Attention-deficit/hyperactivity disorder (ADHD) is a severe mental illness, associated with major impairment and a high comorbidity rate. Particularly undiagnosed ADHD in adulthood has serious consequences. Thus, a valid diagnosis is important. In adulthood, the diagnostic process for ADHD is complicated: symptoms may overlap with comorbid disorders, and the onset and progression of the disorder must be reconstructed retrospectively. Guidelines for the diagnostic process recommend the inclusion of additional informant ratings. Research into the relation between self- and informant ratings shows extremely heterogeneous results. The levels of agreement range from low to high. The focus of this study is the concordance and differences between self- and informant ratings on ADHD symptoms and impairments. In this regard, two possible influencing factors (gender and relationship type) are also examined. 114 people participated in this study, 77 with an ADHD diagnosis and 37 without a diagnosis. For all participants, either parents or partners also rated ADHD symptoms and impairments. Small to moderate concordance was found between self- and informant ratings, with females being slightly more concordant than males, particularly for ratings of problems with self-concept. Examination of the consistency within a particular perspective showed that people with ADHD seemed to be unaware of the causal relation between ADHD symptoms and their impairments. A close investigation found almost no influence of gender and relationship type on differences within perspectives. Based on these results, the implications for the diagnostic process are that additional informant information is clearly necessary and helpful. Attention-deficit/hyperactivity disorder (ADHD) is a severe developmental disorder, appearing in childhood and frequently persisting into adulthood , 2. In ainattention, hyperactivity, and impulsivity—and additional symptoms such as emotional symptoms [ADHD is characterized by three core symptoms—symptoms , 8. Thessymptoms , 10. Peosymptoms , 11–13. symptoms –6. Additsymptoms .Concerning the wide range of functional impairments and the high rate of comorbidity, an early and valid diagnosis of ADHD is important , 15. ParIn many studies, people with ADHD retrospectively rate symptoms in childhood lower than their relatives do , 29. In Differences in perspectives between people with ADHD and their relatives are rarely discussed in literature. So far, no consensus on the validity of the different perspectives has been reached. There is a lack of objective criteria to evaluate the statements, so it cannot be determined with any certainty which ratings are more precise. Nevertheless, there are some indications as to which perspectives are more valid. In retrospective ratings of childhood symptoms, statements of parents highly correlate with daily impairments in childhood and childhood diagnosis of ADHD, and parents were also better at estimating the time of onset of the disorder , 29. ForThese different findings are discussed by various researchers. Some tried to find explanations for the higher symptom self-ratings: one possibility could be an overestimation of the minor executive power limitation found in ADHD . AnotherSome studies address factors influencing the concordance between the different perspectives. These factors include age, gender, ADHD diagnosis, and the identity of the informants (type of relationship they have with the ADHD person). Zucker et al. , for exaA deeper investigation of the concordance between perspectives seems necessary and might help to examine their usefulness for diagnostic purposes and therapy. A precise diagnosis is important for the effective treatment of ADHD . PerspecEthikkommission Nordwest- und Zentralschweiz (EKNZ”). The EKNZ approved the entire study for the clarification of our research questions with the use of routine data of the special consultations unit.Data of patients of the ADHD Special Consultations Unit of the Outpatient Department of the University of Basel Psychiatric Clinics, collected between July 2013 and December 2014, were used for this study. The collected routine data was retrospectively used to investigate the research questions of this study. According to the standard approach of the University of Basel Psychiatric Clinics for routine clinical data, informed consent was given verbal, that data may be used for research. Data were collected in anonymous form in a clinical intern data base. None of the authors had contact with the participants and the data was entered anonymized by researcher assistants of the research group. This procedure was approved before the start of the study by the ethics committee in Basel , structinattention and/or five symptoms of hyperactivity/impulsivity must coexist in adulthood. Important components of the process were the Conners Adult Rating Scales , in selWRAADDS; ). Functi Adults; ). Formernterview  and the . Diagno with an age range from 18 to 75 years. In our sample, 77 participants received an ADHD diagnosis, while 37 did not (ADHD and Non-ADHD group). Demographic characteristics for these two groups are the following: In the Non-ADHD group 24 participants were male (64.9%) and 13 were female (35.1%), while in the ADHD group 53 participants were male (68.8%) and 24 were female (31.2%). The group differences for gender were not significant (t(112) = .42; n.s.). Both groups did neither differ significantly in their mean age  = .45, n.s.), nor their education: In the Non-ADHD group 21 participants (56.8%) finished secondary school and 16 (43.2%) finished grammar school, while in the ADHD group 50 participants (64.9%) finished secondary school and 27 (35.1%) finished grammar school (t(112) = 1.42, n.s.). There were also no significant differences for relationship status, number of children, and the informant identity between both groups.This study includes a clinical sample which was routinely diagnosed in the ADHD Special Consultations Unit. A total of 114 persons participated in the study. Of these, 77 were men (67.5%) and 37 women (32.5%), the mean age was 32.19 years  participants, also partners rated symptoms and impairment, while for the rest (43.0%) parents did.t(107) = 2.40, p < .05), more anxiety problems (t(105) = 3.32, p < .01), more thoughts about suicide (t(112) = 2.87, p < .01), more alcohol abuse (t(109) = 3.19, p < .01), and more substance abuse (t(111) = 2.79, p < .01).In the ADHD group, 47 people (61.0%) had a current comorbid disorder such as a mood disorder, anxiety disorder or a substance use disorder. People in the ADHD group had significantly more former depressions . Th. ThConne . The interobserver agreement for each item was between .44 and .77. Till now, there is no published German version of this questionnaire available. Therefor we used a translation, made by our research group. Because of the small participants’ number, a validation of the questionnaire based on our data was not advisable. For the assessment of functional impairment in our study, four domains of impairment were formed out of cluster analysis results: family life, social life, work, and organization. Cronbach`s alphas for the mean impairment score and the subscales can be found in the results section.s . The BFs . This iInternal consistency was assessed with Cronbach`s alpha. Values were calculated for all subscales of ADHD symptoms and all domains of impairments for self- and informant ratings.Concordance between clinical diagnosis and the diagnosis based on self- and informant statements was examined with Spearman correlations and cross tabulations. Thereby the percent of similarity between the diagnosis  were calculated.mean impairment score (BFIS) and ADHD index (CAARS) were used to test for consistency of symptoms and associated impairment within self- and informant perspectives. The ratio of explained variance should be an indicator for consistency of the perspectives.Regression analyses with the scales of General differences between self- and informant perspectives were examined for both groups separately through t-tests. For differences, also effect sizes (Cohen`s d) were computed.In-depth analysis of the relationship between self- and informant perspectives in ADHD was assessed with the ADHD group only: Spearman correlations for intra-class concordance of self- and informant ratings and Multivariate Analysis of Covariance (MANCOVA) to test the influence of gender and relationship type were used. Via Fisher z-transformations the intra-class correlations were normalized and t-tests conducted. Restricted sample size demanded separate MANCOVAs for the influence of gender and for the relationship type, controlled for comorbidity. Direction, significance, and effect size for the different subscales are reported.ADHD index, the five ADHD symptoms, the functional impairment domains, and the mean impairment score were assessed with Cronbach`s alpha. The following values are the results for (a) self- and (b) informant ratings. For the ADHD index scale, Cronbach`s alpha (a) was .93 and (b) .93. Results for separate ADHD symptoms were as follows: for inattention/memory problems Cronbach`s alpha (a) was .87 and (b) .90, for hyperactivity/restlessness Cronbach`s alpha (a) was .89 and (b) .90, for impulsivity Cronbach`s alpha (a) was .80 and (b) .83, for emotional lability Cronbach`s alpha (a) was .85 and (b) .84, and for problems with self-concept Cronbach`s alpha (a) was .87 and (b) .84. The mean impairment score showed Cronbach`s alpha of (a) .84 and (b) .93, while for the different impairment domains the following results were found: for family life Cronbach`s alpha (a) was .79 and (b) .80, for social life Cronbach`s alpha (a) was .81 and (b) .81, for work Cronbach`s alpha (a) was .57 and (b) .71, and for organization Cronbach`s alpha (a) was .82 and (b) .82. Taken together, internal consistency showed good to excellent values for the total scales, the subscales of ADHD symptoms, and almost all separate domains of impairment for both ratings. An exception was work, which showed low values for self-ratings but acceptable values for informant ratings.Reliability of the r = .53) and a general similarity of 80% (44% for no diagnosis and 97% for diagnosis) were revealed for an ADHD diagnosis based on clinical diagnosis and self-ratings. For informant ratings and clinical diagnosis correlation was small (r = .27) and a general similarity of 68% (51% for no diagnosis and 76% for diagnosis) was found. The agreement between self- and informant diagnosis was also small: r = .22 and general similarity was 70% (56% for no diagnosis and 72% for diagnosis).A moderate correlation  = 99.85, p < .001), and for informant ratings the symptom scale explained 52% of the total variance  = 37.21, p < .001). Findings for the ADHD group were different: self-ratings of symptoms explained only 16% of the total variance  = 13.80, p < .001), while for informant ratings the symptom scale explained still 41% of the total variance  = 50.57, p < .001). To rule out comorbid diseases as the basic cause for lack of consistency within the ADHD self-ratings, a subgroup of ADHD patients without comorbidity was retested (n = 30). In self-ratings of this group, symptoms explained 7% of the total variance  = 2.09, n.s.), while for informant ratings the symptom scale explained 41% of the total variance  = 17.77, p < .001).To examine the consistency of a perspective, hierarchical multiple regression analyses were used. Thus, the prediction of ratings for impairment through symptom ratings was tested separately for the participants and their relatives in both groups (ADHD and Non-ADHD group). For this purpose, the ADHD index subscale of the CAARS-S:L and CAARS-O:L and the mean impairment score of the BFIS, also self- and others-rating form. No significant differences were found in the Non-ADHS group: ADHS index: