Atrial fibrillation (AF) is a cardiac arrhythmia with high risk forthromboembolic events, specially stroke.To assess the safety of left atrial appendage closure (LAAC) with theAmplatzer Cardiac Plug for the prevention of thromboembolic events inpatients with nonvalvular AF.This study included 15 patients with nonvalvular AF referred for LAAC, 6older than 75 years .2 score was 3.4 ± 0.1, and meanCHA2DS2VASc , 4.8 ± 1.8, evidencing a highrisk for thromboembolic events. All patients had a HAS-BLED score > 3 with a high risk for major bleeding within 1 year.The device was successfully implanted in all patients, with correctpositioning in the first attempt in most of them .The mean CHADSThere was no periprocedural complication, such as device migration,pericardial tamponade, vascular complications and major bleeding. Allpatients had an uneventful in-hospital course, being discharged in 2 days.The echocardiographic assessments at 6 and 12 months showed neither devicemigration, nor thrombus formation, nor peridevice leak. On clinicalassessment at 12 months, no patient had thromboembolic events or bleedingrelated to the device or risk factors. In this small series, LAAC withAmplatzer Cardiac Plug proved to be safe, with high procedural success rateand favorable outcome at the 12-month follow-up. Approximately 20% of strokes are estimated to beassociated with AF, frequently leading to death or disability.4Atrial fibrillation (AF) is a cardiac arrhythmia of clinical relevance, because itsignificantly increases the risk for thromboembolic events, which not only worsenthe quality of life but decrease life expectancy as well. That arrhythmia favors theformation of thrombi in the left atrial appendage (LAA), and any presentation of AFcorrelates with a twice higher occurrence of stroke than that in the generalpopulation. In up to 90% of the cases of AF, thrombi are found inside theLAA,2.5 But,because it underestimates the risk in patients at lower risk,CHA2DS2VASc has been used in individuals with aCHADS2 score of 2.6In individuals at high risk, those with a CHADS2 orCHA2DS2VASc score > 2, the prevention of NVAF-relatedthromboembolic events is usually pharmacological, by use of anticoagulants (AC).Regarding the prevention of thromboembolic events, it is important to individualizeeach patient’s risk. The score initially used to estimate the occurrence of thoseevents is CHADS7 For patients athigh risk of bleeding or with contraindication for AC, left atrial appendage closure(LAAC) is an alternative strategy for the mechanical prevention of thromboembolicevents.In that population, hemorrhagic events are estimated by using the HAS-BLEDscore.The primary objective of this study was to assess the safety of LAAC performed withthe Amplatzer Cardiac Plug™ (ACP) device by analyzing the immediate andin-hospital safety outcomes. The secondary objective was to assess that strategy toprevent major cardiovascular events in late follow-up.This was a retrospective, longitudinal, cohort study with prospective data collectionof patients with NVAF submitted to LAAC with ACP, from November 2010 to March 2015,at the Instituto Estadual de Cardiologia Aloysio de Castro. The study was approvedby the Research Ethics Committee of that institution (nº 049018). Allpatients provided written informed consent.The patients included in this study met the following three criteria:NVAF with high risk for thromboembolic events:2DS2VASc > 2;a.1) CHADS > 2 or CHADS = 2 andCHAa.2) or NVAF with previous history of stroke, transientischemic attacks (TIA), or peripheral embolism;Objective evidence of limitation to the use of AC with:b.1) previous history of hemorrhagic stroke or majorbleeding;b.2) or high risk for bleeding with HAS-BLED ≥ 3;b.3) or unstable response to the use of AC, defined as lessthan 60% of prothrombin time (PT) readings within the limitsof the therapeutic range (INR ≤ 2.0 or INR ≥3.0) in the past 12 months;Provided written informed consent.Patients with the following conditions were excluded from this study:Severe consumptive disease with life expectancy shorter than 1 year, orclinical contraindication to the intervention on the initialassessment;Echocardiographic evidence of pathologies that could lead tothromboembolic events or cerebral ischemia, such as intracardiacthrombi, valvulopathies, ulcerated aortic atherosclerotic plaque, orsignificant obstruction of the carotid or vertebral arteries;Unsuitable anatomy for the procedure, with LAA waist diameter onechocardiography smaller than 12 mm or larger than 28 mm.Arquivos Brasileiros de Cardiologiaon the occasion of our initial experience.8The ACP device  has beenDuring hospitalization, the following safety outcomes were considered: death,stroke, device migration, pericardial tamponade, and vascular and hemorrhagiccomplications.During inpatient follow-up, safety outcomes, such as device embolization,pericardial effusion and major bleedings were compiled. During inpatient andoutpatient follow-ups, the occurrence of efficacy outcomes, such as adverseclinical events ,was assessed. Telephone contact was performed on days 30, 60, 180 and 365. Theoccurrence of thrombosis, device migration and peridevice leak was assessed byuse of transesophageal echocardiography on days 180 and 365.Coumarins were suspended 4 days before the procedure. Prophylactic heparinizationwas implemented with low-molecular-weight heparins. All procedures wereperformed under general anesthesia. Vascular access was performed via rightfemoral vein puncture, with initial placement of a 5F or 6F introducer, for theposterior introduction of a 7F or 8F Mullins sheath. Transseptal puncture wasperformed under two-dimensional transesophageal echocardiography on bicavalview, allowing perfect visualization of the fossa ovalis in the interatrialseptum, where puncture with transseptal needle was preferentially performed inthe postero-inferior position, which, in addition to being far from the aorta,facilitates selective LAA catheterization. After transseptal puncture,unfractionated heparin, at the dose of 70-100 IU/kg, was injected, maintainingactivated coagulation time (ACT) longer than 250 seconds during the procedure.Then, the Mullins sheath was inserted through the septum and a rigid 1.5 cmguidewire with flexible tip was positioned in the left superior pulmonary veinfor further introduction of a 10F to 13F delivery catheter. With the deliverycatheter placed inside the LAA, the ACP device was delivered through over thedeployment wire until exteriorization of the lobe release catheter beyond thecircumflex artery, which is perfectly visible under transesophagealechocardiography, so that the ACP device would stabilize and acquire the aspectof a smashed tire, showing its adequate size. With the lobe properly positionedin the landing zone, the proximal disk was unfolded to cover the LAA entrance.Good device positioning was assessed under echocardiography and fluoroscopy,confirming the LAAC  and 2. FImmediately after the procedure, the AC were suspended, and dual antiplatelettherapy (DAPT) initiated with acetylsalicylic acid (ASA - 200 mg/day) andclopidogrel  for 6 months.Before hospital discharge, the presence of complications was assessed withtransesophageal echocardiography.Eighteen patients with indication for LAAC were referred for ACP deviceimplantation. On transesophageal echocardiography assessment, 3 patients showedthrombi inside the LAA: 2 on the preprocedural assessment, and 1 in the 4-dayperiod between warfarin suspension and procedure performance. After exclusion ofthose 3 patients, 15 were left to be assessed. One patient with indication for coronary angioplasty had an episode of hematuriawhen using the association of DAPT and warfarin. Three days after coronary stentimplantation, the patient underwent LAAC, and hematuria resolved aftersuspending the AC.2 score was 3.4 ± 0.1, and the meanCHA2DS2VASc, 4.8 ± 1.8, evidencing the highrisk for thromboembolic events in this cohort (The mean CHADSs cohort .All patients had a HAS-BLED score > 3 (mean of 4.5 ± 1.2), showing thehigh risk for major bleedings in this population . Many paBecause of the inclusion criteria, all patients had NVAF and high risk forbleeding. In addition, the major indication for LAAC was history of majorbleedings  and INRinstability (73%). Other factors that could influence on the choice of thatstrategy are shown in Device implantation was successful in all patients. In most of them , proper positioning was achieved in the first attempt, while 4 patientsrequired other attempts. The access was always via transseptal puncture. Nopatient required exchanging the device for another of different size. Whenrequired, coronary intervention with stent implantation was performed beforeLAAC. Two patients had Bezold-Jarisch reflex with bradycardia and hypotensionduring the delivery catheter introduction, which, in such cases, had the largestcaliber (13F) because larger devices were implanted (28 and 30 mm). One patient showed hypokinetic left ventricular lateral wall at the end of theprocedure, although the controls immediately after the procedure evidenced nocompression of the circumflex artery by the device.the patients had a favorable in-hospital outcome, 2 days being the mean hospitallength of stay due exclusively to the procedure. In the in-hospitalechocardiographic follow-up, neither residual flow in the interatrial septum northrombi on the device was observed.One patient had cerebral arteriovenous malformation with no possibility ofsurgical treatment, which contraindicated any type of AC. Before LAAC, all otherpatients were on any combination of antithrombotic medications, which alwaysincluded warfarin. The new oral AC were not used by that population and were notavailable at our institution. The use of antithrombotic medication after LAACwas restricted to the indications associated with the presence of coronarydisease, and no patient used AC after LAAC .The echocardiographic assessments at 6 and 12 months showed no complication, suchas device migration, thrombi or peridevice leaks. On clinical assessment at 12months, no patient had thromboembolic events or bleeding, showing a favorableclinical course.Percutaneous closure of the left