The Blenniiformes comprises six families, 151 genera and nearly 900 species of small teleost fishes closely associated with coastal benthic habitats. They provide an unparalleled opportunity for studying marine biogeography because they include the globally distributed families Tripterygiidae (triplefin blennies) and Blenniidae (combtooth blennies), the temperate Clinidae (kelp blennies), and three largely Neotropical families . However, interpretation of these distributional patterns has been hindered by largely unresolved inter-familial relationships and the lack of evidence of monophyly of the Labrisomidae.Stathmonotus, and we elevate two subgenera of Labrisomus to establish a monophyletic classification within the family. The monophyly of the Chaenopsidae is supported with the exclusion of Stathmonotus (placed in the Stathmonotini) and Neoclinus and Mccoskerichthys (placed in the Neoclinini). The origin of the Blenniiformes was estimated in the present-day IndoPacific region, corresponding to the Tethys Sea approximately 60.3 mya. A largely Neotropical lineage including the Labrisomidae, Chaenopsidae and Dactyloscopidae (node IV) evolved around 37.6 mya when the Neotropics were increasingly separated from the IndoPacific, but well before the closure of the Tethys Sea.We explored the phylogenetic relationships of the Blenniiformes based on one mitochondrial (COI) and four nuclear  loci for 150 blenniiform species, and representative outgroups . According to the consensus of Bayesian Inference, Maximum Likelihood, and Maximum Parsimony analyses, the monophyly of the Blenniiformes and the Tripterygiidae, Blenniidae, Clinidae, and Dactyloscopidae is supported. The Tripterygiidae is the sister group of all other blennies, and the Blenniidae is the sister group of the remaining blennies. The monophyly of the Labrisomidae is supported with the exclusion of the Cryptotremini and inclusion of Relationships recovered in this study are similar to those of earlier analyses within the Clinidae and Chaenopsidae, and partially similar within the Blenniidae, but tripterygiid relationships remain poorly resolved. We present the first comprehensive phylogenetic hypothesis for a monophyletic Labrisomidae with five tribes . Global distributions of blenny genera included in our analysis support the evolution of a largely Neotropical clade whose closest relatives (clinids and cryptotremines) are temperate in distribution. The Blenniiformes comprises six families, 151 genera and nearly 900 species -4. Becausensu Hubbs, 1952; [The history of blenniiform classification has been reviewed by several researchers e.g. ,10-12). -12. 10-1s, 1952; ) was revs, 1952;  and, bass, 1952; . Springes, 1952; , shares s, 1952; ,18.Inter-familial relationships of blenniiforms have remained largely unresolved because of conflicting morphological and molecular evidence . It is gRecently, the systematics of blennies was thoroughly reviewed, providing convenient reference points: the Labrisomidae, Clinidae, Chaenopsidae, and Dactyloscopidae by Hastings and Springer , the Blehttp://purl.org/phylo/treebase/phylows/study/TB2:S14731). The GC content of the first codon across all markers ranged from 51.1% to 61.9%, the second codon from 32.4% to 47.7%, and the third codon from 39.2% to 84.0%  variable sites, of which 1,392 (39.08%) were parsimony informative. The sequences of the ten partitions provided a range of evolutionary information. The third codon position of all five markers provided significantly more parsimony information (59.09% to 99.47%) than the first and second positions (4.13% to 28.21%). The third codon of the only mitochondrial marker (COI) had the highest proportion of variable characters (100%) and the highest proportion of parsimony informative characters (99.47%). The first and second codon positions of the nuclear marker Histone H3 had the lowest proportion of both variable characters (9.63%) and parsimony informative characters (4.13%).sensu stricto (100/100/100), and Dacty-loscopidae (99/100/100), as well as the monophyly of their sister group, the Gobiesocidae (100/100/100). The Tripterygiidae is the sister group of all other blenniiforms, and the Blenniidae is the sister group of all remaining blennies. Calliclinus geniguttatus (currently a labrisomid) is the sister group of a large clade that includes the Clinidae, Labrisomidae, Chaenopsidae and Dactyloscopidae , Auchenionchus + Alloclinus (both currently Cryptotremini), and the “chaenopsids” Neoclinus and Mccoskerichthys. In addition to a monophyletic Clinidae, all three analytical methods recovered two diverse clades with moderate support values. These included the members of the Labrisomidae (node II) other than the Cryptotremini that together formed a monophyletic group with the inclusion of the genus Stathmonotus (currently considered a chaenopsid). The second lineage (node III) included the Dactyloscopidae plus the Chaenopsidae sensu stricto .Relationships among the remaining four families were well resolved in the shallower nodes, but less so in the deeper nodes Figure . In geneDialommus (Mnierpini) as the sister group of two relatively large clades, the Paraclinini + Stathmonotus, and Starksiini + Labrisomini , BI recovered relationships with sensu stricto . Within the Chaenopsidae all currently recognized genera were recovered as monophyletic, and the genus Coralliozetus was the sister group of all other chaenopsids. That group included two large clades, one with Emblemariopsis, Protemblemaria and Cirriemblemaria, and another with Acanthemblemaria, Ekemblemaria, Hemiemblemaria, Emblemaria, Chaenopsis and Lucayablennius , the monophyletic Dactyloscopidae was the sister group of a monophyletic Chaenopsidae s Figure .The divergence times of blenniiform lineages were estimated from the combined postburn-in trees and parameter values of the BEAST analyses  has beer, 1993; ), our phr, 1993; ,35). Bler, 1993; ,18. Thissensu Hastings and Springer, 1994 [Our study supports the monophyly of four of the six blenniiform families as currently construed. The mono-phyly of the Tripterygiidae, Blenniidae, Clinidae and Dactyloscopidae are also well-supported by morphological synapomorphies ,11,23. Ter, 1994 ) and theCalliclinus geniguttatus) is the sister group of all other clinioids, and the monophyletic family Clinidae is the sister group of the remaining clinioids  as the sister group of the remaining species, and two “chaenopsids” (Neoclinus blanchardi + Mccoskerichthys sandae) as the sister group of all others (unresolved in ML)  Figure . These l) Figure , and a sThe Tripterygiidae, comprising 32 genera and 164 species, can be readily distinguished from other blenniiforms by their three-part dorsal fin which lacks the “last” dorsal-fin spine ,24. Two Blennius by Norman [Blennius ocellaris Linnaeus, 1758) was considered distinctive and it, along with a congener and two species of Spaniblennius, were designated as the tribe Blenniini [Blennius” species were allocated to various other genera and placed in the tribe Parablenniini [The Blenniidae, comprising 57 genera and 387 species, is the largest and most well-studied lineage of blennies . Combtooy Norman  and othelenniini ,46,47. Tlenniini . The Parlenniini ,49, and lenniini .sensu Bath, 2001 [We sampled 20 genera and 48 species, representing four of the six tribes and both subfamilies Blenniinae and Salariinae Table , as is tth, 2001 ) is not Meiacanthus, Plagiotremus, Petroscirtus, and Xiphasia form a monophyletic clade that is sister to the Omobranchini genus Omobranchus Salarias group and the Rhabdoblennius group, the former with a highly modified dentary and numerous premaxillary teeth [Andamia and Salarias  was nested within the Salarias group , Cirripectes and Ophioblennius as sister groups (node B), Atrosalarias and Salarias as sister groups (node C), Blenniella and Istiblennius as sister groups (node D), and Praealticus as the sister group (node E) of a clade including Andamia and Alticus (node F). In the morphology-based tree . However, the molecular analysis includes Entomacrodus, as well as Rhabdoblennius, in this clade (node G'). Finally in the morphological hypothesis, Cirripectes and Ophioblennius (node B) are the sister group of node G, while in the molecular hypothesis, the Salarias clade  is the sister group of node G’.The Salariini is the largest blenniid tribe with well over 200 species and is characterized by unique features of the premaxilla, pharyngeal arches and pectoral girdle . Within ry teeth , and thes Figure . Howeverp Figure . Otherwip Figure b are simp Figure a. Analysp Figure a and 7b Hypsoblennius and Parablennius) are included in our study and these form a monophyletic group , theierpini; ), and tw species  and Hapt species ,58. The Stathmonotus. In our BI analysis, Stathmonotus is the sister group of the Para-clinini, and that clade is the sister group of a clade including the Starksiini and Labrisomini , although their inclusion was based on the plesiomorphic condition of branched caudal-fin rays [Calliclinus is the sister group of all other clinioids, the northern genus Alloclinus is grouped with the southern genus Auchenionchus, and that clade is the sister group of the clinioids exclusive of the Clinidae and Calliclinus. While support values for many of these relationships are not strong, the evolutionary position of cryptotremins as early branching lineages of a diverse clade including the labrisomids was also suggested by morphological [The tribe Cryptotremini is the only exclusively temperate group historically allocated to the Labrisomidae while all others are primarily tropical. This tribe was first described by Hubbs  who inclfin rays . The cauological  and alloological . AdditioLabrisomus and Malacoctenus, is not defined by morphological synapomorphies [Labrisomus and two Malacoctenus species [Labrisomus as currently construed is not supported. Based on our concatenated molecular data, the seven Labrisomus species are divided into two lineages  to the rank of genus, as the differences separating them are trenchant.” Our study includes the type species of all three subgenera and confirms Springer’s assessment. Thus we recognize these three as full genera with the genus Brockius Hubbs, 1953  the sister group of the genus Malacoctenus. Species placed in each of these genera based on morphological criteria are listed in Table The tribe Labrisomini, including morphies . However species . With a s Figure . The fir exposed . Although Hubbs’  and Sprih Hubbs’  three suh Hubbs’ ; p. 422)s, 1953; ) the siss, 1836; ) and theMalacoctenus species are included in our study and these form a well-supported clade that is the sister group of Labrisomus sensu stricto  of robust spines. However, it is similar to chaenopsids in cranial morphology and parsimony analysis of morphological characters places Stathmonotus with the chaenopsids because more characters are evident within the cranial region [The phylogenetic relationships of the seven species of small (< 55 mm SL), cryptic, eel-like blennioids of the genus ny years . Jordan ny years  considerSpringer  includedisomidae ,69. Baseisomidae  placed Ss, 1963; ). The pri Figure . Stathmol region . These ol region , but thil region , we recoNeoclinus with the tropical