Functional constipation (FC) is one of the common diseases among children. The aim of this study was to investigate the health-related quality of life (HRQOL) in preschool children diagnosed with FC and the impact of the condition on affected families.TM 4.0 Generic Core Scale and the Family Impact Module (FIM) were used to assess childhood HRQOL and the impact of FC on family members, respectively. HRQOL scores were compared between children with FC and healthy children. In addition, a multiple step-wise regression with demographic variables of children and their caregivers, family economic status, duration and symptoms of FC, as independent variables, was used to determine factors that influenced HRQOL in children and had impacted caregivers.In this cross-sectional, case-control study, 152 children aged 3–6 years with FC, 176 healthy children aged 3–6 years without FC, and their primary caregivers were selected. Chinese versions of the PedsQLp < 0.05). Physical, emotional, social, cognitive, and communication scores for caregivers, as well as daily activities and relationships for families of children with FC, were significantly lower than those of caregivers and families with healthy children (p < 0.05). Children’s ages, duration of FC, symptoms of FC, the child-caregiver relationship, family economic status, and caregiver education level emerged as the main factors influencing HRQOL in children, caregivers, and family members. Scores of physical, emotional, social and school functions, and summary scales were significantly lower in children with FC than in healthy children (FC had a significant impact on HRQOL of affected children and their caregivers, as well as their family functions. Social characteristics of children and caregivers, duration and symptoms of FC and family economic status significantly affected HRQOL of children and caregivers, as well as family functions of children with FC. Constipation is a common childhood complaint. Its exact prevalence is difficult to ascertain because only a minority of patients suffering from constipation seek medical attention. In the hospital setting, constipation accounts for 3% of visits to pediatric clinics  and up tConstipation rarely leads to life threatening complications, but can cause emotional and physical distress and concern for children and their families, ultimately impairing health related quality of life (HRQOL) -8. The iFC has been defined by the ROME III classification ,13: (1) Diagnosis of IBS requires two criteria ,13 FirstBetween January and July 2011, 152 children (3–6 years old) with FC and their primary caregivers (parents or grandparents) were selected as the patient group from the pediatric outpatient departments of Xijing Hospital and Tangdu Hospital in Xi’an, China. The healthy control group included 176 healthy children (3−6 years old) and their primary caregivers (parents or grandparents) selected from the children’s health care centers at the same two hospitals. Healthy children were all being seen for routine annual wellness check-ups. All subjects had outpatient medical and health care records at one of the above-mentioned hospitals, and caregivers confirmed that the selected hospital was the primary medical or health care institution for the child. Primary caregiver was defined as the main caregiver who took care of the child’s daily living  at home, after school, and during the weekend. Caregivers were asked whether he/she was the primary caregiver for the child; if he/she answered yes, that caregiver was asked to complete the survey.Xijing Hospital and Tangdu Hospital are two of the largest AAA hospitals in Xi’an–one in the urban center, and the other in the suburbs. The AAA distinction means that they are among the best hospitals in China with the capacity to provide high-level medical services, and implement high-level medical education and research. Both hospitals treat a comprehensive spectrum of diseases and cover the whole population of Xi’an. The pediatrics departments provide service to more than 600 patients per day, and each has more than 200 beds for inpatients. The sub-specialties in the pediatric departments include respiratory diseases, digestive diseases, kidney diseases, and cardiovascular diseases.For this study, patients had the following characteristics: 1) age 3−6 years old, 2) medical records at one of the designated study hospitals, 3) a diagnosis of FC, 4) nursery school or kindergarten attendance, and 5) during the preceding year, only study designated hospitals were used for health care/consultation. Child subjects were excluded from the study if they had other medical conditions such as organic causes of constipation , chronic diseases , neurodevelopmental disorders , or growth abnormalities  that influence HRQOL. Subjects were also excluded if their parents/caregivers were illiterate or unwilling to participate, were in poor health or had experienced severe negative events, such as a family member’s death, major accident, etc., in the preceding six months.Members of the healthy control group met the following criteria: 1) age 3−6 years old, 2) health care records located at one of the designated study hospitals, 3) diagnosed by a pediatrician as developing normally, being healthy and free from FC for the past six months, 4) nursery school or kindergarten attendance, and 5) during the preceding year, only study designated hospitals were used for health care/consultation. The exclusion criteria applied to the control group were similar to those given to the patient group. Children who received disability or nutritional counseling were also excluded.The Research Ethics Committee of the Fourth Military Medical University approved this study. All caregivers provided written informed consent. TM4.0) was used in this study. The PedsQLTM4.0 consisted of three parts:A Chinese version of the Pediatric Quality of Life Inventory™, version 4.0 2. The PedsQL developed by Varni et al. [i et al. ,19 and ci et al. , demonst3. PedsQL™ Family Information Form, developed by Varni [by Varni ,15, has TM 4.0 Family Impact Module and the PedsQL™ Family Information Form.Five pediatric nurses, with at least five years of pediatric clinical nursing experience, performed this study. All investigators were trained prior to the survey so that they understood the survey purpose and its requirements. Caregivers completed the HRQOL questionnaires for the children and themselves including the PedsQL™ 4.0 Generic Core Scales, the PedsQLAn investigator explained the purpose and details of all scales to the caregivers so that they could successfully complete the assessments. In addition, one of the main investigators carefully rechecked all the scales, and telephone interviews were conducted for any lost or incomplete information. EpiData 3.1 software was used for data entry. To ensure data accuracy, double entry mode was selected and logistic errors were corrected.2) test was used to compare the distribution of children’s gender, caregiver education level, child-caregiver relationship, family economic status, and non-specific abdominal pain. Independent sample t-tests were used to determine differences in age, frequency of defecation, Generic Core Scales, and FIM scores between the two groups . Pearson correlation coefficients  were calculated to determine the relationship between scores of Generic Core Scale and FIM. Bonferroni corrections were applied to control multiple testing. Multiple step-wise regression analysis was used to select factors that influenced the HRQOL and family function in children and caregivers. Specifically, the influences of age (years), gender, caregiver education level, child-caregiver relationship, family economic status, duration of constipation (months), frequency of defecation (times/week), painful defecation, non-specific abdominal pain and HRQOL scores of caregiver or child on PedsQL™ 4.0 Generic Core Scales or FIM Scale dimensions were determined. Statistical significance was set at p < 0.05. All analyses were performed using the Statistical Package for Social Sciences software program, version 16.0 .Quantitative data were expressed as mean ± standard deviation, and qualitative data were expressed as percentages. A Chi-square (χp > 0.05). Similarly, there were no significant differences in the proportion of child-caregiver relationships, caregiver education levels or family economical status between the two groups . The mean frequencies of defecation and non-specific abdominal pain were significantly different between the two groups .Demographic characteristics of the children and their caregivers are listed in The internal reliability estimates (Cronbach’s α coefficients) for summary scores and subscales of the Generic Core Scale and FIM Scale are presented in p < 0.05). Children with FC had significantly lower scores on the FIM Scale than healthy children