Participants with ADHD  and informants  = 0.27, n.s.; Cohens d = .04); Mean impairment score: Participants with ADHD  and informants  = 1.19, n.s.; Cohens d = .24). In the ADHD group significant group differences were found: ADHS index: Participants with ADHD  and informants  = 3.91, p < .001; Cohens d = .47); Mean impairment score: Participants with ADHD  and informants  = 2.62, p < .05; Cohens d = .33).Independent-samples t-tests were used to evaluate ratings of ADHD symptoms and functional impairments between participants and their relatives. Comparisons between both perspectives showed significant differences for ADHD symptoms and general impairment in the ADHD group, while in the Non-ADHD group no significant differences were found. Calculations were made with the ADHD index, ADHD symptom subscales, and the mean impairment score were tested with mean Spearman correlations  women were more concordant with their relatives than men. This difference was only significant for ratings of problems with self-concept.Concordance of the elations . To thisThe gender of the ADHD person and the relationship type (parents vs. partners) were investigated as possible factors influencing the differences in perspectives between people with ADHD and their relatives. For the purpose of these analyses only the ADHD group was used. Two MANCOVAs were calculated: one with perspectives and gender Tables  and 3, thyperactivity/restlessness and impulsivity: people with ADHD themselves rated their symptoms higher than their relatives did.There was a main effect on perspectives found in hyperactivity/restlessness and problems with self-concept was found. For hyperactivity/restlessness males rated their symptoms significantly higher than females, while for problems with self-concept the contrary was found. The biggest effect was found on problems with self-concept.For gender, a main effect on ratings of hyperactivity/restlessness, there was a significant correlation between perspective and relationship type: while participants rated similar symptoms in both groups, parents rated the problems of their adult children higher than partners did.For relationship type, no main effects were found. For The main goal of this study is the investigation of the self- and informant ratings on symptoms and impairment in ADHD. For this purpose, concordance and differences between the two perspectives were addressed. While concordance measured the similarity of patterns of both perspectives, with differences the levels of agreement between both perspectives were considered. Additionally, the consistency within a perspective and also influencing factors for differences between ratings were observed.Examination of the agreement between self-ratings and clinical ADHD diagnosis revealed higher similarity compared to agreement between informant ratings and clinical diagnosis. This is hardly surprising, bearing in mind that judgments of clinicians mostly depend on the statements of patients. Nevertheless, participants rated their symptoms as clinically relevant more often than did their clinicians, which indicates that although clinicians depend on the statements of patients, they interpret this information carefully. Furthermore, this probable overestimation of ADHD symptoms by patients themselves leads to the conclusion that informants may be important for a second perspective within the diagnostic process.only people with ADHD failed to see these connections. In contrast, a review of Gordon et al. [Results about consistency within the perspectives reveal that in the Non-ADHD group severity of symptoms predicted severity of impairment in self- as well as informant rating, while in the ADHD group only the informant ratings achieved this result. Self-ratings in the ADHD group only explained a small amount of the variance in impairment. These results became even more pronounced after excluding the influence of comorbidity: while informant ratings stayed the same, self-ratings became insignificant. In general people with ADHD rated more symptoms and impairments, compared with their informants. But our results suggest that these ratings are very variable: While some participants with ADHD rated higher symptoms, but lower impairments, others rated lower symptoms, but higher impairments. This indicates that people with ADHD seem to be unaware of the connection between their symptoms and associated impairment. Also an unawareness of a causal connection between psychological symptoms and impairments is documented for some other disorders , it is nn et al.  showed an et al. , 36, 37.problems with self-concepts. While females showed moderate concordance for this subscale, ratings of males with ADHD hardly correlated with those of their relatives. Higher concordance between females and their relatives corresponds with our hypothesis and findings of former studies [Correlations between self- and informant ratings indicate a small to moderate concordance between perspectives, testing the whole ADHD group. The following gender differences in concordance were found: for most ratings females were slightly more concordant than men, which was significant for  studies .hyperactivity/restlessness and impulsivity. The modification of these two groups of symptoms with increasing age can be seen as an explanation: both become more internal with increasing age [inattention symptoms do not decline with age and thus may be relatively better recognized in adulthood. Another explanation for these results may be the negative view people have of inattention in other people: negative feelings in relationships and social dysfunctioning are more closely connected with inattention symptoms than with hyperactive behavior [impulsive and hyperactive or impulsive behavior is less negative for flirting partners: in contrast to inattention, it is perceived more as an interesting personality trait, useful in dating and social relations. However, also an overestimation of symptom severity by people with ADHD themselves cannot be ruled out as explanation for the differences [Differences between self- and informant ratings were also examined. General differences in mean scores indicate that people with ADHD estimate their total symptoms and impairments significantly higher than their relatives. Further investigations for single ADHD symptom subscales revealed that these differences were significant for sing age –55. Thussing age . Consequbehavior , 57. Alsbehavior  reportedferences , 38, 39.ferences , for exageneral impairment score were found, while the separate ratings of the four domains of impairment  did not differ between self and informant. Thus, patients and their relatives generally tell of similar problems in different domains of daily life. Results are in line with former studies, showing high impact of ADHD on daily life [For functional impairment, significant differences for the ily life , 7, 11.hyperactivity and problems with self-concept. For hyperactivity, males had significantly higher values, while for problems with self-concept females rated higher. An explanation for the higher ratings in men may be the differences in symptoms between females and males: according to former studies, men show more symptoms of hyperactivity than women in adulthood . In converview: . Thus, thyperactivity/ restlessness were differences found: parents seem to estimate the severity of symptoms of their adult children higher than partners did. The higher ratings by parents may be because they remembered former childhood problems instead of restricting their rating to current symptoms in adulthood only. Another explanation may be personal perception: as already described above, partners may see these symptoms as personality traits they like, while parents see them in terms of clinical relevance. At the beginning, we hypothesized that partners’ views may be more useful because of a closer personal relationship between partners in adulthood. This hypothesis was disproved: both calculations of concordance and of differences showed similar results, which indicates that relationship type bears no significant influence on similarities or differences between perspectives. It is noteworthy that particularly for people under the age of 30 it tended to be parents who provided the informant ratings. Accordingly, depending on the age of the person with ADHD, parents as well as partners are important sources and can and should be used for the diagnostic process.Outcomes also revealed that the relationship type seems to be unimportant for general accordance between people with ADHD and their informants. Only for For the purpose of this study, two questionnaires in self- and informant report forms were used. This has its strengths and limitations. This procedure enabled perspectives to be compared in detail: the same questions were used for participants themselves and their informants and the same subscales were examined. Other instruments to assess perception of severity of symptoms and impairments in more detail were not included. For future studies, therefore, inclusion of more such measurements may be appropriate.or partners only. This limits the group sizes. Accordingly, a MANCOVA containing gender and relationship type as influencing factors could not be conducted. For future investigations more participants should be assessed. Also, the inclusion of parents and partner ratings for all participants would be meaningful. This procedure would allow a closer comparison of perspectives and enable possible significant differences between partners and parents to be detected.A second limitation is our sample size. In the Non-ADHD group, only 37 participants and their relatives were tested, while the ADHD group consisted of 78 people. In both groups, others’ perspectives were assessed for either parents Finding a valid external criterion for the accuracy of ratings is a considerable problem in studies on self- and informant ratings. For future research, methods such as the ones used by Adler et al.  might beThe last limitation emerges from the assessment of comorbidity. Only a background interview, asking participants for their psychiatric backgrounds, former /actual therapies, and former /actual disorders was used. For further research comorbidity should be evaluate more closely by employing a structured interview for mental disorders. Also the assessment of other neurodevelopmental disorders, like autism, and for seizures should be included. This approach may help to better understand connections between ADHD, perspectives, and comorbidity. Despite these limitations, results show that self- as well as informant ratings should be an important part of the ADHD diagnostic process. Results revealed a low consistency within self-ratings and an overestimation of symptoms in comparison with the clinical diagnosis. Thus, both perspectives are pertinent for clinicians to better understand the individual person with ADHD.Furthermore, impairments in family and social life indicate that including family members in therapy might be reasonable. Former research showed that medication for ADHD has no effect on social and family impairment , 63. By In conclusion, people with ADHD and their relatives are important sources for assessment of symptoms and functional impairment. Nevertheless, there are some significant differences between their respective perspectives of symptoms and impairments. So far, no objective measurement for symptoms and impairments is available, wherefore the level of accuracy of information obtained from patients and other informants remains uncertain. People with ADHD themselves make no causal link between their symptoms and their impairments. The resulting inconsistency within their ratings can be an indication for misjudgment. Accordingly, the additional information informants can give in support of the diagnostic process would appear to be essential.