chaenopsid blennies. This relationship was given further credence by the discovery of the tropical species Mccoskerichthys sandae that resembles Neoclinus, but also shares several morphological features  with chaenopsids [Neoclinus and Mccoskerichthys in the lineage with the chaenopsids based on a parsimony analysis of morphological features [Neoclinus and Mccoskerichthys is well supported in our study, thus we recommend their designation as the Neocliniini. However, their placement as the sister group of the clinioids exclusive of the Cryptotremini and Clinidae  [Neoclinus[Interestingly, the intervening blenniiform clades between the primarily east and west Tethyan groups are almost exclusively temperate in distribution   and the Neoclinus,61, as wNeoclinus. The occNeoclinus,83. BettNeoclinus,78 is anOphioblennius and Scartichthys (the latter not included in our study), part or parts of the Parablenniini [Entomacrodus[Plagiotremus[Labrisomus and Malacoctenus; [Neoclinus in the northwestern Pacific [Other Neotropical lineages of blenniiforms include the salariin blenniid genera lenniini ,84, and lenniini ,24, as wlenniini . A more omacrodus and a sigiotremus. These sgiotremus. Similaroctenus; ,87), and Pacific , likely In this study we reconstruct the phylogeny of the Blenniiformes with significantly broader taxon sampling (150 blenniiform species), substantially more genetic information , and more strategic outgroup representation  than in previous studies. Progress has been made in resolving the blenniiform evolutionary relationships especially at the inter-familial level and within the Labrisomidae. Several nomenclatural changes are proposed especially in the “clinioid” clade. Examination of global distributions of blenny genera included in our analysis and estimation of divergence times imply an origin of the Blenniiformes in the present-day IndoPacific region, consequently in the Tethys Sea around 60 million years ago. A large and diverse Neotropical clade  QIAquick Tissue Kit following the manufacturer’s instructions. DNA sequences of one mitochondrial DNA marker, Cytochrome C Oxidase I (COI), and four nuclear markers, TMO-4C4, RAG1, Rhodopsin and Histone H3, were obtained. In addition to the primers used in a recent publication on chaenopsid phylogeny , six newhttp://www.ncbi.nlm.nih.gov/) for possible stop codons as an indication of pseudogenes. Because all five genetic markers are protein-coding genes, the rapidly evolving third codon positions were partitioned from the slower evolving first and second positions in Bayesian and likelihood analyses, resulting in ten total partitions [Sequences were assembled, edited, and aligned with no gaps interrupting reading frames based on translated protein sequences in Geneious . Nucleotrtitions . To avoirtitions , the chirtitions . The Akartitions  implemenrtitions ,95 was uMaximum likelihood (ML), Bayesian inference (BI), and maximum parsimony (MP) analyses were conducted to reconstruct the phylogenetic relationships. Maximum likelihood tree searching was conducted in Garli 2.0  under thhttp://beast.bio.ed.ac.uk/Tracer) and the generations before reaching a plateau were discarded as burnin. Trees from the stationary phase of the two runs were then pooled by LogCombiner v1.5.4 [Bayesian Metropolis coupled Markov chain Monte Carlo (MCMC) estimation of the phylogeny was carried out using MrBayes v3.1.2  under thr v1.5.4  and the r v1.5.4 . Assignir v1.5.4 .Maximum parsimony analyses were conducted using PAUP 4.0b10. Heuristic searches were performed using tree bisection reconnection (TBR) with branch-swapping from 1,000 random-addition-sequence replicates to avoid entrapment in local optima. All nucleotide sites were equally weighted and gaps were treated as missing characters. Nonparametric node supports for trees were estimated with 1,000 heuristic searches (maxTree = 500) starting with 10 random addition sequence replicates.http://tree.bio.ed.ac.uk/software/treeedit/), the best ML tree from Garli was converted to an ultrametric tree assuming the origin of the Blenniidae as 41 million years old as estimated from a bony fish phylogeny including 21 molecular markers and 1410 fish taxa [Divergence times of the blenniiform lineages sampled in our study were estimated with a relaxed molecular clock analysis . Relativish taxa  and assiish taxa ), becausish taxa ,105, SprPlagiotremus (Blenniidae) was scored as IndoPacific because the single Neotropical species  is nested within an otherwise entirely IndoPacific clade , Neotropical (N), or temperate  methods implemented in Reconstruct Ancestral States in Phylogenetics v2.1 beta  to recoThe authors declare that they have no competing interests.HCL and PAH conceived the study, conducted analyses and wrote the manuscript. Both authors read and approved the final manuscript.Abbreviations, voucher numbers, localities, sample IDs, and Genbank accession numbers for 158 terminal taxa used in this phylogenetic analysis.Click here for filePosterior maximum clade credibility relative time tree of blenniiform species inferred from a relaxed molecular clock analysis using BEAST. Branches are scaled to age estimates. Bars at nodes reflect the 95% highest posterior density of the age estimates.Click here for fileAncestral distribution at each node of the blenniiform phylogeny estimated by MP analysis implemented in Mesquite.Click here for fileBiogeographical distribution of blenniiform genera.Click here for file


Chronic kidney disease related mineral and bone disease (CKD-MBD) is a worldwide challenge in hemodialysis patients. In china, the number of dialysis patients is growing but few data are available about their bone disorders. In the current study, we aimed to evaluate the effect of clinical factors on the serum phosphorus clearance in the 80 maintenance hemodialysis (MHD) patients. Six clinical factors were identified for their association with the serum phosphorus clearance using the analysis of Spearman's single linear correlation, including predialysis serum phosphate level, CRR, membrane surface area of the dialyzer, effective blood flow rate, the blood chamber volume, and hematocrit. In an overall multivariate analysis, pre-P, CRR, membrane SA, and Qb were identified as independent risk factors associated with the serum phosphorus clearance. In conclusion, HD could effectively clear serum phosphorus. The analysis of CRR might help to estimate serum phosphorus reduction ratio. At present, few reports have been made about multivariate analysis of serum phosphorus clearance in single HD treatment. Therefore, we conducted this clinical observation, to further explore the factors related to serum phosphorus clearance.In recent years, with the continuous improvement of the hemodialysis (HD) treatment and water quality, end-stage renal disease (ESRD) patients have led a gradually extended life, and their nutritional status has been improved. But at the same time, the calcium and phosphorus metabolism disorders and renal osteodystrophy are gradually becoming one of the long-term complications that affect the patient's quality of life and survival time, wherein hyperphosphatemia is a common complication of chronic kidney disease and is also one of the risk factors for death in dialysis patients . Studies2, and ultrafiltration coefficient was 5.5 mL/hr/mmHg) for 19 patients, double cellulose acetate membrane dialyzer CA-HP150  for 36 patients, high-flux polysulfone membrane dialyzer F60  for 6 patients, high-flux polysulfone membrane dialyzer APS900  for 9 patients, and cellulose triacetate membrane dialyzer CT-190 G  for 10 patients. There were two types of calcium concentration in dialysate: calcium concentration in dialysate was 1.25 mmol/L for dialysis in 16 patients and calcium concentration in dialysate was 1.5 mmol/L for dialysis in 64 patients. Before single HD treatment, phosphate binders  were not used and in the process of HD eating and urinating were avoided. The study was approved by the Human Tissue Research Committee of the Fourth Hospital of Hebei Medical University. All patients provided written informed consent for the collection of samples and subsequent analysis.As study subjects, we enrolled those patients who were treated in blood purification center of the Fourth Hospital of Hebei Medical University between June 2010 and February 2012. Dialysis patients were considered eligible if they had been receiving HD for more than 3 months, showed no evidence of chronic or acute infections, inflammatory disorders, and malignancy, and were not using anti-inflammatory drugs for 3 months before enrollment. All of the 80 dialysis patients met K/DOQI diagnostic criteria for Stage 5 of chronic kidney disease (CKD) and received the treatment of hemodialysis. Among the dialysis cohort, 43 patients were diagnosed with primary chronic glomerulonephritis, 18 with diabetic nephropathy, 5 with polycystic kidney disease, 4 with IgA nephropathy, 3 with benign arteriolar nephrosclerosis, 3 with aristolochic acid nephropathy, 1 with lupus nephritis, 1 with obstructive kidney disease, 1 with gout kidney, and 1 with Alport syndrome. Patients were managed with German Fresenius 4008S dialysis machine and bicarbonate dialysate was used; dialysate flow rate was 500 mL/min, and effective blood flow rate was 200 to 300 mL/min. Five kinds of dialyzers were used for HD: polysulfone membrane dialyzer F6 (membrane surface area was 1.3 m2CP), and hematocrit (HCT) were tested in the clinical laboratory of our hospital. The patient's name, age, sex, type of dialyzer used in a single HD, membrane surface area, ultrafiltration coefficient, blood chamber volume, effective blood flow rate, and ultrafiltration volume were all recorded.Before single HD blood samples were collected from the arterial end before connecting the arterial line and rinsing the puncture needle; specimens after HD were collected at the end of the dialysis; before collection the blood flow rate was reduced to 50 mL/min and specimens were collected from the arterial end closest to the patient, with 2 mL of blood collected each time. One hour after the collection blood serum calcium (tCa), serum phosphorus (P), serum creatinine (Cr), blood urea nitrogen (BUN), carbon dioxide combining power , polysulfone membrane dialyzer F60 , polysulfone membrane dialyzer F6 , double acetate fiber membrane dialyzer CA-HP150 , 3 diacetate fiber membrane dialyzer CAHP150 , cellulose triacetate membrane dialyzer CT-190G  and polysulfone membrane 4 dialyzer APS900 .SRR(%) = [(CB − CA)/CB] × 100% CB was predialysis solute concentration (mmol/L) in the blood and CA was postdialysis solute concentration (mmol/L) in the blood. Reduction ratio (%) of the solute  was calculated respectively.t-test was used for comparison of their own before and after HD. P < 0.05 was considered statistically significant. 