To date there has been no population-based survey of the major risk factors for non-communicable diseases (NCD) in Uganda. Hospital-based data from urban centres report an increasing burden of NCDs in Uganda. This population-based survey aimed to describe the prevalence of risk factors for NCDs in a rural Ugandan district.n = 611) were residents of the Kasese district selected in a one-step, complete survey of a rural district. Standardised international protocols were used to record history of disease, and measure behavioural risk factors , physical characteristics , fasting blood glucose (BG) and total cholesterol (TC) levels. Data were analysed using simple descriptive analysis.The survey was conducted using the WHO STEPwise approach to surveillance of non-communicable diseases (STEPS) methodology. Participants (2] and 4.9% of men and 9.0% of women were obese (BMI ≥ 30 kg/m2). Nine per cent of participants were diabetic, 7.2% ate five or more combined servings of fruit per day while only 1.2% ate five or more combined servings of vegetables per day. Fifty-one per cent of the population were physically inactive and 9.6% were daily smokers. Thirty-one per cent of females had fasting blood sugar levels (FBS) ≥ 6.1 mmol/l while 10% of males had FBS > 6.1 mmol/l.In this sample, the prevalence of hypertension (systolic BP ≥ 140 mmHg and/or diastolic BP ≥ 90 mmHg) was 22.1% for men and 20.5% for women. Fifteen per cent of men and 16.8% of women were overweight [body mass index (BMI) ≥ 25 kg/mThis study presents evidence on the magnitude of NCDs, their risk factors and gender distribution in a rural population in Uganda, a poor country in east-central Africa. These data, when combined with urban population data, could be useful in the formulation and advocacy of NCD policy and plans of action in Uganda. Non-communicable diseases (NCDs) are currently responsible for 35% of all deaths in low- and middle-income countries,1This epidemiological transition in global health from infectious diseases to NCDs is posing not only a threat to the health of those affected but also places an enormous burden on the health systems of nations, particularly those of the least-developed countries, as they must now address a double burden of acute and chronic diseases amidst scarce resources.5In Uganda, while acute infectious communicable diseases still contribute the major 75%) disease burden, with malaria, acute respiratory infections and HIV/AIDS among the top 10 causes of illness and death,5% diseas9Estimates of age-standardised mortality from NCDs suggest that countries in SSA, including Uganda, might have a more than three-fold higher mortality rate than several European countries, including the UK.14To date, there has been no systematic population-based study on NCD risk factors conducted in Uganda. Accordingly, between December 2011 and February 2012, we conducted a cross-sectional survey using the WHO NCD STEPS survey tools to determine the magnitude of NCDs and their risk factors in Kasese district, Uganda to serve as a pilot study for the nationwide survey of NCD risk factors.Ethical approval was granted by the Uganda National Council for Science and Technology’s Human Research and Ethics Committee, and the President’s Office Research Secretariat. Written informed consent was obtained before participants were enrolled in the study, using the WHO NCD STEPS survey consent form.This study was a community population-based, cross-sectional survey designed according to a WHO STEPwise approach to chronic disease risk-factor surveillance.Kasese district is divided into two counties, Bukonzuo (10 sub-counties) and Busongora (12 sub-counties). One sub-county was selected from each county. Bugoye sub-county from Busongora is predominantly rural, whereas Mpondwe sub-county from Bukonzuo is peri-urban. The two sub-counties selected are the most populous in each county. Both sub-counties comprise 14 parishes, 61 villages with a total of 11 986 households. Using the cluster sampling method, seven households were randomly selected from each village. Finally, at least one adult in the selected households was invited to participate. Where a household had no consenting adults, the neighbouring household was approached.The survey was conducted using the WHO recommended STEPwise approach.Step 2 involved physical body measurements, including BP, height, weight, and waist and hip circumference measurements. BP measurements were taken using battery-powered digital BP machines (Omron M3-I). The participant was asked to sit on the chair and rest quietly for 15 minutes with his/her legs uncrossed. The left arm of the participant was then placed on the table with the palm facing upward. Three readings, three to five minutes apart, were then taken on the left arm. During the analysis the average of the last two readings was the final BP reading used.Height was measured with the participant standing upright against a wall on which a height mark was made. Measurements were taken with the participant barefoot, standing with the back against the wall and head in the Frankfort position, with heels together. The participant was asked to stretch to the fullest. After being appropriately positioned, the participant was asked to exhale and a mark was made with a white chalk to mark the height. The height was then measured to the nearest 0.1 cm from the mark to the floor using a tape measure.Weight measurements were taken on a pre-calibrated weighing scale . Participants were weighed dressed in light clothing and barefoot. Measurements were taken to the nearest 0.1 kg.Step 3 involved laboratory tests. Consenting participants were asked not to consume any food, only water from after supper that day until the survey team collected the blood samples the next day (eight-hour fast). People converged at the agreed place in their community. Those who had complied with the overnight fast were eligible for finger-prick blood sample collection. Total cholesterol (TC) and triglyceride (TG) levels were measured using Reflotron-Plus machines manufactured by Roche. Fasting blood glucose (FBG) level was measured on two machines, the Accu-Chek Active glucometer from Roche and the Soft-Style glucometer from Chem-labs.2 and obesity as BMI ≥ 30.0 kg/m2.Hypertension was defined as a diastolic BP of 90 mmHg or more, or a systolic BP of 140 mmHg or more, or currently on medication for hypertension . Diastolic BP ≥ 110 mmHg or systolic ≥ 180 mmHg was considered to be severe hypertension. Raised fasting blood glucose was defined as a blood glucose level ≥ 7.0 mmol/l or currently on medication for diabetes mellitus . Raised total cholesterol was defined as cholesterol level ≥ 5.0 mmol/l. Overweight was defined as body mass index (BMI) ≥ 25.0 kg/mExcessive or harmful use of alcohol was defined as the consumption of five or more for men, four or more for women, standard units per day for three or more days per week. Physical activity was measured using questions on four different aspects: physical activity at the workplace, physical activity during recreation time, physical activity while travelling, and physical resting time. A heavy smoker is, according to the recommendations of the World Health Organisation (WHO), a smoker with a daily consumption of more than 20 cigarettes.p < 0.05.Data were collected manually using case record forms (CRFs), captured into epi-data and later transferred to STATA version 10 for analysis. Values are expressed as percentages of total respondents. Simple bivariate analysis was used to analyse the data. Priority was given to practical benefit and clinical significance in interpreting statistically significant data. Statistical significance was set at A total of 611 eligible adults were selected and approached to participate in the survey. Of these, 93 (15.22%) refused while 518 (84.87%) consented to take part in the survey. Of the 518 participants who took part, 56% were female and 29% had no formal education, while 41% had primary school education. BP, and fasting blood sugar and total cholesterol levels were measured in 100, 25.7 and 27.8%, respectively of the 518 participants , Table 1p = 0.758; DBP, p = 0.503).Sixteen per cent of females and 11% of males were told by the doctor that they had hypertension, while only 8% of females and 7% of males with diagnosed hypertension were currently on medication for hypertension Ten per cent of males had fasting blood sugar levels > 6.0 mmol/l compared to 33% of females, while 12.5% of male had a positive family history of diabetes mellitus (DM) and 3.5% were on treatment for DM. Sixteen per cent of females had a positive family history of DM and 2.2% were on treatment for DM Figs , 5.The prevalence of underweight, overweight and obesity were more frequent in women than men  p = 0.703)  and excessive alcohol drinking were more common in men than women . There was no significant difference between the genders with regard to physical activity  Figs .This is the first population-based survey using internationally standardised protocols to report the prevalence of risk factors for NCDs in the Kasese district of Uganda. This study demonstrated that chronic non-communicable diseases and their risk factors constitute a public health problem in the Kasese district, with at least one in five men smoking tobacco, one in five with hypertension, one in 10 with a positive family history of DM, one in five being pre-diabetic and therefore a candidate for the metabolic syndrome, and one in five overweight/obese.The first major finding of this study was the high prevalence of hypertension, both self-reported and point-measured BP during the survey. The majority of people with hypertension did not know they had this medical problem, which is consistent with findings from other studies in sub-Saharan Africa.Factors not measured in this survey, and which may explain the observed risk among women, were hormonal status, saturated fat consumption and salt intake. Also, further studies should be done to document the proportion of those on treatment whose BP is under control, as well as the presence of hypertensive heart disease among those with hypertension.The second major finding was that the risk profile of this predominantly rural population of Kasese was markedly different from that reported previously for the urban and peri-urban settings.There was a high prevalence of underweight people (29.9%). When taken together with the observed rates of DM and glucose intolerance, questions arise with regard to the possibility of a connection between under-nutrition and DM.In general, this study highlights the need to undertake population-based studies in all districts in the country to quantify the magnitude of NCDs at a national level. It is evident that there is variation among ethnic groups and locations, as various factors contribute to the development of disease and other factors contribute to the perpetuation of diseases.In order to institute a cost-effective intervention, the specific factors at play in a given population must be identified. It may not be appropriate to generalise these findings to refer to the Karamoja population. These results though are useful in guiding intervention and preventative measures for the Kasese population, and should be well received by policy makers in the local government of Kasese, as well as the ministry headquarters. For example, vegetables and fruits are grown in large quantities in Kasese, but consumption is low. Most are sold to the cities. The population is not aware of the benefits to their health of eating fruit and vegetables. Mass education to encourage increased consumption of fruits and vegetables will benefit the population.A key strength of this study was the use of a representative sample, with analysis taking into account the complex survey design. The relatively high response level minimises the likelihood of selection bias, and the range of factors that were measured should be a good reflection of those factors in the Kasese population. The use of WHO standardised protocols, intensive training of data-collection staff, pre-study testing of procedures, and the close supervision of staff during data collection all highlight the attention that was paid to minimising avoidable sources of measurement error.Limitations of this study need to be borne in mind. The STEPS methodology is designed to provide standardised information on key modifiable risk factors that can be measured in population-based surveys without resorting to high-technology instruments. It is not designed to measure total energy intake, dietary fat, dietary sodium, body fatness or physical activity by objective methods, such as accelerometry and pedometry. Information on these factors would have provided a more comprehensive picture of the relationships we studied. In addition, these cross-sectional data do not allow age-related differences in BP, blood glucose and total cholesterol levels to be attributed to ageing, independent of cohort effects. Assessment of risk factors by age group as well as fasting blood sugar level for different BMIs would have provided more insight. Finally, due to lack of power, we were not able to assess the relationship between underweight and diabetes.This study provides the first NCD risk-factor profile of people in the Kasese district, Uganda, using internationally standardised methodology. Our findings for this predominantly rural sample provide evidence for health policy-makers as well as district authorities on lifestyle problems in the population studied. The burden of more diseases is to be expected if an effective prevention strategy is not undertaken.Although even short-term educational programmes have been shown to be effective in improving lifestyle, a durable education strategy and cost-saving policies supported by sustained largescale media education and school-based educational programmes could be the starting point for a possible national programme on controlling NCDs in Uganda. A national NCD risk-factor survey should however be undertaken to avoid biased generalisation of results, as Kasese is not a representative population of Uganda.