STarMirDB can be searched by miRNAs or mRNAs separately or in combination. The search results are categorized into seed and seedless sites in 3′ UTR, CDS and 5′ UTR. For each predicted site, STarMirDB provides a comprehensive list of sequence, thermodynamic and target structural features that are known to influence miRNA: target interaction. A high resolution PDF diagram of the conformation of the miRNA:target hybrid is also available for visualization and publication. The results of a database search are available through both an interactive viewer and downloadable text files.microRNAs (miRNAs) are an abundant class of small endogenous non-coding RNAs (ncRNAs) of ∼22 nucleotides (nts) in length. These small regulatory molecules are involved in diverse developmental, physiological and pathological processes. miRNAs target mRNAs (mRNAs) for translational repression and/or mRNA degradation. Predictions of miRNA binding sites facilitate experimental validation of miRNA targets. Models developed with data from CLIP studies have been used for predictions of miRNA binding sites in the whole transcriptomes of human, mouse and worm. The prediction results have been assembled into STarMirDB, a new database of miRNA binding sites available at  They have been discovered in plants, animals as well as in some viruses.Computational prediction algorithms have proven to be valuable in the discovery of new miRNA targets. Most of the existing algorithms are based on the seed rule, i.e., the target site within 3′ UTR forms Watson-Crick (WC) pairs with bases at positions 2 through 7/8 of the 5′ end of the miRNA.In recent years, experimental methods based on cross-linking immunoprecipitation (CLIP) have been developed. For human and mouse studies, these include HITS-CLIP,The CLIP studies have provided high throughput quality datasets for regions of mRNAs containing miRNA binding sites. These data allowed us to develop models for improved predictions of miRNA binding sites.H. sapiens (human), M. musculus (mouse) and C. elegans (worm). For human and mouse, we used complete mRNA sequences from NCBI RefSeq build 36.3 and 37.2, respectively. For worm, 3′ UTR sequences were obtained from the Wormbase version WS-190. The current release of STarMirDB includes 38,745 transcripts for human, 34,631 for mouse and 22,926 3′ UTRs for worm. miRNA sequences were obtained from miRBase release 18.The database currently contains records for 3 species, C. elegans is selected as the species for database search. Additionally, for C. elegans, all the prediction data for miRNA binding sites within the 3′ UTR of transcripts are also provided as downloadable files.Our CLIP based models were used to make transcriptome scale predictions of both seed and seedless binding sites.STarMirDB presents a collection of predicted miRNA binding sites on mRNAs through a web interface that enables both search and retrieval of data and visualization of the conformation of predicted miRNA:target hybrid for each predicted site. The web interface has four input fields: species, miRNAs, mRNAs, and logistic probability threshold. The requirements for each input field are described below in detail.Homo sapiens), mouse (Mus musculus) and worm (C. elegans). Next, one or a set of miRNAs can be selected from the miRNA scroll down list, which displays all available miRNAs assembled for the selected species. Additionally, one or more miRNA names can be entered in the text box. The database follows the naming convention used by miRBase,hsa-let7-5p for human, mmu-let7a for mouse, and cel-mir-1018 for worm).To start the database search, the user should first select the species from a dropdown menu. Currently three species are included in the database: human , can be provided. For worm, Wormbase ID is required. For search result display through an interactive site viewer, a user can choose to display only the most relevant site features for each binding site, or the complete list of features. The most relevant features are considered by us to be the most informative. They were selected from those used in the development of the prediction models.Relevant data in the database are retrieved in response to a specific database query and are available through both an interactive site viewer and downloadable files. For the interactive site viewer, the data is classified into three mRNA regions  and seed and seedless sites. To facilitate online viewing, the number of sites displayed in the interactive area is limited to top-ranked sites according to the decreasing order of their logistic probabilities. By default, 100 binding sites are displayed. Alternatively, the user can choose to display the top 250, 500 or 1,000 sites. The results of a search are also available for download as text files, wherein all of the retrieved binding sites are listed. The interactive viewer presents the results with either the most relevant site features or all of the site features as specified by the user in the input page. The downloadable text files provide all site features. In the text files, features marked with an asterisk are those used in the model computations of the logistic probabilities. In addition to comprehensive sequence, thermodynamic and target structural features , a high hsa-7a-5p, hsa-7b-5p, and hsa-7d-5p were selected. In addition, 2 miRNAs, hsa-let-7c and hsa-let-7e were manually entered. For mRNA targets, accession numbers NM_0000024, NM_0000021, NM_0000017, and Gene symbol Lin54 were entered. Next, the option of “Show predictions with the most relevant features in interactive viewer” was selected. Finally, a logistic probability threshold of 0.6 was selected. The “Search” button was then clicked for submitting the query input information for processing by the database server.For an illustration of the database search, total indicates a high structural accessibility at the target site.Upon completion of data retrieval by the database server, the user is presented with an interactive site viewer . By defaUnder the interactive site viewer, links are provided for downloading files of the query results for the 6 combinations of regions and site types . For sitSTarMirDB is a new bioinformatics resource for facilitating miRNA target studies. The current release of database includes 96,302 mRNAs and 3,446 miRNAs for human, mouse and worm. It will be periodically updated and likely extended to other species. It presents predictions for all 3 mRNA regions and for both seed and seedless sites. Importantly, it presents a probability for each site as an indicator of confidence in the prediction. In addition to use for visualization and publication, high quality diagrams of miRNA:target hybrids can facilitate design of nucleotide mutations for experimental validation of binding sites. The option for search by developmental stage shall be useful for studies of miRNAs in worm. The unique tools from STarMirDB will complement the existing miRNA target resources for computational predictions and experimental target data. The database can retrieve miRNA binding sites for single or multiple miRNAs and/or one or more targets. For example, this capability will be useful for elucidating miRNA regulation of genes of interest. It will also be useful in miRNA overexpression and knockout studies, wherein differentially expressed genes can be further examined by prediction and validation of miRNA binding sites.We have also developed STarMir, a web server for prediction of miRNA binding sites.The provision of extensive predictions of seedless sites  is a major feature for both the database and the web server. The functionality of seedless sites has been demonstrated by numerous studies based on diverse methods, which include reporter assays, nucleotide mutation analysis, analysis of microarray data, analysis of proteomics data, and phenotypic analysis.


Capsaicin-evoked TRPV1 currents in dorsal root ganglion (DRG) neurons were examined by the patch-clamp technique. Pain-related behavior was observed in an orthotopic tumor model. sHH and PSCs increased the expression and secretion of TRPV1, SP, and CGRP by inducing NGF and BDNF in a co-culture system, also increasing TRPV1 current. But, suppressing sHH pathway or NGF reduced the expression of TRPV1, SP, and CGRP. In vivo, PSCs and PC cells that expressed high levels of sHH could enhance pain behavior. Furthermore, the blockade of NGF or TRPV1 significantly attenuated the pain response to mechanical stimulation compared with the control. Our results demonstrate that sHH signaling pathway is involved in PC pain, and PSCs play an essential role in the process greatly by inducing NGF.Abdominal pain is a critical clinical symptom in pancreatic cancer (PC) that affects the quality of life for PC patients. However, the pathogenesis of PC pain is largely unknown. In this study, we show that PC pain is initiated by the sonic hedgehog (sHH) signaling pathway in pancreatic stellate cells (PSCs), which is activated by sHH secreted from PC cells, and then, neurotrophic factors derived from PSCs mediate the pain. The different culture systems were established  Abdominal pain is an important clinical symptom of pancreatic cancer (PC) that is characterized by intermittent or persistent pain and contributes to a poor quality of life in PC patients , 2. SomeThere is increasing evidence that PC pain is triggered by pancreatic neuropathy . Recent The neurotrophic factors are known to have a role in the biological behavior of these cells . The neuThe sonic hedgehog (sHH) signaling pathway, a major regulator of cell proliferation and differentiation , contribAs reported previously, sHH regulates nociceptive sensitization and guides the spatial pathfinding of raphespinal tract axons , 24. In in vitro, we extracted DRG from newborn rats [To investigate the possible relationship between PC and pain orn rats , 32. TheTo determine whether PSCs mediate pancreatic pain in PC, we first designed four different culture systems for PC cells, PSCs, and DRG. To eliminate interference from intercellular interactions in these systems, these co-culture systems were not mixed directly, but an indirect co-culture via culture medium exchange was adopted. The culture models are shown in p < 0.05). Additionally, there were no significant differences between the other three culture groups . To supplement the mRNA analyses, Western blotting was used to quantify protein levels, and the results showed the protein expression was similar to mRNA expression  or in the control group Figure  . Thus, the high expression and secretion of TRPV1 