14 clinical parameters and serum phosphorus reduction ratio underwent linear regression analysis , respectively, and P < 0.05 was considered statistically significant; serum phosphorus reduction ratio was regarded as the dependent variable, correlated clinical parameters screened after univariate analysis were regarded as independent variables, multiple linear regression analysis (forward) was then made, and P < 0.05 was considered to be statistically significant.SPSS 13 software package was used for data analysis, statistical description as well as statistical analysis was made in the statistical package, and charts were processed with Excel spreadsheet. Serum phosphorus before and after HD was expressed with mean ± standard deviation and paired A total of 80 hemodialysis patients were enrolled in this study including 52 males and 28 females, with age ranging from 25 to 85 and mean age of 56.1 years; they underwent maintenance HD for 3 to 80 months, with a mean time of 19.13 months. All patients were treated with arteriovenous fistula as vascular access for dialysis three times a week and 4.5 hours each time.P < 0.01) , which was statistically significant (.01) see .r = 0.493, 0.386, 0.368, 0.482, 0.303, and −0.225, resp., and P < 0.05) which can be seen in Figures Y = −12.156 + 6.821X1 + 0.493X2 + 7.307X3 + 0.051X4   see .2, phosphorus metabolism begins to change; when GFR is further reduced to 20~30 mL/min/1.73 m2, phosphorus begins to accumulate in the body, leading to persistent elevations of serum phosphorus, which results in hyperphosphatemia [In normal human body phosphate is about 10 g/kg, while there is only 1% outside the cells. Phosphate in the bone accounts for 85%, including 14% intracellular phosphate and only 1% extracellular phosphate. The intracellular phosphate is mainly organophosphate. Phosphate in the plasma contains the organophosphate or form of phospholipids 70%) and about 30% of inorganic phosphate. Serum phosphorus that we measure usually refers to the inorganic phosphate, and normal plasma phosphorus ranges from 0.81 to 1.45 mmol/L (2.5~4.5 mg/dL). Phosphate is the small molecule toxin with molecular weight of less than 500 Da . In the early stage of chronic renal failure, when glomerular filtration rate (GFR) is reduced to 40~80 mL/min/1.73 mphatemia  that pat0% and abphatemia , renal ophatemia .Controlling the intake of dietary phosphate. Diet control can reduce the intake of phosphate, which is generally no more than 800 to 1000 mg per day [Phosphate binders. (a) Phosphate binders containing aluminum have the risk of aluminum poisoning, which can cause small-cell anemia, osteomalacia, dementia, and so on, so they are rarely used clinically. (b) Phosphate binders containing calcium, which will increase the absorption of calcium in the intestine, causing hypercalcemia and easily causing heart and vascular calcification when one suffers from hyperphosphatemia. (c) There have been new phosphate binders that are aluminum- and calcium-free at home and abroad, such as hydrochloric acid polyacrylamide  [At  present, there are three main approaches  to the treatment of hyperphosphatemia. (1)  per day . HoweverRenagel) , but theRenagel)  reportedRenagel) . In addiRenagel) .HD is a process in which a solution exchanges solute with another solution through the semipermeable membrane, wherein small molecules such as urea nitrogen and phosphorus can be cleared mainly by applying the diffusion principle, while macromolecular toxins can be cleared mainly by applying the principle of convection and adsorption. The semipermeable membrane used in HD is called a dialysis membrane, the dialysis membrane is a major component of the dialyzer, and the physicochemical properties of the dialysis membrane can determine the effect of dialysis. There are three kinds of dialysis membrane commonly used clinically: regenerated cellulose membrane, modified cellulose membrane, and synthetic polymer membrane. It had been reported in China that polysulfone membrane and cellulose membrane showed no statistically significant difference in clearance of small molecule toxins, but in our purification center we chose polysulfone membrane, cellulose diacetate membrane and cellulose triacetate membrane, so in this study different membrane materials were not studied as clinical parameters.Serum phosphorus is mainly cleared by diffusion as small molecule, and studies by many domestic and foreign scholars have confirmed that the general HD can effectively clear serum phosphorus. In this experiment, serum phosphorus reduction ratio was regarded as the observation index, to explore factors associated with serum phosphorus clearance in single HD treatment.The risk factors for serum phosphorus reduction included effective blood flow rate, membrane surface area, predialysis serum phosphorus level, vascular access, hematocrit, and dialysis frequency . ClinicaStudies have shown that more than 80% of patients undergoing maintenance HD suffered from hyperphosphatemia. And in our blood purification center 50 out of 80 patients undergoing maintenance HD had hyperphosphatemia, accounting for 62.5% of the total number of cases. It is reported that predialysis serum phosphorus affected serum phosphorus clearance . To anal2”. Solute clearance was negatively correlated with thickness of dialysis membrane but was positively correlated with membrane surface area of the dialyzer. Studies on a new polysulfone membrane dialyzer have shown that blood flow rate, dialysate flow rate, and membrane surface area of the dialyzer are independent and significant factors that affect urea, creatinine, and serum phosphorus clearance. To increase the effective area of the dialysis membrane and the number of hollow fiber membranes could reduce the resistance of the retention layer of the blood side, increase exchange area between the blood and the dialysate, improve the diffusion rate, and have a significant effect on small molecule solute clearance and the clearance rate. The larger the membrane surface area, the faster the diffusion rate, the more small solutes get into the dialysate per unit time through the membrane hole, and the higher the clearance and the clearance rate will be. Accordingly, in the case of ensuring that the mechanical properties of the membrane could meet the dialysis conditions, the inner diameter of the membrane and wall thickness of the membrane should be reduced as much as possible, so as to increase the effective area of the dialysis membrane and to improve the clearance rate of the solute.Membrane surface area of the dialyzer is one of the parameters for the evaluation of the dialyzer; membrane surface area of the dialyzer r contact portions between the hollow fibers and the dialysate, and it is expressed as “mIn HD, solute diffusion is influenced both by the membrane properties of the dialyzer and by immobile liquid layer between the blood side and the dialysate side. So-called immobile liquid layer refers to the fact that flow rates of the liquid are not the same in the process of flow in pipeline; the liquid in the middle flows faster, while the surrounding liquid flows slower. Near the wall there is a thin layer of liquid that hardly flows, which is referred to as the immobile liquid layer; the thicker the liquid layer, the lower the rate of solute diffusion. When the blood flow velocity is increased, the thickness of the immobile layer is decreased at the blood side, so that the diffusion rate of the small molecular substances is increased, helping reduce the transfer resistance of the blood side, and may improve dialysis efficiency and shorten the duration of dialysis without changing solutes transport coefficient (KOA) in the dialysis membrane; it also helps to improve the dialysis efficiency. However, with the increase in blood flow rate (>300 mL/min), the dialyzer cannot clear the solute with the same efficiency; that is, solute clearance rate cannot be increased indefinitely , 19 (e.gIn multivariate analysis we did not find high-flux hemodialysis, blood chamber volume, and hematocrit to be related to serum phosphorus reduction ratio. But high-flux hemodialysis is better than low-flux dialysis in the clearance of iPTH, and whether long-term observation has a certain effect on serum phosphorus clearance and prevention of hyperphosphatemia needs further prospective studies.In short, hyperphosphatemia leads to complications such as ROD, cardiovascular calcification, and hemodynamic abnormalities, which all have a serious impact on the survival rate and quality of life of patients who undergo maintenance HD, so it is particularly important to control serum phosphorus levels. When it is tolerable for the patients, serum phosphorus clearance can be improved by increasing membrane surface area of the dialyzer and improving effective blood flow rate. At the same time high-flux dialyzers could be applied timely and hematocrit could be monitored regularly to understand serum phosphorus clearance. In clinical practice, we still lack a multicenter prospective controlled study with diverse samples, and various factors affecting serum phosphorus clearance are needed for further analysis and verification, so as to better guide clinical practice.


A 14-year-old-girl undergoing treatment with the BFMTRALL 2000 protocol (MRG ) because of early pre-B-cellacute lymphoblastic leukemia (ALL ) developed chickenpox on the 33rd d of remission induction. As such, chemotherapywas withdrawn and the patient was quarantined.Acyclovir (1500 mg·m–2·d–1 in three divided doses)was then administered in 100 mL of 0.9% sodium chloride,as 1-h intravenous infusions. On the 9th d of acyclovirtherapy 10 min after infusion of the 27th dose startedthe patient complained of the sensation of minor pain andburning in the region of Intracath catheter insertion, anddeveloped slight erythema with irregular boundaries inthe same region.The infusion line was checked for patency by gentlywithdrawing blood before, which showed that the linewas patent, and then infusion was continued, but at aslower rate. The line’s patency was checked frequently andremained patent. The patient no longer experienced thesensation of pain and burning, and the erythema improvedslightly; however, at the end of the infusion (the 65th min)a solitary, bullous painless eruption 1 x 1 cm in diameterwas observed on the tract of the vein, 10 cm distal of theIntracath insertion Figures ,3,4. WitThe known adverse dermatological effects of acyclovir,including erythema, inflammation, and phlebitis at the siteof intravenous infusion, occur in ≤16% of patients, presumablydue to the alkaline nature of the solution (reconstitutedacyclovir has a pH of 10-11) .Wethink Frequent venipuncture of the same veins and use ofchemotherapeutic agents in oncology patients may rendertheir veins fragile and susceptible to the irritant effects ofdrugs. As such, sensation of pain and burning in oncologypatients should be considered a reliable sign of extravasationeven when good blood return is observed. Nonetheless,cutaneous vesicular eruption following intravenousacyclovir administration is rare . It was The presented case shows that the irritant effects ofacyclovir should always be a consideration, especially inoncology patients, and that the development of new vesiculareruptions during acyclovir therapy should not alwaysbe considered progression of herpes infection.Conflict of Interest StatementThe authors of this paper have no conflicts of interest,including specific financial interests, relationships, and/or affiliations relevant to the subject matter or materialsincluded.AcknowledgementI thank Lale Olcay, MD for kindly revising the manuscript.