The retinoblastoma tumor suppressor (Rb) pathway is mutated in most, if not all human tumors. In the G0/G1 phase, Rb and its family members p107 and p130 inhibit the E2F family of transcription factors. In response to mitogenic signals, Cyclin-dependent kinases (CDKs) phosphorylate Rb family members, which results in the disruption of complexes between Rb and E2F family members and in the transcription of genes essential for S phase progression. Beyond this role in early cell cycle decisions, Rb family members regulate DNA replication and mitosis, chromatin structure, metabolism, cellular differentiation, and cell death. While the RB pathway has been extensively studied in the past three decades, new investigations continue to provide novel insights into basic mechanisms of cancer development and, beyond cancer, help better understand fundamental cellular processes, from plants to mammals. This meeting report summarizes research presented at the recently held 3rd International Rb Meeting. The Rb tumor suppressor was cloned more than 25 years ago from children with retinoblastoma -4. This Major challenges in the field include determining the biochemical mechanisms carried out by multiple Rb-containing complexes in cells, exploring the role of novel Rb functions in tumor suppression, and identifying the combinations of genetic alterations that result in tissue-specific cancers. The ultimate goal of the field is to discover novel therapeutic approaches to stop or slow the growth of human tumor cells with mutations in the Rb pathway. Accordingly, research on Rb and the networks around Rb in cells remains intense with publication of nearly 1,000 relevant journal articles a year.Two previous international Rb conferences were organized in 2009 and 2011 in Toronto, Canada by Eldad Zacksenhaus and Rod Bremner. The success of these first two meetings coalesced a large group of investigators with a strong interest in participating in a scientific meeting focusing on the Rb pathway, which would be organized every other year in a rotating manner by active participants. 88 researchers in the Rb field recently gathered to exchange results and ideas at the 3rd International Rb Meeting, which was held October 7–10, 2013, in Monterey, CA, USA. The conference included 33 oral presentations and 45 posters. While we cannot summarize here all these studies, many of them unpublished, we highlight several topics discussed.RB mutations, and the St Jude’s Children’s Research Hospital now provides access to a large number of data and reagents . A number of other groups, including those of Josephine Dorsman and David MacPherson, are performing genomics studies on patient-derived retinoblastomas as well as tumors from genetically engineered mice )C. elegans , in D. melanogaster , and in plants (Wilhelm Gruissem and Arp Schnittger) was presented on the role of Rb-like and E2F-like molecules [The Rb field has been primarily driven by the role of the Rb pathway in cell cycle control and cancer. However, interesting work in yeast (Jan Skotheim), in olecules ,40-47. Tolecules .The Rb field is vibrant and relevant to many areas of biology, including cancer biology, developmental biology, stem cell biology, and regenerative medicine. A major goal of the Rb meeting, and its highest impact, is to offer a unique forum for building a community of scientists working together, advancing scientific knowledge. The 3rd International Rb Meeting offered hope that 20 years of molecular studies would soon translate into novel therapeutic options in a large number of patients. At the same time, the conference further highlighted the need for many more years of biochemical, structural, cellular, and organismal studies to better understand the regulation and the mode of action of Rb in plants and animals. The 4th International Rb Meeting, which will take place in Boston in 2015 and will be organized by Drs. J. Lees (MIT), N. Dyson , and J. DeCaprio , will with no doubt reveal further unexpected findings and continue to strengthen this field of intense research.Rb: retinoblastoma; CDK: Cyclin-dependent kinase.The authors declare that they have no competing interests.Both authors contributed equally to this manuscript and are listed in alphabetical order. Both authors read and approved the final manuscript.


To the Editor: Fluoroquinolones have been the drug of choice for treating typhoid and paratyphoid fever since the beginning of the 1990s. Multidrug-resistant strains began to prevail in disease-endemic areas, and former first-line antimicrobial drugs, such as chloramphenicol, were sometimes ineffective  and to ofloxacin. The MIC of ofloxacin was as high as 256 µg/mL, and the MIC of ciprofloxacin was128 µg/mL . An opengyrA, gyrB, parC, and parE genes were investigated. The primers used for PCR amplification and DNA sequencing have been previously described , which substitutes phenylalanine for serine, and at codon 87 (GAC to AAC), which substitutes asparagine for aspartic acid. The third mutation was in the parC gene, which encodes DNA topoisomerase IV, at codon 84 (GAA to AAA), which substitutes lysine for glutamic acid. No mutations were found in gyrB and pare E.Polymerase chain reaction (PCR) amplification and DNA sequencing were conducted to detect mutations responsible for the fluoroquinolone resistance. Nucleotide sequences of S. Typhi and Paratyphi A with decreased susceptibility to fluoroquinolones emerged on the Indian subcontinent, Southeast Asia, and Central Asia in the mid-1990s (S. Typhi have 1 point mutation at the target site of quinolones, DNA gyrase, in the quinolone resistance–determining region of gyrA, either at codon 83 or codon 87 (S. Typhi and Paratyphi A in ciprofloxacin-supplemented medium (S. Paratyphi A had triple mutations in the gyrA gene at codons 83 and 87 and in the parC gene at codon 84, which are the same triple mutations as those seen in the current in vivo case.An experimental attempt had been previously made to induce the production of strains with high-level fluoroquinolone resistance by culturing strains of Salmonella species. In a clinical isolate of S. enterica serovar Typhimurium, the MIC of ciprofloxacin was 32 µg/mL, and mutations in both gyrA and gyrB were noted (Full fluoroquinolone resistance has already emerged in the community in nontyphoid S. Paratyphi A under selective pressure of frequent quinolone administration. The resistance is associated with the 2 mutation sites in gyrA and 1 site in parC, and multiple point mutations are likely related to the acquisition of full resistance. Physicians should be aware of the emergence of S. Typhi and Paratyphi A, as well as nontyphoid Salmonella species, which are highly quinolone-resistant.Our findings strongly suggest that high-level quinolone resistance was induced through the long-term carrier state of


Teladorsagia circumcincta and, to lesser extent, Trichostrongylus colubriformis, a result that was not achievable by LC. The key findings from this study demonstrate that our PCR-coupled FECRT approach has major merit for supporting anthelmintic resistance in nematode populations. The findings also show clearly that our PCR assay can be used as an alternative to LC, and is more time-efficient and less laborious, which has important practical implications for the effective management and control strongylid nematodes of sheep.The accurate diagnosis of parasitic nematode infections in livestock (including sheep and goats) is central to their effective control and the detection of the anthelmintic resistance. Traditionally, the faecal egg count reduction test (FECRT), combined with the technique of larval culture (LC), has been used widely to assess drug-susceptibility/resistance in strongylid nematodes. However, this approach suffers from a lack of specificity, sensitivity and reliability, and is time-consuming and costly to conduct. Here, we critically assessed a specific PCR assay to support FECRT, in a well-controlled experiment on sheep with naturally acquired strongylid infections known to be resistant to benzimidazoles. We showed that the PCR results were in close agreement with those of total worm count (TWC), but not of LC. Importantly, albendazole resistance detected by PCR-coupled FECRT was unequivocally linked to  Teladorsagia, Trichostrongylus, Haemonchus, Nematodirus, Cooperia, Chabertia and/or OesophagostomumStrongylid nematodes of ruminants are responsible for substantial economic losses due to the diseases that they cause and the costs associated with their treatment and control The accurate diagnosis of nematode infections is central to their effective control, supports investigations into their epidemiology and ecology, and, importantly, can assist substantially in the monitoring of anthelmintic resistance in strongylid populations. Such resistance has emerged as a major economic and bionomic problem in vitro methods, such as egg hatch- and larval development assays, have been used for estimating levels of drug-susceptibility/resistance in strongylid nematodes of small ruminants, cattle and horses. However, these assays can suffer from a lack of reliability, reproducibility and sensitivity Nematodirus). Therefore, the technique of larval culture (LC) is required to allow eggs to develop through to third-stage larvae (L3s), which can then be differentiated morphologically. However, LC has intrinsic limitations, which relate predominantly to the different requirements for hatching and larval development of individual nematode species Various There have been significant advances in establishing molecular methods for the genus- or species-specific diagnosis of strongylid infections in livestock The present study was conducted on a farm in Rokewood with owners permission [37°53′S/143°43′E], Victoria, Australia, with a known resistance problem in strongylid nematodes against one or more benzimidazoles; Relevant permission was granted from the owner of this farm to undertake this observational field study, which involved routine anthelmintic treatment of sheep and collection of faecal samples from sheep on this farm in Rokewood. This study was approved by the Animal Ethics Committee (AEC no. 0810850.1) of the University of Melbourne. Merino sheep  were available for FECRT and were shown previously to have average faecal egg counts of ≥150 EPG. Sheep were divided randomly into four groups (of 20 each), designated AB , ABC , MP (monepantel-treated) and MPC (monepantel-untreated control), respectively. For one sheep in group AB, no faecal sample was obtained after repeated sampling attempts, such that 19 samples could be collected. Groups AB and ABC were kept on the same pasture as were MP and MPC. Albendazole  and monepantel  were administered orally by a qualified veterinarian using a syringe at a dose of 4.75 mg/kg  and 2.5 mg/kg (monepantel), according to the bodyweight of the heaviest sheep in groups AB and MP, respectively. The experiment was conducted over a period of 13 days. Faecal samples were collected from sheep on days 0 and 10. Groups AB and MP were treated on day 0. A total number of 30 sheep (see subsection 2.3) were necropsied on day 13.Fresh faecal samples (6.5–20 g) were collected directly from the rectum of individual sheep into plastic bags, chilled for