dementia has been reported to be as high as 50%–67%, but these estimates come from statistical modeling, not direct observation.The risk that an individual with APOE-e4/e4, as well as estimates for those with one or no copies of APOE-e4. The non-APOE-e4/e4 individuals are not eligible for the Generation Study, but participate in genetic counseling as part of the recruiting process, and might be eligible for future trials.Our study was designed to develop risk estimates for potential participants in the Generation Study, a prevention trial in individuals with APOE-e4/e4, from four different samples of cognitively normal older individuals aged 60–75 years (consistent with the eligibility criteria for the Generation Study). These individuals have been followed for an average of 4 to 18 years and assessed for the development of dementia or a less serious condition called mild cognitive impairment that sometimes leads to dementia.We examined data from 16,844 individuals, 292 with APOE-e4  and age , and developed estimates of the risk of developing mild cognitive impairment or dementia in each group during the five years planned for the trial as well as “lifetime” risk through age 80–85 years.We divided each sample into six groups based on the number of copies of APOE-e4/e4 individuals, it ranged from 0% to 23% in those entering the study at age 60–64 years, 9% to 35% in those entering at 65–69 years, and 19% to 38% in those entering at 70–75 years.Five-year risk was highly variable across the four samples within each group; for APOE-e4/e4.Lifetime risk was more consistent across the two samples in which it could be estimated, and did not vary as much with age, ranging from 31% to 40% for those with APOE-e4, the following variables were associated with increased risk: less education, memory concerns or poorer cognitive screening test scores at the beginning of follow-up, and having a family history of dementia.We developed statistical models to understand the differences across the four samples. These analyses showed that, beyond age and Differences in these characteristics, differences in methods of recruiting and evaluating participants, and statistical fluctuation probably account for a large share of the variety in risk estimates across the samples.APOE-e4/e4 is somewhat lower than previously estimated.The risk of dementia in those with Short-term risk is more subject to variability due to details of how a particular study is conducted than longer-term risk.This information is valuable to those considering joining a prevention trial, as well as those designing such trials. The Generation Study is a double-blind, randomized, placebo-controlled clinical trial of two different anti-amyloid agents in approximately 1,300 participants. Recruitment is through several sources, notably in the United States through the GeneMatch  to construct the confidence interval for cumulative incidence. The transformation not only ensures that the boundaries of cumulative incidence are contained in , but also improves the coverage accuracy [Stratified cumulative incidence curves by age stratum and ortality ; loss toortality . We usedortality  to estimn of Lin , we usedaccuracy .APOE-e4 dose plus additional covariates on the cumulative incidence of MCI/dementia and of dementia alone in order to inform personalized risk assessment and to understand differences across the cohorts. We used subdistribution hazard regression models [We used the same competing risks analytic framework to assess the effects of age and n models  because n models , where tn models ; in preln models .APOE-e4 dose, education, standardized cognitive screening test score, subjective memory concerns, family history of dementia, and vascular risk score. Then, we ran simple multivariable models for each outcome including only APOE-e4 dose and demographic factors . Last, we ran larger multivariable models also including standardized cognitive screening score plus subjective memory concerns and family history of dementia if available for the cohort. The vascular risk score was not included in the full model because findings were inconsistent and primarily null in the univariable models, whether we used our low/moderate/high vascular risk levels described above or the Framingham Stroke Risk Profile.For each cohort and for each outcome, we first fit univariable models for baseline age, sex, Missing data on covariates was generally minimal, <2% for all covariates in all cohorts except family history in the Rotterdam Study (11.5%), vascular risk in SALSA (8.9%), and education in the Framingham Heart Study (3.3%). As these figures were small, participants with missing data were simply omitted from regression analyses in which the relevant missing variable was included.For the Rotterdam Study, the exact date of dementia diagnosis was used if available; otherwise, the midpoint of the interval between visits was used as the onset time of MCI or dementia at a study visit  for both cumulative incidence estimates and subdistribution hazard regression. In addition, as a sensitivity analysis, we repeated our survival curves and regression models treating the onset of MCI or dementia as interval censored in addition to adjusting for competing risk, using the “MIICD” package in R software to estimate the cumulative incidence, and results were extremely similar except for somewhat larger confidence intervals.Unlike in the stratified analyses, in the regression analyses, each participant was used only once. Typically, the baseline visit for the regression analyses was the first visit within the eligible age window of 60–75 y. For the Framingham Heart Study, MMSE was not available at visits prior to 1981 (as described above). Thus, for the regression analyses, we reset the baseline visit as the first visit at which MMSE was available. This had the additional benefit of increasing the range of baseline ages within the cohort.Meta-analyses were conducted for the 5-y cumulative incidence estimates for all four cohorts and then for only the three population-based cohorts. Meta-analyses could not be conducted for the lifetime estimates because they were computed for only two cohorts. As there was considerable heterogeneity among the studies, a random-effects meta-analysis based on the DerSimonian–Laird method  was usedBecause the primary goal was estimating cumulative incidence and understanding differences across cohorts and individuals rather than hypothesis testing, these analyses are reported with confidence intervals rather than statistical significance, and no adjustments are made for multiple comparisons.APOE-e4 dose groups; and regression models including demographic factors, cardiovascular risk, and baseline cognitive performance or symptoms, with survival models accounting for competing risk of death. The idea was that the stratified curves would provide general estimates, and the regression models more individualized estimates (and in any event insight into anticipated differences across cohorts). As noted above, after initial exploration, we decided to use specifically subdistribution hazard regression rather than cause-specific hazard regression models because these offer greater interpretability in the context of risk prediction. In preparation for our first presentation of the findings to the Generation Study team in April 2015, we also decided to make a table of estimated 5-y cumulative incidence to allow easier comparison across the studies. After this initial meeting, we also added the lifetime risk estimate, which we thought would be informative for potential participants. We performed the initial regression models separately by cohort in order to get an idea of how best to present the data given somewhat different variables available in each cohort, and then settled on a final analysis plan in spring 2016 that included univariable and two nested models as consistent as possible across the four cohorts. The NACC dataset was acquired in summer 2014 (the June 2014 data freeze) and then updated in summer 2016 (the March 2016 data freeze). The SALSA dataset was acquired in fall 2014, and the Framingham Heart Study dataset in spring 2015. Rotterdam Study analyses were conducted by Rotterdam Study investigators (F. J. W. and M. A. I.) beginning in spring 2015, in close collaboration with the rest of the group and sharing R code used with the other cohorts to ensure consistency.The study was planned in summer of 2014 and conducted through fall of 2016. The original analysis plan, developed in the initial months of the study, specified using multiple cohort studies, including NACC as well as three population-based cohorts; stratified analyses in the three age and APOE-e4 allele frequency, ranging from 7.5% in SALSA to 17.8% in NACC. NACC also had a 58.3% fraction with a family history of dementia, compared to 18.6% in the Rotterdam Study, the only other site that assessed it.APOE-e4 dose; APOE-e4 dose. However, absolute risks differed substantially across the cohorts, particularly between NACC and the population-based cohorts. Especially for the MCI/dementia outcome, the NACC cohort typically had higher risk for any genotype at any age. Differences among the population-based cohorts were smaller, particularly for longer-term follow-up and the dementia outcome.Overall, within each cohort, risk of MCI/dementia increased with increasing age and APOE-e4-positive individuals, especially homozygote individuals (23% in NACC and 5%–6% in Framingham and Rotterdam). Five-year incidence of MCI/dementia was higher in the highest age stratum, particularly among APOE-e4/e4 homozygote individuals (38% in NACC and 18%–23% in Framingham and Rotterdam). Five-year incidence of dementia alone was negligible at younger ages, even in APOE-e4/e4 homozygote individuals, but rose among older individuals, particularly among those with APOE-e4/e4 (12% in NACC and 7%–12% in Framingham and Rotterdam). The meta-analyses of the 5-y cumulative incidence estimates for the MCI/dementia outcome . Lifetime incidence rose consistently with dementia , it rangia alone , it rangAPOE-e4 dose and demographics), and Results of the subdistribution hazard regression analysis are presented in APOE-e4 dose , and lower education (HR 1.41–1.86 for less than high school compared to high school). Family history of dementia also had a nominally significant effect in both cohorts in which it was measured (HR 1.16–1.27). On the other hand, male sex, which was protective in the population-based cohorts , carried risk in NACC (HR 1.36). Subjective memory concerns carried risk in both cohorts that assessed them (HR 1.71–2.62). Higher standardized baseline cognitive screening test score (MMSE or 3MS) was consistently protective across all cohorts for both outcomes (HR 