Social capital has lately received much attention in health research. The present study investigated whether two measures of subjective social capital were related to psychosomatic symptoms, musculoskeletal pain, and depression in a large population of Swedish adolescents.A total of 7757 13-18 year old students anonymously completed the Survey of Adolescent Life in Vestmanland 2008 which included questions on sociodemographic background, neighbourhood social capital, general social trust, and ill health.Low neighbourhood social capital and low general social trust were associated with higher rates of psychosomatic symptoms, musculoskeletal pain, and depression. Individuals with low general social trust had more than three times increased odds of being depressed, three times increased odds of having many psychosomatic symptoms, and double the odds of having many symptoms of musculoskeletal pain.The findings make an important contribution to the social capital - health debate by demonstrating relations between social capital factors and self-reported ill health in a young population. Mental ill health has been designated as a "global burden of disease", with depression accounting for most of the burden, involving large economic and social costs for society and affected individuals -3. AnothMost research on social capital refers to the original definitions of the concept made by Bourdieu , ColemanSocial capital has, among other things, been related to mental ill health -21, geneMost previous studies of social capital and ill health have focused on health in adult populations, and less is known about how social capital may influence health among adolescents. This age group may be particularly affected by social capital as a cause of limited mobility  and haveWe aimed to determine whether two forms of bonding and bridging social capital, in this study referred to as "neighbourhood social capital"  and "general social trust" , were associated with self-reported health in a large population of Swedish adolescents. We hypothesised that low neighbourhood social capital and low general social trust would be associated with higher rates of psychosomatic symptoms, musculoskeletal pain, and depression.th (13-14 years old) and 9th (15-16 years old) grade of elementary school, and 2nd (17-18 years old) grade of secondary school in the county, a total of 57 schools, were asked to complete a questionnaire during class hours. The questionnaire included questions about demographic background, neighbourhood social capital, general social trust, and psychosomatic, musculoskeletal and depressive symptoms.The present study was part of the Survey of Adolescent Life in Vestmanland 2008 , a survey distributed biannually by the County Council of Västmanland, Sweden. Västmanland is a medium-sized county situated approximately 100 km west of Stockholm. All school students in 7th grade, 1291 boys and 1314 girls in 9th grade, and 1230 boys and 1177 girls in 2nd grade of secondary school. Participation was anonymous and voluntary. The study followed the Swedish guidelines for studies of social science and humanities according to the Declaration of Helsinki. According to Swedish regulations, this type of study no longer applies for ethical approval by the medical faculty.A total of 7906 students completed the questionnaire, comprising 78.2% of the total population. The exclusion of 41 participants who did not state their sex, and 108 participants who did not complete the questionnaire satisfactorily, left 7757 participants for the analyses. There were 1351 boys and 1394 girls in 7Sex, whether the participant was a boy (0) or a girl (1).Parental unemployment, whether both parents were working (0) or one or both parents were unemployed (1). In Sweden, the most common family constellation involves both parents working. Families where one of the parents is a house wife or husband, and thus permanently removed from the labour market, are rather rare [her rare .Living conditions, whether the participant was living in a single-family house (0) or a multi-family house (1).Ethnicity, whether both parents were born in Sweden or Scandinavia (0) or at least one parent was born outside of Scandinavia (1).Subjective socioeconomic status, where participants were asked to rank the socioeconomic status of their family on a 7-point Likert scale by the following question: "Imagine society as being like a ladder. At the bottom are those with the least money, and at the top are those with the most. If you think about how wealthy your own family is compared with the rest of society, where would you place your family on this scale?"Housing area, where the participants stated their living area out of a choice of 31 defined areas of the county. Medium income statistical data for the general population of each of the 31 areas were obtained from Statistics Sweden. The variable was used as an objective measure of the socioeconomic status of the housing areas.st quartile counted as low neighbourhood social capital, the 2nd-3rd quartiles counted as medium neighbourhood social capital, and the 4th quartile counted as high neighbourhood social capital.Participants were asked to respond to seven statements about their neighbourhood : 1, In my neighbourhood, no-one needs to feel afraid. 2, It is unsafe to be outside at night in my neighbourhood. 3, In my neighbourhood, people seldom help each other. 4, If anything at home should break or go missing, we can always get help from a neighbour. 5, Most people know each other in my neighbourhood. 6, There are seldom any fights or trouble in my neighbourhood. 7, I often see graffiti and damaged objects  in my neighbourhood. Response alternatives were: Strongly agree (1), Agree to some extent (2), Disagree to some extent (3), Strongly disagree (4). The internal consistency  of the neighbourhood social capital questions was 0.71. A summation index was created with a range of 7-28 points where items 2, 3, and 7 were reversed. The index was also divided by quartiles, where the 1st quartile counted as low general social trust, the 2nd-3rd quartiles counted as medium general social trust, and the 4th quartile counted as high general social trust.The participants were asked to respond to six statements about how they felt about people in general: 1, Most people can be trusted. 2, You can never be too careful when meeting new people. 3, Most people try to be helpful. 4, Most people would try to use others if they had the opportunity. 5, Most people only care about themselves. 6, Most people are honest. Response alternatives were: Strongly agree (1), Agree to some extent (2), Disagree to some extent (3), Strongly disagree (4). The internal consistency of the general social trust questions was α = 0.73. A summation index was created with a range of 6-24 points, where items 2, 4 and 5 were reversed. The index was also divided by quartiles, where the 1The participants were asked how often they suffered from: 1, Headache. 2, Stomach ache. 3, Feelings of nervousness. 4, Feelings of irritation. 5, Sleep problems. Response alternatives were: Never (0), Rarely (1), Sometimes (2), Often (3), Always (4). The internal consistency of the questions of psychosomatic symptoms was α = 0.75. A summation index was created with a range of 0-20 points. The index was divided by standard deviations, where -1 SD was the cut-off point for few psychosomatic symptoms, +1 SD was the cut-off for many psychosomatic symptoms, and the intermediate group was counted as having a medium number of psychosomatic symptoms. We created a dichotomous variable, with few-medium symptoms (0) and many symptoms (1).Participants were asked how often they suffered from: 1, Pain in the shoulders/neck. 2, Pain in the back/hips. 3, Pain in the hands/knees/legs/feet. Response alternatives were: Never (0), Rarely (1), Sometimes (2), Often (3), Always (4). The internal consistency of the questions of musculoskeletal pain was α = 0.68. A summation index was created with a range of 0-12 points. The index was divided by standard deviations, where -1 SD was the cut-off point for few musculoskeletal pain symptoms, +1 SD was the cut-off for many musculoskeletal pain symptoms and the intermediate group was counted as having a medium number of musculoskeletal pain symptoms. We created a dichotomous variable, with few-medium symptoms (0) and many symptoms (1).th edition (DSM-IV), A-criterion, for major depression with a reported sensitivity of 96.1% and a specificity of 59.4% for major depression [Depressive symptoms were measured by the Depression Self-Rating Scale (DSRS) of the Diagnostic and Statistical Manual of Mental Disorders, 4pression ,47. In t2. Sex differences in socioeconomic status and the dependent and independent factors of the study were analysed using the Mann-Whitney test. For analysis of correlations between psychosomatic symptoms, musculoskeletal pain, depressive symptoms, neighbourhood social capital, general social trust, subjective socioeconomic status, and housing area we used Spearman's rho. Linear and logistic regressions were used for analyses of relations between neighbourhood social capital, general social trust and the different measures of health. As neighbourhood social capital and general social trust on an individual level could be affected by intra-class correlation cluster effects, such as school and housing area, hierarchical linear and logistic regression analyses taking clustering effects into account were performed. We used random-effects regression models (RRM), in view of the fact that the number of subjects within each cluster was unbalanced [Sex differences in the demographic data as well as differences in outcomes related to demographic background were analysed by Pearson's χbalanced . In the 2 = 616.23, p < 0.001), 9.2% of the boys and 17.3% of the girls were classified as having many musculoskeletal pain symptoms , and 15.9% of the boys and 32.4% of the girls fulfilled the criteria for depression . Regarding demographic data, 24.9% of the boys and 25.8% of the girls lived in a multifamily house (p = 0.389), 20.3% of the boys and 21.9% of the girls had at least one unemployed parent (p = 0.091), and 17.4% of the boys and 17.0% of the girls had at least one parent born outside of Scandinavia or were themselves born outside of Scandinavia (p = 0.661). Mean subjective socioeconomic status was higher among boys  than among girls .Girls reported more psychosomatic symptoms, musculoskeletal pain and depressive symptoms, and boys reported higher neighbourhood social capital and higher general social trust Table . A totalThere was a medium-sized correlation between psychosomatic symptoms and musculoskeletal pain, psychosomatic symptoms and depression, and musculoskeletal pain and depression Table . The neir = 0.204, p < 0.001), a higher level of general social trust , and a higher level of subjective socioeconomic status . Higher subjective socioeconomic status was, moreover, correlated with higher neighbourhood social capital and higher social trust , and medium income of the different housing areas ranged between € 13.815 - 24.651. The housing areas differed widely in levels of neighbourhood social capital and general social trust. Higher objective socioeconomic status of a housing area was correlated with a higher level of neighbourhood social capital  and general social trust , as well as the 2-level effect of individuals within schools  were significant. However, the 3-level effect of individuals within schools within housing area was not significant.Neighbourhood social capital and general social trust on an individual level may be affected by intra-class correlation cluster effects, such as school and housing area. Therefore, hierarchical linear regression analysis taking clustering effects into account were performed. There were very similar estimates in the ordinary regression models and the multilevel models for the indexes of psychosomatic symptoms, musculoskeletal pain and depression symptoms (not shown in tables). In the final model including 2- and 3-level effects of psychosomatic symptoms, neighbourhood social capital  and general social trust , as well as the 2-level effect of individuals within schools . The 3-level effect was not significant.The final model including 2- and 3-level effects of musculoskeletal pain showed an association of neighbourhood social capital  and general social trust , as well as the 2-level effect of individuals within schools . The 3-level effect was not significant.The final model including 2- and 3-level effects of depressive symptoms showed an association of neighbourhood social capital . As shown in Table The present study investigated whether subjective neighbourhood social capital and general social trust were associated with self-reported health in a large population of Swedish adolescents. The main finding was that low neighbourhood social capital and low general social trust were associated with higher rates of psychosomatic symptoms, musculoskeletal pain and depression. The association between general social trust and ill health was particularly evident, where the group with low general social trust had a more than three times increased odds of depression, a more than three times increased odds of having many psychosomatic symptoms, and more than double the odds of having many symptoms of musculoskeletal pain compared with the group with high general social trust. The results were controlled for potential confounding factors such as subjective family