transport and then stored at 4°C for a maximum of 1 week Teladorsagia/Trichostrongylus, Haemonchus and Chabertia/Oesophagostomum L3s. Total lengths of L3s were measured to differentiate Teladorsagia from Trichostrongylus, according to the criteria of three different authors Te. circumcincta and Trichostrongylus, 50 L3s from each culture were exsheathed in aqueous hypochlorite (5%), and their caudal morphology examined for the presence/absence and number of tubercles For each of the four experimental groups, an equal amount of faeces (2.5 g) from each individual sample was used to set up a 50 g composite LC in a plastic beaker. The cultures were incubated at 25°C for 10 days. L3s were then recovered by filling each beaker with water (25°C) and inverting it on to a Petridish Three days following the second collection of faecal samples (on day 13), nine, nine, nine and three sheep were selected randomly from groups AB, ABC, MP and MPC, respectively, and then necropsied . The entire gastrointestinal tract was removed from each of these sheep. Ligations were positioned anterior and posterior to the abomasum. TWC was performed as described by Anderson Haemonchus contortus, Teladorsagia circumcincta, Trichostrongylus spp., Chabertia ovina and Oesophagostomum venulosum, respectively. In addition, primer pair NC1–NC2 Te. circumcincta, T. axei, T. colubriformis, T. vitrinus and C. ovina .Genomic DNA from strongylid eggs, isolated from individual faecal samples, were column-purified and diluted (1/50) as described previously H. contortus and then subjected to PCR. The amplification results from these aliquots were compared directly (in the same experiment) with that from 1 pg of H. contortus DNA alone and a sample without DNA (no-template control).Any suspected inhibition in the PCR assay, potentially linked to faecal constituents , was assessed for all samples for which there was a discrepancy in results between faecal egg count and PCR. In brief, aliquots (2 µl) from samples that were test-negative by PCR, but were shown to contain strongylid eggs by coproscopic examination, were spiked with a limited amount (1 pg) of genomic DNA from http://www.vetsci.usyd.edu.au/sheepwormcontrol/index.html). A population of stronglid nematodes was defined as resistant to an anthelmintic if the reduction in EPG was <95% and the lower confidence limit of the percentage of reduction was <90% http://www.clive.ed.ac.uk./winepiscope/); 95% confidence intervals (CI) for sensitivity and specificity values were calculated using the exact binomial method in Stata. The sensitivity of the specific PCRs for the detection of patent strongylid nematode infections was calculated by comparing the presence of adult female worms of individual species and the corresponding PCR results . Of these samples, there were nine, for which no strongylid eggs were detected by faecal flotation. The molecular analysis of 79 individual faecal samples collected on day 0 revealed that the largest percentage of test-positive faecal samples related to Te. circumcincta (84%), Trichostrongylus (92%) and, to a lesser extent, C. ovina (56%), which was a consistent pattern for all four groups on day 0  of these samples contained strongylid eggs. The arithmetic mean EPG in group AB decreased from 142 (day 0) to 41 (day 10), whereas there was no decrease in their corresponding (untreated) control group. The mean number of EPG in the group MP decreased from 177 (day 0) to 5 (day 10), whereas the numbers increased slightly in group-MPC see  during ton day 0 . No sampP  = 0.047). On day 10, all of the 15 test-positive samples in group AB related to Te. circumcincta, and three to Trichostrongylus, whereas C. ovina was not detected . The melting-curve analysis of all 301 amplicons produced in this study  as well as selective sequencing and comparison of resultant sequence tags (n  = 26) with reference sequences demonstrated unequivocally the specificity of both the amplicons and the PCR conditions employed.Using the PCR assay, 19 sheep in group AB were test-positive on day 0 and 15 sheep were test-positive on day 10. In contrast, all 20 sheep in group ABC were test-positive by PCR on days 0 and 10  but not in the others. Morphometric comparisons of these L3s, according to Gordon Te. circumcincta as the most abundant parasite for each group, followed by Trichostrongylus spp., whereas Chabertia/Oesophagostomum were least abundant. This relationship was most pronounced in group AB, wherein >90% of the L3s were identified as Te. circumcincta. Measurements of total body length of L3s with a sheath extension of 30–40 µm inferred Te. circumcincta and Trichostrongylus spp. in groups ABC and MPC, and mainly Te. circumcincta in group AB  and C. ovina in 21 (70%), 16 (53%) and eight (27%) of the sheep examined, respectively , whereas just three, low intensity infections of Trichostrongylus  were found, and no Chabertia or Oesophagostomum. These results are consistent with those achieved by PCR and LC using the morphometric criteria defined by Gordon To provide an independent comparison of LC and PCR, we conducted a routine TWC on 30 sheep . Because test-positive results in LC and PCR are dependent on the presence of eggs in faeces, TWCs related to the numbers of adult female worms in individual sheep, although worms of both sexes were counted see . TWC datectively . MoreoveTe. circumcincta, Trichostrongylus and C. ovina in 22 (73%), 12 (40%) and eight (27%) of the sheep examined, respectively  for which TWC reference data were recorded. Similarly, although Trichostrongylus DNA was detected by PCR in a sample from sheep no. 1442 from group AB, no worms were detected by TWC in the same sheep. Nonetheless, adult females of Te. circumcincta and Trichostrongylus (i.e. T. axei and T. vitrinus) were detected by TWC in sheep no. 1330 from group ABC, but DNAs from these parasites were not detected in the faeces from this sheep by PCR on day 10. Trichostrongylus DNA was detected by PCR in the faeces from 12 sheep with 160 to 11,850 female worms per sheep, but not in four sheep  in which <100 adult female worms per sheep were found. In spite of some differences in results between PCR and TWC, the diagnostic performance of the PCR was high. Using TWC as a reference method, PCR achieved an overall sensitivity  of 100%, a specificity of 87.5% and a Kappa value of 0.91  were PCR-test negative for this genus. Three of these four sheep were in groups AB and MP, suggesting that anthelmintic treatment led to a reduction in fecundity or affected the ability of the female worms to produce intact eggs, although this was not apparent upon morphological examination of these worms following TWC. Alternatively, the eggs themselves, and their DNA, may have undergone degradation in the gastrointestinal tract during or following treatment. Furthermore, the detection of low intensity infections by faecal flotation can be challenging due to the dilution and uneven distribution of eggs in the faeces of the host as well as daily variations in egg excretion H. contortus, O. venulosum and C. ovina) can be more readily detected in sheep with small worm burdens than those for species with low fecundity  The diagnostic performance of the molecular assay assessed herein was high (sensitivity 100% and specificity 87.5%) in relation to TWC. Only for a small number of sheep there was a disagreement in the results between the two tests. Of the 136 faecal samples that contained strongylid eggs, only ten samples were test-negative by PCR (with no evidence of inhibition). Notably, for all PCR test-negative samples, EPG was <250, and all but one were collected from sheep following anthelmintic treatment. Microscopic examination revealed an abnormality in eggs and their shells from these samples, suggesting that the eggs were not viable and that DNA degradation led to these ‘false-negative’ PCR results. However, egg loss during flotation may also have contributed, suggesting that the direct isolation of DNA from faecal matter should be explored. Four sheep with ∼100 adult female worms of False-positive results were uncommon. In all nine cases, for which amplicons were produced from faecal samples in which no strongylid eggs were detected, subsequent sequencing confirmed, unequivocally, their specific identity, showing the limited sensitivity of the McMaster flotation method, also consistent with our previous field study Te. circumcincta in all and T. colubriformis in three sheep with EPGs of 0–120 following treatment. Although C. ovina was initially detected in eight sheep in group AB (on day 0), this nematode was not detected following albendazole treatment (on day 10), providing no evidence of drug resistance in this species. Based on these data, a specific diagnosis of resistance to albendazole was possible and indicated a predominant link to Te. circumcincta and, to lesser extent, T. colubriformis.Consistent with EPG and TWC data, the present PCR results did not show any evidence of resistance to monepantel in gastrointestinal strongylids, supporting previous reports of the efficacy of this new anthelmintic Teladorsagia and Trichostrongylus species. Most notably, when using the criteria defined by Dikmans and Andrews Trichostrongylus rather than Te. circumcincta, thus leading to an entirely different diagnosis and conclusion regarding resistance. The inference that Trichostrongylus had the highest level of resistance to albendazole was neither supported by the PCR-test results nor the TWC data, emphasizing the problems associated with the use of LC. The limitations in the differentiation of some parasites following LC are reinforced by findings that host  and/or environmental factors  can influence the length of the developing L3s C. ovina and Oesophagostomum and differentiate them, L3s of these parasites cannot be delineated morphologically Using the criteria defined by Gordon In conclusion, based on the results of the present and previous studies intra vitam diagnosis of strongylid infections in sheep and, combined with conventional FECRT, for assessing the emergence of anthelmintic resistance, without the need for additional costly and time-consuming ante mortem  or post mortem (TWC) analyses. Further applications of PCR might include its use for assessing the monospecificity of cultures used for a range of experimental investigations of strongylids and mechanisms of drug resistance in particular species or, for instance, to assess the status of parasitism in flocks of sheep destined for import/export. Given the broad applicability of such a molecular-diagnostic assay, our current focus is now on adapting it to a semi-automated platform for routine application in a service laboratory setting.Taken together, our results show that the present PCR is useful as a rapid approach for routine