0.58–0.80 per standard deviation above the mean), except for the MCI/dementia outcome in the Rotterdam cohort. Vascular risk score had a variable and generally nonsignificant effect across all four cohorts.The univariable results  suggest that overall APOE-e4-associated incidence is somewhat lower than the modeled findings previously available in the literature. Comparing 5-y cumulative incidence from the meta-analyses of the three population-based cohorts to that from NACC, in the youngest age stratum, cumulative incidence ranged across the three APOE-e4 doses from 1.46% to 5.60% in the population-based cohorts versus 7.94% to 23.06% in NACC, and in the oldest age stratum from 5.71% to 20.58% in the population-based cohorts versus 15.16% to 38.34% in NACC. Similarly, viewing the cumulative incidence for APOE-e4/e4 genotype across the three age strata, cumulative incidence ranged from 5.60% to 20.58% in the three population-based cohorts versus from 23.06% to 38.34% in NACC. The NACC findings were largely similar to those of the prospective analyses of Bonham et al. [relative risk of APOE-e4 across different age ranges, used different age categories (unrelated to the Generation Study), and did not incorporate several important variables in the models . Moreover, the authors did not perform their analyses in a competing risk framework, which is vital to avoid overestimation of cumulative incidences in aging populations [Of 16,844 participants included from all four cohorts, 392 (2.3%) had the m et al.  in the sm et al.  focused ulations .Variability related to ascertainment and assessment methods has been reported previously for MCI and dementia prevalence ,56. SuchOverall, as might be expected, absolute risk is more vulnerable to methodological differences than relative risk, especially over shorter time intervals and for the MCI/dementia outcome rather than the dementia alone outcome. This is underscored by the generally similar relative hazards across the regression analyses. These regression findings also contribute to an understanding of the variation across the cohorts.APOE strata. The difference between the population-based cohort studies and NACC, on the other hand, is striking. The NACC cohort is a volunteer cohort, and as such would not be expected to represent the general population . Individuals join this cohort for a variety of reasons, but concerns about family history and their own memory are likely to play a role. This probably contributes to the relatively high APOE-e4 allele frequency and reported family history of dementia in this cohort seen in APOE-e4 effect in these and other data [Among the three population-based cohort studies, there are known and unknown differences in race and ethnicity, education, and screening and assessment methods. Nonetheless, these three cohorts were generally similar—within expected sampling variation—in their estimates of cumulative incidence for most age and her data ,58, the her data , and thiBeyond these differences in ascertainment, demographics and other attributes, and follow-up, there are differences in assessment between NACC and the three population-based cohorts that should be noted. The population-based cohorts evaluate cognition with a screening procedure typically followed by more formal clinical evaluation of participants who screen positive. While direct clinical evaluation of all participants at each NACC site is a strength, there are procedural differences across sites, quality control is limited, and the reliability of NACC diagnosis is not well established. In addition, the high educational level of NACC participants is not well captured by available norms, and a subset of individuals may have declined substantially but nonetheless may be viewed as cognitively unimpaired. This is a particular concern because within any group of normal individuals, those who are already declining are more likely to continue to do so –62. ThusOf course, it is likely that there is some insensitivity to MCI and even dementia in the population-based cohort studies as well as differential loss to follow-up, but on balance the volunteer nature of the NACC cohort, the limited quality control across the NACC sites, and the consistency of the population-based cohort findings tend to favor the lower cumulative incidence found in the population-based cohorts.APOE-e4-associated absolute risk for dementia [APOE-e4/e4 individuals from the Framingham Heart Study and the Rotterdam Study are in the 31%–40% range. While we did not estimate lifetime cumulative incidence for NACC given the short mean duration of follow-up, it would be expected to be considerably higher than the 5-y estimates—in the oldest APOE-e4/e4 homozygote individuals, 38.3% for MCI or dementia and 12.4% for dementia alone. However, there are some biases in the modeled estimates that overall are more likely to yield over- rather than underestimates of risk.One could argue that previously available modeled estimates for dementia ,19 are hFor the Cupples et al. estimates used in the REVEAL study , risk cuAPOE-e4 effect) overrepresented. In addition, these models assumed that the controls in GWAS samples were representative of the overall population. This likely does not hold with a very common disease like dementia  and women are overrepresented (80%). Among the 4,978 registrants who were asked about race/ethnicity, 92% are white. The frequency of the APOE-e4/e4 genotype among registrants is higher than in the general population, at 4.47%, and the APOE-e4 allele frequency is 20.4%; among the 3,456 registrants asked about whether they had a family history of dementia or Alzheimer disease, 70.1% said yes. While education was not measured, the high percent of females and individuals with a significant family history (and the high APOE-e4 frequency) suggests a population that may be more like NACC. However, data on education, cognitive performance, and subjective memory concerns are not available. Moreover, over time, if there are broader recruiting efforts in order to reach the target sample size, volunteers could gradually become more reflective of the general population, and lower risks might be expected.For the purposes of the Generation Study and other prevention trials, absolute cumulative incidence, both during the 5-y duration of the trial and over the remaining lifetime, is critical, but the differences across these cohort studies make it difficult to offer precise estimates, even with meta-analyses. In an ideal world, estimates would be tailored to the population entering the trial or, better still, the specific individuals, and would take into account not only explicit inclusion criteria but also any other measureable or predictable characteristics that might predict willingness to volunteer. A review of the first registrants on the GeneMatch registry, which serves as the primary US recruiting site for the Generation Study APOE-e4/e4; 20%–25% for individuals with APOE-e3/e4 and -e2/e4 (with a note that risk might be lower for those with APOE-e2/e4); and 10%–15% for individuals with APOE-e3/e3, -e3/e2, and -e2/e2 (with a note that risk might be lower for those with APOE-e2/e3 and -e2/e2). These values are consistent with our findings, but use round numbers for intelligibility, and broader ranges to reflect statistical and other sources of uncertainty. The regression models are insufficiently precise for “personalized medicine” incidence estimates based on sex, education, or other factors, but they do allow for qualitative adjustments to overall stratified risk estimates. Relative risks by APOE genotype or APOE-e4 dose have limited relevance in the setting of the prevention trial, but may provide context. If these are provided, risk should be compared to the general population , which would more fairly allow a participant to put his or her own risk in the context of friends and acquaintances of unknown genotype. On the basis of our regression findings  as well as regression coefficients for APOE-e4 dose. This issue is further complicated by missing data (likely not missing at random) and likely differential dropout. Second, while the four cohorts are heterogeneous in sex distribution and education, there is little ethnic and racial diversity, so the findings are less relevant to participants of non-European background. Third, variations in the definitions of the exposure and outcome variables may hamper comparisons among cohorts. As noted above, each cohort uses different criteria to define unimpaired at baseline, and to screen, assess, and diagnose new onset cases. Different psychometric tests are applied, and even the same test performs differently across different groups; education- and/or age-adjusted norms can compensate for this, but may introduce other problems in interpretation. Other variation may come from differences in definitions  or in how information is acquired . Moreover, some variables, notably level of education, may be defined similarly but have different meanings within different cultural contexts. Nevertheless, as we have shown, relative risk estimates are consistent despite this variation. Fourth, regression models for MCI or dementia are limited because of confounding and omitted predictors, and are complicated by multicollinearity of exposure and outcome variables that represents confounding, effect modification, and true signal.One major limitation of this study is that Prospective cohort studies can be used to inform study design, power, and informed consent in clinical trials among cognitively unimpaired individuals. While trial designers and participants may be most interested in absolute risk over relatively short intervals, absolute risk is less robustly estimated than relative risk, and short-term risk less robustly estimated  than long-term risk. Estimation that serves informed consent and optimal trial design will require matching the cohort used to estimate risk as closely as possible to trial participants.APOE-associated risk of MCI or dementia were lower in our study than previously reported, and there is reason to believe that the risk estimates obtained in the population-based cohorts more accurately reflect the general population than those obtained in NACC. However, these lower risks may less accurately match the likely trial population. In general, such estimates are also sensitive to variation in sampling, assessment, and modeling. Rigorous attention to sampling, assessment, and statistical methods is critical to developing the best possible answers for clinical trial design.Overall, the estimates for S1 Checklist(DOC)Click here for additional data file.S1 Appendix(DOCX)Click here for additional data file.S1 Text(DOCX)Click here for additional data file.S2 Text(DOCX)Click here for additional data file.