socioeconomic status, type of residence, parental unemployment and ethnicity, as well as clustering effects of school and housing area.It is interesting that even in a highly egalitarian country such as Sweden there is an association between neighbourhood social capital, general social trust and ill health in an adolescent population. Our results agree with previous findings of relations between social capital and ill health among adolescents ,39,40,43Several limitations of the study should be noted. Firstly, the analyses are based mainly on self-reports which involves a risk of information bias due to false or inaccurate responses from the participants. Regarding self-reports of health, girls may be more aware of, and/or more inclined to report ill health which might have influenced the higher rates of it in this group. However, since we were interested in associations between individual perspectives of neighbourhood social capital and general social trust, self-reports were deemed the most convenient choice of measurement. Secondly, there is the problem of causality regarding neighbourhood social capital, general social trust and ill health, as the cross-sectional design of the study involved no possibility to distinguish the directions of cause and effect. Individuals suffering from pain and depression may be more inclined to interpret their environment and relations to other individuals in society in a negative way, which might have influenced the associations between neighbourhood social capital, general social trust and ill health. However, when analysing levels of self-reported neighbourhood social capital and general social trust in different housing areas, these plainly differed depending on the income distribution of each housing area as obtained from Statistics Sweden. A higher objective socioeconomic status of a housing area was correlated with a higher level of neighbourhood social capital, a higher level of general social trust, and a higher level of subjective socioeconomic status. Thus, the differences in self-reported neighbourhood social capital and general social trust were associated with the objective measure of socioeconomic status and would not merely be a question of negative interpretation of social relations and society as a cause of illness.2 R≈ 14-34%) there were just minor correlations between the dependent and independent variables (2 R≈ 2-6%) when analysed as simple correlations  as cut-offs. However, for the outcome measures of psychosomatic symptoms and musculoskeletal pain, we wanted to identify the participants with the most problems and therefore used the stricter cut-offs of standard deviations . However, the measurement of depression had high sensitivity and low specificity, providing a risk for false-positive classifications. The Depression Self-Rating Scale of the DSM-IV, A-criterion, involves the risk of including participants who would be ruled out according to the more strict B-, C-, D-, and E-criteria. This scale has, nevertheless, been proved to be a useful instrument for defining major depression . The outThe present study also has several strengths, particularly regarding the large population based sample of adolescents and the high participation rate which might offer an opportunity to generalise the results to other adolescent populations as well. Most previous studies have examined relations between social capital and health in adult populations. The present study focuses on adolescents, to examine whether social capital may be associated with health outcomes among young people as well. Moreover, the few previous studies of social capital that have focused on adolescent populations have often chosen specific areas of low socioeconomic status and high deprivation for their analyses. The present study involves a large adolescent population from a county that is considered to be representative of Sweden as a whole because of its distribution of educational, income, and employment levels as well as urban and rural areas . Thus, oOur findings suggest a link between subjective neighbourhood social capital, general social trust, and ill-health in a Swedish adolescent population. If our findings are valid, they make an important contribution to the social capital - health debate by demonstrating relations between social capital factors and self-reported ill health in an adolescent population.th edition;DSRS DSM-IV: Depression Self-Rating Scale of the Diagnostic and Statistical Manual of Mental Disorders, text revision, 4The authors declare that they have no competing interests.Study concept and design: CÅ, KWN, BS. Acquisition of data: CÅ, KWN. Questionnaire management: CÅ. Analysis and interpretation of data: CÅ, KWN, BS. Drafting of manuscript: CÅ, KWN. Critical revision: CÅ, KWN, BS. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2458/10/715/prepub


Background. Little is known about Tibetan medicine (TM), in Western industrialized countries. Objectives. To provide a systematic review of the clinical studies on TM available in the West. Data Sources. Seven literature databases, published literature lists, citation tracking, and contacts to experts and institutions. Study Eligibility Criteria. Studies in English, German, French, or Spanish presenting clinical trial results. Participants. All patients of the included studies. Interventions. Tibetan medicine treatment. Study Appraisal and Synthesis Methods. Included studies were described quantitatively; their quality was assessed with the DIMDI HTA checklist; for RCTs the Jadad score was used. Results. 40 studies from 39 publications were included. They were very heterogeneous regarding study type and size, treated conditions, treatments, measured outcomes, and quality. Limitations. No Russian, Tibetan, or Chinese publications were included. Possible publication bias. Conclusions. The number of clinical trials on TM available in the West is small; methods and results are heterogeneous. Implications of Key Findings. Higher quality larger trials are needed, as is a general overview of traditional usage to inform future clinical trials. Systematic Review Registration Number. None. Traditional Tibetan medicine (TM), sometimes called “Lamaist” or “Buddhist” medicine, has developed in 1200 years into a unique medical system . In TM, Besides the regions of the historical Tibet, very similar medical traditions are practised since the Mongolian conquest of Tibet in the 13th century in Mongolia, adjacent Siberia, and in the Russian province Kalmykia  7]. Esp. Esp7]. A preliminary list of 15 literature databases was tested using the search terms “Tibetan medicine,” “Himalaya medicine,” “Tibetan herbal,” and “Lamaistic medicine.” The database list had been compiled from recommendations by experts, by Ovid , and by One of the authors (K. P. Reuter) used a predefined form to extract descriptive study data into MS Access 2003 and MS Excel 2003 , 34 dataMethodological quality of the studies was determined with a DIMDI checklist  that is n = 21) of the publications, the other 46.2% (18) were in German. Most publications came from Poland and Switzerland . The Asian studies were from India  or China . The earliest publication appeared in 1970. Since 1990 every 5 years about 3 new RCTs were published and, less evenly distributed, most of the observational studies . The 5 nonrandomized controlled trials were published between 1986 and 1991, and the 6 case studies or case series in 1998 or later  (the first study in [n = 1) [In the RCTs included were 2028 patients, 1020 of them received the Tibetan medicine treatment. Study duration ranged from 14 days to 12 months (mean = 114 days). Most RCTs investigated Padma 28  or Padm [n = 1) . A whole [n = 1) , arthrit [n = 1)  or hepat [n = 1) . Tibetan [n = 1)  and a si [n = 1)  were eac [n = 1)  was declFrom those publications including herbal medicines, four did not provide details on the used medication , 59, 62,The duration of the non-randomized controlled trials was between 6 weeks and 6 months (mean = 43 d), 54% of the 678 patients received the verum Padma 28. Four non-randomized controlled trials included children with chronic respiratory tract infections , 64, 65 In the observational studies included, there were 1824 patients. The observation duration ranged from 15 days to 2 years (mean = 217 days). In some of the publications, the study duration was not clearly stated  or vaThe duration of the case studies/series ranged widely from several days to 13.5 years . Padma 2n = 1648, 35.2% of all patients in the present review) [n = 955) only were included in 5 studies [All studies included a total of 4684 patients, ranging from 1 to 967 per trial . Ten studies did not state the patients' sex ( review) , 77. Fro studies , 70, 71. studies , 58. In  studies  with a mThe checklist results for quality assessment are presented at item level in All studies followed conventional “Western” medical diagnoses. Additional traditional TM diagnostics were recorded in 11 studies that investigated the traditional multimodal treatment. In 9 of them, the Tibetan diagnosis was used to plan the therapy , 62, 76.n = 25 studies), Padma Lax (3), Byu-Dmar 13 (1), and Zhi Byed 11 (1). The complex traditional Tibetan treatment was studied in 9 trials that included a total of 1140 (24.3%) patients. Here, and in the Padma 28 studies, the treated conditions varied widely. For example, Padma 28 was investigated for arteriosclerosis, infections, neurological disorders, venous insufficiency, arthritis, and hypercholesteraemia.Thirty studies including 3497 patients  investigated single formulations: Padma 28 (n = 37 studies), laboratory tests (19), clinical tests , and other (9), such as microbiology, histology, or the need for conventional medication. The authors drew positive conclusions on their data in 34 studies. In 2 RCTs, TM was found to be inferior to conventional medicine, but better than placebo [Assessed outcomes included clinical outcomes such as symptom scales  in comparison to traditional TM (1 RCT ) or withIn this paper, we presented an overview of the clinical research on traditional Tibetan medicine (TM) that is currently available in the West. Three quarters of the included studies tested single formulations, most of them products of a single company. One quarter investigated the traditional multimodal TM approach. Studies were very heterogeneous regarding study type and size, treated conditions, treatments, measured outcomes, and quality.In this, to our knowledge, first systematic overview of clinical TM research available in the West, we tried to minimize subjectivity using pre-defined systematic methods wherever possible . However, the small number of trials scattered over a whole medical system and very heterogeneous treated diseases prohibited more formal or in-depth analyses.Despite the broad literature search, some studies may not have been identified, for various reasons. Although Mongolian and Tibetan medicine are not completely identical, we have included “mongolian” in the search terms in order to find as much relevant literature as possible. We did not search for single TM interventions such as bathing or bloodletting and assumed that they are well covered under the umbrella term “medicine.” Although we detected with this search a study on Tibetan yoga , we possThe evaluated literature presented a high number of studies without a control group. Only a few single products were subject to in-depth investigation. Both facts indicate an early stage of research in a new and largely unexplored field where only few focused inquiries exist. The predominating countries of origin (>2/3 European) and the 70% of studies on Padma products among the included literature are consequences of the language restrictions of our search as well as of the historical development of TM utilization in the West. Although they are prescribed in a standardized and nonindividualized fashion, the Padma products are a genuine Tibetan medication according to manufacturers, study authors, and independent experts , 83, 84.The heterogeneous nature of the included studies demanded the use of quality assessment instruments that were suitable for diverse study designs, but have the general disadvantage of allowing only rough estimates of the assessed quality. Nevertheless, they allowed spotting the more obvious deficiencies that are symptomatic of research at an early stage and that future research can avoid with improved methodology on the grounds of evidence-based medicine. Case studies and observational studies are useful to gather information on traditional usage and settings and to identify areas where controlled studies seem promising. Then, to provide higher-level evidence, more RCTs will be needed. Methodological issues such as small samples, insufficiently described populations in many studies, pre-/post-comparisons of treatment within a group, or comparator treatments without clinical relevance all indicate that TM research as seen through the Western literature is still at a nascent stage. Furthermore, the quality of most studies and the heterogeneity of interventions and outcomes make clear conclusions impossible. The clinical research on traditional Tibetan medicine (TM) that is available in Western industrialized countries is scarce and scattered over a whole medical system, but shows interesting results. Better research methodology should be applied, and larger trials are needed, as is a general overview of traditional usage to inform future clinical research.