atrial appendage versus warfarintherapy for prevention of stroke in patients with atrial fibrillationtrial) has selected 800 patients in 59 centers in the United Statesand Europe, testing the non-inferiority hypothesis of the Watchman device ascompared to warfarin, in random grouping 2:1 (device:control), withtransesophageal echocardiography follow-up .9 The primaryefficacy outcomes observed were stroke, cardiovascular or unexplained death, andsystemic embolism. The safety outcomes were device embolization, pericardialeffusion and major bleedings. The results showed a 32% risk reduction with thedevice. The use of coumarins was suspended by 87% of the patients. However,there were more episodes of pericardial effusion in the device group, probablydue to the learning curve of the technique. The study has concluded that thedevice proved not to be inferior to coumarins, with better survival free fromevents and stroke. In that study, a CHADS score around 2 and the use of warfarinin the first 45 days after implantation could have interfered with theshort-term results.Three clinical trials assessing the efficacy of LAAC as compared to warfarin havebeen published, none, however, with the ACP device. The PROTECT-AF Trial has included 461 patients at theproportion of 2:1 (device:control) and has also assessed the non-inferiorityhypothesis, but in a population with a higher CHADS2 score.10 The primary outcomes weresimilar to those observed in the PROTECT-AF: stroke, cardiovascular orunexplained death, and systemic embolism. That study has shown that, even inpatients at higher risk, the device can be safely implanted. But thepre-specified criteria of non-inferiority were not met, although the event rateswere within the expected range. The authors concluded that the Watchman deviceis a safe alternative to anticoagulation therapy to prevent thromboembolicevents in patients with NVAF.The PREVAIL Trial (2DS2-VASc: 4.5 ± 1.6) and moderate to highrisk for bleeding (mean HAS-BLED: 2.3 ± 1.2).11 Almost half of the patients had a previoushistory of TIA or ischemic or hemorrhagic stroke. The success rate of theWatchman device implantation was 98.5%, much higher than that reported in thePROTECT-AF Trial (90.9%). Serious complications related to the procedure wereobserved in only 8.7% of the interventions, a 2.7% lower rate than that of thePROTECT-AF Trial. The success rate of the Watchman device implantation was high,with low pre-procedure risk, although that cohort of patients had highercomorbidities and high risk of stroke and bleedings. For the authors, this couldbe attributed to the improvement in the implantation technique, whichsignificantly reduced the complications that limited the clinical benefits ofthat therapy.11The EWOLUTION was a prospective, multicenter, nonrandomized cohort study thatassessed more than 1000 patients at high risk for stroke . The majorindications for the intervention were the high risk for bleeding and INRinstability, both in 73.3% of the patients. Because many patients  had associated coronary disease, requiring antiplatelet aggregation, therisk for bleeding increased in that population, although the age group of oursample (69.0 ± 9.0 years) was lower than those in other studies, such asthe PROTECT-AF Trial (72.0 ± 9.0 years) and the PREVAIL Trial (74.0± 7.0 years).12 Thus, the rates of undertreatment or non-treatment withcoumarins in high-risk patients varies in some series between 20% and 80%,although only 15% of the patients with AF have any contraindication forAC.15The use of warfarin was very difficult in that population, with 11 patients(73.3%) unable to remain in the therapeutic range, with high INR instability,and 9 patients (60.0%) reporting stroke despite the use of warfarin. Somestudies have suggested that only more educated patients could realize the riskof bleeding, the possibility of interaction with other drugs and the need forcontinuous therapeutic monitoring.16 Almost half of the patients inthis cohort  used AC and DAPT, while 4 patients (26.7%) used theassociation of AC and ASA. Under such situations, either the patient already hadAF and required a coronary intervention with stent implantation, or wassubmitted to stent implantation and developed AF later. In both situations, whenusing the conventional stent, AC and DAPT are usually associated for 1 monthonly, clopidogrel being then suspended, and only the AC and ASA maintained. Whena drug-eluting stent is used, DAPT should persist for 6 to 12 months,17 which increases the risk forbleeding with the association of DAPT and AC.None of our patients used the new oral AC, which were not available in the publichealthcare system. In this series, warfarin was parsimoniously used, because73.3% of the patients had established coronary artery disease.18 Regarding major adversecardiac events, there was no difference between those three groups. Whenassessing stroke and embolic events outside the central nervous system, theprevalence of events was higher in the DAPT group. The TT and DT groups did notdiffer regarding stent thrombosis and embolic events, although the TT groupshowed a higher rate of bleedings.17 Recently, the prospective and randomized WOEST study, withalmost 600 patients, showed no superiority of TT over DT to prevent embolic ormajor adverse cardiac events, confirming the higher rate of bleeding withTT.19 Thus, LAAC seemsmore advantageous to patients with coronary artery disease associated with NVAF,to which there is no definition about the ideal antithrombotic therapy. Oneshould consider the risks of stent thrombosis and embolic events due to AF, aswell the risk for bleedings due to drug association.5In this unfavorable scenario, some studies have tested three possibilities:triple therapy (TT) with the association of DAPT and AC; dual therapy (DT) withthe association of AC and ASA or clopidogrel, and DAPT alone.20 In addition, 11 patients in this series (73.3%) hadhigh INR instability with the use of AC, and, in such cases, a preventionstrategy without the AC is highly desirable. Finally, in the physical and mentalassessment of a subgroup of 547 patients from the PROTECT-AF Trial, animprovement in the quality of life was demonstrated, favoring the patients whounderwent LAAC as compared to those treated with warfarin.20In this study, all patients had a HAS-BLED score greater than 3 (mean of 4.5± 1.2), with a highly elevated risk of bleeding. In a risk x benefitassessment, that might not be a reason to suspend the AC, because the patientswith high risk for embolic events and bleeding are probably those that benefitmost from the use of AC. However, they might also be the ones that benefit mostfrom a local intervention, such as LAAC.11 but all thosestudies used the Watchman device, while, in our patients, the ACP device wasused. Currently, there is the second generation of the ACP device, the Amuletocclude device, used in the same way, but with a lower peridevice leak rate. Ina series of 59 consecutive patients of a single center, the Amulet occluderdevice has shown performance similar to that of the ACP in the periproceduraland short-term outcomes, but with significant reduction in perideviceleaks.21Device implantation was successful in all patients, and that might be attributedto the small sample size (15 patients). But we observed some details that couldinterfere in those results. First, it is important to define the anatomicalshape of the LAA, and in those with more than one lobe, try to observe if theirbifurcation site is close to the ostium, which hinders the device implantation.Second, and maybe even more important, to define the size of the device to beimplanted. After performing the LAA measurements recommended, the device usedshould be 20% larger, which hinders its positioning, but ensures perfectocclusion, decreasing the chance of its migration. We believe that such measurescan prevent the device exchange for another of different size. In thePROTECT-AF, PREVAIL and EWOLUTION trials, the number of prostheses used perpatient were 1.6, 1.5 and 1.1, respectively,22Currently some studies are attempting to discover the best therapy for thepatient submitted to LAAC. But, in the absence of specific studies with LAACdevices, that result was transferred to ACP, and DAPT was instituted after theimplantation. In our series, almost all patients  were onwarfarin before the procedure, which was suspended 4 days before ACPimplantation. Although DAPT is programmed for 6 months in the outpatientfollow-up, only 20% of the patients use it.A study of 1998 assessed the antithrombotic regimens after coronary stentimplantations.11 whereone fourth of the patients received no preprocedural AC and 6% continued withoutit after the procedure, there were several therapeutic possibilities for thefollow-up, such as DAPT (59.6%), single antiplatelet aggregation (7.1%), new AC(11.1%), and warfarin alone (15.6%). The groups did not differ regarding embolicevents, but there was a slightly lower rate of bleedings with the use of newAC.11In the EWOLUTION study,23 but only one study assessedthe use of ACP.24 In thatstudy, with more than 1000 patients, compiling results from 22 centers, theannual rate of systemic thromboembolism was 2.3% after LAAC, representing a 59%risk reduction. The annual rate of major bleedings was 2.1%, representing a 61%risk reduction. Monotherapy with ASA or no medication was performed after LAAC,resulting in a reduction in hemorrhagic events. Considering that warfarin wasthe drug used for the comparison, all those studies are somehow outdated,because the currently used new oral AC have superior results.11Two studies have investigated the use of adjuvant drug therapy with the Watchmandevice,25The European guideline recommends LAAC for patients who have life-threateninghemorrhage with no reversible cause, who cannot use anticoagulation .LAAC is a therapeutic alternative for patients with NVAF and difficulties withanticoagulation, either due to contraindications or history of severe adverse eventswhen using anticoagulation, or even for patients at high risk for bleeding,prohibitive HAS-BLED score, because it proved to be safe considering its lowcomplication rates and high procedural success rate.