and pain factors from DRG induced by PSCs in the co-culture system indicates that PSCs play a key role in PC pain.Based on the hypothesis that pain generation is due to the secretion of pain factors, we analyzed the concentrations of SP and CGRP in the culture medium of DRG by ELISA. The results show the secretion of pain factors is much greater in the co-culture group Figure  (p < 0.0p > 0.05). The expression and secretion of TRPV1, SP and CGRP were increased in sHH group compared with the control group . However, cyclopamine added to DRG media did not produce similar results (p > 0.05). This interesting finding suggests the sHH signaling pathway is functional in PC cells and PSCs but not in DRG. We also found that recombinant sHH-pre (added to the medium of PSCs) obviously increased the expression and secretion of these factors compared to control (p < 0.05).To confirm the function of the sHH signaling pathway in our co-culture system, we examined the effects of recombinant sHH and cyclopamine on the expression and secretion of TRPV1 and pain factors. The co-culture system composed of PC cells (AsPc-1), PSCs, and DRG is shown in p Figure  . We did not observe differential expression of GDNF in any group. Thus, the activation of the sHH signaling pathway induced the expression of NGF and BDNF in PSCs.Considering that neurotrophic factors play important roles in pain and to confirm whether the activation of the sHH signaling pathway significantly contributes to the induction of neurotrophic factors in PSCs, we measured the expression of NGF, BDNF, and GDNF in PSCs using immunofluorescence . We thenTo determine whether the PSC-induced increased expression of TRPV1 and pain factors in DRG was mediated by neurotrophic factors, we quantified the expression of TRPV1, SP, and CGRP within DRG treated with neutralizing antibodies to NGF or BDNF in our co-culture system of AsPc-1 and PSCs . The antTo determine whether PSCs and the sHH signaling pathway affect TRPV1 current, we chose AsPc-1 cells for our electrophysiology studies in a co-culture system .p < 0.05). Unfortunately, the cyclopamine-pre group didn't have any obvious difference compared with control . In addition, decreased current was observed in the both the cyclopamine and anti-NGF perfusion groups compared with the control group . Of note, the inhibitory effect of the combined groups was stronger than the effect from treatment with capsazepine alone. Additionally, the greatest inhibitory action was observed in the group with the three inhibitors combined. However, there was no difference among the cyclopamine-pre, anti-NGF, and capsazepine groups.To determine whether TRPV1 contributed to the expression and secretion of SP and CGRP in our experiment, AsPc-1 cells were chosen for the co-culture system . We quanin vitro studies, we concluded that PSCs and activation of the sHH signaling pathway played a key role in the regulation of TRPV1 and pain factors (SP and CGRP). Additionally, we found neurotrophic factors were involved in the mechanism. To determine whether PSCs mediate pancreatic pain behavior in a mouse model, we designed an in situ tumor model in nude mice  (p < 0.05). The group of Panc-1-Sh-sHH combined with PSCs produced the strongest sensitivity of the three groups  (p < 0.05). Subsequently, we quantified the secretion of SP and CGRP in the sera of each group of mice 2 hours after the mechanical stimulation. The results showed the concentrations of these pain factors gradually increased in the following order: Panc-1 cells group < PC cells and PSCs group < Panc-1-Sh-sHH cells and PSCs group  (p < 0.05). Thus, PSCs and activation of the sHH signaling pathway are important for pancreatic pain.From our e Figure . Panc-1 s Figure . The fres Figure  (n = 8) s Figure  (n = 8) p Figure  (n = 8) In addition, to investigate the effect of NGF and TRPV1 on the tumor model, the mixture of AsPc-1 cells and PSCs was co-injected into the pancreases of mice. Results show that combining both inhibitors significantly suppressed the pain-related behavior more than using either inhibitor alone .Abdominal pain is a common symptom in patients with PC. Traditional pain medications, including analgesics and opiates, and operations such as celiac plexus blocks  are onlyThere are many reasons for pain generation, e.g., the damage of the neuronal sheath, inflammatory factors, and cell signaling pathways between PC cells and nerves . HoweverPSCs are a part of the pancreatic stroma. There is now compelling evidence that PSCs interact with PC cells, immune cells, and neuronal cells to promote cancer progression. The influence of PSCs on novel therapeutic approaches is becoming a hot target for researchers , 36. In In addition, it needs to be emphasized that the DRG was regarded as a whole; we did not differentiate constituents, such as nerve cells, gliocytes or schwann cells, except when we used nerve cells in the electrophysiological recordings. Furthermore, to clarify the source of sHH and the activation of the signaling pathway, the indirect co-culture of PC cells and PSCs was used. All the co-culture systems in this study involving co-culture of PC cells, PSCs and DRG are the first of their kind to be used in PC pain research, suggesting that these systems are imperfect and could be improved in further study. However, the advantage of our system is that it focuses on the function of PSCs and DRG while removing interference and obstacles caused by other cells in the microenvironment.in vitro and that the sHH signaling pathway was activated in PSCs. However, when cyclopamine was added into the medium of DRG, the results were not statistically significant compared with the control group, suggesting that, at least in this system, the sHH signaling pathway was not activated in DRG.It has been shown that sHH plays a functionally important role in the development of PC . In thisThe transfections results showed the expression of TRPV1, pain factors and the transcription factors Gli1 and Gli2 in PSCs were affected by sHH secreted from PC cells. These showed that the sHH signaling pathway was important for PSCs to elicit PC pain in the co-culture system. Some research has shown NGF can modulate the expression and function of TRPV1 . We obseTo determine whether the PSC-induced expression of TRPV1 and pain factors are mediated by neurotrophic factors, the expression of TRPV1, SP, and CGRP within DRG was detected after treatment with neutralizing antibodies against NGF or BDNF in the co-culture system. We found decreased expression of TRPV1, SP, and CGRP in the anti-NGF group. Their expression increased after stimulation with recombinant NGF. In further experiments, anti-BDNF did not produce a similar result as anti-NGF treatment; however, recombinant BDNF enhanced the expression of TRPV1, SP, and CGRP. In agreement with the results of the above study, NGF is more significantly involved than BDNF in the mechanism of PSCs aggravating PC pain in our co-culture system. These data are in agreement with other studies , 17. FurNGF is known to activate and promote the growth of sensory neurons. NGF binding with its receptor can alter the responsiveness of ion channels including TRPV1 , 39. In in vitro co-culture system. Although some studies have found that TRPV1 is essential for pain in pancreatic disease [We have previously shown the role of PSCs and the sHH pathway in our  disease , 40, we in vitro co-culture system. Then orthotopic tumor models were examined to confirm the experimental hypothesis. First, we co-injected the PC cells and/or PSCs into the pancreases of nude mice. Von Frey filament testing showed a significant increase of pain behavior in mice with the PSCs, and there was more secretion of SP and CGRP than in the control group. In contrast, there was an enhanced effect in sHH overexpressing cells on the pain behavior and secretion of pain factors. These results demonstrated sHH and PSCs were involved in the pain generation in animals, consistent with our previous studies in vitro. It is worth noting that the method of co-injection into the pancreas is the first of its kind in pain research and thus may have some unavoidable imperfections; however, we have demonstrated the feasibility in our preliminary experiment.In this study, we describe a pivotal role of the SHH pathway and PSCs in the pathogenesis of pain in PC only in an in vivo and in vitro, showed that NGF decreased the pain behaviors via effects on TRPV1. However, the mechanism of neuropathic pain is complex [In addition, we investigated the effect of NGF and TRPV1 on the tumor model. Results suggested that the pain-related behaviors were suppressed after treatment with anti-NGF or capsazepine compared with co-injected untreated cells. Thus, our studies, both  complex , 41, andIn conclusion, we have shown that PSCs play an essential role in the pain mechanism in PC. sHH secreted from PC cells activates the sHH signaling pathway in PSCs and enables the complex pain process via NGF and BDNF up-regulation or sensitization to TRPV1 and pain factors in sensory nerves. Our results should be regarded as one of the major potential mechanisms contributing to neuropathic pain in PC, and they represent a critical step forward for PC pain research.2 atmosphere at 37°C. Antibodies against SHH, SMO, PTCH, Gli1, Gli2, NGF, BDNF, GDNF, TRPV1, SP and CGRP were purchased from Abcam, USA. Recombinant sonic hedgehog, NGF and BDNF were obtained from R & D Systems . Capsaicin was purchased from Sigma, USA.The human PC cell lines AsPc-1 and Panc-1 were obtained from the American Type Culture Collection  and cultured in DMEM supplemented with 10% fetal bovine serum (FBS) and 1% antibiotic/antimycotic in a humidified 5% COTotal RNA was extracted using TRIzol , and cDNA was synthesized using a Prime Script RT reagent Kit . The primers used for SYBR Green RT-qPCR are shown in Cells seeded into small dishes were transfected with 100 nM siRNA using Lipofectamine RNAi MAX Reagent  according to the manufacturer's instructions. The cells were used for further experiments 24 h after transfection. In addition, plasmids for the overexpression of sHH were constructed according to manufacturer's instructions to study the activities of the sHH pathway in PSCs .In our study, different culture systems were designed to clarify the relationship among sHH, PSCs and pain factors. PC cells, PSCs and DRG were cultured together directly and indirectly. The culture medium was used to convey soluble factors. A model of the co-culture system is shown in To quantify the relative levels