Interstitial deletions affecting the proximal long arm of chromosome 3 have been rarely reported in the literature. The deleted segments vary in localization and size with different breakpoints making genotype-phenotype correlation very difficult. Until now, a girl with a 1.9-Mb interstitial deletion of 3q13.2q13.31 and 14 novel patients with deletions in 3q11q23 have been reported.GAP43 and LSAMP. The mutation analysis of the two genes was negative on the other non-deleted chromosome. GAP43 is considered a crucial component for an effective regenerative response in the nervous system and its mRNA is localized exclusively to nerve tissue where the protein is linked to the synaptosomal membrane. LSAMP is a 64- to 68-kD neuronal surface glycoprotein found in cortical and subcortical regions of the limbic system that acts as an adhesion molecule and guides the development of specific patterns of neuronal connection. The deleted region is adjacent to a “desert gene” region extending 2.099 Mb.Here we report on a 7-year-old girl with neuropsychiatric disorders and renal, vascular and skeletal anomalies. Array-CGH analysis revealed a small rare inherited 3q13.31 deletion containing only two genes, GAP43 and LSAMP haploinsufficiency, proposing that their deletion may be responsible for the main phenotype. Further cases with similar microdeletion are expected to be diagnosed and will help to better characterize the clinical spectrum of phenotypes associated with 3q13.31 microdeletion.We discuss the effects of  Interstitial deletions of the proximal long arm of chromosome 3 are quite rare. In addition, the deleted segments vary in localization and size and have different breakpoints, making genotype-phenotype correlation very difficult.GAP43 and LSAMP as strong candidate genes for developmental delay. GAP43 is involved in neurite outgrowth, neurotransmission, and synaptic plasticity. It has been recently identified as a candidate gene for autism and autistic-like manifestations in humans and mice [A girl with a 1.9-Mb interstitial deletion of 3q13.2q13.31 presenting with dysmorphic features, muscle hypotonia, and developmental delay was reported [and mice .LSAMP gene gives rise to LAMP, which is a 64- to 68-kDa heavily glycosylated protein, structurally characterized by three immunoglobulin (Ig) domains [LSAMP in neuropsychiatric features and behaviour [ domains . Studiesehaviour .GAP43 and LSAMP) in a girl with neuropsychiatric disorders associated to renal, vascular, and skeletal anomalies.Here, using array-CGHanalysis, we have identified a small rare inherited 3q13.31 deletion containing only two genes  and LSAMP (MIM 603241), and a long non-coding RNA (LSAMP-AS3) . Mutational screening of GAP43 and LSAMP performed by bi-directional Sanger sequencing of exons and flanking introns, was negative on the homologous allele.Conventional cytogenetic analysis of the proposita and her parents showed a normal karyotype. In the absence of an etiological diagnosis an array-CGH analysis using Human Genome CGH Microarray Kit G3 180  with ~13 Kb overall median probe spacing, was performed. Array-CGH analysis identified a 1.362 Mb deletion at 3q13.31 band with breakpoints at genomic positions 115,157,887 bp and 116,520,120 bp  , as affected by behavioural problems, constipation, mental retardation/developmental delay, and microcephaly.Recently, Molin et al.  reportedGAP43 show multiple failures to establish or maintain long-distance cortical connections. GAP43 was also recently identified as a candidate gene for autism and autistic-like manifestations in humans and mice [+/- heterozygous mice displayed decreased corpus callosum and hippocampal commissure volume [GAP43 is found in growth cones of extending axons in the central nervous system ,13. It hand mice  and Gap4e volume , as alsoe volume .LSAMP encodes the limbic system-associated membrane protein, and studies in both humans and mice have demonstrated the involvement of LSAMP in neuropsychiatric features and behaviour [ehaviour ,9.LSAMP is also expressed in kidney [GAP43 is also expressed in mouse renal-urinary system (MGI database) and in skeletal muscles [In addition to a neuropsychiatric phenotype, our patient presented renal, vascular, and skeletal anomalies. Interestingly, n kidney , in cardn kidney  and in mn kidney ,17. More muscles .LSAMP and GAP43 genes. However, we cannot exclude the possibility of a variable expressivity or an incomplete penetrance, since the father of our patient showed a mild neurological phenotype.Several aspects may account for the phenotypic variability described among carriers of microdeletions/microduplications, including variation in genetic background, epigenetic phenomena such as imprinting, expression or regulatory variation among genes in the rearrangement region, and (in the case of deletions) the unmasking of recessive variants residing on the single remaining allele. In our patient, we excluded the presence of mutations in the homologous alleles of LSAMP and GAP43) inherited from his father. No mutation was present on the homologous alleles. The father had slightly delayed psychomotor development. We suggest that LSAMP and GAP43 genes are the most likely candidate genes for the phenotypic core of our patient. Nevertheless, the description of more patients with similar microdeletions would be useful to further delineate the main clinical features and to understand the function of the genes contained in the deleted chromosomal interval.In conclusion, we have identified a patient with a deletion in 3q13.31 chromosome band containing only two genes  is sufficient. The informed consents of the parents were previously authorized by our Institutional Review Board. We did not conduct research outside our country of residence. We did not approach the local authorities before beginning work on this study. The full name of the Ethics Committee of our institution is Comitato di Etica per la Ricerca Scientifica Biomedica, per la Buona Pratica Clinica e per la Sperimentazione dei Farmaci. The parents of the patient allowed us to publish the descriptive details of their children's malformations.The parents of the individual in this manuscript have given written informed consent to publish these case details. We have the consent from the parents to publish photographs.The current study was performed using peripheral blood of the patient and her parents treated at the Istituto Giannina Gaslini, Genova, Italy.The authors declare that they have no competing interests related to this manuscript.SG, SP, CC, GC, GG, ET have made substantial contributions to conception and design, acquisition of data, analysis and interpretation of data. ML, MD, CC, GG, ET have been involved in drafting the manuscript and revising it critically for important intellectual content. All authors read and approved the final manuscript.


Herpes zoster (HZ) is caused by reactivation of the varicella-zoster virus (VZV) and mainly affects individuals aged ≥50 years. The forthcoming European launch of a vaccine against HZ (Zostavax®) prompts the need for a better understanding of the epidemiology of HZ in Europe. Therefore the aim of this systematic review was to summarize the available data on HZ incidence in Europe and to describe age-specific incidence.The Medline database of the National Library of Medicine was used to conduct a comprehensive literature search of population-based studies of HZ incidence published between 1960 and 2010 carried out in the 27 member countries of the European Union, Iceland, Norway and Switzerland. The identified articles were reviewed and scored according to a reading grid including various quality criteria, and HZ incidence data were extracted and presented by country.The search identified 21 studies, and revealed a similar annual HZ incidence throughout Europe, varying by country from 2.0 to 4.6/1 000 person-years with no clearly observed geographic trend. Despite the fact that age groups differed from one study to another, age-specific HZ incidence rates seemed to hold steady during the review period, at around 1/1 000 children <10 years, around 2/1 000 adults aged <40 years, and around 1–4/1 000 adults aged 40–50 years. They then increased rapidly after age 50 years to around 7–8/1 000, up to 10/1 000 after 80 years of age. Our review confirms that in Europe HZ incidence increases with age, and quite drastically after 50 years of age. In all of the 21 studies included in the present review, incidence rates were higher among women than men, and this difference increased with age. This review also highlights the need to identify standardized surveillance methods to improve the comparability of data within European Union Member States and to monitor the impact of VZV immunization on the epidemiology of HZ.Available data in Europe have shortcomings which make an accurate assessment of HZ incidence and change over time impossible. However, data are indicative that HZ incidence is comparable, and increases with age in the same proportion across Europe. Varicella-zoster virus (VZV) is a herpes virus that infects nearly all humans and causes two distinct diseases: varicella, the primary infection which usually occurs in childhood, and herpes zoster (HZ), a result of reactivation of VZV which remains latent in the sensory ganglia following varicella. This reactivation occurs when VZV-specific cellular-mediated immunity decreases, mainly due to age-related immunosenescence and immunosuppressive conditions.HZ is characterized by a vesicular skin rash localized in the sensory region of the affected ganglia, and is often preceded, or accompanied by acute pain or itching. The individual lifetime risk of developing HZ is between 23.8% and 30%, or approximately 1 in 4 people . HoweverHZ is painful during the acute phase, but pain may persist for months or even years. Post-herpetic neuralgia, defined as chronic pain persisting after rash onset, occurs in 20% to 50% of patients, and can lead to several months of treatment and loss of quality of life ,10. AfteThe forthcoming European launch of a vaccine against HZ (Zostavax®) prompts the need for a better understanding of the epidemiology of HZ in Europe. Therefore the aim of this review was to summarize the available data on HZ incidence in Europe and to describe age-specific incidence, notably among individuals aged over 50 years.The Medline database of the National Library of Medicine was used to conduct a comprehensive literature search of population-based studies of HZ incidence published between 1960 and 2010. Articles had to include the MeSH term “herpes zoster” or “shingles”, as well as the keyword “incidence” or “age-specific incidence”. Only articles reporting on studies carried out in the 27 European Union Member States, Iceland, Norway, or Switzerland (complete list can be found at end of this paper) were considered. Publications in Dutch, English, French, German, Italian or Spanish were considered.References lists from retrieved publications were also checked manually for any additional studies or review articles on the epidemiology of HZ, and if necessary the authors were contacted to obtain data on age-specific HZ incidence rates. National surveillance data, the websites of the National Institutes of Health of the United Kingdom (UK), sentinel networks and data from the World Health Organization were also consulted, especially for countries where no publications were found. However, no additional data were identified.Included articles had to have HZ incidence data available, a population-based study design and information on the quality criteria used to score the studies in this review. Any study that did not contain this information was excluded.All studies limited to immunocompromised populations/populations with primary or acquired immunodeficiency status, patients with hematological malignancies , persons with AIDS, patients on immunosuppressive therapy  were excluded. A few articles were also excluded due to duplicate publication, or lack of study dates.In order to provide a methodological classification of the studies, a reading grid was created specifically for this review based on set quality criteria. According to these criteria, each selected article was scored by two independent readers. The reading grid allowed for a total of 30 possible points:1) Representativeness of the sample of patients (12 points): number of practitioners or specialists, sampling method description and validation—if any, geographic distribution, population covered.2) Incidence calculation (12 points): estimation of the denominator used to calculate incidence, presence of confidence intervals, estimation