To measure the extent to which health-related quality of life (HRQoL) in people living with HIV is associated with duration of antiretroviral therapy (ART) after controlling for sociodemographic, clinical, and other therapy-related factors.Cross-sectional analysis.A gender-stratified random sample of 421 participants aged 18–64 years was selected from the patients on ART at a health facility in Kenya. Three hundred and ninety two patients participated in the study, representing a 93% response rate. Data on general physical and mental health functioning status were collected using the SF-36 health survey questionnaire. Hierarchical logistic regression analysis was used to predict the SF-36 summary scores.In regression analyses, the duration of ART was negatively associated with HRQoL (odds ratio (OR): 0.6, 95% confidence interval (CI): 0.45–0.92) after controlling for sociodemographic, clinical, and other therapy-related factors. Patients with chronic diseases or clinical symptoms of acute illness had significantly worse HRQoL . Therapy interruptions, adverse drug reactions, and World Health Organization stage at initiation of therapy were not associated with HRQoL.Patients on ART for a relatively longer duration reported poorer HRQoL at the study facility independent of the effect of other therapy-related, clinical, and sociodemographic factors. Program managers and clinicians in the Kenyan health system may need to refocus attention on this subgroup to avert ‘loss to treatment’ that may have negative repercussions on the substantial gains made against the HIV scourge. While the HIV epidemic remains a major global public health concern, and more so in developing countries, considerable gains have been made in stemming its economic and social toll on communities . AntiretHealth-related quality of life (HRQoL) is a multidimensional psychometric construct that is distinct from the concept of ‘quality of life’ in that it focuses on those aspects of the human experience and a person's assessment of the same that are amenable to health interventions . It deriOf those that have assessed the variation of HRQoL in PLHIV with time, findings have been mixed. On one hand, in a longitudinal study assessing factors associated with HRQoL, Jelsma et al.  found thThe aim of the this study was therefore to investigate to what extent duration on ART in PLHIV predicts patients’ self-perceived health status independent of their current and pretreatment clinical health status as well as other well-known therapy-related and sociodemographic factors associated with HRQoL. If duration of ART is associated with changes in HRQoL, then a good level of understanding of the underlying mechanisms may aid health system and HIV program managers to supplement objective clinical status measurements with self-assessed general health in ensuring an optimal health outcome environment among patients at different stages of treatment.The cross-sectional study was conducted between February and April 2013 at Nyeri Provincial General Hospital (Nyeri PGH), Nyeri County, Kenya. Nyeri County is located in the central highlands of Kenya, about 150 km north of the capital Nairobi. Nyeri PGH is the main referral hospital in the region, with the catchment area extending to at least four other neighboring counties. As a regional referral hospital, it serves both curative and rehabilitative functions in addition to preventive services to a population of about 700,000. HIV prevalence in Nyeri County is estimated at 4.4% compared to the national average of 6.2% .Practical Manual for Sample Size Determination in Health Studies  for at least 1 month, and had a clinic appointment within the study period. Consequently, from a total population of 1,693 patients on HAART, 1,189 met the inclusion criteria. Since HIV prevalence is biased on gender .The 36-Item Short-Form Health Survey (SF-36)  instrumeThe study's primary explanatory variable (duration of ART) and control variables were obtained from an addendum to the SF-36, clinical, and pharmacy records. The electronic clinical and pharmacy records were imported and collated into a software application with a relational database management system at the backend. The variables were classified into three broad categories:Information on age and gender was obtained from the pharmacy records, whereas information about the participants’ education, income, marital status, religion, and occupation was captured through the addendum to the SF-36. Patients’ pretreatment clinical status was assessed using the WHO HIV stage at therapy initiation obtained from clinical records. Information on the patients’ current health was obtained from questions about their experience of acute and HIV-related constitutional symptoms in the 4 weeks preceding the interview as well as comorbidities. Checklists from prior studies assessing constitutional symptoms  and chroPharmacy and clinical records were used to obtain information on medication adherence, therapy interruptions, and clinic appointments. Medication adherence was weighted with the extent to which patients made clinic appointments on time. The algorithm is summarized in Sample characteristics were assessed using measures of central tendency and dispersion. Further analysis of dependence involved the Pearson chi-square test of independence and the OR.In order to study the effect of duration on ART on HRQoL and how this effect improved the ability to predict membership in the levels of the binary HRQoL outcome variables after controlling for the potential confounders, a three-step hierarchical binomial regression analysis approach was used. In the initial step, all sociodemographic factors were entered into the regression equation, followed by the clinical factors. Clinical factors were included in the second step. In the final step, all of the therapy-related factors, including duration on ART, were added, and the changes in the predictive abilities of the models at each step were assessed using the likelihood ratio test and model accuracy. An additional step, where the duration variable was added separately from the other therapy-related factors, was used to establish the overall importance of the variable independent of the other theoretically related variables.p-value of less than 0.05 was considered statistically significant for all hypothesis tests. Data were analyzed using Stata/SE 12.0 and IBM® SPSS® Statistics.A two-tailed SD=8.3) years. The final gender distribution was consistent with the gender distribution in the sampling frame  and target population . Except for religion and income, other sociodemographic factors were not significantly associated with duration on ART, indicating that duration was independent of the participants' age, gender, education level, marital status, and occupation. A total of 392 patients participated in the study, representing a 93% response rate. The median time on ART for the sample was 4.5 years (interquartile range: 2.6–6.5 years), and this was used to dichotomize the duration on ART variable for the regression analyses.χ2=8.2, not significant (NS)), and none of the therapy-related factors were significant.In the baseline model , age  and to model accuracy (from 63.0 to 70.2%)  . In the χ2=39.1, p<0.05, to LR χ2=11.5, p<0.05) and accuracy (from 69.6 to 73.2%). Results from steps 1 and 2 were practically comparable, save for a noticeable 16% reduction in gender's effect size in step 2. In the final step, duration on ART was a significant predictor of HRQoL score, as was adherence . Similar to the PCS regression, a negative dose-dependent-like effect size gradient was discerned for the association between duration and HRQoL scores. The effect of age was fully statistically mediated in the final model, suggesting that the variance in classification of overall health scores explained by age was indistinguishable from that explained by the therapy-related factors.χ2=6.0, p<0.05; PCS model step 4: LR χ2=5.7, p<0.05; and MCS model step 4: LR χ2=2.3, NS).In order to test whether duration on ART significantly changed the models’ predictive ability independently, the variable was removed from the cluster of therapy-related variables and added in a fourth step separately. Results (not shown) indicated that duration remained significant in the fourth model, and it performed better than the step 3 model  impact health status may be partially statistically explained by aspects of therapy and current clinical status , and 4.Although this study assessed patients on ART over a relatively wider time span than most prior work , 10, 21,Based on the notion of treatment fatigue in HIV treatment , 24, howParticipants who had concurrent chronic comorbidities and/or had experienced clinical symptoms of an acute illness in the previous month were more likely to rate their health states significantly lower than those who had been free of the same, irrespective of duration on ART or other therapy-related factors. This would appear reasonable, since such physiological aberrations typically manifest physically, emotionally, and socially, hence affecting the perception of one's general health , 27.In the analysis, duration on ART was associated with both chronic comorbidities and pretreatment WHO HIV stage . This maa priori understanding of adherence in HIV and the post-hoc sensitivity analyses. Adherence was negatively associated with HRQoL, independent of duration on ART, and the negative association strengthened away from the null with increasing adherence. While most studies have found high adherence to be a significant predictor of better HRQoL  to increase their adherence to medication and instructions . Conversely, as a patient's health approaches normalcy relative to their baseline status because of treatment, they may relax their compliance to medication and other instructions (In this study, a multidimensional measure of adherence was used , justifier HRQoL , 29, other HRQoL . Though ructions .This being a cross-sectional study, causal relationships cannot be conclusively determined. Nonetheless, cross-sectional findings prompt hypotheses justifying further investigations – a case in point here being the puzzle of adherence. Though the study sought to control for known potential confounders, omissions are expected and acknowledged – the most prominent being psychosocial factors such as stigma, social support networks, depression, disclosure, and occupation-related health. We cannot rule out, based on current literature , 32, theIn addition, since participant selection was partly based on clinic attendance, those with appointments outside the study period may have been missed. Post-hoc cross-tabulation showed no significant differences between the two groups with respect to gender and age, but those not selected were more likely to have been on ART for longer. This is expected as they usually have widely spaced clinic appointments.Patients’ assessment of their well-being during HIV treatment was negatively associated with their duration on treatment irrespective of sociodemographic, clinical, and other therapy-related variables. This may have implications in the design and implementation of effective interventions to improve the uptake and retention of patients in HIV treatment programs that take a treatment-stage-targeted approach. In light of the strong negative association between constitutional symptoms and chronic comorbidities with both treatment duration and HRQoL, HIV care programs may benefit from strategies that strengthen the patient–provider relationship with a particular focus on those on treatment for a relatively longer duration. Finally, further research into the role of a wider definition of adherence in HIV research is recommended.