of neurotrophic and pain factors in culture media and serum, an enzyme-linked immunosorbent assay (ELISA) kit  was used according to the manufacturer's instructions.TRPV1, SP, and CGRP were localized to DRG, and NGF, BDNF, and GDNF were localized in PSCs by immunofluorescence. The details were shown in 2.The DRG were isolated from the newborn rat , stored 6/μl). After 4 weeks, the carcinoma model was highly successful (85%), and drug treatment and pain behavior could be tested.Prepared PC cells and PSCs were injected or co-injected into the pancreases of nude mice exposed by midline laparotomy   at 5 mg/ml for 12 h. As a control, cyclopamine, a sHH pathway inhibitor, was diluted to 18 μg/ml in PSC media (labeled as cyclopamine-pre) or DRG media(labeled as cyclopamine) and incubated with cells for 12 h. In addition, to detect the effect of neurotrophic factors, 60 ng/ml NGF or 50 ng/ml BDNF were added into the medium of DRG. As controls, 0.5 μg/ml polyclonal NGF antibody or 20 μg/ml BDNF antibody were used to block their effects in DRG media. Moreover, capsaicin (1 μM) was used to evoke TRPV1 currents in DRG. Furthermore, 20 μg/kg NGF antibody or 3 mg/kg capsazepine (TRPV1 inhibitor) were administered to animals by intraperitoneal administration.t test or one-way analysis of variance (ANOVA) for in vitro and in vivo results. The of significance level was set at p < 0.05. Patch clamp data were analyzed by pClamp 9 . All results were expressed as the means ± SD. All the experiments have been repeated 3 times, n = 8 per group.The analyses of results were performed using the SPSS statistical software package (version 13.0). The significance of the data was determined using Student's


Two purposes were followed in this study: 1) comparing case and control group in eight factors separately and 2) performing a multivariate analysis for identifying risk and protective factors in relation to drug abuse.A casual-comparative study was conducted to investigate the study goals. Fifty Cases in a convenient sampling of addicts referring to addiction withdrawal centers and fifty eligible controls (recruited in a randomly sampling) were identified. One-sample independent T-Test for a univariate and Logistic regression model for a multivariate was conducted.Univariate analysis: addicted group compared with control group, in terms of aggression, easy access to drugs and depression had higher scores and of other factors  cases had lower scores (p<0.05). Multivariate analysis: Easy access to drugs and depression identified as risk factors (OR>1) and high self-esteem, family socioeconomic status and responsibility as protective (OR<1).Addiction is a multivariate phenomenon and before any intervention, we have to consider personal, familial and environmental factors and separate subjects by them. We can’t give all of addicts the same prescription and follow a drug therapy approach to treat them. Any addict has a unique profile that should be taken into consideration. Nowadays, drug addiction is one of the serious social problems in many parts of the world which has a high priority for health managers and decision makers. Drug addiction, not only have negative consequences for individuals, but also threat welfare, political stability, economic and social structure of countries . The traPsychologists view behavior as determined by a multitude of factors including culture, family, social group, lifestyle, environment, behavior skills, thoughts, feelings and physical factors . ObviousTo our knowledge, there are many models for understanding and treating addicted persons prior to 1600 AD ; 1600 to 1900 AD (e.g. epidemic and illness); and models appearing since 1900 AD  . AccordiBased on previous studies, there are some risk and protective factors that can increase risk of drug abuse and addiction. Some of these factors are listed below: low or high self-esteem , depressHowever, there are a large body of literature about the role of determinant factors of addiction process, any of them considered the risk and protective factors  simultaneously. There is not just one factor that predisposes an individual to drug use, but a multiplicity of factors can contribute to decision of his/her for drug using. Therefore, it is necessary to do more studies in this context. The first aim of this study was to compare case and control group in eight factors separately. The second aim was to identify adjusted risk and protective factors of drug abuse.A casual-comparative study was conducted among 100 participants in Shahrekord city (in the west of Iran) during 2013-2014. Fifty Cases were selected by using convenient sampling among addicts who attended to addiction withdrawal centers and had a history of addiction. Also, simple random sampling was used for selection of fifty eligible controls. The two groups were matched by age and residence.Data collection tools In order to compare the case and control groups, investigator-constructed questionnaire was used. It was constructed based on eight scales, including religious belongings, F-SES, family environment, easy access to drugs responsibility, Coopersmith self-esteem, Ahvaz aggression, and Beck Depression. This questionnaire has 59 item with eigh domains, including self-esteem (10 item), aggression (10 item), religious belongings (10 item), family socioeconomic status (7 item), family environment (7 item), easy access to drugs (4 item), depression (7 item) and responsibility (6 item). All of the items were answered on a five point Likert scale ranging from strongly agree to strongly disagree. Exploratory factor analysis (EFA) was used to determine construct reliability of the questionnaire. Prior to performing EFA, suitability of data for factor analysis was assessed. The Kaiser-Meyer-Oklin values are presented in In bivariate analysis, After the assumptions of homogeneity of variances and normality for all variables were met, Chi square for the comparison of proportions and independent-sample T-Test for comparing differences between groups) were used.. The adjusted association of all proposed factors on the youth’s tendency to drug abuse and addiction were examined by multiple logistic regression model. The following independent variables were entered into the model: self-esteem, aggression, religious affiliation, family socioeconomic status, family environment¸ easy access to drugs, responsibility and depression. Level of confidence interval was 95%. Statistical Package for the Social Sciences (SPSS) was used to the data analysis.Mean age of the participants in the case group was 27 (SD= 3.16) years with a range of 18 to 33 years and in the control group was 27.4 (SD=3.95) years with a range of 16 to 32 years. The mean of addicted history was 8 (SD=4.09) years with a range of 2 to 5 years As In the bivariate analysis, the case and control groups’ status in the eight factors were examined separately. An independent-sample T-Test was conducted to compare the scores of eight factors for the case and control groups. As The multiple logistic regression analysis demonstrated the risk and protective factors of drug abuse and addiction in young adults. The full model which considered all predictors was statistically significant that indicates the model was able to distinguish between addicted and non-addicted participants . The model as a whole explained the variance in person status between 51.2% (Cox and Snell R square) to 70.8% (Nagelkerke R squared) of, and correctly classified 87% of cases (sensitivity and specificity of the model was 82% and 89.6% respectively). As shown in The strongest predictor was easy access to drugs variable, OR=1.36 . This indicated that participants in the case group were 1.36 times more likely to report an access to drugs than those who were in the control group, after adjusting for other factors in the model. The odds ratio of 1.34 for depression, indicating that for every additional score of depression, participants in the case group were 1.34 times more likely to have had depression than the control group, adjusting for other factors in the model. Self-esteem (OR=0.777), family socioeconomic status (OR=0.711) and responsibility (OR=0.671) indicates that the control group had more scores than the case group. Remained variables  had no significant effects in the model see .The present study was designed to determine the effect of eight factors on young adults’ tendency to drug abuse and addiction. Firstly, the case and control groups were compared by the eight factors separately and then a multivariate analysis was used to identify the risk and protective factors.The results of bivariate analysis showed that the case group had a higher scores than the control group in terms of some factors as aggression, easy access to drugs and depression. Also, in terms of other factors, including self-esteem, religious affiliation, socioeconomic status, family environment and responsibility the cases had lower scores. These findings are consistet with most conducted research . Eta squAlso, as the results showed the family environment, religious affiliation and aggression had no significant effect on attitudes to addiction. This finding can be explained as follows: Firstly, an addiction phenomenon among Iranian families is a taboo that they generally have a negative view toward it. Secondly, religious affiliation among the studied target population, especially in Shahrekord city, is high and they are committed to such beliefs. Finally, other variables in the model, including family environment and religious affiliation that had a negative correlation with aggression acted as a buffer and neutralize the effect of aggression.Studies support the notion that self- aggression is linked with depression. Becker & Lesiak  found thTotally, the results of present study showed that personal, familial and environmental factors have to be considered before any intervention and subjects be separated by them. Any addict has a unique profile that should be taken into consideration. All of them can not take the same prescription and follow a drug therapy for treatment.The findings should be considered in the light of several limitations. Firstly, this study only examined the voluntary addicts who attended to addiction withdrawal centers, not all addicts around Shahrekord city. Secondly, our statistical analyses were based on self-report data not diagnostic tests. Thirdly, because of limited sample size (n=100), any generalization should be done cautiously. It is required that results to repeat in different and broader contexts.