on each dimension except for “worry” .p < 0.05).p < 0.05). Each dimension score on the Generic Core Scale was differentially affected by these variables . Each dimension score of the FIM was differentially affected by these variables  and gastroesophageal reflux disease (GERD). Parents of constipated children reported lower perceived emotional and social scores for their children compared to parents of healthy children and those with other chronic gastrointestinal diseases. In Australia [TM 4.0 Generic Core Scale and found that total HRQOL scores were substantially lower in constipated children than their healthy peers, for both parent- and self-reported scores; STC appeared to impinge on both physical and psychosocial HRQOL. Faleiros and Machado [A few studies have focused on HRQOL in children suffering from FC ,11,22,23 Machado  assessed Machado  and Clar Machado , Faleiro Machado  observedTM 4.0 Generic Core Scale with higher maternal education level. The younger the patient is, the worse the score will be, across the dimensions. In our study, the effects of caregiver education level and child age on HRQOL were similar to correlation of these parameters in the study by Gerson et al. HRQOL was influenced by many factors. The duration and symptoms of diseases and social-economic characteristics of patients were the main factors influencing HRQOL. A study  in the NIn pediatric chronic diseases, the impact of disease and treatment, on family functioning is a major concern -29. KrisThe minimum age of the child to self-report HRQOL instruments varies from 7–9 years . As our The effects of medical interventions are reflected not only as changes in somatic parameters, but also in emotional and social aspects of patients’ lives. HRQOL assesses unexpected functional disability, monitors disease progression, and thus contributes to improvement of the prognosis. It is acknowledged as an essential health outcome measure in clinical trials, and in health services research and evaluation , and a rTM 4.0 Generic Core Scale, which is a general questionnaire and thus may lack precision and sensitivity to identify important effects of distinctive symptoms of FC, such as fecal incontinence. But the scale was accepted by parents under non-supported conditions and had appropriate Chinese cultural adaptations. The use of generic instruments to evaluate HRQOL is indicated when subsets of children with the same problem are compared, or when comparing children with chronic conditions to healthy children. We did not have a gold standard for assessing the HRQOL of children with FC, therefore a specific instrument for the assessment of children with constipation and encopresis, like DDL, was proposed by Voskuijl et al. [We believe that our findings have an important value regarding HRQOL of children with FC. However, this study had several limitations too. First, HRQOL was assessed using PedsQLl et al. . DDL hasFC is a frustrating symptom for children and their caregivers. Social characteristics of children and caregivers, duration and symptoms of FC, and family economic status significantly affected HRQOL and family function of affected children and caregivers. The lower HRQOL in these children, and high level of parental concern, create the need for more prompt management. Early recognition of symptoms and adequate treatments are necessary for successful outcomes. Therefore, it is important for problems identified in the HRQOL domains to be recognized and addressed as early as possible. HRQOL assessment can enable this recognition and may provide targets for additional  intervention.


Wistar rats treated with Mentha piperita (peppermint) juice. Male offspring from nondiabetic dams  and from dams with streptozotocin-induced severe diabetes  were used. They were treated during 30 days, and, after the treatment period, levels of glycemia, triglycerides, total cholesterol, and fractions were analyzed in the adult phase. The offspring from diabetic dams treated with peppermint showed significantly reduced levels of glucose, cholesterol, LDL-c, and triglycerides and significant increase in HDL-c levels. The use of the M. piperita juice has potential as culturally appropriate strategy to aid in the prevention of DM, dyslipidemia, and its complications.This study aimed at evaluating glycemia and lipid profile of offspring from diabetic  Diabetes mellitus (DM) is considered to be a syndrome associated with disorders in the metabolism of carbohydrates, lipids, and proteins caused by the absolute or relative lack of insulin , and it Studies show that obesity and DM2 are more frequent in children and adolescents whose mothers were diabetic or had gestational DM. Maternal metabolic disorders affect the growth and the metabolism of descendants, leading to diabetogenesis in different phases of the offspring life, including their pregnancies. Hence, the next generation will also be affected, and the same consequences will influence other generations, thus showing the diabetogenic tendency –12.The problems resulting from DM and its complications bring high costs to the Brazilian Health Care System. The search for medical alternatives to reduce costs can be highly valuable for those living below the poverty line. An alternative can be the use of medicinal plants, which have been increasingly used in the treatment of DM and other metabolic syndrome risk factors –15.Mentha piperita L  is one of the ten most widely used plants in Brazil and is commonly used in the treatment of loss of appetite, common cold, bronchitis, fever, nausea, vomiting [Wistar rats treated with Mentha piperita juice.vomiting , spasmodvomiting , and antvomiting , 19. It vomiting . HoweverWistar rats used were kept in the vivarium of UNIMEP (Lins Campus) under controlled conditions . These animals were treated according to the “Guide to the care and use of experimental animals,” which delineates the principles by the Canadian Council for the care to laboratory animals. The study was initiated after its approval by the Ethics Committee under registration number 2500000764/2007-47.The n = 20) weighing approximately 250 g underwent a seven-day adaptation period in the room where the experiment was conducted. Thereafter, randomly selected rats received an intravenous administration  of 40 mg of streptozotocin (STZ)/Kg  diluted in citrate buffer . Nondiabetic animals (n = 20) received only the vehicle (citrate buffer) in a volume that was equivalent to that of the diabetogenic drug [n = 20) when showing glycemia above 200 mg/dL and nondiabetic  when showing glycemia below 120 mg/dL.Nondiabetic rats .In the mornings of days 0, 7, 14, and 21 of pregnancy, a blood drop was collected from the caudal vein for glycemia measurement by using glucometer n = 15 animals/group): G1: offspring from control dams treated with vehicle (water), G2: offspring from control dams treated with Mentha piperita juice, G3: offspring from diabetic dams treated with vehicle, and G4: offspring from diabetic dams treated with Mentha piperita juice. After weaning, the offspring  were kept in collective cages until they reached adulthood. The adult animals, weighing approximately 250 g, were divided into 4 experimental groups (Mentha piperita juice at a dose of 0.29 g/kg once a day (at early morning) for 30 consecutive days. The dose administered to the animals was based on 100 g/L, which corresponds to the daily intake of 200 mL of juice by an adult man weighing 70.0 kg (such intake was based on population consultation).The animals in groups G2 and G4 received Mentha piperita leaves were washed, weighed (100 g/L), and triturated with water in a blender for 7 minutes. The juice was filtered and frozen in an amber flask. Each flask was thawed daily at ambient temperature two hours prior to administration.After 30 days of treatment, the animals were anesthetized with sodium pentobarbital 150 mg/kg) and killed. Subsequently, blood samples were collected in order to determine the biochemical profile . Tests were performed according to the methodology proposed by commercial kits: LABTEST  for glycemia, total cholesterol and HDL-c, and triglycerides and WIENER LAB  for LDL-c. The results were interpreted according to criteria established by the American Diabetes Association [50 mg/kg t test, and the level of significance adopted was P value <.05%.Data analysis was performed by using Student's M. piperita (G2). No significant differences were observed for glycemia between these two groups, but there were a significant reduction in plasma levels of cholesterol, triglycerides, and LDL-c and significant increased HDL-c values in the offspring from group G2 in relation to those from group G1.M. piperita (G4). The glycemia and the levels of cholesterol, LDL-c, and triglycerides were significantly reduced and the levels of HDL-c were significantly increased in group G4 as compared to group G3. M. piperita juice (G2) and from diabetic dams treated with M. piperita juice (G4). There were no significant differences in the glycemia, cholesterol, LDL-c, and triglycerides between the offspring from G4 and G2 groups. It was observed that offspring from G4 dams showed increased HDL-c levels in relation to those from G2. No differences were found in food intake and body weight among the groups at the beginning and end of the treatment Figures  and 6.Mentha piperita (peppermint) is one of the plants most frequently used by the Brazilian population for therapeutic purposes. Its medicinal use includes anti-inflammatory, antispasmodic, and analgesic activities and the treatment of respiratory and gastrointestinal problems, as well as its antioxidant and antiperoxidant effects [There are a large number of medicinal plants that are popularly used for diabetes mellitus (DM) and hypercholesterolemia treatment , 21–24.  