Although yoga is an effective treatment for chronic low back pain, little is known about the mechanisms responsible for its benefits. In a trial comparing yoga to intensive stretching and self-care, we explored whether physical (hours of back exercise/week), cognitive , affective , and physiological factors  mediated the effects of yoga or stretching on back-related dysfunction ). For yoga, 36% of the effect on 12-week RDQ was mediated by increased self-efficacy, 18% by sleep disturbance, 9% by hours of back exercise, and 61% by the best combination of all possible mediators (6 mediators). For stretching, 23% of the effect was mediated by increased self-efficacy, 14% by days of back exercise, and 50% by the best combination of all possible mediators (7 mediators). In open-ended questions, ≥20% of participants noted the following treatment benefits: learning new exercises (both groups), relaxation, increased awareness, and the benefits of breathing (yoga), benefits of regular practice (stretching). Although both self-efficacy and hours of back exercise were the strongest mediators for each intervention, compared to self-care, qualitative data suggest that they may exert their benefits through partially distinct mechanisms. In the last decade, results from 11 clinical trials evaluating yoga as a treatment for chronic back pain have been published , 4, 6–8,As part of a large trial of yoga compared with stretching exercise of comparable physical exertion and usual care , we collBecause our trial protocol  and primA total of 228 participants were randomized in a 2 : 2 : 1 ratio to 12 weeks of weekly yoga classes, 12 weeks of weekly intensive stretching classes, or a self-care book. Participants were permitted to seek additional health care as needed, but this was uncommon and did not differ between groups. Follow-up interviews by interviewers masked to treatment were conducted by telephone at 6, 12, and 26 weeks after randomization.Attendance at classes was similar in both yoga and stretching, with 65% of the yoga participants versus 59% of the stretching participants attending at least 8 classes. Home practice was also comparable. For example, in the last week of classes, 71% of yoga class attendees versus 63% of stretching class attendees reported practicing at least 3 times at home, with a median of 20 minutes per class in both groups.Because mediation is the focus of this analysis, we included only the 192  participants who had both 6- and 12-week follow-up data . Of those, we had saliva data for 133 participants .Mediating variables are those responsible for all or part of the effects of a treatment on outcome. Therefore, a mediator variable must change during treatment, be associated with treatment, and have an effect on outcome. In this trial, most of our mediator variables were specified in our heuristic model and developed prior to the funding of the study. Sleep disturbance was added because it is known to have an important effect on back pain. Hours of back exercise were added as a proxy for physical movement.We measured variables representing a number of aspects of cognitive appraisal, affect and sleep, physical movement, and neuroendocrine function that we hypothesized would mediate any effects of yoga on low back pain. (1) Cognitive Appraisal. Aspects of cognitive appraisal were assessed with measures of fear avoidance, self-efficacy, and self-awareness. Fear avoidance was measured with the Tampa Scale for Kinesiophobia , a 17-itSelf-efficacy was measured with a 5-item version of the validated and reliable Arthritis Self-Efficacy Scale  modifiedAwareness was measured specifically as conscious awareness of the body using two complementary validated questionnaires, the Body Awareness Questionnaire  and the (2) Affect and Stress. We measured psychological distress, perceived stress, and positive states of mind. In addition, we measured impact of back pain on sleep disturbance, which was not part of the original model.Psychological distress was measured with the 5-item mental health index of the SF-36 . This scPerceived stress was measured with the 10-item version of the perceived stress scale , the mosPositive states of mind were measured with the positive states of mind scale, a 6-item scale that has good internal consistency  , 30 and Sleep quality was measured using one question from the Roland-Morris Disability Index . The que(3) Physical Activity. To remove physical activity as a mediator, we measured hours of back exercise by asking about the number of hours the participant had performed back exercises in the past week.(4) Physiological Measures of Neuroendocrine Function. We measured cortisol and DHEA from saliva samples. Both measures are highly correlated with serum levels  training had on you? For example, this might include your thoughts, feelings, reactions, or activities” and “what were the most important things you learned from being in those classes?” A final question inquired whether they had anything else to tell us. The short open-ended responses were coded for themes by two researchers using an iterative approach.Previously, Sherman et al.  showed tP = 0.010), decreased sleep disturbances due to back pain (P = 0.050), and increased hours of back exercise in the past week (P = 0.0006). Compared to usual care, stretching showed improved self-efficacy (P = 0.002) and increased hours of back exercise (P < 0.0001).Both yoga and stretching were associated with statistically significant changes in several of the 6-week mediator variables at the 0.10 level , self-efficacy (P < 0.0001), conscious awareness of body (P = 0.027), sleep disturbances due to back pain (P = 0.0006), and hours of back exercise performed in the past week (P = 0.081) were associated with statistically significant changes in 12-week RDQ at the 0.10 level. In the stretching group , fear avoidance (P < 0.0001), self-efficacy (P = 0.003), positive states of mind (P = 0.0064), sleep disturbances (P = 0.00038), and hours of back exercise (P = 0.040) were associated with statistically significant changes in 12-week RDQ.The results described above identify a subset of mediator variables where both the association between the mediator and the intervention and the association between the 12-week RDQ and the 6-week change in the mediator are significant at the 0.10 level. For yoga (versus self-care), self-efficacy, sleep disturbances, and hours of exercise performed for back pain were jointly significant. For stretching (versus self-care), only self-efficacy and hours of back exercise were jointly significant. Of the total estimated reduction in 12-week RDQ associated with yoga , self-efficacy accounted for 36% percent of the benefit , decreased sleep disturbances due to back pain accounted for 18% , and hours of back exercise accounted for 9% . The combination of these three variables accounted for 56% of the total benefit . The best possible subset of all potential mediator variables included self-efficacy, conscious awareness of body, psychological distress, perceived stress, sleep disturbances due to back pain, and hours of back exercise and accounted for 61% of the total decrease in 12-week RDQ due to yoga . Of the total estimated reduction in 12-week RDQ associated with stretching , self efficacy and hours of back exercise accounted for 23%  and 14%  of the benefit, respectively. Both variables together accounted for 30% of the benefit . The best possible subset of mediators included fear avoidance, self-efficacy, conscious awareness of body, psychological distress, positive states of mind, and hours of back exercise and accounted for 50% of the total benefit . Analyses confined to the subset of participants with saliva samples did not find that either cortisol (average awakening response) or DHEA  met the criteria for mediators Tables  and 3. HIt gave me good tips on doing some of the stretching exercises. (Stretching participant)I've noticed, there is an increase in flexibility and strength and muscle tone. (Stretching participant)It provided a safe way for strengthening and stretching my back. (Yoga participant)The exercises, the stretching and strengthening I can do now. (Yoga participant)Comments about the classes were made by 77 of the 79 interviewed participants in the yoga group who attended at least one class and 72 of the 73 interviewed participants in the stretching group who attended at least one class . Most paOther commonly reported benefits from participants in the yoga group were relaxation and stress reduction (40.5%), increased awareness (36.7%), and the importance and benefits of breathing (29%). I have little to no back pain anymore. It helps me relax. I sleep much better. I just feel generally stronger and healthier. My overall well-being feels better; happier, better frame of mind, not so stressed. I loved it! (Yoga participant)It kind of got me back in touch with my body again and it was very calming. (Yoga participant)Really positive effects! …. I would add awareness or being able to tell what I need. (Yoga participant)… I can breathe easier when I feel I might be getting anxious. I have an instant position that I can maintain when I feel my back pain so it doesn't last hours as before and I am excited that I have a new tool …. (Yoga participant)It's changed the way I breathe. It's changed the way I move, stand and sit. It's changed the way I hold myself like how I lift things. [I learned] how to strengthen my core muscles, how to breathe correctly, and how to hold my back and stomach. (Yoga participant)Some example comments are shown below:I think its good for my back and more and I think its good for relaxing me as well as good for my muscular structure and my body core getting together with other people was good. (Yoga participant)I feel stronger in my back, relief in some cases, feel relaxed and at ease, centered. (Yoga participant)Participants in the yoga classes were also more likely to speak of the holistic benefits (see quotes earlier and below). It has a really good effect, I feel better … when you get stretch out it keep, everything in sync. It makes you feel better the key is sticking to it. It's okay to skip a night, but the key is to try and do it every night. (Stretching participant)Just it made me a lot more flexible to walk and things like that. It just made me more confident in my physical well being … It wasn't so much learning the exercises. It was more the idea of consistency. Having a schedule for a particular exercise was pretty important for me …. (Stretching participant)By contrast, participants in the exercise group were more likely to mention the importance of discipline and routine (39.7%). Some examples are shown below:Roughly, 10% of participants in both groups reported increased self-efficacy. A variety of other benefits were mentioned occasionally by participants in both groups, including increased energy and better mood. Five participants in the stretching group (6.8%) thought some of the stretches were harmful, while six participants in the stretching group (8.2%) and five in the yoga group (6.3%) mentioned that the classes were not helpful or were boring. Using a comprehensive set of mediator variables encompassing the categories of physical movement, cognitive appraisal, and affect and stress, we found that both self-efficacy and hours of back exercise in the prior week mediated the effects of yoga and stretching on back dysfunction. In addition, sleep disturbance had a small effect on back dysfunction in the yoga group. These variables mediated 56% of the relationship with yoga and 30% of the relationship with stretching. The strongest mediator for both treatments was self-efficacy (36% for yoga and 23% for stretching). Hours of back exercise had roughly similar mediation effects in both groups, about 10–15%. These results might be surprising because yoga and stretching had similar effects . QualitaFew other variables explained much of the relationship between yoga and improved back dysfunction, although the qualitative analyses suggest that increased awareness and relaxation were important. Yoga is a complex multifactorial intervention with a number of potentially different therapeutic mechanisms, including physical effects of movement, benefits of breathing, and benefits of concentration. Wayne and Kaptchuk  describeIn addition, many of the measures we selected may not have completely addressed the constructs in our model. For example, measuring body-focused awareness has been challenging because, in extant questionnaires, distinctly different processes are subsumed under this concept . While m Strengths of these analyses include the comparison of two treatments with self-care, a comprehensive theory-driven selection of mediators, the measurement of mediators preceded that of outcomes which strengthens a causal interpretation, the use of qualitative results to confirm or refute findings of the formal mediation analysis, and the conduct of these analyses in the context of a large, rigorous randomized trial. Our mediator analyses have several limitations. Because we found no difference between yoga and stretching, we were unable to directly compare the mediators of these interventions. Furthermore, because our study population was fairly healthy and excluded individuals with moderate or severe depression, it may have been unable to detect some of the purported benefits of yoga, such as stress reduction. Finally, we did not assess mindfulness, another construct that is challenging to measure but might have accounted for some of the benefits we observed.Both yoga and stretching were superior to self-care, and our mediator analyses suggest that increased participation in back exercise and self-efficacy was responsible for most of these benefits. However, these are both complex interventions and qualitative data suggesting that relaxation and increased awareness may have contributed to the benefits of yoga, while, increased discipline and routine may have contributed to the benefits of stretching. To better understand the common and unique mechanisms responsible for the benefits of yoga and exercise, future research should compare types of yoga that are more distinct from intensive stretching exercise programs through greater emphasis on meditation and breathing components.