Tumour-induced osteomalacia (TIO), is a rare paraneoplasatic syndrome found in >95% of benign tumours that secrete fibroblast growth factor 23 - a phosphaturic circulating hormone. A rare case of a TIO secondary to a sarcoma, in a 21-year old man with history of bone fractures and distinctive physical and biochemical characteristics is presented and discussed. It is characterised by hypophosphatemia, hyperphosphaturia, elevated alkaline phosphatase, and low serum 1-25(OH) vitamin D. Pathophysiologically, TIO is caused by tumours that secrete fibroblast growth factor 23 (FGF-23), a phosphaturic circulating hormone.Oncogenic osteomalcia, also known as tumour-induced osteomalacia (TIO), is a rare paraneoplasatic syndrome with around 350 reported cases.2 Ten cases of TIO in the literature have been reported to be secondary to sarcomas, however, all of them were reported before it was known that the secreted molecule by these tumours was FGF-23, hence the diagnosis remained ‘uncertain’. Herein, we report the case of a 21-year-old male with a TIO associated with spindle cell sarcoma.TIO tumours are usually benign (in >95% of cases), however, they are a diagnostic challenge owing to their small size , which makes them difficult to localise. The differential diagnoses are genetic causes such as X-linked hypophosphatemic rickets, autosomal dominant and recessive hypophosphatemia, Dent’s disease, idiopathic hypercalciuria, and hereditary hypophosphatemic rickets with hypercaliuria.Figure 1). Interestingly, a 4 x 10 cm tumour was noticed in the inner thigh of his right leg . The neurologic evaluation and strength were unremarkable.A 21-year-old man presented for evaluation of a pathological femur fracture. The patient had been otherwise healthy until age 18, when he noted onset of lower back pain after soccer practice, which was exacerbated by exercise and improved when being resting. This pain was progressive and he started noticing a loss of height. Over the next several months he experienced sudden, intense lower back pain and was diagnosed with a femur neck fracture. He had surgery with internal fixation, and stayed mainly in bed for the next 6 months. During this time, he recognised a growing tumour (around 2 cm) in the inner thigh of his right leg. This tumour progressively grew until it was around 4 x 10 cm. During this time he also lost height (going from 1.75 m to 1.65 m) and weight , and noticed kyphosis in the thoracic spine and sternum protrusion. While he was walking, he fell and suffered a pathologic right femoral fracture. On physical examination, his vital signs at presentation were normal and he was noted to have kyphosis, sternum protrusion, and no Harrison’s sulcus or pain at rib palpation (see Table 1) was noteworthy for severe hypophosphatemia associated with hyperphosphaturia and reduced tubular reabsorption of phosphorus (0.5 g in 24-hour collection), low serum 1, 25(OH)2 D, increased serum alkaline phosphatase (ALP). The serum 25(OH) D levels were low and the FGF-23 was 389 RU/m. The remainder of the chemistry profile was within normal limits, including the serum calcium and intact parathyroid hormone (PTH). A diagnosis of hypophosphatemic osteomalacia due to a tumour was made. The magnetic resonance scanning demonstrated a 9 cm mass in the medial right femur, which involved bone and soft tissue .A biochemical evaluation .3 who attributed cure to high-dose vitamin D treatment. In 1964, in a similar case, Dent and Friedman4 described spontaneous recovery after surgical enucleation of the tumour and recognised the link between the neoplasm and metabolic bone disease. In 1959, Prader et al.5 were the first to recognise tumour (a giant cell reparative granuloma of the rib) as a cause of osteomalacia. Most of these cases were benign TIO and belong to the same histopathologic entity of phosphaturic mesenchymal tumour (PMC). In fact, Folpe,6 in a comprehensive review of the literature found that most of the cases reported as other pathologies were secondary to these. There have been, however, reported cases of malignant tumours such as adenocarcinoma of the colon,7 prostate cancer, metastatic tumours, as well as oseteosarcoma.12The first patient with TIO was reported in 1947 by McCance15 since histologically fusiform cells present invasion, which differentiate them from mesenchymal tumours. In this case, unlike the previous reported osteosarcoma, we had levels of FGF-23 that decreased after surgery, however, they will not be normalised until after treatment with chemotherapy. Because of the high recurrence risk in these tumours, it is important to keep monitoring this patient .It is important to differentiate our case of malignant presentation PMCFGF-23 inhibits the NaPO4 renal co-transporter and also suppresses 1α-hydroxylase activity, resulting in decreased renal reabsorption and increased urine excretion of the phosphate. When a tumour is surgically unresectable or not localised after an extensive workup, oral combined with phosphate treatment, calcium, and calcitriol is recommended, along with phosphate monitoring, a treatment similar to that used in the genetics forms . In our case, the tumour was relatively easy to find. Most tumours are found in the extremities, but conventional X-ray, magnetic resonance imaging (MRI), and computed tomography (CT) scans are usually not sufficient for tumour identification and localisation. Because these tumours typically express somatostatin receptors, functional imaging with radiolabeled somatostatin analogs  is probably the most valuable diagnostic tool. The treatment of TIO is resection of the tumour and the symptoms and phosphorus levels return to normal. If the tumour is not found, usually we must continue with medical treatment with phosphorus supplementation and vitamin D. Overall, the tumour prognosis is good, however, in our patient, due to the diagnosis of sarcoma, close follow-up will be mandatory.TIO, which is currently not frequently suspected, generally occurs when the disease is advanced and the patient has experienced multiple fractures and other complications. Usually they are benign tumours however, as in our case, a small proportion of them can be malignant.


Coronary artery ectasia (CAE) without specific symptoms is the localised or diffuse swelling of the epicardial coronary arteries. Magnessium (Mg) plays an important role in cardiac excitability, vascular tonus, contractibility, reactivity and vasodilatation. In our research, we aimed to study the vasodilatory effect of Mg in the aetiopathogenesis of ectasia.Patients identified during routine coronary angiograms in our clinic between January 2010 and 2013 were included in the study. Sixty-two patients with isolated CAE, 57 with normal coronary angiograms (NCA), 73 with severe coronary artery disease (CAD), and 95 with stenosis of at least one coronary artery and CAE (CAD + CAE) were included in the study. Serum Mg levels were measured in mg/ dl after 12 hours of fasting.There were no statistically significant differences between the groups in terms of age, hypertension, smoking, hyperlipidaemia, diabetes mellitus, family history of coronary artery disease and medications used. Serum glucose, thyroid stimulating hormone (TSH), urea, total cholesterol, triglyceride, low-density lipoprotein (LDL) cholesterol, sodium and potassium levels were similar in all groups. Serum Mg levels were 1.90 ± 0.19 mg/dl in patients with isolated CAE, 1.75 ± 0.19 mg/dl in those with CAD, 1.83 ± 0.20 mg/dl in those with CAD + CAE, and 1.80 ± 0.16 mg/dl in the NCA group. These results show that Mg levels were higher in ectasia patients with or without CAD.The histopathological characteristics of patients with CAE were similar to those with CAD. The specific mechanism of abnormal luminal dilatation seen in CAE however remains to be elucidated. Mg is a divalent cation with powerful vasodilatory effects. In our study, serum Mg levels were found to be statistically higher in ectasia patients with or without CAD. Coronary artery ectasia (CAE) without specific symptoms is the localised or diffuse swelling of the epicardial coronary arteries to at least 1.5 times the adjacent normal coronary segment.113Atherosclerosis, congenital factors, and inflammatory or connective tissue disorders may play a role in the aetiology, however, the aetiopathogenesis remains unclear despite some molecular, cellular and vascular mechanisms being defined in previous studies.4Magnesium, the second most abundant intracellular cation, is an essential element that plays a crucial role in cardiac and vascular functions. Magnesium regulates contractile proteins, modulates transmembrane transport of calcium (Ca2+), sodium (Na+) and potassium (K+), acts as a co-factor in the activation of ATPase, controls regulation of energy-dependent cytoplasmic and mitochondrial metabolism, and influences DNA and protein synthesis at the subcellular level.6Small changes in concentration of extracellular and/or intracellular free Mg have important effects in cardiac excitability, vascular tonus, contractibility, reactivity and growth.889In our study, we aimed to study the vasodilatory effect of Mg in the aetiopathogenesis of ectasia, and the long-term effects of elevated Mg levels on the vascular structure, leading to abnormal coronary dilatation.A total of 4 800 patients identified during routine coronary angiograms in our clinic between January 2010 and 2013 were included in the study. The study was planned to be prospective and was approved by the local ethics committee. After