effects .Mentha piperita on diabetic rats. These results show that the use of peppermint juice can be beneficial in the therapy and/or prevention of DM and its complications in the offspring from dams with diabetes. Other studies in the literature show that the use of plants or antioxidant substances can help avoid damages associated with diabetes [In this study, it was observed that the offspring from diabetic dams showed high levels of blood glucose and lipids. However, significant reductions were also found for the glycemia of offspring from diabetic mothers treated with peppermint juice, thus corroborating the findings by Narendhirakannan et al. , who evadiabetes , 29–36. Wasabia japonica in vitro and in vivo and observed significant antioxidant activities and anti-hypercholesterolemic effects. Kumar et al. [Anthocephalus indicus root.The importance of peppermint can also be extrapolated to the offspring of nondiabetic dams (normoglycemic) as they also benefitted from using the plant. Peppermint juice also positively influences the concentration of plasma lipids in the studied animals, both in the offspring from nondiabetic and in those from diabetic dams. Barbalho et al.  observedr et al.  found siMentha genus have substances that may be related to such effects. M. arvensis contains menthol, murol, eugenol, thymol, and hydrocarbonates. Menthol and other volatile compounds can be found in the leaves of M. piperita [Ficus racemosa Stem Bark Extract [Phaulopsis fascisepala [The species from the piperita , and suc Extract  and Adescisepala . Samarthcisepala .As medicines used to regulate glycemia and dyslipidemia are costly, the use of peppermint juice may be an alternative low-cost strategy to treat noncommunicable diseases associated with the insulin dysfunction. It can also be used to prevent the complications of gestational DM, thus preventing fetal hyperglycemia and hyperinsulinemia, metabolic abnormalities, and the metabolic syndrome in the offspring from mothers with DM. As peppermint also shows antioxidant and antiperoxidant effects, it also can prevent oxidative damages , 46–49. Mentha are aromatic plants traditionally used as medicinal remedies and culinary herbs but this study suggests that the use of the M. piperita juice has potential as a culturally appropriate strategy to aid in the prevention of DM, dyslipidemia, and its complications.Species of Despite the promising results concerning the use of peppermint, it is fundamentally important to perform further studies in order to evaluate its effects on human beings and the ideal doses to be used.


Antibiotics are amongst the most sold drugs. Inappropriate use of antibiotics leads not only to emergence of resistant bacteria, but also economic loss and adverse reactions. Knowledge, attitude and practice of academic staff and high school teachers about the use of antibiotics and self-medication are assessed in this survey. Also, the relationship between these factors is determined.In this cross-sectional survey, 320 academic staff  and 150 high school teachers were questioned by a questionnaire composed of 15 questions to assess their knowledge, attitude and practice about the use of antibiotics and self-medication. The reliability of the questionnaire was assessed by Crohnbach’s alpha internal consistency coefficient and the results were analyzed, using Mann-Witnney U. Spearman’s Correlation Coefficient was used to determine the correlation between knowledge, attitude and practice.The questionnaires were completed by 134 academic staff and 308 high school teachers, among whom, respectively, 35.8% and 47.1% had had self-medication during the previous year, mostly to relieve sore throat in both groups. The teachers were significantly better than the faculty staff in knowledge (P= 0.008) and practice (P<0.001).In both teachers group and academic staff, a direct linear poor relationship was detected between attitude and practice , and a poor reverse linear relationship was seen between knowledge and practice (P= -.0218) in the teachers group.According to our results, Self-medication and irrational use of antibiotics is common among highly educated people in the community in Iran, which can be prevented by improving their knowledge.None declared.


Purpose. To determine the effects of concurrent strength and endurance training (concurrent training) on the Health-Related Quality of Life (HRQOL) and cardiopulmonary status among HIV-infected patients, using a systematic search strategy of randomized, controlled trials (RCTs). Methods. A systematic review was performed by two independent reviewers using Cochrane Collaboration protocol. The sources used in this review were Cochrane Library, EMBASE, LILACS, MEDLINE, PEDro and Web of Science from 1950 to August 2012. The PEDro score was used to evaluate methodological quality. Result. Individual studies suggested that concurrent training contributed to improved HRQOL and cardiovascular status. Concurrent training appears to be safe and may be beneficial for medically stable adults living with HIV. The rates of nonadherence were of 16%. Conclusion. Concurrent training improves the HRQOL and cardiopulmonary status. It may be an important intervention in the care and treatment of adults living with HIV. Further research is needed to determine the minimal and optimal duration, frequency, and intensity of exercise needed to produce beneficial changes in the HIV-infected population subgroups. The introduction of highly active antiretroviral therapy (HAART) has dramatically reduced mortality and morbidity in HIV-infected patients. On the other hand HIV-infected patients are experiencing an increasing frequency of noninfectious problems, which can significantly impair the benefits of HAART , 2. Exercise training improves and maintains health and reduces the risk of chronic disease in healthy adults . ExercisResistance training has been employed as a therapeutic tool in patients with HIV and is considered safe and effective in improving muscle strength and body composition , 8. AeroRecently, the combination of two exercise modalities: concurrent strength and endurance training (concurrent training) has been employed, as recommended by the American College of Sports Medicine . ParticiThe physiological stimuli directed to skeletal muscle as a result of strength training or endurance training are divergent in nature, due to competition in metabolic adaptation to exercise. As a consequence, its effects may be limited when compared to training, in terms of specific parameters , 14, butSome studies have shown a significant improvement in components of muscle performance and endurance during concurrent training in patients with HIV/AIDS –19. The The goal of this systematic review was to analyze the impact of concurrent strength and endurance training termed concurrent training on HRQOL and cardiopulmonary status of patients living with HIV/AIDS and discuss their implications for clinical practice.We performed a computer-based search querying Ovid MEDLINE (1950 to August 2012), LILACS (up to August 2012), CINAHL , EMBASE (1980 to August 2012), PEDro (Physiotherapy Evidence Database), and the Cochrane Central Register of Controlled Trials for original research articles published in English, Spanish, and Portuguese. We also performed a manual tracking of citations in the selected articles.The design group included the terms randomized controlled trials, clinical trials, and controlled trials. The HIV group included the terms human immunodeficiency virus, acquired immunodeficiency syndrome, HIV, HIV infections, HIV long-term survivors, AIDS, and HIV/AIDS. The exercise group included the terms exercise, training, physical exercise, fitness, strength training, progressive resistive/resistance aerobic, aerobic training, concurrent strength and endurance training, concurrent training, anaerobic, exercise therapy, or physical training.The outcome measures group