Previous studies showed that intake of yacon or some lactic acid bacteria was able to inhibit the development of diabetes mellitus, by reducing glucose and associated symptoms, for example, the lipid profile.Enterococcus faecium CRL 183 and Lactobacillus helveticus ssp jugurti 416 in reducing blood glucose and lipid levels in an animal model.The purpose of this study was to assess the consumption influence of a potential symbiotic product of soybean and yacon extract and fermented Diabetes mellitus was chemically induced by intraperitoneal administration of streptozotocin (50 mg/kg body weight). The rats were divided into four groups (n=10): GI – non-diabetic animals that received only a standard chow diet (negative control), GII – diabetic animals that received only chow diet (positive control), GIII – diabetic animals that received the chow diet + 1 mL/kg body weight/day of soybean and yacon unfermented product, GIV – diabetic rats that received the chow diet + 1 mL/kg body weight/day of soybean and yacon fermented product. There was a seven-week treatment period and the following parameters were evaluated: animal body weight, food and water intake, blood glucose, enzyme activities of aspartate aminotransferase (AST) and alanine aminotransferase (ALT), triglycerides levels, total cholesterol, HDL-C, non-HDL-C. Cell viability of the fermented product was checked weekly for a seven-week period.8-109 CFU/mL, by ensuring both the rods and cocci regular intake. No difference was observed between the water and feed intake and body weight of groups that received unfermented and fermented products and the untreated diabetic group. The same was observed for the blood glucose and AST and ALT activities, while some improvement was observed for a lipid profile, represented by reduction of triglycerides level by 15.07% and 33.50% in groups III and IV, respectively, and an increase of 23.70% in HDL-C level for group IV.The product average viable population was 10Enterococcus faecium CRL 183, as well as Lactobacillus helveticus ssp jugurti 416 and yacon extract (symbiotic product).The results showed that the ingestion of a potential symbiotic product was neither able to promote improvement in some of the disease symptoms, nor reduce blood glucose. However, a positive effect on triglycerides levels and HDL-cholesterol was observed in the groups that received the unfermented product containing yacon extract and the fermented product with  Diabetes mellitus is among the tenth leading causes of death in western countries and, despite progress in its clinical management, it is not yet possible to control its lethal consequences. This disease is a chronic disorder that affects the carbohydrates metabolism, fats and proteins. The characteristic of diabetes mellitus is hyperglycemia, which reflects a deterioration in the use of glucose  due to defective insulin secretion or deficient response to it ,2. DiabeThe atherosclerosis risk is twice to three times greater in diabetics than in non-diabetics. The absence of insulin promotes hydrolysis of stored triglycerides in the adipocytes and their presence in the circulation, and the leading to a reduction in serum levels of HDL-C -11.The probiotic foods are those that contain microorganisms that modulate the intestinal microbiota and aid the functioning of the gastrointestinal tract and thus may prevent the disease, while prebiotics are food containing substances which are resistant to enzymatic breakdown, which stimulate the proliferation or activity of certain bacteria in the intestinal microbiota, acting as a selective substrate in the colon. Foods that have both probiotics and prebiotics are called synbiotics .Within this context, fermented foods containing probiotics and prebiotics can be important diet components, due to their nutritional characteristics and ability to reduce the risk of chronic diseases -17.Smallanthus sonchifolius), a natural plant in the Andean region, has aroused the interest of researchers as it provides bioactive compounds considered important for human health [In recent decades, the yacon , aged 5 weeks (weight 130-170 g), were obtained from the Central Animal Facility of the Campus of Botucatu -UNESP, SP, Brazil. During the 59-day experiment, the animals were kept under controlled temperature (22°C ± 2°C), with a light–dark cycle of 12:12 h, with free access to standard chow and water. The product under study was administered to the animals for seven weeks.Rats were fed a standard chow diet  for a week, to acclimatize them, and then they were randomly allocated to four experimental groups (n=10): GI - non-diabetic animals that received only the chow diet (negative control); GII - diabetic animals that received only chow diet (positive control); GIII – diabetic animals that received chow diet + 1 mL/kg body weight/day of soybean and yacon extract unfermented product; GIV – diabetic rats that received chow diet + 1 mL/kg body weight/day of soybean and yacon extract fermented product.The fermented product, based on aqueous extracts of soybean and yacon, was processed at the Development and Production Unit for Soybean Derivatives (UNISOJA), Food and Nutrition Department of the School of Pharmaceutical Sciences, UNESP in Araraquara, SP, Brazil, by methods described by Pauly-Silveira , but allEnterococcus faecium CRL 183 (probiotic microorganism from CERELA - Argentina) and Lactobacillus helveticus ssp. jugurti 416 . The aqueous extracts mixed at soybean rates: yacon of 60.00% to 25.86% [The Foscarin soybean variety  was used in the soy milk processing . The hulled grains were submitted to a heat treatment (95°C/7 min) and led to a continuous extracting machine  to obtain the soy milk. The used yacon was of yellow variety and was purchased in local marketing. Immediately after yacon cutting, the pieces were blanched in hot water (97°C) and citric acid was added, for a 15-min period. Finally, the yacon was ground and filtered to obtain the aqueous extract . The baco 25.86% . The ferThe unfermented product was prepared by chemical acidification of the synbiotic product base mixture  with food-grade lactic acid , to reach the same pH as the fermented product (4.4 - 4.6).After the period of adaptation, the rats were fasted for 12 h. Afterwards, the rat group II; then, the groups III and IV by injections  of 50 mg per kg body weight of streptozotocin (STZ)  ,35 disso7 CFU/day of E.faecium and of L.helveticus ssp jugurti, in the fermented products for a seven-week period. The fermented product contained 108- 109 CFU/mL of each microorganism.The unfermented and fermented administration products started after confirmation of diabetes induction. The products were administrated to the animals by gavage of 1 mL/kg body weight once every day, to ensure a minimal intake of 10The experimental design received approval from the Research Ethics Committee of the School of Pharmaceutical Sciences, UNESP in Araraquara, SP, Brazil (protocol CEP/FCF no. 21/2010)The total fructan content was measured in triplicate by a spectrophotometric method and was carried out in yacon extract, in the unfermented and potential synbiotic products  using the Megazyme Fructan HK Assay kit  .The body weight of each animal was recorded weekly throughout the experimental period.The feed and water intakes of each animal were determined by weight difference between chow offered and orts and the difference between the amounts of water offered from remaining bottles, respectively, and recorded daily throughout the experimental period.Blood samples were collected from a small longitudinal incision made at the animal tail end .The level of glucose in the plasma was assessed at the beginning of the experiment, three days after induction of diabetes, to verify the diabetic state, 14 days after proof of the diabetic state and at the end of the experiment, after the final administration of the products, using Labtest Diagnostic® Kit SA  ,39.The enzymatic activity of the transaminases AST and ALT was determined in the plasma by Labtest Diagnostic® Kit SA , at the same time as the glucose analysis ,39.Lipids were determined in the plasma, by using Labtest Diagnostic® Kit SA  ,39. nHDLAll experimental animals were decapitated by guillotine at the end of the experiment (after seven weeks of treatment).Results are presented as mean ± standard deviation. One-way ANOVA was used to determine a significant difference between groups (p < 0.05) and Tukey's test to perform multiple comparisons between means.The total concentration of fructans found in the aqueous yacon extract was 7.96 g/100 g; 4.32 g/100 g in the unfermented product and 4.30 g/100 g in the symbiotic product. The concentrations of unfermented and synbiotic product did not show statistical difference (p < 0.05), suggesting that the microorganisms used in fermentation process were not able to modify the total fructans level.Table It is observed that for the three variables presented in Table In Table The AST and ALT serum levels were presented in Table Regarding the enzyme alanine aminotransferase (ALT), there were significant differences among group I and the others, starting from time T2. Note also that all diabetic groups showed a significant increase in ALT activity after seven weeks of treatment, but noting that, once again, groups II, III and IV did not differ significantly from each other.Table It is observed that, at the end of the experiment, triglycerides levels were lower in the groups receiving treatment (III and IV) than in the positive control (group II), although these levels are higher than that observed in group I.As for total cholesterol, it is clear that at the end of the experiment (T3), groups II, III and IV did not differ, while they were significantly different from group I.Regarding HDL-C at the end of the experiment (T3), group IV, which consumed the potential symbiotic product, differed from all the other groups, with the highest value for this parameter. On the other hand, there was no statistical difference in non HDL-C among any of the groups during the experiment.Bifidobacterium[The fructans content, determined in the unfermented and symbiotic product, was found to be compatible with recommended daily intake of prebiotics (4-5 g/day) to stimulate the growth of bacterium, while dbacterium and provbacterium. Althougbacterium,45.The highest feed intake observed in the diabetic groups can be explained by the absence of circulating insulin, which causes a deficiency in glucose transport, leading to a deficiency of energy in the cells, resulting in increased feeding to compensate for that lack of energy .In addition, it can be explained by physiological processes related to the pathology, such as hyperglycemia, glycosuria, and polyuria, while the weight loss is due to the catabolic processes involved in diabetes mellitus .While in the non-diabetic group (group 1), the animals appeared, throughout the experiment, in good general condition, with normal appetite, progressive weight gain and maintenance of water intake, food intake and diuresis, the diabetic animals had a strong odor of urine and functional changes, such as polyuria and polydipsia. However, there were no significant changes of the coat or apathy, as described by Passos and Park .In the present study, the increased serum glucose levels in groups II, III