coronary angiography, the patients were informed about the study and written consents were given.Sixty-two patients with isolated CAE, 57 with normal coronary angiograms (NCA), 73 with severe coronary artery disease (CAD), and 95 with stenosis of at least one coronary artery and CAE (CAD + CAE) were included in the study. All of the patients were questioned on their cardiovascular risk factors and medication used. Routine biochemical and haematological laboratory tests were done.Previous history of myocardial infarction, percutaneous coronary intervention, left ventricular hypertrophy, left ventricular dysfunction [ejection fraction (EF) < 50%], moderate to severe valvular disease, rhythms other than sinus, congenital heart disease, chronic obstructive lung disease and/or cor pulmonale, chronic systemic illness, active infection, renal failure, neoplastic disease, antioxidant drug usage and alcohol abuse were the exclusion criteria.Coronary angiography was performed on a Siemens Axiom Artis angiography device with standard Seldinger’s technique using isohexol. In order to evaluate each coronary artery, at least four views from the left and two views from the right side were taken. Patients were allocated into four groups: patients with CAD, those with isolated CAE, those with CAD + CAE, and subjects with normal coronary angiograms. Angiographic images were evaluated by two independent researchers.Isolated CAE was defined as dilatation of at least one epicardial coronary artery to 1.5 times the reference vessel diameter and absence of critical stenosis (> 50%) in any of the coronary arteries. NCA were defined as the absence of angiographic atherosclerosis during routine coronary angiography; 60% or greater stenosis in at least one epicardial coronary artery was defined as CAD. CAD + CAE was defined as 60% or greater stenosis in at least one epicardial coronary artery and the presence of ectasia in any of the coronary arteries.Serum Mg levels were measured in mg/dl after 12 hours of fasting. Haemograms, renal and liver function tests, lipid profiles, serum glucose and electrolytes and thyroid stimulating hormone (TSH) levels were also evaluated in all patients.Statistical analysis was performed using the SPSS 14  statistics program. Data are given as percentages and mean ± standard deviation. ANOVA and post hoc Tukey tests were used in the comparison of parametric variables between groups. A chi-squared test was performed in the comparison of non-parametric values and percentages. Statistical significance level was taken as p ≤ 0.05.The mean age was 62 ± 10 years in the CAE patients, 61 ± 11 years in CAD patients, 64 ± 8 years in those with CEA + CAD, and 59 ± 8 years in the NCA patients. There was no statistically significant difference between the groups in terms of age, hypertension, smoking, hyperlipidaemia, diabetes mellitus, family history of CAD, and medications used .Serum glucose, calcium, TSH, urea, total cholesterol, triglycerides, low-density lipoprotein (LDL) cholesterol, sodium and potassium levels were similar in both groups . Serum cSerum Mg levels were 1.90 ± 0.19 mg/dl in isolated CAE patients, 1.75 ± 0.19 mg/dl in those with CAD, 1.83 ± 0.20 mg/ dl in those with CAD + CAE, and 1.80 ± 0.16 mg/dl in the NCA group. These results showed that Mg levels were higher in the ectasia patients with or without CAD.Mg is a divalent cation with powerful vasodilatory effects. In our study, serum Mg levels were found to be statistically higher in the ectasia patients with or without CAD.CAE is dilatation of the coronary arteries to at least 1.5 times normal, and the basic pathogenic mechanism is destruction of the musculo-elastic layers of the arterial tunica media, and the accumulation of collagen in place of elastin, leading to thinning of the arterial wall.151011CAE can be divided into four different types according to the classification of Markis and colleagues. Type 1 indicates diffuse ectasia in two to three different vessels, type 2 shows diffuse disease in one vessel and local disease in another, type 3 is diffuse disease in one vessel, and type 4 indicates localised or segmental ectasia. In our study there were 24 (16%) patients with type 1 CAE, 43 (27%) with type 2, 54 (34%) with type 3, and 36 (23%) with type 4 CAE.The histopathological characteristics of CAE are similar to those of CAD, however the specific mechanism of abnormal luminal dilatation seen in CAE remains to be elucidated. Negative remodelling is found in stenotic CAD, however positive remodelling is seen in CAE.12Yetkin and colleagues showed that carotid–intima media thickness was statistically lower in CAE patients with stenotic CAD than in individuals who had CAD alone, and reported that ectasia was not an atherosclerotic process limited to the coronary arteries.2+, which works as an allosteric modulator of several proteins, controls nucleotide and protein synthesis, regulates Na+, K+, and Ca2+ channels, and plays a crucial role in enzymatic reactions involving kinases, is an abundant intracellular divalent cation.14+ concentration circulates in the blood, and it is stored primarily in bone and the intracellular compartments of muscle and soft tissue.15+ regulates vascular tone, cardiac rhythm and platelet-activated thrombosis.1718MgMg stimulates nitric oxide release, which has a potent vasodilatory effect, from the endothelium. It is a co-factor for the delta-6-desaturase enzyme, which plays an important role in the synthesis of prostoglandin E1 (it has vasodilatory and antiplatelet effects) from linoleic acid.19An increase in extracellular Mg concentration causes vasodilatation, a reduction in vascular resistance, an increase in capacitance function in peripheral, coronary and cerebral arteries, and a decrease in agonist-induced vasoconstriction. Mg deficiency causes oxidative stress, inflammation, decreased luminal diameter, medial hypertrophy, vascular remodelling, it potentiates agonist-evoked vasoconstriction, and increases vascular tonus.20+)i], vasodilation occurs and agonist-induced vasoconstriction decreases. Reduced (Mg2+)i leads to hypercontractility and it impairs vasorelaxation.21As a result of increased intracellular Mg2+ concentration [(Mg2Mg is a unique calcium antagonist, has an effect on most types of calcium channels in vascular smooth muscle, and can decrease intracellular calcium levels.22As a calcium antagonist, Mg decreases the activity of voltagedependent calcium channels, diminishing calcium release from the sarcoplasmic reticulum.23In previous studies, Mg was reported to play a role in the aetiopathogenesis and management of eclampsia and hypertension. Eclampsia is characterised by myogenic vasoconstriction of the cerebral arterioles and arteries, increased permeability of the blood–brain barrier, and oedema formation due to acute blood pressure increase.23Mg is now being used in coronary stents because of its strong antiproliferative and vasodilatory effects. In a study by Yener and colleagues, it was shown that Mg supplementation after coronary artery bypass surgery may delay the onset of atrial fibrillation.24In studies related to the aetiopathogenesis of hypertension, a Mg deficiency was reported to have hypertensive effects, and dietary Mg intake was related to hypotension, showing the reverse positive relationship between blood pressusure and serum Mg levels.20The direct vascular effect of Mg was first suggested in early 1990 in a study in which Mg salt infusion was reported to have a blood pressure-lowering effect by decreasing peripheral vascular resistance, with a mild increase in myocardial contractility.26Similar to previous studies, our research found CAE to be significantly more prevalent in males.127In our study, there was a significant difference in HDL cholesterol levels between the groups. In a study by Randell and colleagues, HDL cholesterol levels were found to be positively correlated with Mg levels. Our results are consistent with this study, showing higher Mg and HDL cholesterol levels in isolated ectasia and lower levels in CAD patients, indicating that there was no impact of this correlation on our results.28In our study, serum Mg levels were statistically higher in isolated ectasia patients than in the NCA and CAD groups. Mg levels were lowest in the CAD group. Mg levels in the CAD + CAE group were higher than in the NCA group but lower than in the isolated ectasia group. The higher levels of Mg in the CAD + CAE than in the CAD group reached statistical significance.White blood cell count, as an indicator of inflammation, was significantly lower in isolated ectasia patients than in the CAD group, relating to the anti-inflammatory effect of Mg. Another inflammatory marker, ESR, was also found to be higher in CAD patients than in isolated ectasia patients. Mg in the extracellular fluid constitutes only 1% of the total body Mg concentration. However our findings suggest that chronically higher levels of serum Mg, with its anti-inflammatory effects, play a crucial role in the pathogenesis of ectasia by leading to vasodilation and negative remodelling. We proposed that factors other than atherosclerosis may play an important role in ectasia formation.The histopathological characteristics of patients with CAE were similar to those with CAD. The specific mechanism of abnormal luminal dilatation seen in CAE however remains to be elucidated. Mg is a divalent cation with powerful vasodilatory effects. In our study, serum Mg levels were found to be statistically higher in ectasia patients with or without CAD.