Background: According to clinical experience, Traditional Chinese Medicine (TCM) herbs added to platinum-based therapy (PBT) improve the Quality of Life (QOL) in metastatic non-small cell lung cancer (NSCLC) patients, but this must be prospectively validated.Patients and Methods: Based on clinical impressions regarding the effect of adding TCM herbs to platinum-based chemotherapy, we anticipated that 2 × 21 patients would be sufficient to obtain significant results with an α < 0.05 and power (1 - β) of 90%. To be on the safe side, we enrolled at least 28 patients in each group. In a prospective randomized controlled trial, 61 uniquely defined consecutive patients  with stage IIIB-IV, Eastern Cooperative Oncology Group (ECOG) performance scores (PS) = 0–1 and TCM syndrome combined Qi-Yin deficiency were enrolled. These 61 patients were selected from originally 154 consecutive stage IIIB-IV lung cancer patients in the enrollment period. Patients were hospitalized and strictly controlled/surveyed during the entire 2-month treatment period, to guarantee use of or abstinence from TCM herbal and placebo fluids. Occurrence of nausea-vomiting, QOL by Functional Assessment of Cancer Therapy-Lung (FACT-L) scales and changes in ECOG “improved and stable rates” were compared before and after two treatment cycles.Results: Before treatment, the clinico-pathologic and QOL features in PBT+PLACEBO and PBT+TCM patients did not differ (P > 0.10). The only side effects attributed by some of the patients to the TCM herbs were transient, mild gastric/abdominal heaviness in the first 2 weeks, but these also occurred amongst the PBT+PLACEBO patients . The incidence rates of nausea during treatment were 17% in PBT+TCM versus 75% in PBT+PLACEBO; vomiting rates were 14 and 56% (P < 0.0001 and 0.002). Moreover, ECOG “improved and stable rates” were 90% in the PBT+TCM versus 69% in the PBT+PLACEBO group (P = 0.04). In PBT+TCM patients, FACT-L social/familial and functional subscales were better after 2 months’ treatment (P = 0.02 and 0.03). Contrarily, in PBT+PLACEBO patients, the QOL variables total score, physical and emotional subscales were worse after PBT treatment .Conclusion: In stage IIIB-IV ECOG-PS = 0–1 NSCLC patients with Qi-Yin deficiency and platinum-based chemotherapy, adding TCM herbal medication improves the QOL. As this category of patients constitutes 40% of all metastatic NSCLCs, these results could have significant clinical impact. Lung cancer is the leading cause of cancer-related mortality; about 1.4 million lung cancer patients die from their disease worldwide each year . In ChinThe global overall 5-year survival rate of NSCLC is only 16%  and chemWe have recently shown in a case-control study, that adding TCM herbs to platinum-based chemotherapy in stage IIIB-IV pulmonary adenocarcinoma patients, significantly improves the 1 and 2 years’ survival rates . MoreoveIt is unlikely that these findings by various independent research groups from different countries are due to chance. However, prospective studies are required to finally support the survival advantage apparently caused by additional TCM herbal treatment. Moreover, before such studies will be approved by ethics committees, it is important to know if adding TCM herbal treatments has serious side effects and thus an effect on the QOL. Widespread clinical experience in China and elsewhere claims that using high quality TCM herbs has only minimal transient side effects and in fact improves the QOL in patients with metastatic lung cancer. However, as far as we know, a formal prospective RCT comparing the QOL specifically in patients with stage IIIB-IV pulmonary NSCLC treated with PBT, or PBT+TCM herbs, has not yet been undertaken. We therefore set out to study whether administering TCM herbal treatment to these patients has significant side effects and whether it improves the QOL.This randomized, prospective, controlled study on patients with first-time onset advanced NSCLC was approved by the Institutional Research Board of the Longhua University Hospital, Xuhui district, and the Respiratory University Hospital, Yangpu district, Shanghai, China before the study commenced. More recently, the Regional Ethics Committee of Health West  also allowed one of the co-authors (JB) to participate in the study.Table 1 shows the number of available, excluded and remaining included patients. In total, 64 patients fulfilled all criteria, but three refused chemotherapy. This left 61 patients who were randomized into PBT+PLACEBO (N = 32) or PBT+TCM group (N = 29). Table 2 shows the characteristics of the patients. For details of the chemotherapy and TCM herbal treatment, see below.There were 154 consecutive new metastatic lung cancer patients between December 1, 2009 and February 1, 2011 at the Longhua University Hospital, Xuhui district, and the Respiratory University Hospital, Yangpu district, Shanghai, China. We used the following eligibility criteria: pathology-confirmed diagnosis of primary NSCLC , inoperaMany Chinese patients receiving chemotherapy secretly use TCM herbs without informing their treating specialists . On the N = 19): vinorelbine 25 mg/m2, was administered on days 1, 8, and cisplatin 75 mg/m2, was administered on day 1 of a 4-week cycle. (2) TP program (N = 16): paclitaxel 135 mg/m2, and cisplatin 75 mg/m2 was administered on day 1. The cycle was repeated every 4 weeks. (3) GP program (N = 26): gemcitabine 1250 mg/m2, was administered on days 1 and 8, and cisplatin 75 mg/m2, was administered on day 1 of a 4-week cycle. Patients with grade 1–3 nausea or vomiting routinely received pharmaceutical anti-emetic Ondansetron (Zofran) treatment.The patients were randomly treated with platinum-based chemotherapy according to one of the following regimens [there were no differences in outcome of lung cancer with these different platinum-based regimens ]: (1) NPThe patients were classified according to well-established criteria for the determination of TCM syndromes . Only paMain symptoms: (1) Coughing with little sputum, (2) Shortness of breath, (3) Fatigue, and (4) Dry mouth.Secondary symptoms: (1) Spontaneous sweating, (2) Night sweating, (3) Red tongue with teeth marks, and (4) Weak pulse.Table 3 gives a summary of the medications. The general TCM treatment principle was Benefiting Qi, Nourishing Yin and Removing Toxicity.Traditional Chinese Medicine herbal treatment consisted of basic herbs which were given throughout the entire treatment period, and additional herbs which were selected each week based on specific symptoms the patients were experiencing during the treatment (in addition to the symptoms specific to the Qi and Yin deficiency syndrome mentioned above). It is important to emphasize here, that the coding of the bottles with the different decoctions, were changed each week and only disclosed after the end of the study. Moreover, not only the patients were blinded to the contents of the decoctions, but also the doctors treating the patients and the nurses providing the decoctions to the patients each day.Table 3).The basic herbs were the following: Radix Astragali Mongholici 30 g, Rhizoma Atractylodis Macrocephalae 9 g, Poria 15 g, Radix Glehniae 30 g, Radix Adenophorae Strictae 30 g, Radix Asparagi 15 g, Radix Ophiopogonis 15 g, Selaginella Doederleinii Hieron 30 g, Salvia Chinensis Benth 30 g . The herbal decoctions were all anonymized, and the codes of the different bottles were regularly changed during the study, to prevent bias amongst the patients, doctors, and nurses. The decoctions were administered orally twice per day , for 2 months, under strict supervision by medically trained personnel, as described above in the section “Ethics and Patients”. We controlled the liver and kidney enzymes during the treatment cycles, but no major changes occurred in any of the patients.Table 3. All herbs used are well established and widely used as traditional Chinese medications and their active components have been described in detail in the Chinese Pharmacopoeia 2006, National Pharmacopoeia Commission, published by the China Medical Science and Technology Press, Beijing, China. Moreover, the production and quality control of the herbs, by the companies supplying the herbs to the Pharmacy Department of the Longhua University Hospital, is also very rigid and under strict control of the Chinese Food and Drug Administration. This implies, that all batches sold, are regularly controlled by the companies for toxic and microbiological impurities , macroscopic and microscopic morphological analysis, and content of active chemical components, by fingerprinting and HPLC. We therefore did not perform during our study analysis of the active components of the decoctions delivered by the Pharmacy Department of the Longhua University Hospital. On the other hand, we did test later at the Norwegian Toxicology Institute, Oslo a representative decoction sample of the herbs from the Longhua Hospital Pharmacy Department. In agreement with the findings in China, we did not find detectable evidence for heavy metals, pesticides, or hormones. This confirms the quality of the herbs used in the present study.The herbs