Persons with multiple sclerosis (MS) are less physically active than nondiseased persons and often report low self-efficacy levels. In the context of an awareness project to promote physical activity and participation in MS, we addressed the impact of training for and participation in a unique expedition. Medical events, relapses, and self-reported neurological worsening were followed from 6 months before and up to 4 months afterwards. Validated patient-reported outcome measures were used to assess fatigue, self-efficacy in exercising, walking abilities, and illness perception. Nine participants completed the training, expedition, and observational study. Minor events, relapses, and/or neurological worsening were reported in six participants. The three participants with mild disability and no cardiovascular risk factors or comorbidities were free of medical and neurological events. We found a significant reduction of motor fatigue at last when compared with the first assessment. The reduction tended to be more evident in participants with mild disability  <4 at baseline). Cognitive fatigue, self-efficacy, and self-reported walking abilities did not change significantly. Illness perceptions tended to be reduced over time in the domains of consequences, identity, and concerns. Overall, no major adverse events occurred. The benefits of physical activity for overall health have been extensively documented. Persons with multiple sclerosis (MS), even when having limited neurological disability, appear to be less physically active when compared to age-matched controls .Therefore, they may lack, at least partially, the positive effects of physical activity on general health and MS-related changes in body structure, body functions, activities, and participation . The benUnfortunately, the barriers to be physically active are multiple and include illness perceptions that exercise might facilitate MS relapses . Meanwhihttp://www.msmachupicchu2012.be/. The opportunity of providing professional coaching and medical support during training, travelling, and expedition was taken to prospectively collect data on disease activity, fatigue, illness perception, walking abilities, and self-efficacy for exercise during a 10-month period.In the context of an awareness project to promote physical activity and participation in MS, PvA initialized an Andes trekking for 10 persons with MS, with Machu Picchu (Peru) as final destination, Ten candidates were recruited by neurologists and physiotherapists affiliated with the MS Center in Melsbroek and the fitness center “Fit up” in Kontich, Belgium. Only patients with a mild or moderate degree of neurological disability due to MS and a high potential of motivation were considered. After the first meeting in March 2012, one woman decided not to continue. Among other reasons, she did not want to have her diagnosis to be known in the public domain.Nine accompanying persons with a medical or physiotherapeutic background were also involved from the start: 3 physiotherapists, 1 exercise physiologist, 2 coaches, 1 general physician, 1 neurologist, and 1 medical student.The study protocol was approved by the leading ethical committee of the University Hospital Leuven and the local ethical committee of the MS Center, Melsbroek, Belgium.Longitudinal data were collected on medical and MS variables, fatigue, self-efficacy, walking disability, and illness perception. An overview of the timeline and assessments is given in T0, 6 months prior to the expedition) demographic, medical, and MS variables were collected, including the Expanded Disability Status Scale (EDSS) [T1), 2 during the training period , and 2 following the expedition . Illness perceptions were assessed at 3 time points . Nine participants signed the informed consent.At the first meeting, defined as time point 0 (e (EDSS) , assesseWe used the self-assessment scale of disability developed for the European study on costs and quality of life in MS , 15, whiThe “Fatigue Scale Motor Cognition” (FSMC)  was usedThe “MS walking ability scale” (MSWS 12) , 19, a rThe brief version of the Illness Perception Questionnaire (IPQ)  assessesTo improve our understanding of how participants experienced this expedition, a questionnaire was developed. Potential changes in thoughts, illness beliefs, and self-esteem were asked, as well as the contributing factors and messages for the MS community.Results were analyzed descriptively given the small sample size. For some analyses, a distinction was made between persons with EDSS 4 at baseline compared to those with a lower score. Data were also analyzed using a nonparametric test. We used the Wilcoxon signed-rank test because measurements of continuous dependent variables were available. We compared between different time points before and after the intervention for the group.Five months prior to the expedition, subjects performed a maximal graded exercise test on an electronically braked cycle ergometer . Ventilatory parameters and heart rate were continuously monitored by a 12-lead ECG device . Following a 10 min warm-up at 40 W, subjects were seated on cycle ergometer for three minutes to obtain resting data. Next, subjects were instructed to cycle at a rate of minimum 70 rpm, against a starting workload of 40 W. Hereafter, workloads were increased every 3 min by 40 W (♂) and 30 W (♀) until voluntary exhaustion. Just before workloads were increased, heart rate was registered, and capillary blood lactate , oxygen uptake, and respiratory exchange ratio were measured.T1). Group meetings were planned to evaluate walking capacities and training progression of the participants.Based on the results, a personalized training schedule was provided in May 2012  and a trip to the Colca Canyon valley, getting over 4,900 m, introduced altitude experience. The flight to Cusco  and a bus trip on September 27 brought the group to the start of the 5-day Salkantay trekking. The estimated altitude at start, altitude meters, walking time, and distance are given in Walking was also measured by accelerometer . The performance of participants was monitored by heart rate measurements (POLAR) and regular self-reported rating of walking ability and energy levels, to adapt walking pace and rest breaks when necessary. Horse assistance was provided when necessary and feasible (steepness) during the first 3 days. Because the effort was estimated to be too strenuous, parts of the trail during the last 3 days have been done by bus.Baseline characteristics of the nine participants with relapsing MS are found in Training schedules started from low levels in 3 (group 3), from intermediate levels in 4 (group 2), and from high levels in 2 participants (group 1). Each group contained one male representative.T0-T1), one subject was treated with steroids for a relapse. Two other subjects developed a relapse during the training phase (T1–T3). One of them was treated with pulse steroids. Another subject was treated with antibiotics because of a bronchial infection.During run-in . Another patient experienced increased fatigue and dizziness after having crossed high altitudes (>4000 m). Most subjects got some experience with altitude sickness at altitudes of 3600 m or more. Treatment with analgesics was given if needed. During the 5-day trekking, transient sensory complaints were mentioned and increased equilibrium disturbances were observed in several participants, without evidence for a relapse. Walking measurement by accelerometer revealed, across 5 days, an average step count of 17409 with an average daily step ratio of 94, 8% between start and end.In the months following the expedition, four patients reported increased neurological symptoms, suggestive of a relapse. For two subjects, this was the second episode. One of them was treated with pulse steroids at the two occasions.P = 0.09) and at the aerobic threshold  tended to be, respectively, lower and higher following the training and expedition period. Furthermore, POST workloads at the anaerobic threshold  were lower and peak blood lactate concentrations were higher after the training and expedition period .Compared to PRE, heart rate at 40 W . No further worsening was reported after Overall, median values of the FSMC sum transiently declined .T1 and T5 (P = 0.007). Median values for motor fatigue appeared to be reduced persistently in participants with mild disability (EDSS < 4).When using the Wilcoxon signed-rank test to compare fatigue scores at the different time points, a statistically significant difference was obtained for motor fatigue when comparing T3).Longitudinal data of the number of patients with their graded fatigue for the sum, cognitive, and motor subscale of the FSMC are shown in Overall, self-reported walking abilities and self-efficacy for exercise did not change significantly over time. However, the higher median values of the MSWS 12 in participants with EDSS 4 at baseline tended to decline transiently.Median values with interquartile ranges are presented in Participants described this expedition as heavy, both physically as mentally. Motivation and training were thought to be essential. Several subjects reported a less dominant perception of MS as they expressed having a life with MS, to make their own decisions and get respect from family and friends. Although most participants reported feeling stronger, some of them also expressed the hard confrontation with limitations due to MS. The experience of wellbeing when being physically active, the support from family, friends, and MS community, and professional coaching were experienced as very helpful and encouraging. The messages to other people with MS included advices to be physically active, to be open for new experiences, and to never give up.T5) when compared with the first (T1). When stratifying the results based on the degree of disability (having reached EDSS 4 or not), the persistence of motor fatigue tended to be more evident in participants with mild disability. Cognitive fatigue, self-efficacy, and self-reported walking abilities did not change significantly. The perceived illness consequences, identity, and concerns appeared to be declined over time.In the context of an awareness project to promote physical activity and participation in MS, we obtained prospective information on medical and disease variables, fatigue, illness perception, walking abilities, and self-efficacy for exercise from 6 months before and up to 4 months after the expedition in the 9 selected candidates. Three minor medical events (3 subjects), 7 relapses (5 subjects), and sustained neurological worsening (3 subjects) were reported in six participants. We found a significant reduction of motor fatigue at the last assessment , and the expression of concerns. Together with the message for the MS community to be open for new experiences, expressed by several participants, our data suggest a less dominant and less negative perception of MS.When diagnosed with MS, uncertainty and potential functional loss are leading to overall anxiety and threatening health-related quality of life. In an attempt to make sense of this illness experience, individuals construct cognitive models about MS. These beliefs are thought to be important for determining an individual's response , which in = 2 only). Fifth, the occurrence of medical events, relapses, and neurological worsening was primarily based on judgement by the participant. Nevertheless, confirmation by the treating physician was asked and information about MS diagnosis, comorbidities, and EDSS was obtained from the treating neurologist.We fully acknowledge the limitations of this exploratory study. First, the number of participants is limited. Second, individuals were selected on motivation and disability, given that this was the first expedition that focused on feasibility rather than proposing a standard intervention for all. We cannot generalize our findings to persons with MS with severe disability, even though we aim to encourage all persons with MS to be physically active and to participate in the community with an active lifestyle. Third, the intervention included but was not limited to physical training. In the absence of a control group, we cannot exclude random or time-dependent changes in the severity of MS-related fatigue or illness perceptions. Fourth, the small sample did not allow us to look for interaction effects in participants with mild and moderate disability (This 10-month observational study allows concluding that physical training and participation to a unique expedition has been feasible for the selected individuals with MS. Overall, minor events were observed in two thirds of the participants. All of them either had moderate disability, cardiovascular risk factors, and/or comorbidities at baseline. Motor fatigue was significantly reduced. This effect tended to be more evident in participants with mild disability.Illness beliefs tended to be reduced including a less dominant perception of MS.Further studies in MS are needed to address the role of disability, disease stage, cardiovascular risk factors, and comorbidities in training and the severity of fatigue. Distinguishing motor and cognitive fatigue and assessing illness perceptions may help to clarify the underlying mechanisms of MS-related fatigue.