Cellular-based machine-to-machine (M2M) communication is expected to facilitate services for the Internet of Things (IoT). However, because cellular networks are designed for human users, they have some limitations. Random access channel (RACH) congestion caused by massive access from M2M devices is one of the biggest factors hindering cellular-based M2M services because the RACH congestion causes random access (RA) throughput degradation and connection failures to the devices. In this paper, we show the possibility exploiting the capture effects, which have been known to have a positive impact on the wireless network system, on RA procedure for improving the RA performance of M2M devices. For this purpose, we analyze an RA procedure using a capture model. Through this analysis, we examine the effects of capture on RA performance and propose an Msg3 power-ramping (Msg3 PR) scheme to increase the capture probability (thereby increasing the RA success probability) even when severe RACH congestion problem occurs. The proposed analysis models are validated using simulations. The results show that the proposed scheme, with proper parameters, further improves the RA throughput and reduces the connection failure probability, by slightly increasing the energy consumption. Finally, we demonstrate the effects of coexistence with other RA-related schemes through simulation results. Supporting Internet of Things (IoT) services is emerging as one of the most important problems facing communication systems ,2. ThereCellular networks are expected to play a major role in enabling M2M communications because they can provide seamless coverage over a large area, support mobility, and offer security. However, there are several problems with enabling M2M communications over cellular networks because these networks are optimized for human-to-human (H2H) communications and the characteristics of M2M communications are different from those of conventional H2H communications. For example, M2M communications are triggered by events, time-controlled, involve the transmission of small amounts of data, and are energy-limited . The 3rdBecause RACH congestion due to massive access causes the degradation of RA throughput, increasing the RA throughput has become a major research target. The ACB method efficiently solves the RA throughput problem by controlling the access probabilities of separate access classes. In , the autA preamble-separation method has also been proposed to increase the RA throughput. In , two preThe energy consumption of M2M devices is also a very important issue because most M2M devices are vulnerable to energy consumption. Therefore, many studies have been conducted on the energy consumption of the RA process. In , furtherAnalyzing the RA procedure is fundamental to understanding the RACH congestion problem and to providing the proper solutions. Various studies have analyzed an RA procedure to solve the RACH problem. These studies have mostly focused on the well-known multi-slotted Advocates of Linux Open-source Hawaii Association (ALOHA) model. The RA throughput, access delay, efficiency, and energy consumption of the RA procedure have been well analyzed using the multi-slotted ALOHA model ,12,13,14We formulated analysis models of the RA procedure considering the capture effect. Previous studies ,12,13,14Exploiting the capture effect to improve the RA performances, we propose the Msg3 PR scheme. This scheme causes a difference in the received power of messages at the eNB, so that the capture effect occurs frequently. In addition, it is easy to apply because the proposed scheme adopts the power ramping scheme that has already been used in the cellular system. Moreover, by applying this new technique, a device that has performed many retransmissions would have a higher RA success probability; thus, the connection failure probability could be reduced.In the simulation, we demonstrate the accuracy of proposed analysis and the advantages of the Msg3 PR scheme. In addition, the effects of various network parameters on the performance of the technology are demonstrated. Moreover, we discuss the beneficial points of the proposed scheme when used with other RA-related schemes.In this paper, we provide novel solution to resolve the RACH congestion problem due to massive access of M2M devices by exploiting the capture effect: Msg3 power ramping (PR) scheme. The main contributions of this paper are summarized as follows:The rest of the paper is organized as follows. In Msg1. Preamble transmissionV at a predetermined RA slot. As a result, there are three cases: singleton preamble, collided preambleand empty preamble. Singleton preamble is chosen by exactly one device, the collided preamble preamble is chosen by multiple devices, and the empty preamble is chosen by none of the devices. An eNB can only detect whether a specific preamble is transmitted, but cannot determine whether it is a collided preamble or a singleton preamble ) ,5,9,14. V, where In  studies ,6,8,12 , even under heavy access loads. Moreover, the proposed scheme reduced the connection failure probability, which disturbs the M2M communications, by slightly increasing the average energy consumption.Moreover, by conducting additional simulation, we discussed the benefits of using the proposed scheme and the effects of coexistence with other RA-related technologies. The simulation results show that the proposed algorithm can be combined with other technologies to achieve a larger performance improvement. In future work, further optimization could be performed for RA-related technologies using the Msg3 PR scheme.


Stress-strain curves at preset strain rates were obtained. The test data were then used to derive the parameters in a model based on the dynamic increase factors (DIFs) of strengths and the Johnson–Cook constitutive model. Results indicated that a significant strain rate effect was observed for the four rebar grades. The dynamic yield strengths increased from 13% to 41% and their ultimate strengths improved from 9% to 19% in the strain rate range during testing. The strain rate behavior of the four rebar grades could be appropriately predicted using the parameters in the model based on the DIFs of strengths and the Johnson–Cook model.The strain rate effect of reinforcing steel bars is generally indispensable for modeling the dynamic responses of reinforced concrete structures in blast and impact events. A systematic experimental investigation was conducted on the strain rate behavior of reinforcing steel bar grades HPB235, HRB335, HRB400, and HRB500 which are widely used in the field of civil engineering in China. The dynamic testing was performed using a servo-hydraulic Instron VHS160/100-20 in a strain rate range from 2 to 75 s Blast loading and impact action are occasionally considered for some structures in the field of civil engineering. Typical scenarios include a nuclear containment subjected to an aircraft crash, a control room in a chemical plant under blast loading, protective structures, and bridge piers impacted by ships. The involved facilities are usually constructed using reinforced concrete, due to its excellent blast resistant performance . Consequ−2 to 103 s−1. He used dynamic increase factors (DIF) based on the ratio of dynamic strength to static strength with connections to strain rates to describe the strain rate effect. After that, investigations on the strain rate effect continued. Hu et al. recently demonstrated strain rate dependent behavior of AerMet 100 steel, which had excellent mechanical properties [−1. In addition, the effects of strain rates on the tensile properties of a TRIP (transformation induced plasticity) -aided duplex stainless steel were studied by Choi et al. [−3, 5 × 10−2, and 10−2 s−1. On the other hand, for reinforcing steel bars that are widely used in concrete structures, relatively few studies were found in the literature. Early experimental studies were conducted by Brandes et al. [−4 to 10 s−1, and the yield strengths of the rebars were in the range of 290 to 710 MPa. He also proposed DIF formulations to describe the strain rate effect in terms of rebar strengths. More recently, the strain rate behavior of several particular types of reinforcing steel bars were investigated, including cold formed steel B500A (−1) [−1) [−3, 5, 30, 250, 500, 1000 s−1) [−3, 5, 35, 300, 500, and 850 s−1) [An increase in yield strengths and ultimate strengths have been confirmed;Yield strength is more strain rate-sensitive than ultimate strength;Steels with relatively low strengths are susceptible to strain rates compared to those with relatively high strengths;No changes have been found in the elastic modulus;The magnitude of the strain rate effect is different for various types of steel materials;The variation tendency of plateau lengths (only for hot rolled rebars) and ultimate strains under high strain rates are inconsistent based on different test sources.Efforts have been made to investigate the strain rate behavior of various types of steel alloys and a few types of reinforcing steels in terms of strengths and deformation capacities ,7,8,9,10operties . They usi et al.  using ths et al.  in 1986.s et al. . Later, s et al.  presente000 s−1) , quenche−1, which are the strain rates that typically occur in blast [The reinforcing steel bars HPB235, HRB335, HRB400, and HRB500 are different rebar grades and have been widely used in reinforced concrete structures in China. Their strain rate behavior has not been systematically and experimentally investigated so far. These four types of rebars belong to hot rolled and low-carbon structural steels and possess good properties of strength, ductility, and processability. The rebars HPB235 and HRB335 are usually used as stirrups to resist shear forces, while rebars HRB400 and HRB500 commonly serve as longitudinal reinforcements to avoid bending failure. For each steel grade, the number  denotes the yield strength used for design. As a matter of fact, the analyses of reinforced concrete structures under blasting and impact loads were short of full confidence due to the lack of the appropriate constitutive models of rebars. Evidently, the test results of other rebars in the literature were only of reference value for understanding the strain rate behavior of the rebars HPB235, HRB335, HRB400, and HRB500, because the dynamic behavior of steels is type-dependent. In