included the terms quality of life, health-related quality of life, life expectancy, and cardiopulmonary status.We included randomized controlled trials (RCTs) comparing concurrent training with nonconcurrent training or with another exercise modality, performed at least two times per week and lasting at least four weeks. Studies of adults (18 years and older), regardless sexes, at all stages of infection were included. The concurrent training was defined as the application of aerobic and resistance exercise in the same training session, performed at least two times per week for at least four weeks. Resistance training was defined as exercise that requires muscle contraction against resistance. Aerobic exercise was defined as a regimen containing aerobic interventions . Exercise programs were described with respect to type of exercise, volume, intensity, frequency, and duration.max) (beats/min), fatigue (time on exercise), and dyspnea (rate of perceived exertion).Cardiopulmonary measures considered in this review included but were not limited to maximal/peak oxygen consumption (V02 max/peak) (mL/kg/min), oxygen pulse (02pulse), maximum heart rate . If a trial was not included in PEDro or had not been previously rated twice, it was rated independently by two investigators. Studies were excluded in subsequent analysis if the cutoff of 4 points was not reached.The PEDro scale  is basedWe identified a total of 98 articles with the search strategy applied to the databases MEDLINE, Scielo, AMED, Lilacs, and PEDro. These 37 items were sent to reviewers for evaluation, selection, and inclusion in the review. Twenty-six were excluded, and 11 papers met entry criterion according to reviewers. Three additional studies were excluded after retrieving the full text. Of these, 2 were RCTs that did not examine outcomes of interest to this review and one study was a duplicate of Mutimura et al. .The remaining eight articles were fully analyzed and approved by both reviewers and had the extraction of data from each RCT .Participants included adults infected with HIV at various stages of the disease with CD4 counts ranging from <100 to >500 cells/mmStress test was used with a treadmill, stationary bike, and cycle ergometer. Submaximal tests were also used, as the Shuttle test, Kasch Pulse Recovery Test, and six-minute walk test.WHOQOL-BREF and MOS-HIV health surveys were the tools used to evaluate HRQOL. The exercise intervention characteristics of included studies are provided in The duration of intervention programs with concurrent training ranged from 6  to 24 weFor resistance training only two studies , 29 specmax), ranging from 45 to 80% HRmax. For the application of aerobic exercise, all studies reported the treadmill, bike, walking, or joging. Except for the study of Rigsby et al. , all repSeven studies reported significant improvement in the concurrent training group compared to control group. One study did not compare the improvement intergroups, because they used a before and after evaluation .2max). It was improved from 4.7 ± 3.9 to 0.5 ± 0.3 mL/kg per min in the intervention group compared to control (P < 0.001). In the study of Fillipas et al. [P < 0.001). In the study of Hand et al. [2 estimated in the exercise group while there was no improvement in the control group (P < 0.001).In the study of Mutimura et al. , Shuttles et al. , the Kasd et al. , there w−1, P < 0.001) in VO2max in the training group compared to control. In a study by Driscoll et al., fitness assessment was performed using the time to perform the exercise on a cycle ergometer, with a significant increase in the exercise group compared to control . Rigsby et al. [P < 0.001). Dolan et al.  observedy et al.  also use2max after training was observed, compared to baseline. In the study by Rojas et al. , a signiFour researches included HRQOL outcome between the endpoints. All reported significant improvement in HRQOL of the concurrent training group compared to control group.P < 0.0001), independence , social relationships , HIV HAART-specific , and QoL domains  significantly improved in the concurrent training compared to control group.Mutimura et al.  assessedP = 0.09), QOL significantly increased (P < 0.01) in the training group after the intervention period, whereas no change was observed in controls.In the Pérez-Moreno et al. study , althougP = 0.03). The experimental group improved their cognitive function while the control group stayed much the same; the between-group difference was 14 points . In the study of Fillipas et al. , and RojP > 0.05).In second study  six domaAdherence to exercise is the ability to maintain a program for a certain time. In all studies a varied proportion of patients are excluded before the end of program. In this review, from 471 patients that entered the protocol, only 396 (84%) remained on study at closure.Mutimura et al.  showed tThis systematic review demonstrated that there is sufficient evidence to support the inclusion of concurrent training for adults living with HIV/AIDS.It is evident that the effectiveness of concurrent training improves aerobic capacity in this population. Despite major differences in exercise prescription and duration of different programs, the aerobic capacity was significantly improved. These findings coincide with results of previous studies that found significant improvements in cardiopulmonary fitness , 33.The effect of concurrent training on QOL is less clear. Only one study showed significant improvement in all domains, while two studies showed impact in specific domains, and in one study the statistical significance was not reached for the combined effect of group and time. This discrepancy can be due to intensity, frequency, and duration of the programs in the analyzed studies, which can result in a different impact on such parameters.Physical therapists can play an important role in diagnosis and management of the physical dysfunction in HIV-infected patients , 35. ThiIntervention strategies should focus on increasing exercise, considering cessation of smoking, dietary counseling, and treatment of arterial blood hypertension and dyslipidemia . Researc2max. Resistance training should focus on large muscle groups, such as the chest, biceps brachia, quadriceps, and hamstrings. The intensity should be moderate (set at 60% to 80% of the one MR) and progressively increased. Overload should be selected with the level this patient can comfortably perform, 8 to 12 repetitions [The number of weekly exercise sessions should be increased until the patient can tolerate three to five sessions weekly. Aerobic exercise should be performed at a moderate intensity: from 11 to 14 on the Borg Rating of Perceived Exertion Scale, at 50% to 85% of peak heart rate, or at 45% to 85%  VOetitions . The role of a well-planned exercise program should therefore be emphasized and used as medical treatment among patients and health care professionals. When implementing therapeutic exercise programs for HIV-infected patients, it is recommended that programs be individualized on the basis of the functional capacity and individual symptoms presented by each patient , 38. A patient participating in an exercise intervention should be monitored by a physical therapist qualified health-care provider for potential changes in their health status, especially those in more advanced stages of immunosuppression, to prevent any potential adverse events of exercise .Adherence to exercise is an underresearched area with regards to HIV treatment. Very few studies have been reported on the adherence of HIV patients to exercise in the clinical setting. The strongest motivators of adherence to exercise have been shown to be self-efficacy (the concept that a person is capable of performing a course of action to attain a desired outcome) and outcome expectation  , 41.Further research into reasons for nonadherence as well as for dropouts would be beneficial. In order to gain the most from the exercise, combined exercise programs including targeted psychological support might be the way forward .Future research needs to identify which patient subgroups might benefit the most, the optimal exercise dose needed to lessen disease-related symptoms and maximize clinical benefit, and the effects with different types of programs.Meta-analyses were not performed due to variability of characteristics of the studies pertaining to the exercise, variation among individual studies in the types of interventions the differences in endpoints, assessment instruments, and variables of exercise prescription.Concurrent training is efficacious in treating disability in outpatient men who are HIV positive and showed to be a safe and beneficial intervention in the treatment. Exercise improves aerobic cardiopulmonary status and HRQOL. It may be an important intervention in the care and treatment of adults with HIV.