Introduction. The MANGUA cohort is an ongoing multicenter, observational study of people living with HIV/AIDS in Guatemala. The cohort is based on the MANGUA application which is an electronic database to capture essential data from the medical records of HIV patients in care. Methods. The cohort enrolls HIV-positive adults ≥16 years of age. A predefined set of sociodemographic, behavioral, clinical, and laboratory data are registered at entry to the cohort study. Results. As of October 1st, 2012, 21 697 patients had been included in the MANGUA cohort . At enrollment 74.1% had signs of advanced HIV infection and only 56.3% had baseline CD4 cell counts. In the first 12 months after starting antiretroviral treatment 26.9% (n = 3938) of the patients were lost to the program. Conclusions. The implementation of a cohort of HIV-positive patients in care in Guatemala is feasible and has provided national HIV indicators to monitor and evaluate the HIV epidemic. The identified percentages of late presenters and high rates of LTFU will help the Ministry to target their current efforts in improving access to diagnosis and care. Ministerio de Salud Pública y Asistencia Social (MSPAS) started to implement specialized hospital-based HIV units—Unidades de Atención Integral (UAIs)—across the country; therefore, extending ART coverage and increasing access to care for people living with HIV/AIDS (PLHIV) : 47–240). The treated cohort has 41 741 person-years of follow-up and a median follow-up time of 2.3 years.During follow-up, 67.4% (14 616/21 697) started ART of which 98% started cART. At cART initiation, the median CD4 cell count was 126 cell/mmRetention analysis was based on the definition described elsewhere , 12. RetOverall, for the 11-year period 2001–2011, the average retention proportion was 73.8% and 61.5% at 12 and 24 months, respectively.Attrition analysis was adapted from definitions described elsewhere , 13 and In order to calculate the global LTFU rate, the analysis took into account that a single patient might have had more than one episode of LTFU. Thus, during 41 741 person-years of follow up, 8572 episodes of LTFU (including cART stops for other reasons), were recorded with a rate of 20.5 per 100 person-years, very close to the rates seen elsewhere .n = 2785) of patients were lost to the program: 575 patients (20.6%) did not return to the clinic after cART initiation (no follow-up), 1568 (56.3%) were LTFU (including cART stops for other reasons), and 642 (23.1%) died. In the first 12 months after starting cART 26.9% (n = 3938) of patients were lost to the program: 618 patients (15.7%) did not return to the clinic after cART initiation (no follow-up), 2510 (63.7%) were LTFU (including cART stops for other reasons), and 810 (20.6%) died.Attrition rates at 6- and 12-month follow-up period were studied; the 6-month interval was chosen to be consistent with the LTFU definition used; the 12-month interval was used to analyze the evolution of LTFU episodes and to be able to compare LTFU outcomes with retention rates. In the first 6 months after starting cART, 19% . Late presenters are often more ill, have a higher mortality risk, and are less likely to respond to treatment after initiation [Nevertheless, only approximately half of the patients registered in the cohort have data available on CD4 cell counts at baseline, partly due to under-notification and the fact that only some UAIs have available CD4 cell count analyzers. Among those with baseline data on CD4 cell counts, as much as 82.6% do not present for HIV testing until advanced symptoms of HIV infection  epidemiologic patterns of the HIV epidemic, (ii) delayed access to cART and burden of opportunistic infections, (iii) risk factors for LTFU and late diagnosis, and (iv) long term cART outcomes.The strengths of this cohort include its size and the representativeness of data collected from almost all registered HIV patients in Guatemala gathered from 14 of the 16 UAIs. As a main strength, data within MANGUA covers the spectrum of engagement in care, including late HIV diagnosis, suboptimal linkage to and retention in HIV care, insufficient use of antiretroviral therapy, and suboptimal adherence to therapy .In Guatemala, the AIDS surveillance system is composed of several sources of information that are not yet linked. As a result, the system is highly heterogenic and complex, making it difficult to extract data for decision making . InformaThe cohort is dependent on the quality of data entered by data entry managers from written medical records; therefore, long standing and skilled staff are required to maintain the quality of the clinical data, which is not always feasible. We attempt to validate clinical data and provide feedback to the UAIs in order to minimize errors and improve data recording. Nonetheless, data omissions, duplicated patient records, and incomplete and out-of-date laboratory and sociodemographic information might occur. In fact, there is a high proportion of missing data in key variables such as CD4 cell counts at baseline, treatment status at enrollment, transmission route of infection, and clinical stage category. This limits the ability to draw conclusions from the entire cohort because of data representativeness and selection bias due to differences in characteristics of patients with data available compared to patients without complete data available. In most UAIs it is not possible to maintain computerized records; clinical data are collected for administrative purposes rather than for clinical ones. Although the MSPAS is currently working through this, there is no standardized paper-based instrument shared in all UAIs to collect the essential variables recorded in MANGUA cohort, which would help in homogenizing data collection.The MANGUA cohort is not linked with the national registry of deaths; consequently, there is little information on AIDS-related deaths, and mortality rates may be underestimated. In addition, TB and HIV services are not well integrated in Guatemala. TB screening of HIV-positive patients is poorly performed in UAIs and patients are referred to the primary health care center for TB preventive chemotherapy and treatment. Thus, data entry managers from UAIs lack information on TB treatment outcomes on HIV patients, hampering data entry into the MANGUA application from the UAIs, and underestimating TB associated incidence among HIV-positive people.Nevertheless, the two main limitations are: first, the MANGUA application is not used directly by medical staff as an EMR in most UAIs, rather data are collected initially on paper and then digitalized. The process of informatization of the UAIs in the country may, on a medium-term basis, contribute to correct this situation. Second, high rates of LTFU may introduce selection bias due to differences in follow-up. UAI decentralization needs to be consolidated to partly overcome this problem, the stabilization of the staff in peripheral UAIs being one of its main challenges, which will assure the continuum of care and facilitate adherence to treatment.The MANGUA cohort aims to put Guatemalan HIV/AIDS research on a par with other international collaborations in the field. This will be achieved through the development of a nationally and internationally recognized policy-relevant program of research in HIV therapy and public health and through the establishment of training and research opportunities to graduate students, postdoctoral fellowships, and clinicians across the country.Our efforts to improve research dissemination to physicians and PLHIV as well as to improve knowledge and translational research will contribute to global recognition of the MANGUA cohort. Over the past 6 years, we have expanded our capacity to recruit participants, collect, extract, and analyze data, and engage clinicians, policy stakeholders, and funders. We are committed to share and promote MANGUA research findings to help shape programs and policy that will improve the lives of PLHIV in Guatemala and elsewhere.


The incidence of cardiovascular diseases (CVD) is increased in rheumatoid arthritis (RA) patients. It remains unclear whether the load of RA increases cardiovascular (CV) risk especially in female and in younger RA patients. In the present study we aim to analyse the influence of age and gender on CV risk in RA relative to the general population, using meta-analysis of direct comparative studies.Systematic literature search was performed in MEDLINE for studies reporting on occurrence of CV events in RA as compared to the general population, stratified for gender and/or age. Quality was appraised using the Newcastle-Ottawa scale. Meta-analysis was performed on rate ratios using inverse variance methods.There were 1372 records screened and 13 studies included. RA females and males have a similar higher risk (95%CI) to develop stroke with RR 1.35 (1.30–1.40) and RR 1.31 (1.21–1.43); coronary artery disease with RR 1.65 (1.54–1.76) versus RR 1.55 ((1.41–1.69) in men; cardiovascular disease with RR 1.56 (1.49–1.62) versus 1.50 (1.41–1.60). The highest incidence of CV events was observed in the youngest patients, RR 2.59 (1.77–3.79), whereas older patients had the lowest relative risk when compared to the general population, RR 1.27 (1.16–1.38).The relative risk of RA patients for CVD is age dependent, but does not depend on gender: the relative risk on CVD appears to be equally raised for males and females, while relatively young RA patients (<50 years) have the highest, and older patients the lowest relative risk. It is well-known that CV risk in RA is increased, and that the ‘excess’ risk of CVD in RA is not explained by ‘traditional’ risk factors –4. RA itThe objective of the present study is to analyse the influence of age and gender on CV relative risk in RA patients as compared to the general population, using meta-analysis of direct comparative studies.This is a systematic literature search with meta-analysis of cohort studies. A systematic literature search of the MEDLINE (via PubMed) database (1980 to December 2013) was performed to identify studies reporting on the relative risk of cardiovascular events in RA patients, as compared to people from the general population, stratified by gender and/or age. Results were pooled in meta-analysis, stratified by age and gender and CV outcome.The search strategy was performed together with a librarian, using Rheumatoid Arthritis (MESH or title/abstract), combined with: stroke, myocardial infarction, cardiovascular diseases, cerebrovascular accident, (MESH or title/abstract) combined with: men, women or male, female (MESH and title/abstract), and a limitation to English language. Reference lists of systematic reviews were screened for potential eligible studies.One author (C.P.) screened all titles and abstracts of the search result for potential inclusion. Two authors (C.P. and S.B.) then independently read the full text of the selected studies for inclusion, according to the in- and exclusion criteria. Disagreements were resolved by consensus. If consensus was not reached, another author (J.F.) was asked to read the study and a final decision was made by consensus.Studies were included if: the relative risk of CV events was assessed in a cohort of RA patients in comparison with a control cohort from the general population; if the CV outcome included myocardial infarction and/or stroke, or mortality due to CV events; if CV risk was separately reported for males and females and/or for different age groups. Studies were excluded if no comparison between RA patients and controls was made or could be made from the data available, if data were not stratified by age and/or gender, if less than 100 patients were included; if it were reviews or meta-analyses; if written in a language other than English.One investigator (J.F.) systematically extracted the following data from each study for all age groups