used were obtained from high quality companies, as shown in The American FACT-L Quality of Life Functional Assessment of Cancer Therapy-Lung version 4 (FACT-L v4) questionnaire and its lung cancer subscale (LCS)  were assThe ECOG score after the treatment was categorized as improved (score decreased ≥ 1), stable (score not changed) or worse (score increased ≥ 1).Nausea and vomiting was assessed according to the National Cancer Institute’s Common Terminology Criteria for Adverse Events Nausea, Vomiting , as follWe recorded the QOL items four times in each patient: before and after treatment of each cycle. As there were two cycles, totally four times. For the data analysis and comparison, we used only two scores: the one before the first cycle treatment (first month), and after the second cycle treatment (second month).P < 0.05 was used as the level of significance. SPSS Statistics is a software package used for logical batched and non-batched statistical analysis. Long produced by SPSS Inc., it was acquired by IBM in 2009. The software name originally stood for SPSS, reflecting the original market, although the software is now popular in other fields as well, including the health sciences and marketing.SPSS version 21 was used for the statistical analyses  and MedCalc  for power calculations and assessment of the sample size. Based on the previously published improvement of survival results and clinical impressions regarding the effect of adding TCM herbs to platinum-based chemotherapy, we anticipated that 2 × 21 patients would be sufficient to obtain significant results with an α < 0.05 and power (1 - β) of 90%. To be on the safe side, we enrolled at least 28 patients in each group. The paired-test was used to compare the continuous features. Frequency distribution with the chi-square test was used in numeration data. In all analyses, P > 0.13) in any of the characteristics between the two treatment groups, showing that there has not been any selection bias during randomization (Table 2).There were no differences , which they attributed to “the additional drinks,” but these complaints also occurred in 4/32 = 12% of the PBT++PLACEBO group patients, Table 4).In PBT+PLACEBO patients, most QOL features showed a trend of being worse after PBT-treatment and the FACT-L physical and emotional subscales and the Total Score were significantly worse after than before treatment . On the other hand, the Social/Family subscale improved (P = 0.02 and 0.03). On the other hand, none of the other subscales became worse (Table 4).In the PBT+TCM group, the Social/Family, and functional subscales improved following treatment than prior to treatment commencement (Table 5). Likewise, vomiting rates were 14 and 56% . Moreover, nausea and vomiting were not only less frequent in the PBT+TCM group than in the PBT group, but also less severe . Consequently, PBT+TCM patients received ondansetron much less frequently than the PBT+PLACEBO group. The evaluation of the incidence and degree of severity of nausea and vomiting was performed at the end of the second treatment month, after the second chemotherapy cycle. This means, that all patients with grades 1–3 nausea and vomiting already had received the anti-emeticum ondansetron, if they required it. Moreover, patients in the PBT-TCM intervention group had received ondansetron much less often than those in the PBT+PLACEBO group. In spite of this, nausea and vomiting was much less frequent and severe in the PBT+TCM group. This proves, that adding TCM to PBT treatment strongly reduces nausea and vomiting and such patients require much less ondansetron treatment.The incidence rates of nausea during treatment were 17% in the PBT+TCM versus 75% in the PBT+PLACEBO group (P = 0.04).Moreover, ECOG “improved and stable rates” were 90% in the PBT+TCM versus 69% in the PBT group (P = 0.03), but not in the PBT+PLACEBO group (P = 0.56). Moreover, the differences after treatment were also significantly better in the PBT+TCM group compared to the PBT+PLACEBO group .In agreement with this, the Functional subscale demonstrated improved results in the PBT+TCM group before and after treatment . Moreover, one could object, that the number of patients is relatively small. However, the power calculations , before the study started, made clear that the number of patients enrolled should be enough. If not, we would have enrolled more patients. Most important, the patients group studied is very pure . In fact, the total group came from a much larger group of 154 consecutive stage IIIb-IV lung cancer patients. It is the strict definition of our selection criteria, which reduces the patient numbers, but makes this a very pure patient group, which makes the study unique.In this tightly controlled prospective RCT in patients with stage IIIB-IV NSCLC and ECOG performance score 0–1 in addition to the TCM syndrome Combined Qi and Yin deficiency at the time of diagnosis, adding TCM herbs during the first two cycles of platinum-based chemotherapy improves nausea and vomiting, ECOG rate and the QOL. Such patients constituted 40% of all patients with metastatic lung cancer presenting at our hospital. Patients with other characteristics exhibit very different clinical symptoms, clinical behavior and outcome.Apart from the Social/Family feature, all QOL features point in the same direction; QOL in the PBT group was reduced after than before treatment but improved in the PBT+TCM group. Moreover, after treatment, the QOL features in the PBT+TCM group all showed a better trend than those in the PBT group.The high incidence and the very low overall survival rate for advanced (stage IIIB and IV) lung cancer treated with cytostatic drugs, are strong motivators for many patients to seek new therapeutic avenues which may improve prognosis and QOL. In the past, patient well-being often has been regarded as less important than survival improvement and not tangible enough for straight forward scientific assessment. Over the past decade, however, reducing the suffering of cancer patients has become increasingly regarded as an important therapeutic goal and a well-established end-point in clinical trials, especially when survival improvement is marginal. Medical oncologists today are expected to seriously discuss with the patients the QOL as a trade-off and end-point in treating advanced NSCLC. Moreover, QOL is an independent prognostic factor for patients with NSCLC .In a previous study, we concluded that adding TCM herbal medication to platinum-based chemotherapy in advanced lung cancer patients could prolong survival time, but QOL was not evaluated. Good QOL is important as prolonged survival time with good QOL meets the principle “to live with a malignant tumor” . TCM conA very important question is, how TCM herbs work on NSCLC, and the QOL features. In a previous paper, we have tried to summarize the possible prognosis-improving mechanisms . There cRegarding fatigue, this also occurs in neurological diseases and chronic inflammatory diseases. Increasing evidence points to genetic and molecular mechanisms that are activated and cause fatigue during inflammation and cellular stress conditions, and signaled via neuro-immune and oxidative/nitrosative stress pathways. Heat shock proteins (HSP), particularly HSP90α, also may signal fatigue in chronic inflammation , and posNausea and vomiting are quite common after chemotherapy and are controlled by the brain. The most important cause of chemotherapy-induced nausea and vomiting is the activation of the chemoreceptor trigger zone by the chemotherapy agents circulating in the blood. Other pathways are also involved: from the brain cortex and limbic system , from a part of the ear that responds to motion (and so causes motion sickness in some people) and from some other organs and nerves . These signals are transmitted with the help of neurotransmitters. The sight and smell of chemotherapy are the main causes of ‘anticipatory nausea and vomiting.’ Antinausea drugs include prochlorperazine, droperidol, metoclopramide, and marijuana or marinol. The most common anti-emetic medications are serotonin receptor blockers, also known as 5-HT3 receptor antagonists such as Zofran  and Aloxi . Emend (aprepitant), a neurokinin receptor blocker, is another drug added to the 5HT3 blockers  stage IIIB-IV with ECOG 0-1 performance status NSCLC patients with the TCM syndrome of combined deficiency of Qi and Yin and treated with platinum-based chemotherapy, shows a significant better EORTC-QOL and ECOG Scores and much less Nausea/vomiting for patients receiving additional personalized TCM herbal medication, whilst having no significant side effects.HG, JL, and HL: Design of the study, execution of the study, collecting data, analysis of data, writing the manuscript, and approval of the manuscript. JB: Design of the study, analysis of data, writing the manuscript, and approval of the manuscript.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 MH declared a shared affiliation, though no other collaboration, with one of the authors JB to the handling Editor, who ensured that the process nevertheless met the standards of a fair and objective review.