this sense, to fill the current knowledge gap and enrich the database, the strain rate behaviors of rebars HPB235, HRB335, HRB400, and HRB500 were experimentally investigated in this study. The strain rates in testing ranged from 2 to 80 sin blast ,15 and iin blast . The par−1 and were preset to three strain rate levels. For each preset strain rate level, three specimens were tested for the individual rebar grades to minimize the result variation. Tensile testing was performed for rebar samples HPB235, HRB335, HRB400, and HRB500 at four strain rates using two test facilities at room temperature. Quasi-static testing was carried out using a universal electromechanical CSS-44500 testing machine  with a maximum load bearing capacity of 100 kN. Dynamic testing was conducted using a servo-hydraulic Instron VHS160/100-20  with a maximum load bearing capacity of 100 kN. This machine is particularly designed for elevated strain rate testing with preset tensile speeds. Round dumbbell-shape samples were fabricated with 50 mm length in the middle portion and 5 mm in diameter, as illustrated in −1, in accordance with Chinese standards [The quasi-static tests were conducted with a strain rate of less than 0.0003 standards . Figure A scanning electron microscope (SEM) FEI QUANTA650  was used to observe the microtopography of the fractured surfaces of the specimens. For each sample after rupture, a rebar portion, including the fractured surface, was cut from the sample and placed in absolute alcohol to prevent rust. The observation location was near the center of the fractured surface for each sample.The yield strengths and ultimate strengths increase with the increase in strain rates in the ranges from 13% to 41% and from 9% to 19%, respectively;The increased magnitudes of the yield strengths are greater than those of the ultimate strengths;The rebar grades with relatively low strengths  are more susceptible to strain rates than the rebar grades with relatively high strengths ;Elastic moduli are independent of strain rates;No statistical tendency was found for the plateau lengths;No statistical tendency was found for the ultimate strains and all the rebars failed in a ductile manner.Fe was detected in a small number of dimples using energy spectrum analysis.These results were qualitatively consistent with the previous understanding relating to other rebars. These data built the basis for calibrating the parameters in empirical models with consideration of the strain rate effect. As an example, Two commonly used constitutive models were adopted to describe the strain rate behavior of the rebars. One was the model based on the DIFs of strengths ,12 in refy,d/fy,st, and for the ultimate strengths, fu,d/fu,st, of the rebars can be expressed as:fy,d and fy,st represent the yield strength of individual rebars under dynamic and static loading, respectively; fu,d and fu,st are the ultimate strengths of individual rebars under dynamic and static loading, respectively; −1 is the strain rate under quasi-static loading. D1 and D2 are two parameters which are determined using linear regression analysis and result in D1 = 10.05, 8.73, 8.72, and 9.72 MPa, and D2 = 6.38, 6.54, 6.54, and 7.78 MPa for reinforcing steel bars HPB235, HRB335, HRB400, and HRB500, respectively.The DIFs for the yield strengths, σ, can be expressed as:εp is the equivalent plastic strain; −1; and parameters A, B, n, and C are the material constants to be determined using the test data. The parameters B and n are related to the strain-hardening, while C represents the strain-rate sensitivity. A, B, n, and C.The Johnson–Cook model is based on three independent phenomena, i.e., isotropic hardening, strain-rate hardening, and thermal softening. Only the isotropic hardening and strain-rate hardening were considered in this study. Thermal softening was not studied in the present tests due to the difficulty to monitor the temperature variation during loading. Similar consideration was also adopted in references ,7,8,13. fy,st is required in ksi and the expressions are applicable for strain rates up to 10 s−1 in Equations (6) and (7). In the comparisons, the formulations in [−1.The formulations proposed by Malvar are :(6)fy,dtions in  were use−1 and for rebar grade HRB500 at a strain rate of 4.9 s−1. Good agreement was achieved.Results found that Equations (1)–(3) well predicted the test data with a maximum error of about 21%. Formulations in  could be−1. However, these equations are also suggested to apply for those with −1 based on check calculations and the details are not presented for brevity.Generally, Equations (1)–(3) can be used to describe the strain rate effect of rebar grades HPB235, HRB335, HRB400, and HRB500 with strain rates in testing of −1 were obtained. The test data were then used to calibrate the parameters in a model based on the DIFs of strengths, and the JC model, both of which are frequently used in simulations of the dynamic performance of reinforced concrete structures. The following conclusions were drawn:(1)Significant strain rate effect was observed for the four rebar grades. Their yield strengths increased from 13% to 41% and their ultimate strengths improved from 9% to 19% in the strain rate range in the testing.(2)−1.The strain rate behavior of the four rebar grades could be appropriately predicted using the parameters in the model based on the DIFs of strengths and the JC model for strain rates less than 75 sStrain rate tests were conducted to investigate the strain rate effect of reinforcing steel bars HPB235, HRB335, HRB400, and HRB500. The stress-strain relationships at different strain rates in a range of


Geotrygon species. Therefore,although birds have a smaller amount of repetitive sequences when compared toother Tetrapoda, these seem to play an important role in the karyotype evolutionof these species.An extensive karyotype variation is found among species belonging to theColumbidae family of birds (Columbiformes), both in diploid number andchromosomal morphology. Although clusters of repetitive DNA sequences play animportant role in chromosomal instability, and therefore in chromosomalrearrangements, little is known about their distribution and amount in aviangenomes. The aim of this study was to analyze the distribution of 11 distinctmicrosatellite sequences, as well as clusters of 18S rDNA, in nine differentColumbidae species, correlating their distribution with the occurrence ofchromosomal rearrangements. We found 2n values ranging from 76 to 86 and nineout of 11 microsatellite sequences showed distinct hybridization signals amongthe analyzed species. The accumulation of microsatellite repeats was foundpreferentially in the centromeric region of macro and microchromosomes, and inthe W chromosome. Additionally, pair 2 showed the accumulation of severalmicrosatellites in different combinations and locations in the distinct species,suggesting the occurrence of intrachromosomal rearrangements, as well as apossible fission of this pair in  Columbiformes is one of the most easily recognized bird orders in the world, withmore than 300 species and traditionally divided into two families: Columbidae(pigeons and doves) and Raphidae  and transposable elements (transposons and retrotransposons)  .These rsposons) . For exaequences .in tandem and dispersed throughthe genome. Mono-, di-, tri-, and tetranucleotide repetitions are the most commontypes of microsatellites , associatedto the differentiation and heterochromatinization of these chromosomes  repeated tellites .Mutatiotellites . In geneMyiopsitta monachus  thesesequences accumulated preferentially in the W sex chromosome, which has the samesize of the Z chromosome, unlike most Neognathae bird species  10, (CAC)10,(CAG)10, (CAT)10, (CG)15,(CGG)10, (GA)15, (GAA)10,(GAG)10 and (TA)15, directly labeled with Cy3 at the5terminal were obtained from SIGMA. After denaturation, probes were applied onthe slides and incubated for 16 h at 37 ºC in a humid chamber. Next, slides werewashed twice in 2xSSC, twice in 1xSSC, and in PBS ,and then dehydrated in an ascending ethanol series .FISH experiments using microsatellite probes were done according to At least 30 metaphase spreads were analyzed to confirm the 2n, karyotypestructure and FISH results. Images were captured using a Zeiss Imager Z2,coupled with the software Axiovison 4.8 . The chromosomes wereclassified as metacentric (m), submetacentric (sm), telocentric (t) oracrocentric (a) according to their arm ratios .L. verreauxi, which corresponded to asubmetacentric or acrocentric element  in the shortarms in P. cayennensis. The highest number ofsequences was found in L. verreauxi  to 86 (G. violaceaand G. montana) L.verreauxi and C. livia showedan intermediate 2n . Among the species, the karyotype ofG. violacea was described for the first time,showing that this species has a karyotype very similar to another species of thisgenus, G. montana, both in terms of chromosomemorphology and in the diploid number.Corroborating previous studies  we obserColumbinapicui, which showed three pairs of microchromosomes bearing 18S rDNAclusters, the other eight species analyzed presented only one microchromosome pairbearing these clusters, including two other Columbina species. Oneof the most accepted causes of this variation, even among phylogenetically relatedspecies, is the transposition or translocation of these sequences ,although in different positions 15 hybridized in pair 2 of G. montana andG. violacea. In the remaining species, a higher number ofsequences accumulated in pair 2: L. verreauxi; P.cayennensis ; C.talpacoti , and; C.passerina .Accumulation of microsatellites in pair 2 was observed in practically all species,15,(GAA)10 and (CAC)10 in the species L.verreauxi, C. talpacoti, andC. passerina, and the three first ones inP. cayennensis. Furthermore, a more detailedanalysis of these sequences in pair 2 of Columbidae species revealed that this pairis very informative about the karyotypical evolution in this group.From a phylogenetic point of view, the occurrence of the same sequences found in thesame position in pair 2 of different species could be a reflection of a commonorigin, as for example the sequences (CA)15 in pair 2 ofGeotrygon species, which is telocentric in this species butsubmetacentric in most of the other ones, suggests the occurrence of a chromosomalrearrangement, such as an inversion or fission in this