Introduction. Obesity is a condition that causes damage to the respiratory function. However, studies have demonstrated that weight loss due to bariatric surgery has resulted in a huge improvement on some lung volumes, but controversy still persists regarding the behavior of the respiratory muscle strength and IRV (inspiratory reserve volume). Objective. To evaluate the effect of weight loss, after 1 year of the Roux-en-Y gastric bypass surgery (RYGB), on the lung volumes and the respiratory muscle strength in obese women. Methods. 24 obese women candidates were recruited for RYGB. Lung volumes (spirometry) and respiratory muscle strength were evaluated in preoperative period and one year after surgery. Results. There was a significant increase in some lung volumes. However, when examining the components of the VC  separately, an increase in ERV (expiratory reserve volume) and reduction of IRV were observed. Moreover, a statistically significant reduction in the values of respiratory muscle strength was recorded: MIP  and MEP . Conclusion. Weight loss induced by bariatric surgery provides an increase in some lung volumes of obese women, but reduction in IRV. Additionally, there was also a reduction in the respiratory muscle strength. Obesity is a condition that causes damage to the various body functions, such as cardiovascular, musculoskeletal, and metabolic functions amongst others . The res1), improved alveolar-capillary diffusion capacity [A few studies have demonstrated that weight loss due to bariatric surgery has resulted in a huge improvement in some functions, such as decrease in hemoglobin and hematocrit , decreascapacity  and imprcapacity , 13 haveThere is strong evidence supporting the increase in FVC and ERV (expiratory reserve volume) after weight loss , 12, 13.The objective of the present study was to evaluate the effect of weight loss, after 1 year of the Roux-en-Y gastric bypass surgery (RYGB), on the lung volumes and the respiratory muscle strength in obese women. 2 were included if they met the minimal criteria for bariatric surgery proposed by the World Health Organization (WHO) report of 2000 [Were recruited 24 obese women candidates for RYGB at the Meridional Hospital. Patients with body mass index (BMI) 35–50 kg/m of 2000 . The fol1) and the FEV1/FVC ratio. The MVV, a variable that evaluates the respiratory endurance, was expressed in liters per minute and as a percentage of the predicted reference value for the Brazilian population [The evaluation of the pulmonary function was carried out by conventional spirometry using a personal computer version of the NDD EasyOne Spirometer Model 2001 . Parameters, such as volume, capacity, and flow of the lungs, were directly evaluated by using the slow vital capacity (SVC), the forced vital capacity (FVC), and the maximum voluntary ventilation (MVV) tests, with volunteers in a sitting position and a minimum of three repetitions, as recommended by the American Thoracic Society (ATS) and the European Respiratory Society (ERS) . The obtpulation .2O (±300 cm H2O), and equipped with a 2 mm hole to relieve the oral pressure. The procedure was carried out as described by ATS/ERS [The respiratory muscle strength was determined through the maximal static respiratory pressures measured during forced inspiration and expiration—maximal inspiratory pressure (MIP) and maximal expiratory pressure (MEP). The measurement was carried out using an aneroid manometer , calibrated in centimeter H ATS/ERS . MIP and ATS/ERS .The patients were evaluated in the preoperative period, and one year after surgery, they were asked to return for a reevaluation of the pulmonary function tests, by the spirometry and respiratory muscle strength.t-test was used to compare the preoperative and 1-year postoperative results.The data collected were expressed as mean ± standard deviation and analyzed by the Shapiro-Wilk test. After verifying the normal distribution of the variables, the paired The Pearson correlation was used to correlate these variables: W/H ratio and ERV; IRV and MIP.The sample size had an 80% power at the 5% level of significance with MEP as the main variable.2), and only 2 patients remained obese, despite significant reduction in the BMI one year after surgery. Before surgery, 12 patients had hypertension, 7 had dyslipidemia, and 8 had diabetes. One year after the surgery, 6 patients continued with hypertension and 2 with dyslipidemia. However, the diseases were less severe than in the preoperative period.The characteristics of the patients, such as age, BMI, weight, and W/H ratio, are shown in 1. However, when examining the components of the VC separately, an increase in ERV and reduction of IRV, keeping the VT unchanged 1 year after surgery, was observed. Furthermore, respiratory endurance assessed by MVV also increased after weight loss   (There was a significant negative correlation between W/H ratio and ERV ( = 0.01)  and a si= 0.004) .Based on the obtained results, it was established that 1 year after the RYGB surgery, the patients showed a significant reduction in the measures of weight, BMI, and W/H ratio, especially changes in the lung function tests, such as spirometry and respiratory muscle strength.Studies by some authors , 12, 18 1 could be observed after weight loss. Other authors have also found similar results in previous studies [With respect to the volumes, an increase in VC, FVC, and FEV studies , 20–22. r = −0.37; P = 0.01) (The reduction of ERV is a major known change in the respiratory function caused by obesity. According to Koenig (2001) , this fa = 0.01) .Weiner et al. (1998)  also revEl-Gamal et al. (2005)  evaluater = 0.41; P = 0.004)  may also have contributed to the reduction of IRV, since the inspiratory muscles are responsible for expanding the rib cage and promote entry of air into the lungs. This finding can be confirmed by the significant and positive correlation between these variables—MIP and IRV (= 0.004) .The respiratory muscle strength is also an important variable that influences the lung function, and the available data in the literature are still few and controversial about this variable after weight loss. Dávila-Cervantes et al. (2004)  and WeinThe average weight loss with RYGB is 30% , which iAnother hypothesis is that the reduced work of breathing in the obese individuals achieved with weight loss , no longDespite a trend to decrease the maximal static respiratory pressures—MIP and MEP, there was an increase in MVV . This fact can be justified as the weight loss promotes an improvement of the chest mechanics, increases the lung volumes , 22, and1) and respiratory endurance (MVV) of obese women. Furthermore, the reduction in IRV appears to show a trend distribution of static lung volumes in the pattern as seen in the nonobese patients. Additionally, there was also a reduction in the respiratory muscle strength, which could be caused by a loss of lean body mass and a reduction in the work of breathing after weight loss. However, further studies are warranted to confirm this hypothesis.Based on the obtained findings, it was concluded that weight loss induced by bariatric surgery provides an improvement in the ventilatory mechanics, as evidenced by the increase in lung volumes (ERV, VC, FVC, and FEV


Several aspects linked to social are involved in the onset of depressive feelings. We aimed to find out if social adaptability and substance abuse predict depression among end-stage renal disease (ESRD) patients undergoing hemodialysis (HD).We included 145 ESRD patients undergoing HD. Social adaptability was estimated by the Social Adaptability Index (SAI). Substance abuse was defined according to SAI. We screened for depression by applying the 20-item version of the Center for Epidemiologic Studies Depression Scale. A score ≥ 24 classified the patients as depressed. Comparisons between depressed and non-depressed patients were carried out and logistic regression was performed to test gender, age, total SAI, SAI without the substance abuse item, only the substance abuse score and substance abuse as a categorical variable (yes/no) as predictors of depression.There were 36 (24.8%) depressed patients. There were no differences regarding demographic and laboratory data between the depressed and non-depressed patients. Mean SAI among depressed and non-depressed patients was, respectively, 6.1 ± 1.6 vs. 6.2 ± 1.9 (p=0.901). The percentage of patients with or without substance abuse among depressed patients was, respectively, 13.8% vs. 13.9% (p=1.000). Gender, age, total SAI, SAI without the substance abuse item, only the substance abuse score and substance abuse as a categorical variable did not predict depression.Social adaptability and substance abuse did not predict depression in HD patients. We propose that aspects related to socioeconomic status not comprised in SAI items should be ruled out as predictors of depression. End-stage renal disease (ESRD) patients undergoing hemodialysis (HD) cope with several problems and difficulties related to the disease and its treatment. As a consequence, depressive feelings are common among them ,2. We caIn light of our daily practice of caring for socially disadvantaged patients, the data on the influence of socioeconomic status on depression led to our interest in finding socioeconomic predictors of depression among HD patients ,5. SearcTherefore, we aimed to compare the SAI between depressed and non-depressed HD patients and to test the SAI and its substance abuse item separately as predictors of depression.The sample was composed of ESRD patients undergoing HD during June 2011 in the only renal unit in the north of Ceará state, northeastern Brazil. The renal unit works in the reference