We examined the associations of alcohol consumption and liver holidays with all-cause mortality and with mortality due to cancer, heart disease, cerebrovascular disease, respiratory disease, and injury using a large-scale prospective study in Japan.We followed 102,849 Japanese who were aged between 40 and 69 years at baseline for 18.2 years on average, during which 15,203 deaths were reported. Associations between alcohol intake and mortality risk were assessed using a Cox proportional hazards model, with analysis by the number of liver holidays .A J-shaped association was observed between alcohol intake and total mortality in men  and in women . In current drinkers, alcohol consumption was associated with a linear, positive increase in mortality risk from all causes, cancer, and cerebrovascular disease in both men and women, but not heart disease in men. Taking of liver holidays was associated with a lower risk of cancer and cerebrovascular disease mortality in men.Alcohol intake showed J-shaped associations with the risk of total mortality and three leading causes of death. However, heavy drinking increases the risk of mortality, which highlights the necessity of drinking in moderation coupled with liver holidays. While past studies have reported a reduced risk of total mortality,5,6 cardiovascular diseases,7 and cancer8 in light-to-moderate drinkers, heavy alcohol consumption has been positively associated with mortality from the same causes of death.9,10 This means that light-to-moderate drinkers may receive health benefits from alcohol intake, although the optimal range varies across studies and by population.Many Asian countries have witnessed an increase in the level of alcohol consumption over the past decades, including Japan.11 and past studies pointed out the association of slow-metabolizing aldehyde dehydrogenase polymorphisms with myocardial infarction12 and site-specific cancers13–15 in Asians. However, the optimal limit to prevent premature mortality in Asian populations has not been well demonstrated. To date, only a few studies in Asia have assessed total and cause-specific mortality by alcohol consumption status, including one from the Japan Public Health Center-based Prospective Study.5,16–22 Even among existing studies, no study has comprehensively assessed the impact of alcohol intake on the five leading causes of death: cancer, heart disease, cerebrovascular disease, respiratory disease, and injury.23 Second, even among regular drinkers, the impact of alcohol consumption may differ by the number of drinking days in a week.24 Abstaining from drinking for several days a week, or the taking of so-called “liver holidays”, has been socially accepted, and is thus traditionally practiced in Japan to allow recuperation of the normal metabolic function of the liver. However, only one study, which employed JPHC study data, has reported the association of liver holidays with total mortality.18In assessing the impact of alcohol consumption on mortality outcomes, some questions need to be addressed in Asian populations. First, the impact of alcohol intake might be different in Asian than in Western populations. Asians have a high prevalence of people with facial flushing response due to inactive aldehyde dehydrogenase enzyme variants, which increases the blood level of acetaldehyde. Acetaldehyde is a major risk factor for cardiovascular and other diseases,Here, we aimed to estimate the impact of alcohol intake on total and five leading causes of death and to assess the association of liver holidays and risk of mortality using a large-scale, prospective cohort study in Japan.25–27 The baseline study for Cohort I started in 1990 and that for Cohort II started in 1993, covering a total of 140,420 participants  in 11 public health center areas. The study enrolled participants aged 40 to 59 years in Cohort I and 40 to 69 years in Cohort II. Non-eligible participants were excluded (n = 291). Of the 140,129 eligible participants, 113,380 subjects  completed the questionnaire. Of the subjects who returned the questionnaires, those who died, moved out of Japan, or lost to follow-up before the start of the follow-up period but who reported later were also excluded (n = 57). We excluded participants with self-reported past cancer, stroke, or myocardial infarction . Subjects without information on alcohol consumption or intake of fruits, vegetables, total energy, meat, fish, and dairy products were also excluded , leaving 102,849 participants for inclusion . The study was approved by the Institutional Review Boards of the National Cancer Center in Tokyo and The University of Tokyo, Japan.Details of the Japan Public Health Center-based Prospective Study have been described elsewhere.26 The analysis included the five leading causes of death in Japan using the ICD10 classifications: cancer (C00–C97); heart disease (I20–I52); cerebrovascular disease (I60–I69); respiratory disease (J10–J18 and J40–J47), including pneumonia, influenza, chronic obstructive pulmonary disease, and associated conditions; and injuries and accidents . Causes of death other than the above causes were also included.Study participants were followed-up from enrollment in the baseline study (1990–1994) until the date of death or the end of follow-up , whichever came first. Subjects who migrated to other areas were followed through the residential registry. Of all subjects, 0.9% were lost to follow-up during the study period. Cause of death was ascertained using death certificates, with permission from the Ministry of Health, Labour and Welfare.The baseline questionnaire in Cohort I contained information on the frequency of alcohol intake: almost never, 1–3 days/month, 1–2 days/week, 3–4 days/week, 5–6 days/week, or every day. Subjects who drank more than 1–2 days/week were asked about the type of beverage and the average amount of intake per day. The questionnaire in Cohort II asked about the current drinking status, as never, former, or current drinkers. Former and current drinkers were then asked about the frequency of alcohol intake: 1–3 days/month, 1–2 days/week, 3–4 days/week, or almost every day, along with the type and amount of average consumption per day. In the 5-year and 10-year follow-up surveys for both cohorts, alcohol intake was assessed in accordance with the Cohort I baseline survey.gou) of sake, 36 g ethanol for 180 mL of shochu and awamori, 10 g ethanol for 30 mL of whisky or brandy, 6 g ethanol for 60 mL of wine, or 23 g ethanol for 633 mL of beer (a large bottle). Third, we estimated the weekly ethanol intake at each survey year by multiplying the quantity by score. Fourth, cumulative average intake of alcohol was estimated by taking the average of the available time points starting from the baseline survey. For instance, cumulative average alcohol intake at the time of 5-year follow-up was calculated by averaging alcohol intake at baseline and 5 years, and the same intake at 10-year follow-up onwards was calculated by averaging the intake at baseline, and 5-year and 10-year follow-ups, or any combination of available time points, and used as a time-dependent variable.28 Subjects were classified for cumulative average intake of alcohol into seven groups for men: non-drinkers, occasional drinkers (1–3 day/month), and five groups of regular drinkers . Cumulative average intake was categorized into six groups for women: non-drinkers, occasional drinkers (1–3 day/month), and four groups of regular drinkers . An ethanol intake of 150 g/week is equivalent to having less than one bottle of beer or one gou of sake per day, 300 g/week to two bottles of beer or two gou of sake per day, and 450 g/week to three bottles of beer or three gou of sake per day.We defined the drinking status as follows: non-drinkers denote people who reported “almost never” in Cohort I and “never/stopped drinking” in Cohort II at baseline, or who reported “almost never” in 5-year and 10-year follow-up surveys; current drinkers denote people who reported drinking more than 1–3 days/month at the time of the survey. In the subgroup analysis, former drinkers were defined as people who stopped drinking before baseline in Cohort II. To calibrate alcohol intake, we first assigned a score for each category of intake frequency: 0 for almost never, 0.5 for 1–3 days/month, 1.5 for 1–2 days/week, 3.5 for 3–4 days/week, 5.5 for 5–6 days/week, and 7.0 for every day in the Cohort I baseline; and 0 for almost never, 0.5 for 1–3 days/month, 1.5 for 1–2 days/week, 3.5 for 3–4 days/week, and 6.0 for almost every day in the Cohort II baseline. For 5-year and 10-year follow-up surveys, we assigned the same scores as in the Cohort I baseline survey. Second, for regular drinkers who drank more than once a week, alcohol intake was estimated by multiplying the grams of ethanol contained in each type of drink. In the JPHC study, one drink is assumed to contain 23 g ethanol for 180 mL  among regular drinkers who consume alcohol more than once a week. We conducted a stratified analysis by light-drinking men (<150 g/week), moderate-drinking men (150–299 g/week), and heavy-drinking men (300+ g/week), while analysis of drinking patterns in women included those with all amount categories to allow a sufficient number of cases for analysis.29 and 0.59 for men and 0.40 in women in Cohort II,30 both for the baseline survey. For the 5-year follow-up survey, the correlation coefficients of alcohol intake were 0.77 for men and 0.51 for women.31 The reproducibility of alcohol intake in Cohort I was 0.66 between 1990 and 1995 at a 5-year interval, and 0.63 in Cohort II between 1993 and 1997 at a 4-year interval.29 The reproducibility of the comprehensive food frequency questionnaires for the 5-year follow-up survey, administered at a 1-year interval, was 0.79 in men and 0.71 in women.32Dietary records for 28 days  or 14-day dietary records were used to validate the baseline, 5-year, and 10-year questionnaires. Spearman rank correlation coefficients of alcohol intake between the questionnaires and dietary records were 0.79 for men and 0.44 for women in Cohort I2; <18.5, 18.5 to <25, 25 to <30, and ≥30); flushing response after drinking (no or yes); history of hypertension (no or yes); history of diabetes (no or yes); leisure-time sports ; consumption of green tea and coffee ; total energy consumption per day (continuous); log-transformed, daily consumption of fruit, vegetables, meat, fish, and dairy products, with adjustment of total energy intake using the residual method (continuous); and job status at baseline (employed or unemployed). The same analysis was conducted after excluding deaths occurring within 5 years after baseline, to reduce the chance of reverse causality from ongoing but subclinical illnesses. Further, we conducted a secondary analysis excluding past drinkers in Cohort II, and further analyses by smoking status . We