and IV confirmed that the STZ was effective in inducing diabetes mellitus, values of around 120 mg/dL rising to nearly 500 mg/dL, a level correlated with severe experimental diabetes .In the blood tests used to check for induction reversal (T2), the highest blood glucose levels were recorded, thus confirming the absence of reversion. The rate of induction was 100%, since long-term diabetes mellitus was found in all animals, as observed by Rakieten et al. , in ratsAt T0, there was no statistical difference in glycemic level among the groups. After induction and until the end of the experiment, only group I (non-diabetic) maintained low values, by significantly differing from the other groups, which all had become diabetic.Although a reduction in blood glucose occurred at the end of the experiment, it cannot be suggested that, thus revealed a tendency for diabetes to stabilize, owing to the presence of yacon and/or probiotic bacteria, since the animals in group II received only water and feed and showed the same reduction. Studies by Maffezzoli  showed rThe organism itself tends to normalize high blood glucose levels by three main routes: stimulating glucose uptake by peripheral tissues (muscle and adipose tissue); altering the insulin metabolism (by reducing the degradation of insulin in the liver or stimulating insulin secretion) and, finally, by inhibiting the reabsorption of glucose by the kidneys, resulting in the elimination of glucose in the urine .The glycemic control observed in animal studies and early studies in humans has indicated that ingested fructooligosaccharides probably act to stimulate glucose utilization in peripheral tissues (muscle and adipose tissue) .The enzymes analyzed in this study are markers of liver injury; the observed increase in AST and ALT activity indicates an aggressive hepatocyte injury  with regA study by Baroni et al.  evaluateRegarding the lipid profile, it was observed that at the end of the experiment, triglycerides levels were lower in groups III and IV than in group II, although all these levels were higher than that observed in group I, indicating that both the unfermented and fermented products may have reduced this serum lipid in STZ-induced animals. Numerically, group IV had the lowest triglycerides, which may be related to the aqueous yacon extract  and the Whereas diabetes results in increased lipolysis in adipose tissue, leading to higher blood levels of fatty acids, there is also a greater production of ketone bodies by the liver. However, the excess fatty acid captured by the liver is not fully oxidized to ketone bodies by ketogenesis. Thus, these excess fatty acids are directed to the synthesis of triglycerides, which is converted into VLDL. As VLDLs in excess are not be fully metabolized by lipoprotein lipase, a state of a hypertriglyceridemia would occur .E. faecium CRL 183 was able to reduce total cholesterol levels by 18.4% in hyperlipidemic rabbits.As for total cholesterol, note that at the end of the experiment groups II, III and IV did not differ, although they were significantly different from group I. However, group IV again showed, numerically, the lowest value for this parameter, although not statistically different from the others; that may be an indicative of a tendency, in agreement with the results observed by Rossi et al. , which sin vitro experiments and in vivo trials have provided evidence to support the roles of probiotics in lowering serum cholesterol and improving lipid profiles.A variety of past Several mechanisms of cholesterol reduction by probiotics via control of cholesterol metabolism have been proposed. One such mechanism is the removal of cholesterol by assimilation. The assimilation of cholesterol by probiotics in the small intestine could reduce serum cholesterol by reducing the absorption of cholesterol in the intestines . ProbiotE. faecium CRL 183. This ability of E. faecium CRL 183 to promotion increase in HDL-C has been observed in a study by Rossi et al. [Regarding HDL-C at the end of the experiment (T3), group IV (symbiotic) differed from the other groups, with the highest value for this parameter, which may be due to the presence of i et al. , where tBifidobacterium and Lactobacillus acidophilus, separately or in combination to diabetic albino rats, the presented results were more satisfactory in terms of the increase in HDL-C in group IV, which received the symbiotic product; this is an important condition in reducing the risk of onset of coronary heart disease in diabetics.In comparison to the results of Khamisy , who admE. faecium CRL 183, only HDL levels were changed positively, by showing a 46% increase.In another study conducted by Manzoni et al. , concernL. acidophilus 145 and B. longum 913 plus 1% oligofructose [L. acidophilus DDS-1, B. longum UABL-14 and fructooligosaccharides, found no effect [Research indicates that the hypocholesterolemic action of probiotics may be enhanced by the use of a prebiotic . The efffructose  raised to effect .Regarding the fraction nHDL-C, no statistical difference was observed among the 4 groups during the experimental period.Enterococcus faecium CRL 183 and Lactobacillus helveticus ssp jugurti 416, showed no positive effect on blood glucose levels, but was effective in reducing triglycerides both unfermented and symbiotic products and increasing HDL-cholesterol .The product based on aqueous extracts of yacon and soybean fermented or not with AST: Aspartate aminotransferase; ALT: Alanine aminotrasferase; HDL-C: High density lipoprotein cholesterol; n-DHL-C: Non high density lipoprotein cholesterol; VLDL: Very low density lipoprotein; STZ: Streptozotocin.The authors declare that they have no competing interests.MNR: was involved in design, data collection, drafting the manuscript and revising it critically for important intellectual content. NDPS, DCUC, LSC, RCV, RAP: participated in data collection, interpretation of results and drafting the manuscript. EAR: was involved in design, drafting the manuscript and revising it critically for important intellectual content. All authors read and approved the final manuscript.


Clinicians, providers and guideline panels use absolute effects to weigh the advantages and downsides of treatment alternatives. Relative measures have the potential to mislead readers. However, little is known about the reporting of absolute measures in systematic reviews. The objectives of our study are to determine the proportion of systematic reviews that report absolute measures of effect for the most important outcomes, and ascertain how they are analyzed, reported and interpreted.We will conduct a methodological survey of systematic reviews published in 2010. We will conduct a 1:1 stratified random sampling of Cochrane vs. non-Cochrane systematic reviews. We will calculate the proportion of systematic reviews reporting at least one absolute estimate of effect for the most patient-important outcome for the comparison of interest. We will conduct multivariable logistic regression analyses with the reporting of an absolute estimate of effect as the dependent variable and pre-specified study characteristics as the independent variables. For systematic reviews reporting an absolute estimate of effect, we will document the methods used for the analysis, reporting and interpretation of the absolute estimate.Our methodological survey will inform current practices regarding reporting of absolute estimates in systematic reviews. Our findings may influence recommendations on reporting, conduct and interpretation of absolute estimates. Our results are likely to be of interest to systematic review authors, funding agencies, clinicians, guideline developers and journal editors. When contemplating a recommendation, either in favour of or against an intervention, guideline developers need to consider the balance between desirable and undesirable consequences of treatment alternatives . Also, cMeasures of effect of an intervention on dichotomous outcomes may express a change in risk in relative terms ), in absolute terms , also known as risk difference), or as the inverse of the risk difference ) .The impact of an intervention may appear small or large depending on which measure of effect is reported, an issue that is referred to as statistical framing ,3. CliniEmpirical evidence suggests that relative effect measures are, on average, more consistent than absolute measures ,8. IndeeTo report one or more absolute effects in accompaniment to relative effects, systematic review authors should apply the measure of relative effect to a baseline risk or control group risk. This involves expressing the absolute difference for each clinically identifiable risk group, and clarifying the time period to which this applies. Consequently, a relative risk is expressed as a variety of risk differences or NNTs across a range of control risks in subpopulations that clinicians can easily identify ,9,11. GRAn analysis of the top general medical journals showed that 68% of randomized controlled trials (RCTs) and cohorts failed to report absolute risks in the abstract. Of these articles, about half did report the underlying absolute risks elsewhere in the article  but half did not report them anywhere . More reLancet, JAMA and BMJ) Sedrakyan and Shih [et al.[In the case of systematic reviews in three leading medical journals  express the risk of an outcome in one group compared with another. As relative measures of effect, the relative risk is the ratio of the risk of an outcome, whereas the odds ratio (OR) is the ratio of the odds of an outcome . As an aCochrane Database of Systematic Reviews. All the other systematic reviews will be considered non-Cochrane systematic reviews.Cochrane systematic reviews are defined as all systematic reviews published in the We will include systematic reviews published in English meeting the following criteria:1. Described as a ‘systematic review’ or a ‘meta-analysis’;2. Reports a search strategy in at least one database;3. Published in 2010; in the Cochrane Database of Systematic Reviews or indexed in MEDLINE;4. Includes a comparison of an intervention with another intervention or no intervention in human beings;5. Reports measures of effect for at least one dichotomous outcome either from a single study or from a pooled analysis.If there is more than one pairwise comparison, reviewers will select the comparison that reports the largest number of dichotomous outcomes. If more than one comparison reported the same number of dichotomous outcomes, reviewers will select the comparison that reports the largest number of absolute estimates. We will identify the most patient-important outcome using a hierarchical approach (Appendix 1). If the outcome is a composite outcome, we will select the most patient-important of those included in the composite, if authors provide disaggregated data in the review (according to the hierarchy in Appendix 1). Otherwise, we will choose the next most important dichotomous outcome. Since we are interested in how authors present the results of their systematic reviews , we will not collect information about absolute effects presented when describing individual studies included in the review, unless the comparison of interest includes only one trial.https://systematic-review.ca) for eligibility screening and data