hospital of the region. The criteria for exclusion were age below 18 years and less than three months on dialysis. One hundred forty-five patients were included of a total of 160. Among the patients excluded there were 7 with less than three months on therapy, 5 who refused to participate and 3 under 18 years. All patients were undergoing conventional HD (three sessions of four hours per week) with polysulfone dialyzers (maximum number of reuses=12). The study protocol and informed consent were approved by the ethics committee of Vale do Acaraú University, with which the hospital is associated. All patients gave written consent to participate in the study. Even though not a criterion for exclusion, we determined after the informed consent that none of the patients in the sample had received treatment for depression previously.The index was calculated by the sum of five components: employment status, education level, marital status, substance abuse and income, as described by Goldfarb-Rumyantzev et al. . All comWe used the 20-item version of Center for Epidemiologic Studies Depression Scale (CES-D) . We haveThe demographic data, time on dialysis and underlying etiology of ESRD were assessed in unit records. The underlying kidney disease was classified by clinical criteria and not by histopathology. The laboratory results were those routinely measured in HD patients: creatinine, albumin, hemoglobin, calcium and phosphorus and Kt/V. Kt/V was estimated using a second-generation Daugirdas formula .Comparisons between depressed and non-depressed patients were carried out by the Chi-square test for categorical variables, and by the Student-t and Mann–Whitney tests, when indicated, for continuous variables. Logistic regression was performed to test gender , age, time on dialysis, total SAI, SAI without the substance abuse item, only the substance abuse score and substance abuse (no substance abuse as reference category) as predictors of depression. Statistical significance was considered to be a P value of <0.05. All the statistical analyses were performed using the SPSS version 13.0 program package [The sample characteristics are shown in Table Our finding of 24.8% depressed patients is in accordance to the overall literature, which reports depression of 20 to 30% among HD patients . We founWe aware of divergences about the optimal cut-off of CES-D to classify depression. We chose a cut-off of ≥ 24, which is within the range for the screening of mild depression, described in the literature as being between 16 and 26 .We were surprised that even though the patients come from a low-income area, the mean SAI of our sample is close to that found among American patients ,7. This We were disappointed that SAI was not different between depressed and non-depressed patients, and did not predict depression. Our initial hypothesis of SAI being a predictor of depression was based on data about the relationship of socioeconomic aspects with depression ,5. On thIn clinical practice, there are no widely used and well-validated instruments to assess socioeconomic status able to work as predictor tools in ESRD. So, an instrument like the SAI, validated as a predictor of objective clinical outcomes among HD and transplanted patients, seemed to us a very practical way of using a short instrument also to predict subjective outcomes, such as depression, surely a main outcome among HD patients. Medical monitoring of patients on HD is a hard task and renal units need to work with practical and, if possible, few instruments. Unfortunately, based on our preliminary data, SAI does not predict depression. Granted, our sample is small and from an underdeveloped area, which means there are more young patients and fewer diabetics, with glomerulonephritis being the main cause of ESRD. So, our results may not hold for other more typical samples. In our country, SAI was never tested as a predictor tool for any outcome. We believe our results can stimulate further research using SAI in larger samples with different profiles from ours.The use of the SAI offered us an opportunity to evaluate an important question in HD patients: substance abuse. In the nephrology area, substance abuse must be highlighted as a risk for ESRD ,22. SubsThere were limitations of this study, mainly due to the cross-sectional design. Trends of causality related to depression, social adaptability and substance abuse cannot be clarified. Also, no data about duration of substance abuse  were collected. A sample from a single renal unit is always a barrier for generalizations, and as previously commented, our sample is quite different from those from developed areas. However, despite these limitations, we emphasize that it is the first time the SAI has been studied in Brazil, which contributes both to stimulate new research in our country using the same instrument and opens the possibility for comparing results across different countries.Social adaptability and substance abuse prevalence did not differ among depressed and non-depressed HD patients, and therefore these variables cannot be used as predictors of depression. We propose that aspects related to socioeconomic status not comprised in SAI items should be ruled out as predictors of depression.CES-D: Center for Epidemiologic Studies Depression Scale; ESRD: End-stage renal disease patients undergoing; HD: Hemodialysis; SAI: Social Adaptability Index.The authors declare that they have no competing interests.PRS was responsible for the conception, design, analysis and interpretation of data. FPNA edited and made critical revision of the manuscript. Both authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2369/14/12/prepub


To the Editor: The cat flea  is a ubiquitous parasite of domestic and wild animals that also feeds readily on people. Recent studies have implicated the cat flea as a vector of new and emerging infectious diseases , according to the manufacturer’s instructions. When polymerase chain reaction (PCR) was performed with primers for gltA and rOmpA as described (Rickettsia felis (GenBank AF191026) with infected fleas taken from both dogs  and cats . When PCR was performed with primers for the 16S-23S rDNA interspacer region as described (Bartonella henselae (GenBank AF312495), and the sequence of the product of one flea (from a cat) was identical to that of B. clarridgeiae (GenBank AF167989).R. felis in Oceania. The organism is a recently described human pathogen, and infections with this spotted fever group rickettsia have already been reported in 11 persons: 4 persons in the United States, 2 persons in Brazil, 4 persons in Europe, and 1 person in Thailand. The symptoms of the patients were nonspecific and included fever, headache, and rash. Diagnoses were made by sequencing products obtained by PCR with primers for the 17-kDa protein (R. felis has been established in tissue culture (XTC-2 and Vero cells) (Our study is the first to identify B. henselae is an agent of cat-scratch disease, bacillary angiomatosis, bacillary peliosis, endocarditis, bacteremia, and various neurologic and ocular conditions. Cats are the reservoir hosts, and contact with cats and their fleas is an established risk factor for most infections. Although B. henselae has been isolated from 17% of domestic cats in New Zealand (B. clarridgeiae which has been implicated as an agent of cat-scratch disease in humans and aortic valve endocarditis and hepatic disease in dogs (B. clarridgeiae in New Zealand, this description is the first of the organism in Oceania. However, B. clarridgeiae has been found in domestic cats in nearby Indonesia and the Philippines (R. felis, B. henselae, and B. clarridgeiae and should alert medical workers in New Zealand, a common tourist destination, to the possibility that their patients may be infected with these organisms.Our findings add to the accumulating data on


Mammographic density (MD) is a strong, independent risk factor for breast cancer, but measuring MD is time consuming and reader dependent. Objective MD measurement in a high-throughput fashion would enable its wider use as a biomarker for breast cancer. We use a public domain image-processing software for the fully automated analysis of MD and penalized regression to construct a measure that mimics a well-established semiautomated measure (Cumulus). We also describe measures that incorporate additional features of mammographic images for improving the risk associations of MD and breast cancer risk.r) was used to compare the MD measurements by Cumulus and our automated measure, which mimics Cumulus. The likelihood ratio test was used to validate the performance of logistic regression models for breast cancer risk, which included our measure capturing additional information in mammographic images.We randomly partitioned our dataset into a training set for model building  and a test set for model assessment . The Pearson product-moment correlation coefficient  in an external test set. Adding a variable, which includes extra information to percentage density, significantly improved the fit of the logistic regression model of breast cancer risk (P = 0.0002).We observed a high correlation between the Cumulus measure and our measure mimicking Cumulus (Our results demonstrate the potential to facilitate the integration of mammographic density measurements into large-scale research studies and subsequently into clinical practice. Extensive mammographic density (MD) is a strong risk factor for breast cancer. MD refers to the different radiologic patterns of dense and nondense tissue in the breast. Radiologically dense tissue  appears light on a mammogram . NondensComputer-assisted methods are also used to assess MD. The interactive thresholding technique