estimated P for interaction by using likelihood-ratio tests which compared the models with and without cross-product terms for smoking status, with alcohol intake as a continuous term. Tests for non-proportional hazards by Therneau and Grambsch were used to evaluate departures from proportional hazards assumption, and no violation of the assumption was observed. Since the questionnaires for both cohorts were designed differently, we evaluated whether the associations varied between cohorts by combining the cohort-specific estimates in a fixed-effects meta-analysis and then performing Chi-square tests for heterogeneity. Cohort-specific HRs for alcohol intake and all-cause mortality were weighted by the inverse of the sum of their variance. For sub-analyses by smoking status, without abstainers during follow-up, and for tests for heterogeneity, we grouped men who drink ≥450 g/week into a single category to allow enough number of cases. All P-values were two-sided, with values smaller than 0.05 indicating statistical significance. All analyses were conducted with STATA version 14.0 software .Associations between cumulative average alcohol intake, drinking patterns, and the risk of mortality were measured from hazard ratios (HRs) and 95% confidence intervals (CIs) using a Cox proportional hazards regression model. Tests for non-linearity were conducted by assigning the scores for each category of cumulative alcohol intake from zero for never drinkers to 5 for the highest intake category, and then alcohol intake was used as a continuous variable; the likelihood ratio test was used to compare the model with only the linear term and the model with both the linear and quadratic terms. Tests for linear trend in drinkers were conducted using the same scores but restricting the subjects only to current drinkers. For the liver holidays, we tested for linear trends by assigning the scores for each category of the number of liver holidays taken, from zero for no liver holidays to three for 5–6 liver holidays per week. The model was adjusted for the following potential confounders: age at baseline (continuous); public health center; smoking status ; BMI .HRs with 95% CIs for the association between cumulative average intake of alcohol and all-cause and cause-specific mortality are presented in Table Similarly, the multivariate model showed that the cumulative average consumption of alcohol had a J-shaped association with mortality from cancer and cerebrovascular disease in men, with the risks lower in occasional drinkers and those who drank 1–149 g/week to 150–299 g/week compared to non-drinkers, and increase in mortality risk with ≥450 g/week for cancer and ≥600 g/week for cerebrovascular disease. On the other hand, a U-shaped association was seen in mortality from heart disease and respiratory disease in men. The adjusted HRs in women showed the same J-shaped association with mortality from all causes, cancer, heart disease, and cerebrovascular disease, in which the risk reduction remained in women who drank 1–149 g/week compared to non-drinkers. When we restricted our analysis only to current drinkers, tests for linear trend showed a linear increase in the risk of mortality due to all causes, cancer, cerebrovascular disease, and injury in men, and to all causes, cancer, cerebrovascular disease, heart disease, and respiratory disease in women. The analysis of drinking patterns showed that and having 5–6 days of liver holiday a week was associated with a lower risk of cancer and cerebrovascular disease mortality in light-drinking men, while having 1–2 days of liver holiday a week was associated with a lower risk of total mortality in light-drinking men and a lower risk of cancer and cerebrovascular disease mortality regardless of the weekly amount intake  is consistent with that in Western populations: a large-scale cohort study in Sweden showed no significant rise in total mortality risk among those who drank up to ∼140 g per week,35 However, although the number was limited, 14.6% of men and 8.3% of women in Cohort II who abstained before baseline died during follow-up, which is lower than the mortality witnessed in the overall study participants (20.2% in men and 17.9% in women). Our analysis excluding abstainers before and during the follow-up period also showed similar associations.Caution should be raised, though, that such J-shaped associations could have occurred because non-drinkers contain a high-risk group of former drinkers who quit drinking due to ill health.18 From a combined analysis of drinking quantity and drinking patterns, we showed that Japanese men who abstain from drinking for 5–6 days with the intake below 150 g/week had a significantly lower risk of cancer and cerebrovascular disease mortality relative to daily drinkers, even though they consume a maximum of 6.5 large bottles of beer in 1 or 2 days. Further, men who abstain from drinking for 1–2 days a week had a lower risk of cancer and cerebrovascular disease mortality than those who drink everyday among light drinkers (<150 g/week), moderate drinkers (150–299 g/week), and heavy drinkers (≥300 g/week), and a lower risk of all-cause mortality in light drinkers. One possible explanation for the relative benefits of liver holidays might be that daily heavy-drinkers are consistently exposed to acetaldehyde compared with liver holiday takers, which may increase their cancer risk. Another possible explanation is the social support: the benefit of light-to-moderate drinking in preventing cardiovascular disease was reported to be enhanced in subjects who receive stronger social support.36 In Japan, social drinking is an important social event, especially for middle-aged men: in our study, men in Cohort II who responded to the frequency of social drinking reported that those who take “liver holidays” were more likely to drink on socializing occasions than those who drink almost every day,18 suggesting a possible link between liver holidays, social drinking, and social support.Relatively high tolerance for alcohol in Japanese men suggests a paradox: the optimal limit of alcohol intake may be higher than in Western populations, despite the high prevalence of people with a facial flushing response. The tradition of ‘liver holidays’ in Japan may partially explain the reasons for the optimal limit of alcohol at high levels.37 Light-to-moderate alcohol consumption is also known to exhibit anti-inflammatory effects.24 Any of these factors may contribute to minimizing the mortality risk from cardiovascular disease. J-shaped associations with the cancer risk can be explained by the fact that light-to-moderate drinking has been shown to improve immunologic function via increased cell-mediated and humoral immune responses.38 A previous study using the same JPHC data showed that light-to-moderate drinking is associated with a lower risk of Non-Hodgkin’s lymphoma39 relative to non-drinkers. Moderate alcohol intake is also associated with an improvement in insulin resistance, contributing to a reduced risk of type 2 diabetes mellitus,40 which is a risk factor for cancer. However, overdose of alcohol is a common risk factor for multiple morbidities: the International Agency for Research on Cancer reported that alcohol is carcinogenic to humans (Group 1) in different types of cancers,3 and acetaldehyde associated with alcohol consumption is a known carcinogen.41 Excess intake of alcohol also impedes absorption of dietary folate and its bioavailability,42 which contributes to aberrant DNA synthesis and methylation, leading to carcinogenesis.43 Our study also indicated that the mortality risk due to all causes, cancer, and cerebrovascular disease in both men and women, and to heart disease in women, may linearly increase when we restricted our analysis to current drinkers.In our study, alcohol intake also showed associations with the risk of heart disease, cerebrovascular disease, and cancer mortality, depending on the amount of drinking. Previous studies reported that regular low-dose drinking is protective against heart disease, mediated via an increase in high-density lipoproteins, lower concentrations of fibrinogen, and inhibition of platelet aggregation.7 Further study is required to investigate the associations between light-to-moderate drinking and respiratory disease mortality.With regard to respiratory disease mortality, our subgroup analysis by smoking status showed risk attenuation, suggesting residual confounding by smoking. A study in Europe reported a lower risk of respiratory disease death in light-to-moderate drinking men (>0 to ≤60 g/day), but the results were of borderline significance.44 and unintentional injuries.45Further, our study showed a J-shaped association with mortality from injury in both men and women. However, this association might have been due to reverse causality, since people with psychological problems tend to quit drinking or continuously drink extreme amounts. In current drinkers, mortality risk due to injury was found to increase linearly: past studies similarly reported that heavy alcohol intake was associated with increased risk of suicide and violence28,46 However, several limitations warrant mention. A certain proportion of drinkers may have been classified as non-drinkers if they rarely consume alcohol. However, such misclassification would only have attenuated the results toward null, and misclassification bias over time is unlikely, since we used measurement of alcohol intake over 10 years. Second, we did not have information on age at onset of alcohol intake or duration of abstaining from alcohol in the past, which restricted our analysis of updated exposure to the follow-up period, instead of lifetime exposure to alcohol. Third, our analyses were constrained by the limited number of heavy-drinking women, which made it difficult to assess mortality risk in women who drink more than 300 g per week. Fourth, validity of alcohol questionnaires was relatively low in women compared with men, but the validity is comparable to previous studies from Japan.5,22The strengths of the study include prospective and updated analysis of alcohol consumption, in both quantity and frequency of drinking, with a long-term follow-up period and enrollment of more than 100,000 participants, to examine associations between alcohol and mortality risk by gender and by subgroup. Because alcohol use changes over time, updating the information on alcohol intake should improve the accuracy of assessment during the follow-up period.In conclusion, this study suggests J-shaped associations between alcohol intake and the risk of total mortality and three leading causes of death. However, alcohol intake was associated with a linear, positive increase in mortality risk when we restricted our analysis to current drinkers, which highlights the necessity of drinking in moderation coupled with liver holidays.