and gender by type of outcome: standardized mortality ratio, standardized morbidity ratio, or incidence rate ratio, their components, group size, 95% confidence interval, standard error, or p-value. All included studies were analyzed in meta-analysis for the CV outcomes presented. However, not all studies contributed data for the same CV outcomes (e.g. if data were present on coronary artery disease but not for stroke) and some studies had data on multiple outcomes (e.g. on coronary artery disease as well as on stroke) or combined outcomes (e.g. coronary artery disease and/or stroke). In To indicate the risk of bias, all selected studies were assessed for quality at study level by two reviewers (J.F. and C.P.) independently using the Newcastle-Ottawa Scale; cohort studies can receive a maximum of 4 points (‘stars’) for Selection, 2 points for Comparability, and 3 points for Outcome . Disagre2.Extracted data were combined for meta-analysis using Review Manager (RevMan 5.3) software (Cochrane Collaboration). Available estimates of relative risk were combined using the inverse variance method in a random effects model . Forest We identified 1372 unique references through searching the literature databases . Based oOf the 13 included studies , 9 recei2 < 25%) to moderate (I2 < 50%) in all analyses above. When CVD was used as combined outcome measure, women and men with RA also have a similar increased risk: RR 1.56 (95% CI 1.49–1.62) in women and RR 1.50 (95% CI 1.41–1.60) in men, respectively (2 > 95%) in total and after stratification for gender (no forest plots shown).In 12 of the 13 included studies, CVD risk of RA patients was compared to people from the general population for males and females separately, one study reported only about females see . Using tectively . FinallyThere were five studies in which CVD relative risks were stratified by age group , reporti2>50%) within age groups and for the overall effect.As shown in According to the results of this meta-analysis, the well-known increased risk for cardiovascular disease of RA patients, as compared to the general population, is dependent on age, but does not depend on gender. That is to say, the relative risk on CV disease appears to be equal for males and females, the relative risk was just only slightly, non-significantly, higher in females. It also appeared that the relative risk on CVD in RA was age dependent, with relatively young RA patients (<50 years) bearing the highest relative risk and the elder RA patients (>65 years) having the lowest relative risk. Consequently, it appears that RA increases the risk on CVD in all patients, but the relative risk is largest in younger patients, for males and females alike. Due to lack of information and due to heterogeneity between studies, we were not able to pool absolute risks in this meta-analysis. Notably, relative risks are better generalizable than absolute risks and risk differences. For that same reason, it was refrained from calculating a number-needed-to-screen, a number-needed-to-treat analogue, from the inverse of the risk differences . From thHaving increased CV risk has bearings on CV prevention in RA. However, CV risk calculators used in the general population are of a limited utility in RA. They mostly underestimate the CV risk, especially in the group of patients originally classified as having a low or intermediate risk . The resTherefore, instead of searching for new cardiovascular risk factors specific for RA , improving the evaluation of CV risk in this group of patients might have perhaps a simpler solution. Based on the results of the present analysis we suggest that age must gain a different weight and meaning in RA with respect to the future risk of developing CV events. There may be at least two strategies to translate this into practice. The first one implies the change of age’s weight in the current CV risk calculators, in order to redistribute patients from lower to higher risk categories. This would result into a larger number of RA patients entitled to receive primary prevention measures/therapies. This strategy may however lead to over-diagnosis, over-treatment and might raise the costs unnecessary. Yet, no data is available to confirm or infirm this strategy. We currently undergo a study to look for the cost-effectiveness of screening for CV risk factors using various risk calculators in a primary prevention setting. One such calculator is recommended by the Dutch National Guidelines for CV risk management, and suggest adding 15 years to the age of all RA patients . If our Interpreting the evidence from observational studies requires caution. Some of the included studies had a retrospective design, which may contribute to bias. However, all included studies were of reasonable to good quality, according to the quality ratings using the Newcastle-Ottawa Quality Assessment Scale. To their strength, most of the studies used national or regional registries for diseases and all retrieved the RA sample and the general population sample from the same source population. Most studies used incidence rate ratios to compare occurrence of CVD in RA and general populations, but some used standardized mortality rations or standardized morbidity ratios. Using the inverse variance method for meta-analysis may compensate for these differences. For most of the included studies, the age and gender association with CVD was not the primary objective, which was why not all of them showed results stratified by age and gender. However, all existing studies providing these data have been included in the analysis, and therefore our results are likely to be the most representative on this topic. The most important limitation we regard, is the fact that not all the studies investigated the same CV end-points, while some studies used a combined CV outcome, which led to a relative low number of studies included in analysis per type of event .To corroborate the results of this meta-analysis, the analyses could be repeated, stratified by age and gender, for specified outcomes, in several large databases, after which the results may be combined in meta-analysis. Maybe even individual patient data meta-analysis can be used.Male and female patients with RA have a similar relative risk on CVD. Interestingly, in the youngest RA patients the relative risk on CVD is highest, independently of gender. These results may help to raise clinical attention to the risk groups, especially the younger RA patients, to improve the accuracy of predicting CV risk in RA and eventually diminish the incidence of and death due to CVD in this population.S1 Table(DOCX)Click here for additional data file.


AbstractGeophilomorpha (Chilopoda) recorded from Europe, including species of uncertain identity and those whose morphology is known partially only. The key is intended to assist in identification of subadult and adult specimens, by means of microscopy and simple dissection techniques whenever necessary. The key is freely available through the web at: http://www.biologia.unipd.it/chilokey/ and at http://www.interactive-keys.eu/chilokey/.ChiloKey is a matrix-based, interactive key to all 179 species of  Purpose: At present, species identification of centipedes (Chilopoda) can be hardly carried on through effective identification tools, because adequate keys or diagnostic tables are available only for selected faunas and taxonomic subgroups. More often, the identification of specimens still requires retrieving and interpreting the original species descriptions, which are scattered in the primary taxonomic literature. Additionally, it often requires comparing the specimens of unknown identity with reference specimens that have been already identified by expert taxonomists.Geophilomorpha, which comprises 40% of all known species of Chilopoda  are also sexually dimorphic, and because some characters are applicable and effective in distinguishing species only for the male but not for the female or vice versa.Morphological terminology: The key follows the conventional morphological terminology defined and illustrated by Operational methods: Only a few characters can be evaluated properly by means of a stereomicroscope, with incident light and at low magnification. In most cases, it is recommended to examine the specimen by means of a microscope, in transmitted light and at higher magnification, after including the specimen in a non-permanent microscopic slide.The effective evaluation of some characters requires one or both of the following operations:– detaching head from trunk. Recommended protocol: keeping the specimen under a stereomicroscope, on soft ground, with the dorsal side upwards; piercing the dorsal membrane between head and forcipular tergite repeatedly by means of a scalpel-like pin;– detaching the maxillary complex from the remaining part of the head. Recommended protocol: after detaching head from trunk, keeping the head under a stereomicroscope, on a soft ground, with the ventral side upwards; piercing the lateral membranes connecting the second maxillary coxosternite to the pleurites repeatedly by means of a scalpel-like pin.Further practical instructions are given by PageBreakCharacters: A total of 89 characters have been considered, including 51 binary characters, 37 multistate characters with 3–5 alternative states each, and a “filtering” character (number of leg-bearing segment), which is allowed to assume any integer value up to 999. Of the characters, 15 are depending on the state of another character, therefore their applicability is constrained. The characters have been selected giving priority to those with null or negligible intraspecific variation with respect to our state definitions, and to those that do not require dissection. Among the characters proposed and employed in the literature as diagnostic between species, we excluded those that have been found or suspected to be actually poorly effective, because of either intraspecific variability or artifactual origin (l origin . In the l origin : (i) chaSources of data: Characters have been coded for each species referring to selected published descriptions and illustrations  there is interindividual variation, including sexual dimorphism, or (ii) the actual condition of the character is uncertain in the species, or (iii) subjectivity in evaluation could bring different users to score different states as present in the specimens at hand.PageBreaktentatively by considering the known average figure in the species and hypothesizing a 30% coefficient of variation ; “Short description”; “Similar species” ; “Distribution” ; “Taxonomic notes”; “Main references” http://www.biologia.unipd.it/chilokey/b)http://www.interactive-keys.eu/chilokey/Repository: Department of Biology, University of Padova, Padova, ItalyMetadata language: EnglishDate of metadata creation: 2014-06-05Platform: Windows Server 2003 - Microsoft Framework. NET 4Programming Language: Asp.NETData base: MS Windows SQLSERVER, IIS6, NET 4.0Application version: ChiloKey 1.0Update police: The application can be augmented/updated only by, or in agreement with, the corresponding authors of this paper. Authors keep updated both the web apPageBreakplication, by implementing new functions, and the data matrix, by improving encoded descriptions of terminal taxa. Every change can be monitored on the homepage and reported in the TXT export data file, by updating the number of the application version and by changing the date of the last modification to the data matrix. A short message on the homepage may describe differences from the previous version, if needed.Use of the primary data: Primary data are available from the corresponding authors by agreement.Licence for the use of the key: Creative Commons Attribution License 3.0 (CC-BY), which permits unrestricted use, distribution, and reproduction in any medium, provided the original authors and source are credited.