of age- or sex-specific incidence, size of the study, diagnostic criteria of HZ.3) Study design (4 points):a) Prospective inclusion of patients  suffering from HZ in health care facilities during a defined study period, either during an ad-hoc study or through a sentinel surveillance network.b)) Retrospective identification of HZ cases either through the review of medical files in a sample of practitioners, or through the analysis of large databases . In the first case, potential issues could arise from the quality of files and missing data. Database studies are less time- and cost-consuming for assessing incidence rates; however these studies are subject to bias related to the completeness of the database and inference to the general population.4) Discussion of the study limitations and study results put in perspective with the data from the literature (2 points).Papers with a quality score of less than 15 out of the 30 possible points were excluded from the literature review. For the selected articles, pertinent information was extracted, including study dates, setting, study population, sample size, diagnostic criteria used for HZ, overall HZ incidence with 95% confidence intervals (when available), and incidence data by age, and by sex (when available).The present systematic review is following the PRISMA guidelines .The Medline search identified 1 644 articles, of which 1 563 were immediately excluded based on their abstracts. A review of the reference lists of the 81 remaining articles identified 23 additional articles, making a total of 104. Of these, 77 were excluded due to the inclusion and exclusion criteria: four hospital-based studies, six cost-effectiveness studies , 34 general reviews, 18 studies in countries not included in this review, and 15 with no exploitable incidence data or that lacked information on the quality criteria necessary to score the publication.The 27 remaining articles that corresponded to the inclusion criteria were scored using the reading grid. After the reading grid was applied, six of the 27 studies were further excluded as they did not meet the threshold for inclusion i.e., 15 points) -19. Ther5 points The 21 reports of HZ incidence from European countries included one from Belgium, four from France, two from Germany, two from Iceland, two from Italy, three from the Netherlands, two from Spain, one from Switzerland, and four from the UK , showed that the risk of HZ was higher in the general population  than among immunocompetent people (9.50/1 000 (Germany) and 4.07/1 000 ) ,29.The present literature review of HZ incidence in Europe showed similar HZ incidence across the included countries for which data was available. Overall annual HZ incidence varied from 2.0–4.6/1 000 PY depending on the country, which is consistent with previous published estimates , and simet al. [Our review confirms that HZ incidence increases sharply with age, from around 1/1 000 children <10 years up to 10/1 000 people over 80 years of age. These results are consistent with recent published estimates by Volpi et al. . Annual et al. .As expected, the same increase in incidence rates with age was observed in the studies included in this review that reported age-specific incidence Figure . The corThis review showed that incidence rates are systematically higher among women than men , and this difference increases with age, which has also been found in other studies ,53. WomeOur review excluded studies limited to immunocompromised populations, or individuals with primary or acquired immunodeficiency status. Nevertheless, as included studies were population-based, some of them made a distinction between the total study population and the immunocompetent population ,29. ThisIn Europe, not all countries have some form of surveillance in place for HZ ,56 and tThis review highlights the need to identify standardized surveillance methods in order to improve data comparability within European Union Member States and, in the framework of introducing HZ vaccination, to monitor the impact of immunization on the epidemiology of HZ.vs. 3.73/1 000 people in 2000 [Since most of the European studies in this review were performed and published in the last 10 years, it was difficult to look at a time trend variation in the risk of HZ. The only country (the UK) with two incidence rate estimates, which were about 30 years apart, provided two close figures: 3.40/1 000 people in 1975  in 2000 ,40. Howe in 2000  and the In the literature, there are conflicting data with regard to whether age-adjusted HZ incidence is changing over time ,58. IndeThis literature review has various limitations. First of all, this review included studies with different designs: direct prospective recruitment of patients with HZ in health care settings during a defined study period, and retrospective identification through medical files from a number of practitioners. In general, prospective recruitment methods are considered to be preferable, whereas retrospective recruitment poses some methodological problems regarding data quality and missing data. However, this was taken into account in the reading grid, which assigned a higher quality score to prospective studies than retrospective studies.et al. showed that administrative data use alone appears to overestimate the number of HZ cases [Moreover, in spite of their potential shortcomings, some studies based on large databases  were included in this review. It is true that in the past the methods used in population-based studies, such as those used to extrapolate results obtained from a single database to the entire North American population, have been criticized . Indeed,HZ cases , and theHZ cases .Available European epidemiological data on HZ have shortcomings which make accurate assessment of HZ incidence and change over time impossible. However, data are indicative that HZ incidence across Europe is comparable  and increases with age, especially after 50 years of age. This equates to a total of 1.7 +/− 0.1 million new HZ cases each year in Europe.Austria, Belgium, Bulgaria, Cyprus, Czech Republic, Denmark, Estonia, Finland, France, Germany, Greece, Hungary, Iceland, Ireland, Italy, Latvia, Lithuania, Luxembourg, Malta, the Netherlands, Norway, Poland, Portugal, Romania, Slovakia, Slovenia, Spain, Sweden, Switzerland, United Kingdom.HZ: Herpes zoster; PY: Person-years; UK: United Kingdom; VZV: Varicella-zoster virusThis study was funded by SPMSD.SP is an employee of Biostatem, Castries, France. She had specified relationships with Sanofi Pasteur MSD that might have an interest in the submitted work in the previous 6 years.HB is an employee of SPMSD, Lyon, France.AC declares that she has no competing interests.RJ has received honoraria for consultancy, lectures and scientific meeting attendance from Sanofi Pasteur MSD, Merck Inc., Merck Frosst, Novartis and Astellas.SP carried out the literature search, the selection of the articles, the scoring of the selected papers, and the extraction of the data and drafted the manuscript. HB performed the scoring of the selected papers, the extraction of the data and participated in drafting the manuscript. AC and RJ helped to interpret the results of the review and to draft the manuscript. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2334/13/170/prepubIncidence rates of herpes zoster (HZ) by age group and by sex when available (/1 000) [(/1 000) ,34,35,37(/1 000) ,40,64.Click here for file


EWSR1-CHN . EMCS is marked by >40% incidence of metastases in spite of its indolent behaviour. It is generally resistant to conventional chemotherapy, and, to the best of our knowledge, no data have been reported to date about the activity of tirosin-kinase inhibitor (TKI) in this tumor. We report on two consecutive patients carrying an advanced EMCS treated with sunitinib.Extraskeletal myxoid chondrosarcoma (EMCS) is a rare soft tissue sarcoma of uncertain differentiation, characterized in most cases by a translocation that results in the fusion protein EWSR1-CHN translocation.Since July 2011, 2 patients with progressive pretreated metastatic EMCS  have been treated with continuous SM 37.5 mg/day, on an individual use basis. Both patients are evaluable for response. In both cases diagnosis was confirmed by the presence of the typical Both patients are still on treatment (11 and 8 months). Patient 1 got a RECIST response after 4 months from starting sunitinib, together with a complete response by PET. An interval progression was observed after stopping sunitinib for toxicity , but response was restored after restarting sunitinib. Patient 2 had an initial tumor disease stabilization detected by CT scan at 3 months. Sunitinib was increased to 50 mg/day, with evidence of a dimensional response 3 months later.Sunitinib showed antitumor activity in 2 patients with advanced EMCS. Further studies are needed to confirm these preliminary results. Extraskeletal myxoid chondrosarcoma (EMCS) is a rare soft-tissue sarcoma (STS) first described in 1972. BesidesCHN to EWSR1fluorodeoxyglucose–positron emission tomography scan (PET). No evidence of relapse to the primary tumor site was observed. Patient was asymptomatic, ECOG performance status (PS) = 1.A complete response by PET to all lesions was evident after 4 weeks of treatment Figure with a mUnfortunately, 4 weeks after starting treatment, therapy was complicated by an abscess to the primary site, around femoral fixation. The infection was confirmed by clinical signs , CT and PET. In fact, CT showed a tumor response to all sites, as described above, together with a new mass in the right gluteus muscles characterized by fluid content with rim enhancement Figure which waEWSR1-CHN translocated progressive EMCS, metastatic to the lung and LN, pretreated with multiple lines of chemotherapy, started sunitinib in October 2011. After 3 months of treatment with sunitinib 37.5 mg/day a tumor disease stabilization was observed. At that point sunitinib was tentatively increased to 50 g/day, with a dimensional response by CT detectable after 3 months of therapy, 6 months from baseline.Following this experience another 67-years old consecutive patients, ECOG PS 1, affected by a Both patients are still on treatment and responsive, 11 and 8 months from baseline, respectively, without evidence of further major side effects.EWSR1-CHN translocation. In the first case the response was evident after only one month of treatment and marked by shrinkage of all lesions, on the face of a complete PET response. Decrease in tumor size was confirmed by further CT scans for 4 months after stopping treatment because of a therapy-related abscess. When disease progressed after 4 months from sunitinib discontinuation, response was restored by restarting treatment. At 9+ months of follow-up, tumor response was confirmed. In the second patient a dimensional response was evident at 6 months, after an initial tumor stabilization.We report on the tumor response to sunitinib in two consecutive patients with pretreated, progressive, metastatic extraskeletal myxoid chondrosarcoma, carrying the EMCS is a very rare STS, with low sensitivity to cytotoxic chemotherapy,20-24. TSunitinib is a multi-targeted tyrosine-kinase (RTK) inhibitor and antiangiogenic drug approved for the treatment of gastrointestinal stromal tumor (GIST) and renal cancer,29. EvidUnlike GIST, no specific genetic alterations associated with sensitivity to sunitinib have been identified in STS. As shown in ASPS, anotherThe most common toxicities with sunitinib are hand-foot syndrome, rash, fatigue, hypertension, hypothyroidism and diarrhea. It is known that the sunitinib and other antiangiogenetic agents can interfere also with the normal vasculature formation and, possibly, with the T-cell mediated immunity,35,36. TA tumor response to sunitinib was seen in two consecutive patients with EMCS. In one case the response was complicated by infection and was restored when treatment could be restarted after a while. Differential diagnosis of complicated tumor response versus tumor progression was crucial to continue with therapy in the first responding patient. Further prospective studies are needed to confirm these results and to better understand the molecular basis for the activity of sunitinib in this disease.Written informed consent was obtained from the patients for publication of this Case Report and any accompanying legend. A copy of the written informed consents are available for review by the Editor-in-Chief of this journal.Stacchiotti S Pfizer srl: travel coverage for medical meetings, research funding. Casali PG Pfizer spa: advisory, research funding.SS, PD, SP, AG and PGC contributed to the conception and design, to the analysis and interpretation of data, to manuscript drafting PD and TN carried out the molecular study CM carried out the radiological evaluation and contributed to the analysis and interpretation of data AR contributed case material, and contributed to the analysis and interpretation of data All the authors read and approved the final manuscript