pair. However, if we considerthat the 2n of Geotrygon is higher than that for the other species(2n=86), with pair 2 being slightly smaller , in which GGA2 corresponds tothree different pairs  smaller , it seem15 did not produce any positive signals in our studies, revealinga possible characteristic intrinsic to the genome of birds. Although the absence ofsignals may reflect not only the inexistence of clusters of this sequence, it mayinstead represent a lower number of repetitions, considering the limitationsinherent to FISH techniques, which needs at least 2–5 kb to be visible. This lowernumber of repetitions may be related to the small size of the genome of birds, atthe expense of loss of repetitive sequences 10,(CGG)10, (GA)15 and (GAG)10];G. violacea [(GA)15 and(GAG)10], and L. verreauxi. Of these, twowere also found in the W chromosome in Gallus gallus: sequences(GA)15 and (GAG)10 (Concerning sex chromosomes, it is widely accepted that the accumulation of repetitivesequences plays an important role in the differentiation of the element foundexclusively in the heterogametic sex – W or Y (In summary, this study demonstrated the ubiquitous presence of repetitive elements inthe genome of several Columbidae species, highlighting their possible role in thechromosomal diversification within this group. In addition, our data reinforced theview that the existence of one pair of microchromosomes bearing 18S rDNA clusters isapparently an ancestral character retained in Columbidae, and that repetitivesequences did preferentially accumulate in the centromeric regions of macro andmicrochromosomes, as well as in the W chromosomes. Additionally, despite the factthat studies with repetitive sequences in birds are still incipient, the comparisonof our data with the ones for Psittaciformes, Piciformes and Galliformes (


A worse outcome was associated with a lower mPFS in patients with liver metastases (p = 0.2) and with a high tumor burden (number of metastatic sites < 6 vs. ≥6) (p = 0.08). Worst OS was observed in patients aged ≥70 years old . The treatment was well-tolerated: no grade 4 adverse events, nor discontinuation due to toxicities was reported. Grade 3 hypertension affected positively the OS reaching the statistical significance . Thyroid dysfunction (hypo and hyperthyroidism) seems to correlate with better outcome in terms of a longer mPFS . Our results are consistent with those reported in prospective phase III trials and the published retrospective “real world” experiences. This analysis confirms the safety and efficacy of pazopanib in first-line setting, both in frail patients with multiple co-morbidities and Karnofsky PS < 80% and in younger, healthier patients with a number of metastatic sites < 6.Pazopanib is an oral angiogenesis inhibitor, currently approved for treatment of metastatic renal cell carcinoma (mRCC) and soft tissue sarcoma. The present study analyzed the outcomes of pazopanib in first-line treatment of mRCC, in a single Italian cancer center. In the light of the retrospective, observational nature and the unselected population, our experience can be defined a “real-world” study. The medical records of 38 mRCC patients treated with front-line pazopanib were retrospectively reviewed and analyzed. The progression free survival (PFS) and the overall survival (OS) were the primary endpoints, while secondary objectives included objective response rate (ORR), disease control rate (DCR), and treatment tolerability. Pazopanib achieved a median PFS (mPFS) of 12.7 months . The median OS (mOS) was 26.2 months ; the observed ORR and DCR were 30.3 and 72.7%, respectively, with a median duration of response of 11 weeks. mPFS appeared not to be influenced by number of co-morbidities (< 3 vs. ≥3), gender, Fuhrman grade and age. Conversely, the ORR and the DCR positively affect the mPFS (HR = 0.05 ,  VHL, PBRM1, SETD2, and BAP1 genes, no biomarkers are currently available, thus there are no molecular factors, which may guide the clinicians in choosing the therapeutic strategy , is the most common subtype of kidney cancer  has revolutionized the mRCC treatment with an impressive effect on the overall survival (OS), which increased from an average of 9 months in 1995, when the only option in first-line was interferon alfa (IFN-α), to a median of 28–29 months in 2013, the TTs era  as well as in the second-line setting  and in the overall cohort ; the median OS was 22.9 months with PAZ and 20.5 months with placebo, with an ORR of 30 vs. 3% with placebo , with a slightly different toxicity profile in favor of PAZ . Categorical variables are described by patient counts and percentages. PFS by treatment line of therapy was analyzed using Kaplan-Meier analyses and log rank comparisons Kaplan-Meier survival curves. The Cox proportional hazards model was used to test the effect of those variables that reached the statistically significance at univariate analysis, on survival outcomes in multivariate analyses. Hazard ratios (HRs) and 95% CIs were estimated, adjusting for age and gender.The primary endpoints were progression free survival (PFS) and OS; the secondary endpoint included the objective response rate (ORR), the disease control rate (DCR), and the safety profile. The potential relationships between patients' characteristics, AEs and response were also explored. PFS was defined as the interval between the date of the first dose of PAZ and the date of the disease progression or death from any cause; disease progression was defined as radiological tumor progression according to Response Evaluation Criteria In Solid Tumors, RECIST  were treated with PAZ, 38 (30.6%) were eligible for the final analysis.In regards to demographics and baseline features, median age was 61 years old, most patients were male (57.9%), the 87.6% had a Karnofsky Performance Status (Karnofsky PS) ≤ 80%, more than half (73.6%), had two or more co-morbidities. In terms of disease characteristics, the 60.5% underwent to prior nephrectomy; few patients had a histology different from clear cell (15.8%); almost all (86.8%) had both bone and visceral metastases. According to Memorial Sloan-Kettering Cancer Center Score (MSKCC), the most of patients were classified as “intermediate” (63.1%) and “good risk” (13.1%), only 4 patients were “poor risk,” unfit for starting sunitinib or temsirolimus for multiple and specific co-morbidities (Table The median PFS (mPFS) was 12.7 months , with median OS (mOS) of 26.2 months . A worse mPFS was achieved in patients with liver metastases  and with higher tumor burden (number of metastatic sites < 6 vs. ≥6) with mPFS 19.2 vs. 6.3 months (p = 0.08). Patients that gained a higher ORR and DCR had better outcomes in terms of both mPFS , gender, Fuhrman grade and age Table . A longep = 0.03; Table p = 0.6; Table p = 0.6) and OS significantly  of our population, 6 patients, had a histology different from clear cell. One patient had a type I papillary tumor; two had a type II papillary tumor; one had a chromophobe; two a sarcomatoid variant of renal cancer. PAZ has been active and well-tolerated with 3 patients achieving PR and 3 SD, the median duration of treatment in such subgroup has been 9.3 months, the mPFS of 10.6 months .Randomized clinical trials are the gold standard to evaluate the efficacy of a new treatment within a specified patient population and the available international guidelines for physicians for treatment of mRCC essentially reflect the evidences for the different agents emerged from the respective clinical trial AIOM, . NeverthIn terms of mPFS, we observed a median of 12.7 months, which is longer than the one reported in the COMPARZ , in the Christie study  compared to the available literature; our efficacy data are substantially consistent with those reported in both the prospective phase III trials and the retrospective analyses , the elevation of the liver function tests of grade 3 involved only 6 patients, and this event has been reversible and was not related to liver metastasis or other liver illness.Six patients were treated with a lower dose of PAZ for concomitant diseases for the entire duration of treatment; we found that dose reduction was not associated with reduced efficacy, suggesting that the personalization of the drug schedule and the early management of the emerging toxicities represent crucial steps to maximize the therapeutic benefit.We failed to identify predictive factors of response, although the occurrence of a thyroid dysfunction and grade 3 hypertension seemed to be related to a prolonged PFS and OS, respectively.The use of PAZ out of clinical trial allowed us to evaluate its activity also in a subset of patients with histology other than clear cell, usually excluded from academic studies for their poor prognosis and limited sensibility to anticancer drugs. Our patients were not candidate for sunitinib and or temsirolimus treatment due to several specific co-morbidities. PAZ demonstrated to be still active also in this subset of patents with a mPFS of 10.6 months , data that are longer compared to those from pivotal phase III trial of sunitinib, and that will probably contribute to enrich the very few anecdotal literature data.Our results are consistent with those reported in prospective phase III trials and the published retrospective “real world” experiences. This analysis confirm the safety and efficacy of PAZ in first-line setting, both in frail patients with multiple co-morbidities and Karnofsky PS < 80% and in younger, healthier patients with number of metastatic sites < 6. Thyroid dysfunction and hypertension may represent prognostic factors for longer PFS and OS, respectively. More extensive data and larger sample are needed in order to appropriately guide real-world practice.SC, AC, GF, CD conceived the study, performed the statistical analysis, and wrote the paper. SR, CDP conceived the study, collected the data and wrote the paper. CC, MD, DS, GC, PMa, PMu, SiP, MB, SaP conceived the study and wrote the paper. GI, RP provided assistance with patients, wrote the paper and participate in the design of the study.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. The reviewer FFM declared a shared affiliation, though no other collaboration, with several of the authors SC, SR, CDP, MD, AC, GI, RP, DS, GC, PMa, PMu, SiP, SaP, and GF to the handling Editor, who ensured that the process nevertheless met the standards of a fair and objective review.