To determine whether various proteins in the cervicovaginal fluid (CVF) known to be involved in immune regulation, alone or in combination with clinical risk factors, can predict spontaneous preterm delivery (SPTD) in women with cervical insufficiency or a short cervix (≤25 mm).This retrospective cohort study included 62 asymptomatic women with cervical insufficiency (n = 27) or an asymptomatic short cervix (n = 35) at 18–27 weeks. CVF swab samples were taken for assays of vitamin D binding protein (VDBP), interleukin (IL)-8, matrix metalloproteinases (MMP)-9, tissue inhibitor of metalloproteinases (TIMP)-1, and Dickkopf-related protein 3 (DKK3) before cervical examination, and maternal blood was collected for the determination of the C-reactive protein (CRP) level. The primary outcome measurement was SPTD at <32 weeks of gestation. Logistic regression analysis and receiver operating characteristic curves were used for the statistical analyses.The rate of SPTD at <32 weeks was 40.3% (25/62). The CVF levels of VDBP, TIMP-1, and DKK3, but not IL-8 and MMP-9, were significantly higher in the women who had SPTD at <32 weeks than in those who did not deliver spontaneously at <32 weeks. The women who had SPTD at <32 weeks had a significantly more advanced cervical dilatation at presentation and a higher level of serum CRP. Using the stepwise regression analysis, a prediction model was developed by combining various proteins in the CVF and clinical factors, resulting in the inclusion of cervical dilatation, CVF VDBP, and use of corticosteroids .In women with cervical insufficiency or a short cervix, VDBP, TIMP-1, and DKK3 in the CVF may be useful as non-invasive predictors of SPTD at <32 weeks. A combination of these markers and clinical factors appears to improve the predictability of SPTD compared with the markers alone. Cervical insufficiency complicates 0.1–1% of all pregnancies and is thought to be the main cause of second trimester pregnancy loss or early preterm birth . DespiteAccumulated research data indicated that in flammatory and immune responses are involved in the mechanisms responsible for premature cervical ripening and dilatation, which are the predominant features in women with cervical insufficiency/short cervix, as the result of an extensive cervical remodeling , 5. ImpoIt is generally considered that cervical insufficiency/sufficiency might be a continuum, using transvaginal sonographic examination of the cervix and a mid-trimester short cervix is associated with cervical insufficiency and subsequent preterm birth , 17. TheThis was a retrospective cohort study conducted at Seoul National University Bundang Hospital , a tertiary-care teaching hospital, from September 2009 to December 2015. The patients consecutively recruited in this study were singleton pregnant women with a diagnosis of cervical insufficiency  or a short cervix between 18+0 and 27+6 weeks of gestation. The inclusion criteria were as follows: 1) a live fetus, 2) intact amniotic membranes, and 3) a CVF sample available for analysis. The exclusion criteria were as follows: multiple pregnancy, prior cervical cerclage, major congenital anomalies, preterm labor, or preterm premature rupture of the membranes at diagnosis, vaginal bleeding, and clinical signs of chorioamnionitis. Cervical insufficiency was defined as a painless cervical dilation of ≥1 cm and exposed fetal membranes determined via visual evaluation using a sterile speculum, without contractions of the uterus. A short cervix was defined as a cervical length of ≤25 mm measured via transvaginal ultrasound. Gestational age was calculated based on the last menstrual period and first trimester or second trimester (≤20 weeks) ultrasound results when available. However, in most of the study subjects, gestational age was confirmed using ultrasonography in the first or second trimester. This study was approved by the Institutional Review Board of Seoul National University Bundang Hospital (project number B-1105/128-102). The patients provided written informed consent for the collection and use of the CVF samples for research purposes. The primary outcome measure was SPTD at <32 weeks of gestation; SPTD was defined as delivery after spontaneous onset of preterm labor, premature rupture of membranes, or development of clinical chorioamnionitis.At the time of admission, CVF samples were obtained from all participants. CVF sample collection, processing, and storage have been previously described in detail . BrieflyThe CVF samples were assayed for various proteins  using an enzyme-linked immunosorbent assay human DuoSet Kit  according to the manufacturer’s instruction. The ranges of the IL-6, IL-8, VDBP, MMP-9, TIMP-1, M-CSF, and DKK3 standard curves were 7.8–600, 31.2–2000, 156–10000, 31.2–2000, 31.2–2000, 15.6–1000, and 31.2–2000 pg/mL, respectively. Prior to the measurement of these seven proteins, the CVF samples were diluted using the ratio 1:4 for DKK3 and M-CSF, 1:5 for IL-6 and IL-8, 1:100 for MMP-9 and TIMP-1, and 1:500 for VDBP. In the samples with protein concentrations lower than the lowest point on the standard curve, the lowest detected values were used for the analysis. All the samples were assayed in duplicate. The intra- and inter-assay coefficients of variation were <10% for all analyzed biomarkers.3); maternal tachycardia (> 100 beats/min); and fetal tachycardia (> 160 beats/min), following the recommendations of Gibbs et al. }  and a specificity of 75.7% . The positive and negative likelihood ratios (LRs) were 3.95  and 0.05 , respectively. The AUC for the combined predictive model was significantly greater than that for cervical dilatation (P = 0.044) and VDBP (P = 0.005)  .P = 0.006; DKK3 ≥1.22 ng/mL, P = 0.010).When separate analyses were performed on the dataset after removing 5 women who developed clinical chorioamnionitis before the onset of labor, the results were almost the same as in the present analyses (data not shown).The principal findings of this study are as follows: (i) In women with cervical insufficiency or a short cervix, VDBP, TIMP-1, and DKK3 in the CVF may be useful as non-invasive predictors of SPTD at <32 weeks; (ii) a combination of these markers and clinical factors appears to improve predictability of SPTD in comparison to the markers alone; and (iii) the median CVF levels of VDBP, MMP-9, TIMP-1, and DKK3 were significantly higher in the women with cervical insufficiency than in those with a short cervix. To our knowledge, this is the first study to demonstrate the distinctive changes in various proteins present in the cervicovaginal compartment between women with cervical insufficiency/short cervix who had SPTD at <32 weeks and delivered 32 weeks later. Similar results regarding pro-inflammatory cytokines and VDBP were also documented in the CVF of women with preterm labor and intact membranes , 8, 13.The present study has several limitations. The major limitation of the study is that the study population constituted a heterogeneous group in terms of disease entities  and treatment , despite the fact that a short cervix cannot be equated with cervical insufficiency. However, it is unlikely that this has changed our main findings because we adjusted for these confounders in the multivariate analysis. Second, this study is limited by its retrospective nature and relatively small sample size from a single center. Data from the current study may provide pilot information with regard to concentrations and role of various proteins present in the CVF compartment in cases of cervical insufficiency. Therefore, our finding should be confirmed by prospective studies with larger population sizes. Third, we included women who presented with cervical insufficiency at an advanced gestational age  to increase the sampler size, even though the assessment of cervical insufficiency beyond 26 +0 weeks is too late to be clinically relevant. Fourth, this study lacked data on the CVF fetal fibronectin test, which has been reported to be useful in predicting SPTD in asymptomatic women and women with preterm labor , 26. TheThe present study demonstrates that a combination of various proteins in the CVF and clinical factors can improve the predictability of SPTD, and this combination is more accurate than these factors alone. These observations are consistent with the results of our previous studies on multiple proteins in the amniotic fluid (AF) and serum compartments in cases of cervical insufficiency , 27. Colin vitro [Consistent with the findings of previous studies on women with preterm labor , 13, an in vitro , of whicin vitro , 8, 27 ain vitro , 33. In in vitro , 34. Meain vitro . In contin vitro . We cannin vitro , 10. Ourin vitro . The disIn our study, CVF DKK3 displayed the strongest association with SPTD among the measured biomarkers (see the supplementary files). Although DKK3 is a relatively less-studied protein particularly in obstetrics, the highest DKK3 levels are found in organs classically considered as immune privileged, such as the embryo, placenta, and uterus , 36. ImpWe also found that the levels of VDBP, MMP-9, TIMP-1, and DKK3 and percentage above the limit of detection for IL-6 in the CVF were significantly higher in the women with cervical insufficiency than in those with a short cervix. In addition, we have found a significant correlation between cervical dilatation and these protein levels in the CVF, except for MMP-9. Similarly, in the context of the AF compartment, previous reports by Kiefer et al. and our group have shown a significant correlation between inflammatory cytokine levels in the AF and the degree of cervical shortening in women presenting with mid-trimester short cervix or the degree of cervical dilatation in women with cervical insufficiency , 40. WheIn conclusion, VDBP, TIMP-1, and DKK3 in the CVF may be useful as non-invasive predictors of SPTD in women with cervical insufficiency or a short cervix. A combination of these markers and clinical factors appears to improve the predictability of SPTD compared with markers alone. Further large prospective studies are needed to determine whether our prediction model as a management strategy can be used to identify the patients who would benefit from cerclage.S1 TableP = 0.300–0.879). ROC, receiver operating characteristics; SE, standard error; CI, confidence interval; VDBP, vitamin D binding protein; TIMP, tissue inhibitor of metalloproteinases; DKK, Dickkopf aComparison with cervical dilatation.The AUC values with their 95% CIs and best cutoff values of VDBP, TIMP-1, and DKK3 in the CVF and serum CRP in relation to the occurrence of SPTD at <32 weeks. The AUCs for these three proteins in the CVF ranged from 0.735 to 0.799, which were not significantly different from each other Click here for additional data file.S1 File(SAV)Click here for additional data file.