introduced by Byng et al. [MD can be evaluated and reported by radiologists on the basis of visual analysis of mammograms. Examples of quantitative and qualitative classification methods based on the visual characterization of mammographic parenchymal patterns include BIRADS, Wolfe , and Tabg et al. , CumulusMD is not yet an integral part of predicting the risk of breast cancer at screening and has limited influence in the clinical decision-making process for breast cancer-preventive interventions. A key challenge in the incorporation of MD data in research studies or clinical practice is that the assessment of MD by using the described methods, when performed on a large scale, is heavily restricted because of time and cost. The second challenge is that these methods are to some extent dependent on a subjective interpretation by the reader, some more so than others. A robust automatic method that measures MD, developed to work in a high-throughput setting, would thus be of great benefit to both single assessments of MD and longitudinal studies assessing risk of breast cancer with respect to MD change in large-scale screening programs.We present a fully automated method of assessing MD quantitatively from digitized analogous film mammograms by using ImageJ , a publiThis study is an extension of a breast cancer case-control study carried out among Swedish residents born in Sweden and aged 50 to 74 years, between October 1, 1993, and March 31, 1995 ,11. InfoPostmenopausal women with incident primary invasive breast cancer were identified via the six Swedish Regional Cancer Registries. The 3,979 women with a diagnosis of invasive breast cancer were identified, and 84%  of these women participated in the study. The primary reasons for nonparticipation were patient's refusal or doctor's refusal because of the patient's poor health.Controls were frequency matched by the expected age distribution  among cases and identified through the Swedish National Population Register holding data on national registration number, name, address, and place of birth of all Swedish residents. The response rate among controls was 82% .et al. [We sought to retrieve all mammograms for the eligible women in the initial cohort of the main study population by using the Swedish national registration numbers . We couFilm mammograms of the mediolateral oblique (MLO) view were digitized by using an Array 2905HD Laser Film Digitizer, which covers a range of 0 to 4.7 optical densities. The density resolution was set at 12-bit dynamic range. For participants in this study with multiple mammograms, the most recent mammogram was used; for cases, this was the mammogram before diagnosis. The mammogram contralateral to the tumor was chosen for cases. If this image was missing, the examination before the most recent examination was selected. For controls, we randomized side and used the same procedure as for cases. Women with bilateral breast cancer were excluded.Cases lacking information on tumor side or lacking films of the contralateral breast were excluded, as were subjects with previous reduction mammoplasty, and subjects who only had mammograms of very poor quality. There were 3,593 participants with eligible film mammograms .2-squared of 0.95. In addition, LE regularly calibrated herself against a training set of mammograms measured by Professor Boyd, an expert on, and one of the developers of, Cumulus [Mammographic density was measured by using the Cumulus software, a computer-assisted technique developed at the University of Toronto, Ontario, Canada . For eac Cumulus .To process automatically the digitized film mammograms and to measure PD, we used ImageJ , a publiPatient-identification tags were first automatically removed (cropped) by ImageJ from the images. Further preprocessing of the images was required to extract the breast region from the rest of the image. Background of the image was subtracted by superimposing a "mask" derived by applying grayscale erosion and gaussian Blur filters, followed by implementing the Kittler and Illingworth Minimum Error thresholding , implemeHaving identified the breast region of the image, we further applied automated thresholding methods to separate the areas of "dense" breast tissue ("regions of interest") from the remaining area of the breast. In total, 15 thresholding methods, which vary according to the type of pixel-intensity information they exploit  were applied to the preprocessed image, and the same preprocessed image after subtracting background by using a rolling-ball algorithm and further filtering/de-noising of the image. Areas corresponding to "dense" tissues were subdivided into smaller objects by using the watershed algorithm. Figure The Analyze command in ImageJ was then used to count and measure objects in the thresholded images . A variety of measurements were obtained for the breast as a whole, as well as for the "objects" of dense tissue, under each thresholding method . Analysis was limited to 772 variables with less than 200 NaN ("not a number") values. All remaining NaN values in the 772 variables were converted to zero in subsequent analyses.t test was used to compare the means of continuous variables. Because of the nonnormal distributions of MD measures, we used the nonparametric Wilcoxon test to compare the distribution of percentage density and absolute dense area. Distributions of categoric variables were compared by using the χ2 test. All tests were two-sided.The two-sample Student To build and assess a PD estimation model, we randomly partitioned the dataset, consisting of information on 2,993 women, into two parts: a training set for model building , and a test set for model assessment (765 cases and 747 controls).Principal component analysis was used to carry out feature selection. Instead of directly using the 772 nonindependent "raw" (ImageJ) variables, for building a model of PD, we substituted, in their place, 123 principal components (PCs). The weights (of the raw variables) used by each PC were calculated from a principal component analysis (PCA) of the training set. These 123 PCs captured 90% of the total variance of the original 772 variables (in the training set). The Scree plot, showing the fraction of total variance, as explained or represented by each PC, is displayed in Additional file Our first aim was to select a model for Cumulus PD, as a function of the PCs. As other researchers have done , we workThe same procedure may be applied to get a trained estimate of other MD measures by ImageJ, such as total breast area, absolute dense area, or absolute nondense area.r) was estimated. The Bland-Altman plot was used to assess the agreement between the two methods of measurement.To test for an association between Cumulus PD and ImageJ PD, the Pearson product-moment correlation coefficient  was evaluated by calculating the area under the curve (AUC) of the receiver operating characteristic (ROC) curve. The pROC package in R was used to calculate AUCs along with their standard errors and 95% confidence intervals. The DeLong test  was usedIn addition to using ImageJ to mimic the Cumulus measure of PD, we performed a systematic evaluation of the information in the ImageJ variables in terms of their ability to predict breast cancer risk. We fitted logistic regression models with the lasso penalty in the training set (consisting of 733 cases and 748 controls) by using a similar procedure to that described earlier for the linear model for PD. The same 123 PCs were included in our analysis, and repeated 10-fold cross validation was again used to obtain the optimal value of the tuning parameter. We "trained" three models:1. 123 PCs as covariates; all regression coefficients included in the penalty term.2. PD + 123 PCs as covariates; coefficients for the 123 PCs included in the penalty term, but not the coefficient for PD.3. PD + 123 PCs as covariates; all coefficients (123 PCs + PD) included in the penalty.Based on these three models, we formed three "scores" for each image, derived by summing the products of the nonzero regression coefficients of the PCs with the corresponding PC values of that image. We refer to these scores as score 1, score 2, and score 3 (according to these three models). The test set was then used for "external" assessment of the predictive ability of the "trained" ImageJ scores; we fitted logistic regression models with breast cancer status as outcome variable, with different combinations of the scores and Cumulus or ImageJ PD as covariates.R (version 2.13.0)  was usedP < 0.001), absolute dense area (P < 0.001), age at diagnosis or reference date (P < 0.001), age at mammogram (P < 0.001), age at menopause (P = 0.001), alcohol consumption (P = 0.008), parity/age at first birth (P < 0.001), hormone-replacement therapy (P < 0.001), family history of breast cancer (P < 0.001), and benign breast disease (P < 0.001). A near-significant association was observed for age at menarche (P = 0.084). Body mass index (BMI) (P = 0.801) was not significantly associated with breast cancer case status in this subset of the main population case-control study.A summary of descriptive statistics of breast cancer risk factors for the subjects included in this study, presented by breast cancer case status, is shown in Table Descriptive statistics for the study population according to training and test sets are given in Additional file r = 0.884; 95% CI, 0.872 to 0.894; Figure r = 0.902; 95% CI, 0.892 to 0.911). From fitting a linear regression model (test set), we found that a 1% increase in the value of ImageJ PD was associated with a 1.029% increase in the value of Cumulus PD. The range of square-root transformed PD values for ImageJ (0 to 9.10) was similar to that