Associations between mastication and insufficient nutrient intake, obesity, and glucose metabolism have been shown in previous studies. However, the association between mastication and diabetes has not been clarified. Our objective was to examine the association between mastication, namely masticatory performance or rate of eating, and diabetes in a population-based cohort.We conducted a cross-sectional study of the association between mastication and diabetes in the Nagahama Prospective Cohort Study, an ongoing study which recruits citizens of Nagahama City in Shiga Prefecture, central Japan. 2,283 male and 4,544 female residents aged 40–74 years were enrolled from July 2009 to November 2010. Masticatory performance was evaluated by spectrophotometric measurement of color changes after masticating color-changeable chewing gum. Categorical rate of eating  was self-assessed using a questionnaire.177 males (7.7%) and 112 (2.4%) females were diagnosed with diabetes. We divided participants into four groups by quartile of masticatory performance, namely Q1 (lowest), 2, and 3 and 4 (highest). Compared to the lowest performance group, the multivariable adjusted odds ratio (OR) of diabetes was 0.91 , 0.58–1.4) in Q2, 0.77  in Q3, and 0.53  in the highest group in males, and 1.2 , 0.95  and 0.56  in females. We also estimated ORs of diabetes by rate of eating. Compared to the fast eating group, ORs in males were 0.87  in the intermediate group and 0.38  in the slow group, and ORs in females were 0.92  and 1.5 .These findings support the hypothesis that higher masticatory performance and slow eating prevent the occurrence of diabetes. Diabetes is a group of metabolic diseases which is characterized by hyperglycemia resulting from defects in insulin secretion, insulin resistance, or both. The pathogenesis of diabetes involves lifestyles and environmental factors A number of studies have identified associations between mastication and insufficient nutrient intake. People who were unable to fully masticate due to teeth loss or ill-fitting dentures had insufficient daily nutrient intake of dietary fiber, magnesium or calcium On the other hand, a few studies have demonstrated direct relationships between mastication and glucose metabolism. Thorough mastication elicited a lower postprandial plasma glucose concentration because of the potentiation of early-phase insulin secretion Recently, a few studies have reported an association between the rate of eating and the risk of diabetes Here, we investigated the association between mastication, namely masticatory performance or rate of eating, and diabetes in a population-based cohort.We conducted a cross-sectional study of the association between masticatory performance and diabetes. Subjects were participants in the Nagahama Prospective Genome Cohort for Comprehensive Human Bioscience (the Nagahama Study) This study protocol was approved by the Ethics Committee of Kyoto University Graduate School and Faculty of Medicine, the Ethical Review Board of the Nagahama Study, and the Nagahama Municipal Review Board of Personal Information Protection. Written informed consent was obtained from all participants.Participants were instructed to masticate a piece of chewing gum  as usual for one minute. Participants who had a denture were instructed to wear it and masticate. The chewing gum changes color as mastication proceeds. After each trial, the chewed gum bolus was placed between two plastic films and pressed into an approximately 30-mm diameter disk. Color measurement using a CR-13 spectrophotometer  was performed through the plastic films at five sites, one in the center and four others in the midpoint of imaginary spoke lines extending from the center to the superior, inferior, left, and right margins on the surface of the flattened gum E*ab, which is calculated by the following equation: ΔE*ab  =  {(ΔL*) 2 + (Δa*) 2 + (Δb*) 2}1/2E*ab as the masticatory performance of the participant Measurement was performed by an experienced dentist. Color was evaluated using the L*a*b* color space, which was developed by the Commission Internationale de l'Eclairage (CIE) for measuring object color The value for HbA1c (%) was estimated as an National Glycohemoglobin Standardization Program (NGSP)-equivalent value (%), calculated by the formula A1C (%)  =  A1C (Japan Diabetes Society (JDS)) (%) + 0.4%, in consideration of the relational expression of HbA1c (JDS) (%) measured by the previous Japanese standard substance and measurement methods and A1C (NGSP) The health examination included height, weight, blood pressure, and blood tests. Two sitting blood pressure measurements were averaged for analysis. Blood samples from each participant were used to measure total cholesterol, high-density cholesterol, triglyceride, plasma glucose, and HbA1c. In addition, oral examinations were conducted by two trained dentists, with an inter-examiner reliability of 0.77 to 1.0 by kappa statistics. Oral examination included DMF index and periodontal status, excluding third molars. The DMF index, which comprises the number of decayed (D), missing (M), and filled (F) teeth, has been established as a key measurement of caries experience in dental epidemiology A self-administered questionnaire was used to assess medical history, including history of diabetes, type of hypoglycemic medication, and history of diabetes in a first-degree relative (no or yes). In addition, life-style variables were surveyed, including smoking habit , alcohol drinking habit , physical activity , caloric restriction  and rate of eating . We also surveyed the intake of 18 kinds of foods, including rice, meat, fish, tofu (soybean curd), eggs, milk, and vegetables using a self-answered questionnaire, with categories of every day, 4–5 times per week, 2–3 times per week, and l time or less per week.P values were two sided at a significance level of 5%. All statistical analyses were performed using Stata 11.2 software .All analyses were stratified by sex. A nonparametric test for trend across ordered groups were performed. Spearman correlation coefficients were used to assess the association between masticatory performance and the other continuous variables. To adjust for demographic and possible confounding factors, logistic regression analysis was performed with diabetes as a dependent variable, and the odds ratio (OR) of diabetes and 95% confidence interval (CI) were estimated in three models: Model 1, crude; Model 2, adjusted for age ; and Model 3, adjusted for model 2 and other possible confounding factors. In the selection of variables, we used a forced entry method and entered the following variables into the model as possible confounding factors: age, body mass index (BMI) , family history of diabetes (no or yes), current smoking (no or yes), current alcohol drinking (no or yes), physical activity , caloric restriction , rate of eating  and periodontal status , periodontal pockets (score 3 and 4), or edentulous). Goodness of fit of the model was examined using the Hosmer-Lemeshow goodness of fit test. Linear tests for trend were performed with the median value in each group as a continuous variable The distribution of masticatory performance and prevalence of diabetes in the participants are shown in Masticatory performance was divided into quartiles, namely quartiles one (1.85 to 34.21), two (34.22 to 40.45), three (40.47 to 46.12) and four (46.14 to 59.9) in males, and one (2.63 to 32.44), two (32.45 to 38.21), three (38.22 to 43.05) and four (43.06 to 56.15) in females. We divided participants into four groups according to quartile of masticatory performance, namely Q1 (lowest), 2, and 3 and 4 (highest) groups. Characteristics of males and females by masticatory performance are shown in P for trend  = 0.015) and for demographic and possible confounding factors (P for trend  = 0.031). The multivariable adjusted OR of diabetes was 0.91  in Q2, 0.77  in Q3 and 0.53  in the high group. In contrast, we found no significant association between masticatory performance and diabetes in females. The final multivariable adjusted model was reliable .We investigated the association between masticatory performance and prevalence of diabetes and found an inverse dose-dependent association . CompareP for trend  = 0.048). In contrast, we found no significant association in females.We also conducted an additional analysis and estimated OR of diabetes by the rate of eating . As withWe examined the association between mastication and diabetes in a population-based cohort. An inverse dose-dependent association was observed between masticatory performance and diabetes in both males and females in the estimation of crude odds ratio. The association was maintained in males after adjustment for potential confounding factors. In addition, slow eating was significantly associated with decreased odds for diabetes in males. In females, in contrast, no associations were found after adjustment, albeit that this might have been due to the low prevalence of diabetes in females in our study population. To our knowledge, this is the first study to clarify the association between mastication, namely masticatory performance or rate of eating, and diabetes.We hypothesize two possible mechanisms underlying the association between masticatory performance and diabetes. The first involves the reduced intake of nutrients such as dietary fiber or magnesium, which were lower in subjects who were unable to fully masticate due to teeth loss, ill-fitting dentures or edentulousness Second, we found that slow eating was significantly associated with decreased odds for diabetes in males, after considering dental problems and other potential confounding factors. Recent studies have found that eating fast by self-assessed questionnaire was associated with a higher risk of diabetes in middle-aged Japanese males The mechanism underlying the association between rate of eating and glucose metabolism may be elucidated from the following studies. Lengthening mastication (thoroughness of mastication) was reported to elicit lower postprandial plasma glucose concentrations, because of the potentiation of early-phase insulin secretion E*ab for small color differences in the L*a*b* color space and for differences which result from colorant mixtures E*ab to evaluate masticatory performance.Mastication or chewing serves several functions, namely the breakdown of large food particles into smaller particles suitable for gastrointestinal absorption of nutrients; and lubricating and softening food particles into a bolus conducive to swallowing, thereby facilitating gastrointestinal absorption of food particles Participants who answered that they ate slowly were more common in the lower masticatory performance groups. In the multivariate analysis, in contrast, slow eating was associated with decreased odds for diabetes. This result appears contradictory. Although the speed of chewing, namely the number of chewing strokes per minute, was reported to be related with masticatory performance Several limitations of this study warrant mention. First, it was a cross-sectional study, and a follow-up survey is accordingly required to draw causal conclusions. For instance, diabetes may influence masticatory performance by increasing susceptibility to infections and thus the risk of periodontal disease In conclusion, we identified an inverse dose-dependent association between masticatory performance and diabetes in a population-based cohort. After adjustment for possible confounding factors, odds of diabetes decreased gradually as masticatory performance increased. In addition, fast eating was found to be a possible risk factor for the development of diabetes. Taken together, the present and previous results indicate that slow eating and preservation of high masticatory performance by the prevention of tooth loss or maintenance of dental prosthesis might prevent the occurrence of diabetes. These are potentially modifiable factors, and this study provides important new information for physicians and dentists concerned with the prevention of diabetes.Appendix S1Distribution of masticatory performance and prevalence of diabetes stratified by sex and age in the Nagahama cohort.(DOCX)Click here for additional data file.