Although cross-sectional studies suggest that cognitive aging starts in midlife, few longitudinal studies have documented within-individual declines in cognitive performance before the seventh decade. Learning from repeat testing, or practice effects, can mask the decline in younger cohorts. In women, the menopause transition also affects test performance and can confound estimates of underlying decline. We designed this study to determine if, after controlling for practice effects, the menopause transition, and the symptoms associated with it, there is evidence of cognitive aging in midlife women. We used data from a longitudinal observational study in 2,124 participants from the Study of Women’s Health Across the Nation. Outcomes examined were scores on annual tests of processing speed, verbal episodic memory (immediate and delayed), and working memory. To reduce the impact of practice effects and of the menopause transition, we used the third cognition testing visit as the baseline. Average age at this baseline was 54 years, and the majority of the women were postmenopausal; half the cohort was 2 or more years beyond the final menstrual period. There were 7,185 cognition assessments with median follow-up time of 6.5 years. In mixed effects regression, adjusted for practice effects, retention, menopause symtoms , and covariates, scores on 2 of 4 cognition tests declined. Mean decline in cognitive speed was 0.28 per year  or 4.9% in 10 years, and mean decline in verbal episodic memory (delayed testing) was 0.02 per year (95% CI: 0.00 to 0.03) or 2% in 10 years. Our results provide strong, longitudinal evidence of cognitive aging in midlife women, with substantial within-woman declines in processing speed and memory. Further research is needed to identify factors that influence decline rates and to develop interventions that slow cognitive aging. Although decline in cognitive functioning is common in older ages ,2, thereimprovements in performance over multiple years [improvements in cognitive performance in midlife have been documented in the Baltimore Longitudinal Study of Aging, and attributed to learning or practice effects from repeat testing [Yet, in midlife women going through the menopause transition (MT), at least 2 cohorts found no evidence of cognitive aging; instead they documented significant le years ,9. Simil testing . The phe testing ,10,11,12rd cognition testing; thus commencing analysis at 3rd testing reduces effects of the MT on estimates of cognitive performance trajectories. We hypothesized that, after largely eliminating practice effects by initiating our analysis at the 3rd third testing occasion, and explicitly controlling for the MT and associated symptoms, midlife women would indeed show gradual declines in cognitive performance.Practice effects are largest at first re-testing and diminish significantly with further re-testing ,14. We tth follow-up to 2709 women, and repeated in 6th and subsequent visits up to the 12th follow-up, except that only half the cohort was tested in the 8th follow-up and the remainder in the 9th, and there was no cognition testing in the 11th follow-up.SWAN is a community-based, longitudinal study of midlife women. Entry requirements were: 42 to 52 years of age; intact uterus; at least one ovary; no estrogen use; and at least one menstrual period in the 3 months prior. Seven study sites together recruited 3302 women ; the basrd cognition testing as baseline. Because only 21 (<1%) were from the Hudson County (New Jersey) site, they were excluded; an additional 23 were excluded because of a stroke before their 3rd test, leaving a sample of 2124. Because cognitive aging may accelerate after the menopause [Of the 2709 women in the SWAN cognition cohort, 2168 (80%) had testing at 3 or more visits—an inclusion criterion for this analysis, which used the 3enopause , we creaCognitive processing speed was assessed with the the symbol digit modalities test (SDMT), in which participants match numbers to symbols in a specified time period ; score rAt SWAN baseline, questionnaires collected age, race/ethnicity, and education. Annually administered questionnaires assessed financial hardship (difficulty paying for basics), diabetes mellitus, sex hormone use, interim hysterectomy and/or bilateral oophorectomy, MT stage , and FMP date. The Center for Epidemiologic Studies Depression (CES-D) Scale quantified depressive symptoms , and codAfter excluding scores from the first 2 cognition testing occasions, we examined LOESS-smoothed plots of cognition scores as a function of ‘time from FMP’  and ‘time elapsed since the 3rd cognition testing’ . Time from FMP more closely captures biological aging in a midlife woman, because of the large changes around the FMP not only in sex hormone levels but also in multiple other physiological markers ,25,26. Ard testing occasion’ showed gradual decline only in SDMT , and included the following time-fixed variables: age at FMP, education , race/ethnicity , testing language , difficulty paying for basics , use of sex steroids prior to the 3rd cognition testing (yes/no), and the total number of cognition assessments per participant , use of sex steroid hormone therapy (yes/no), bilateral oophorectomy before natural menopause (yes/no), diabetes (yes/no), and MT-associated symtoms . Analyses were conducted using complete cases (no covariates missing).We fit linear growth curves to the repeated measurements of each cognition score as function of time from FMP, allowing for a residual practice/learning effect from the 3 cohorts ,27,28). rd cognition testing, with all the same covariates except that age at FMP was replaced by age at the 3rd cognition testing . We included one additional time-varying covariate, MT stage at the time of testing, to remove effects of the MT, and isolate chronological aging effects. Because this analysis did not require an FMP date, it was done in the larger sample of 2124 participants who met study entry criteria (except not requiring known date of FMP).To examine the relation between cognitive performance and chronlogical aging, we ran parallel models that fit linear growth curves to the cognition scores as a function of time since 3rd cognition testing , median age was 54 years (interquartile range 52 to 56), and the majority of the women were post-menopausal. Nearly half were Caucasian, and the majority were tested in English. About a quarter had post-graduate education. The FMP subsample was very similar to the study sample . There was a total of 7,185 repeated assessments in the study sample, and 4,163 in the FMP subsample. Some women did not complete all 4 cognition tests at every testing occasion: in the study sample, there were 31 missing SDMT scores, 2 missing EBMT immediate recall, 6 missing EBMT delayed recall, and 171 missing DSB scores; corresponding missing numbers in the FMP subsample were 18, 0, 2, and 94. The median length of follow-up was 6.5 years (interquartile range 5.2 to 6.8) in the study sample, and 6.5 years (interquartile range 5.6 to 6.8) in the FMP subsample.In the study sample and FMP subsample, the mean number of cognition testing occasions available for analysis was 3.4, but the majority of women participated in all 4 cognitive visits , and EBMT delayed recall scores decreased on average by 0.02 per year (p = 0.01). These declines persisted after additional adjustment for education, race/ethnicity, testing language, clinical site, financial hardship, oophorectomy, sex hormone use, diabetes, and symptoms of depression, anxiety, sleep disturbance, and vasomotor instabily, although the decline in EBMT-delayed recall scores became marginally significant  from the 3nificant .rd to 4th testing was 0.62 (p = 0.01). In addition, there were retention effects seen in 3 of the 4 tests; scores were higher in those who were tested more often: SDMT (p = 0.0001), EBMT delayed recall (p = 0.04) and DSB (p = 0.06).There were also strong practice effects in SDMT, but not in the other 3 test scores: mean SDMT learning from 3rd cognition testing—and yielded similar findings. Adjusted only for age at the 3rd testing, practice from the 3rd to 4th fourth testing, and retention, SDMT scores decreased on average by 0.24 per year (p < .0001). This decline persisted in the fully adjusted model  in the ovarian aging model  and 0.25 per year  in the chronological aging model .To remove residual confounding by persisting practice effects, we conducted a sensitivity analysis in which we ran the mixed effects models after dropping data from the 3As hypothesized, after controlling for practice effects, the MT and MT symptoms, midlife women did show longitudinal declines in cognitive performance, mainly in processing speed. The average, within-woman rate of decline  in processing speed was essentially identical to the average, between-women difference by age at time of FMP (0.28 per year vs. 0.31 per year). However, as in previous studies , cross-sPrevious studies have found that cognitive procesing speed is especially sensitive to early changes ,30,31. Wbefore the FMP, and declines in other estrogen-dependent biological systems, such as bone, commence well before the FMP [Although there is some evidence that circulating estrogen might protect premenopausal women from cognitive aging ,33, we d the FMP ,34. Becath decade, but concluded that selective retention did not bias estimates of longitudinal cognitive decline [As in older cohorts, we also saw a retention effect in this midlife cohort: Cognitive performance was better in women who stayed in the study longer, although attrition was not primarily due to death in this cohort. At least one other study found similar differences by retention in cognitive performance in the 6 decline .Limitations of our study include the inability described above to detect initiation or acceleration of cognitive decline at the time that estrogen starts declining, absence of men from the study, and limited generalizability to women not represented in this study, including those who use sex hormones during the MT, who had a hysterectomy without bilateral oophorectomy prior to natural menopause, who were too ill to participate, from less developed economies, and women from race/ethnicity groups not represented in SWAN.In conclusion, this study provides good new evidence of cognitive aging in women in midlife, with significant longitudinal declines in both processing speed and verbal memory. Unlike previous longitudinal studies in midlife that were based on 3 or fewer cognition assessments, and could not adequately account for practice effects, we analyzed up to 6 annual or biennial assessements, allowing us to minimize the impact of practice effects and unmask declines. Practice effects are larger in younger, cognitively intact individuals than in older adults  and can A decline in processing speed in midlife is not a harbinger of declines in other domains of functioning , there a