The aim of the present study was to evaluate the determinants of muscular strength by examining hand grip force in relation to CoQ10 status, gender, age and body mass index (BMI) in two independent cohorts . Furthermore, peak flow as a function of respiratory muscle force was assessed. Spearman’s correlation revealed a significant positive association between CoQ10/cholesterol level and hand grip in the basic study population (p<0.01) as well as in the validation population (p<0.001). In the latter, we also found a negative correlation with the CoQ10 redox state (p<0.01), which represents a lower percentage of the reduced form of CoQ10 (ubiquinol) in subjects who exhibit a lower muscular strength. Furthermore, the age of the subjects showed a negative correlation with hand grip (p<0.001), whereas BMI was positively correlated with hand grip (p<0.01), although only in the normal weight subgroup (BMI <25 kg/m2). Analysis of the covariance (ANCOVA) with hand grip as the dependent variable revealed CoQ10/cholesterol as a determinant of muscular strength and gender as the strongest effector of hand grip. In conclusion, our data suggest that both a low CoQ10/cholesterol level and a low percentage of the reduced form of CoQ10 could be an indicator of an increased risk of sarcopenia in humans due to their negative associations to upper body muscle strength, peak flow and muscle mass.Aging is associated with sarcopenia, which is a loss of skeletal muscle mass and function. Coenzyme Q Sarcopenia is a common problem in the Western world. It is characterized by progressive and generalized loss of skeletal muscle mass and strength with the risk of adverse outcomes, such as physical disability, poor quality of life and death ,2. Furth10 (CoQ10) plays a crucial role in mitochondrial bioenergetics, including ATP production [10 could act as an antioxidant, preventing oxidative damage of lipids, proteins and DNA [10 has been identified as a modulator of gene expression [10 [10. Hence, pro-apoptotic responses to TNF-α are mediated by activation of the plasma membrane neutral sphingomyelin phosphodiesterase (SMPD2) [10 (ubiquinol) [Coenzyme Qoduction ,6. Furth and DNA ,8. Moreopression , 10 and pression  and pyripression . The perpression . On the sion [10 . Previou (SMPD2) . Navas a (SMPD2) ,17. Diet (SMPD2) . Moreove (SMPD2)  and thatiquinol) .10 in two independent cohorts that compromise a total of n = 1301 subjects. The European Working Group on Sarcopenia in Older People (EWGSOP) has recommended hand grip strength as a robust and simple measure of muscle strength [10 status, age, BMI and peak expiratory flow (PEF) as a measure of respiratory muscle function, which could also be affected in age-associated alterations in skeletal muscles [10 in serum [10 share parts of a common synthetic pathway [10/cholesterol ratio was used in ANCOVA. Additionally in the basic study population, the muscle mass, creatinine content and creatine kinase activity were determined.In the present study, we aimed to investigate the determinants of muscular strength with a particular focus on CoQstrength . Furtherstrength ,23. Thus muscles . Accordiin serum ,25 and c pathway , the plaThe basic study population consisted of 334 apparent healthy blood donors and is part of the PopGen control cohort ,28. The S1 TableThe present study was conducted according to the guidelines laid down in the Declaration of Helsinki, and all of the procedures that involve human subjects were approved by the ethics committee of the Medical Faculty of the Christian-Albrechts University of Kiel. All participants gave their written informed consent before participation.Analysis of ubiquinol-10 and ubiquinone-10 was based on the method of HPLC with electrochemical detection after hexane extraction and has been described before . UbiquinBlood samples were taken from every participant after an overnight fast. Serum concentrations of total cholesterol were measured by an enzymatic colorimetric assay . Creatinine and creatine kinase were analyzed by standard clinical chemistry.2). Total plasma creatinine values were used to calculate the muscle mass in the basic study population [Standing height and weight were measured in light clothing without shoes. Body mass index (BMI) was calculated by dividing the weight (kg) by the square of the height  was characterized with a digital dynamometer . The participants maintained the standard bipedal position during the entire test with the arm in complete extension. Each participant performed the test three times with each hand. The highest value was chosen as the test score for each hand (dominant and non-dominant hand), and an average score for both hands was computed as the bimanual hand grip score according to [10/cholesterol as independent covariates. Prior to ANCOVA, the different terms were controlled for the significance of interaction.Statistical analysis was performed using IBM SPSS 23.0 software  and GraphPad Prism 4.0 package . The data are expressed as the mean ± SD, and statistical significance was set at p<0.05. After testing for normality (Kolmogorov-Smirnov), significant differences between sexes were analyzed by a two-sided, unpaired Student’s t-test in the case of normally distributed parameters or by the Mann-Whitney-U-Test in the case of non-normally distributed parameters. Correlation analysis  was conducted for all of the measured variables in both of the study populations and separately for both genders. Analysis of covariance (ANCOVA) was performed on both cohorts, with “hand grip” as the dependent variable. Gender was taken as an independent factor and BMI, age and CoQ10 status and functional status , of the study population, separated by gender, are shown in 10, CoQ10 redox state , peak flow and hand grip. As expected, men had a significantly higher body weight, height, BMI, muscle mass, peak flow and hand grip compared to females. With regard to the biochemical profile, men also showed higher serum levels of total CoQ10, CoQ10/cholesterol, creatine kinase and creatinine.The age, body composition , and biochemical profile, including the CoQ10 status) are determinants of hand grip, a valid proxy of upper-body muscular strength , CoQ10 redox  and total cholesterol . Except for the parameters BMI  and age , which were only significantly correlated to hand grip in females, similar outcomes were found when both genders were correlated separately.We hypothesized that the selected parameters  were incorporated to provide a broader BMI range. In total, the population showed a mean BMI of 32.2 ± 10.4 kg/m2, which is considered to be obese. The remaining parameters, however, were within the normal range, including the total CoQ10,CoQ10 redox state  and hand grip. Similarly, males had a significantly higher body weight, height, total CoQ10 levels and hand grip and were on average 6 years older than females.To further evaluate the determinants of muscular strength, we validated our results derived from the basic study population on a second, independent cohort. The characteristics of this validation population are given in 10/cholesterol ratio , but not in overweight subjects  or obese subjects . Furthermore, hand grip was negatively correlated with age  in subjects who exhibited lower muscular strength. In the validation population, similar outcomes were found when males and females were correlated separately with hand grip, with the exception of total CoQ10  and cholesterol , which were only significantly correlated in females.To substantiate our results in the basic study population, we correlated the parameters that were available with the values of the hand grip measurements , Fig 2. 10/cholesterol, age and BMI as the independent covariates, gender was found to be the main effector . Next, we analyzed the remaining variables independent of gender, which revealed a significant effect on hand grip according to BMI , whereas CoQ10/cholesterol (p = 0.099) and age (p = 0.563) were not significant predictors of hand grip in this study population  in the basic study population, analysis of covariance (ANCOVA) was performed with hand grip as the dependent variable. In a model, including the gender of the study subjects as the independent factor and CoQpulation .10/cholesterol and BMI as independent covariates, gender was found to be the strongest effector of hand grip . However, when we analyzed the remaining variables independent of gender, we found a significant effect on hand grip by CoQ10/cholesterol  and age , whereas in this study population, which is characterized by a higher percentage of obese subjects, BMI was no longer a significant predictor of hand grip  in ANCOVA with gender as an independent factor and CoQ10 plays a crucial role in mitochondrial bioenergetics and can act as an antioxidant [10 as a determinant of muscular strength is not well documented. Therefore, this study is, to the best of our knowledge, the first to examine the determinants of muscular strength with a special focus on the serum CoQ10 status in two independent cohorts. We showed that the CoQ10/cholesterol ratio was significantly correlated with a lower hand grip and a predictor of hand grip outcome. Gender was found to be the main influencing factor. Age was also significantly negatively correlated with muscle strength, but only in older subjects  of the validation population, which exhibited a mean age of 52.6 ± 14.1 years in males or 39.8 ± 11.5 years in females, of the basic study population. Interestingly, the positive association between hand grip and BMI was dependent on the BMI classes because we found a significant correlation in the subjects of the validation population who exhibited a normal BMI, but not in overweight or obese subjects . In this context, it is worthwhile to mention that physical activity has been shown to generate reactive oxygen species (ROS) [10/cholesterol versus PEF, a significant Spearman correlation coefficient  was evident (data not shown). Similarly, CoQ10/cholesterol was significantly correlated with muscle mass .The relationship of obesity and health and CoQ coupler  is currestigated . In a coes (ROS) ; howeveres (ROS) . Importaes (ROS)  that diees (ROS) . In a stes (ROS) . In the 10 supplementation increases plasma levels of CoQ10 [10 in middle-aged, untrained men did not improve the aerobic capacity of forearm exercise metabolism [10 supplementation on parameters related to exercise in healthy humans revealed that CoQ10 has the potential to be used as a nutritional supplement to improve exercise capacity; however, the current literature shows a disparity and inconsistency, possibly due to differences in the CoQ10 formulations used, dosage, timing of the supplement, exercise tests performed and study participants [CoQof CoQ10 –46. Nevetabolism . On the tabolism . A systeicipants .10/cholesterol are determinants of muscular strength, with gender being the main influencing factor. In older subjects, age is an additional inverse determinant of muscular strength, whereas the body mass of a person ascertains muscular strength only when in the normal range. A lower CoQ10/cholesterol level could be a predictor of an increased risk of sarcopenia in humans due to its association to upper body muscle strength, peak flow and muscle mass. The present study provides further evidence that a higher muscular strength or physical activity in risk groups, including older and obese subjects, could lead to a more a favored outcome in the cholesterol metabolism, CoQ10 and CoQ10 redox status.In conclusion, the present data suggest that gender and CoQS1 TableRaw data of the A) Basic study population and the B) Validation population.(XLSX)Click here for additional data file.