extraction.We will use the MEDLINE database to search for potentially eligible systematic reviews. We will use two distinct search strategies. First, we will use an adaptation of the systematic review filter, designed by the Health Information Research Unit of McMaster University to retrieve non-Cochrane systematic reviews. Second, we will use the Ovid ‘search by journal’ filter to identify Cochrane systematic reviews (Appendix 2). We will limit both searches to the year 2010. We will subsequently export citations to Endnote X4.0.2., and then into a web-based systematic review software .We will undertake, in a duplicate and independent manner, title and abstract screening, full text screening and data abstraction. Irrespective of discrepancies, all studies selected at a title and abstract level will be included for the full text screening. Reviewers will resolve discrepancies at the level of full text and data abstraction by consensus, and if unsuccessful, with the help of a third reviewer. This arbitrator will independently review the article before discussing it with the reviewers. To ensure the validity and consistency of the process, we will conduct calibration exercises for each step of the process. We will also develop and pilot-test standardized forms and upload them onto the online systematic review software application. We will accompany all forms with detailed instructions. A core group will meet regularly to discuss progress and potential difficulties. We will create a study flow to describe the results of the different steps of the selection process.We will extract the following information from each included systematic review: study characteristics, quality of the systematic review, the calculation and reporting of absolute estimates of effects, and the interpretation of absolute estimates of effects.For all included systematic reviews, we will extract the following information:1. Type of systematic review (Cochrane vs. not Cochrane);2. Type of intervention (pharmacologic vs. other);Journal of the Medical Association, New England Journal of Medicine, Lancet, Annals of Internal Medicine, Journal of the American Medical Association and PLoS Medicine) vs. other journals;3. High-impact .Journal of the American Medical Association, New England Journal of Medicine, Annals of Internal Medicine, Lancet and PLoS Medicine), the population and the intervention and control of interest. We will also extract information about source of funding  and the type of intervention (pharmacologic vs. other). We will note whether the systematic review used the GRADE approach; this includes whether authors provide a summary table, such as a summary of findings.Specifically, we will collect information about whether the review was published in the five journals with the most journal citations  for the most patient-important outcome for the selected comparison. We will also note this for any outcome other than the most patient-important, for both the comparison of interest and, if available, any other comparison. For the selected comparison, we will note whether the authors report benefits and harm outcomes and whether they report a measure of relative effect, a measure of absolute effect or both.We will assess the methodological quality of eligible systematic reviews using the AMSTAR instrument .For those reviews that report at least one absolute effect estimate, we will record whether these estimates relate to the most patient-important outcome, any outcome within the comparison of interest or elsewhere in the full text. For the reviews that provide an absolute estimate for the most patient-important outcome, we will collect information about the type of measure  and the expression used when reporting if available . We will explore how authors calculated the absolute estimates ; or modelled from baseline risk  and whether they state the calculation methods in their methods section. We will document the number of estimates of effect for different baseline risks and, if available, whether authors specify the source of these baseline estimates. If needed, we will contact authors for additional information.Regarding interpretation, we will document whether authors discuss the fact that risk differences may vary to an important degree across subpopulations. We will also document the extent to which authors discuss this potential variability and their interpretation of the main effect of interest. Finally, we will assess whether the absolute estimates of effects are considered in the conclusion (a separate conclusion section or in the conclusion of a discussion section).We will calculate the sample size on the basis of an examination of study characteristics associated with the reporting of absolute effects for the most patient-important outcome: we will undertake this by means of a regression analysis. In this model we will include seven study characteristics with a total of eight categories of variable. We will require ten events per category to examine the association. Previous estimates show that approximately 50% of systematic reviews report an absolute estimate of effect . We willWe will assess agreement between reviewers’ judgements of whether the investigators reported an absolute measure of effect for the most patient-important outcome. We will calculate chance-corrected agreement and interpret the results according to Landis and Koch guidelines  .We will calculate the proportion of systematic reviews, reporting at least one absolute estimate of effect for the most patient-important outcome, for any outcome within the comparison of interest, or for any comparison and any dichotomous outcome excluding the comparison of interest. We will conduct two multivariable logistic regression analyses to examine the association between pre-specified study characteristics and, first, the reporting of an absolute estimate of effect for the most patient-important outcome and, second, the reporting of an absolute estimate of effect for any outcome within the comparison of interest.We will also calculate the proportion of systematic reviews that report the method they used to calculate the absolute estimate. We will calculate the proportion of systematic reviews that discuss whether risk differences may vary across populations anywhere in the article. We will conduct two separate multivariable logistic regression analyses to examine the association with the pre-specified study characteristics and respectively these two features of risk difference calculation and interpretation.In addition, we will calculate the proportion of systematic reviews that use, for the comparison of interest, relative measures for benefit outcomes and absolute measures for harm (‘mismatched framing’ henceforth). Treating the reporting of results with mismatched framing as the dependent variable, we will conduct multivariable logistic regression analyses to examine its association with the pre-specified study characteristics.Our pre-specified study characteristics for the regression analyses are listed and ranked by importance. If there are sufficient events, we will include them all. Otherwise, we will include as many as possible according to our ten events-per-category rule (see section on sample size). The first two factors to be examined will be type of systematic review (Cochrane vs. not Cochrane) and use of GRADE. However if, as we will explain, there is excessive confounding, we will not include GRADE in the regression:Journal of American Medical Association, New England Journal of Medicine, The Lancet, British Medical Journal, Annals of Internal Medicine and Public Library of Science Medicine).We hypothesize that systematic reviews are more likely to report absolute effects or report them appropriately if they: (i) are Cochrane reviews, (ii) use GRADE, (iii) are of better quality, (iv) achieve statistical significance for the most patient-important outcome, (v) do not receive funding from for-profit organizations or their authors have financial conflicts of interest, (vi) evaluate pharmacological interventions, (vii) are published in a high-impact journal  showing that approximately 50% of the reviews included frequency data and one-third mismatched framing of benefit and harms [et al. have explored this issue but only in the abstract of systematic reviews [Several studies have addressed the use of absolute effects in leading medical journals. Two of them explored this issue in individual studies observing that absolute estimates are very often not reported, especially in the abstract . In the nd harms . This an reviews .While there is agreement that both patients and health professionals understand absolute estimates better than relative estimates, there is inconclusive evidence about the optimal way, in terms of understanding, for reporting absolute estimates. Some studies suggest that natural frequencies are preferable and others favour percentages ,28,29. PThe findings of ARROW will inform the systematic review community about the current practice of absolute estimates reporting in both Cochrane and non-Cochrane reviews. Our findings may influence recommendations on reporting, conduct and interpretation of absolute estimates in this type of research design. Our results are likely to be of great interest for systematic review authors and developers, funding agencies, health decision makers, guideline developers, and journal editors.I. Mortality;a. All causes of mortality;a. Disease-specific mortality.II. Morbiditya. Cardiovascular major morbid outcomes;a. Other major morbid outcomes ;a. Recurrence, relapse, remission of cancer, disease-free survival;a. Renal failure requiring dialysis;a. Hospitalizations;a. Infections;a. Dermatological or rheumatologic disorders.III. Symptoms, quality of life, or functional status ;IV. Surrogate outcomes .Categories I, II, or III but not category IV define a patient-important outcome. For a composite endpoint to be patient-important all its components have to be patient-important.1. Meta-Analysis as Topic/2. meta analy$.tw.3. metaanaly$.tw.4. Meta-Analysis/5. (systematic adj (review$1 or overview$1)).tw.6. exp "Review Literature as Topic"/7. 3 or 4 or 5 or 68. cochrane.ab.9. embase.ab.10.  (psychlit or psyclit).ab.11.  (psychinfo or psycinfo).ab.12.  .ab.13.  science citation index.ab.14.  bids.ab.15.  cancerlit.ab.16.  8 or 9 or 10 or 11 or 12 or 13 or 14 or 1517.  reference list$.ab.18.  bibliograph$.ab.19.  hand-search$.ab.20.  relevant journals.ab.21.  manual search$.ab.22.  17 or 18 or 19 or 20 or 2123.  selection criteria.ab.24.  data extraction.ab.25.  23 or 2426.  Review/27.  25 and 2628.  Comment/29.  Letter/30.  Editorial/31.  animal/32.  human/33.  31 not (31 and 32)34.  or/28-30,3335.  7 or 16 or 22 or 2736.  35 not 3437.  36 not "cochrane database of systematic reviews".jn.38.  limit 37 to yr = "2010"1. "cochrane database of systematic reviews".jn.2. limit 1 to yr = "2010"ARR: Absolute risk reduction; NNT: Number needed to treat; RCT: Randomized controlled trial; RRR: Relative risk reduction.The authors declare that they have no competing interests.PAC and GHG conceived the study. PAC, GHG, ACL, RBP, IN, EA and HJS developed a first design proposal. All authors provided feedback about the design. PAC wrote the first draft of the manuscript. All authors read and approved the final manuscript.