of Cumulus (0 to 8.96). Bland-Altman analysis for Cumulus PD and ImageJ PD, based on the 1,512 samples in the test set, showed good agreement  were similar for both Cumulus PD and ImageJ PD . Not including PD as a penalized covariate during the process of forming score 2, meant that score 2 was "forced" to be independent of PD, whereas score 3 was constructed based on a model that penalized PD along with the PCs. Additional file P = 0.0002 for both Cumulus and ImageJ) significant, indicating that information is contained in mammographic images, not captured by PD, that is important for discriminating between cases and controls. The extra information captured by ImageJ is independent of PD in predicting risk. We also note that the fully automated ImageJ PD + score 3 model has a lower Akaike information criterion (AIC) [Having assessed the ability of our ImageJ PD measure to mimic Cumulus PD, we next turned to whether ImageJ might hold extra information (not captured by Cumulus) for discriminating cases and controls. We selected three models based on the training set. Three scores were constructed as linear combinations of 28, 3, and 37 PCs from fitting penalized regression models , respectively. As expected, score 3 included considerably more PCs than score 2 and was more strongly associated with PD (on (AIC)  than theWe developed an automated thresholding method for obtaining quantitative measurements of MD that compares favorably with the established semiautomatic computer-assisted Cumulus method in predicting risk of breast cancer. The algorithm is based on an established Java-based image-analyses program, ImageJ. Furthermore, we showed evidence that additional features in a mammogram captured by ImageJ, summed into a collective score, represent a significant and independent marker of breast cancer risk.et al. [et al. [r = 0.875; 0.863 to 0.887), which was similar to that of Kallenberg et al. [r = 0.895), and substantially higher than that of Heine et al. [r = 0.70). In our study, the odds ratios associated with breast cancer risk were also similar between PD measured by Cumulus and ImageJ, suggesting that PD measured by ImageJ is as good as PD measured by Cumulus in indicating the likely development of breast cancers. Kallenberg et al. [Other researchers have developed automated approaches to measure MD. For example, Heine et al.  describe [et al.  describeg et al.   compared with what has been reported before, for example, for the parenchymal pattern-based BIRADS density measure (AUC = 0.658) . HoweverP = 0.0002). ImageJ might be capturing information not related to PD, for example, features related to mammographic texture, in the mammograms. PCs with nonzero coefficients in each score  that is freely available. ImageJ can automatically open, process, and analyze a digitized mammogram in less than 12 seconds, offering a huge advantage over time-consuming measurements using Cumulus, which typically takes a reader between 2 and 5 minutes to achieve the same result. The software runs on Java and is thus not based on any specific platform and is inexpensive in terms of expertise needed to run the macros for processing mammograms. Its open-source design makes ImageJ more easily evolvable and correctable than many proprietary packages, allowing the fine-tuning of parameters for nonstandard mammograms or potentially, with further development, non-film mammograms. As the PD estimates are derived from a machine-learning-based method, the data can be easily retrained to output other measures, such as absolute dense and nondense areas. An additional strength includes our large population-based breast cancer case-control study, which allows us to apply and validate ImageJ PD alongside Cumulus PD in the estimation of breast cancer risk.A robust, automated thresholding method would shorten the time and cost needed to acquire MD data via parallel processing of the images. Large archives of film mammograms could then be rapidly revisited and read to answer epidemiologic research questions. Images from current and future studies may also be read at the same time as they are acquired, and the resultant readings, which could encompass both PD and additional mammographic features, could perhaps be used to estimate breast cancer risk better for each individual when incorporated into current breast cancer prediction tools, such as the Gail or the Claus models.We acknowledge the weakness of using a largely postmenopausal study population, which, on average, has lower mammographic density than do premenopausal women. Caution is needed when evaluating mammograms with very high density values with the new method. In addition, the generalizability of the new automatic mammographic density thresholding method is currently limited to the MLO images (taken from an oblique or angled view) analyzed in this study. In many countries, the MLO view is preferred over lateral, perpendicular projections during routine screening mammography, as more of the breast tissue is visible in the upper outer quadrant of the breast and the axilla. Further work is required to extend the application of the method to other projections . The high-throughput capacity of an automated method makes it feasible to base future assessments of MD on more than one view.The generalizability of our new MD measurement method is at present confined to digitized screen film mammograms. With the paradigm transition from analogue to digital mammography, it is of high clinical relevance to extend the use of the automated PD thresholding method to digital mammograms. In contrast with current applications used to determine MD from digital mammograms, which have to be present as the image is being acquired by the machine, ImageJ can be applied at any time after image acquisition, making it feasible to read digital images retrospectively. However, many concerns must be addressed before MD can be confidently measured from processed digital mammograms in general. A more detailed discussion of this topic is beyond the scope of this article. Nevertheless, the availability of phenomenal archives of unread film mammograms for historical cohorts with good follow-up data justifies the development of an automatic tool.Despite the remarkably strong influence of MD on breast cancer risk, it has had limited influence in clinical decision making and has not yet been included in any established risk-prediction tool. It is, however, likely that the purpose of future mammography screening programs will not be limited to the detection of early breast cancers, but also to stratify women according to their individual risk of breast cancer. Such stratification will make it possible to tailor screening intervals based on individual risk, add complementary diagnostic techniques , and select high-risk women for appropriate preventive interventions . A robust, fully automated thresholding technique that can assess density in an objective and high-throughput manner is the first step to achieving these goals, with the ultimate aim of reducing the incidence of and mortality from breast cancer.We describe a novel method for using a public domain software for the automated analysis of mammographic density, with the intent of duplicating the findings of an established method (Cumulus), and improving the risk associations of mammographic density and breast cancer risk. Further work is required to validate and extend the application to mammographic images of other views and those produced by a digital mammography system.P: P value; PC: principal component; PD: percentage density; r: Pearson product-moment correlation coefficient.AIC: Akaike information criterion; BMI: body mass index; CI: confidence interval; MD: mammographic density; MLO: mediolateral oblique; OR: odds ratio; The authors declare that they have no competing interests.PH, LS, KC, and KH conceived and designed the study. BH, AS, and LE collected and assembled data, and JL, KH, and LS were responsible for data analysis and interpretation. All authors contributed to manuscript writing and read and approved the final manuscript.Figure S1. An example of a digitized mammogram before and after thresholding and application of the watershed algorithm by using different global thresholding algorithms.Click here for fileFigure S2. Scree plot showing the proportion of variance explained for from principal component analysis of 772 ImageJ variables. PC, Principal component.Click here for fileTable S1. Weights of original variables. Each principal component (PC) is a linear combination of the original variables. Loading values represent relative contributions of the original variables to each PC. "Total" measurements are made on particles of at least 5 pixels. Particles1, -2, and -3 denote measurements on particle size ranges of 5 to 100, 101 to 1,000, and at least 1,001 pixels, respectively.Click here for fileTable S2. Descriptive characteristics of study population by training or test subgroups.Click here for fileNonzero coefficients of penalized regression models.Click here for file


With the rapid development of P2P technology, P2P IPTV applications have received more and more attention. And program resource distribution is very important to P2P IPTV applications. In order to collect IPTV program resources, a distributed multi-protocol crawler is proposed. And the crawler has collected more than 13 million pieces of information of IPTV programs from 2009 to 2012. In addition, the distribution of IPTV programs is independent and incompact, resulting in chaos of program names, which obstructs searching and organizing programs. Thus, we focus on characteristic analysis of program resources, including the distributions of length of program names, the entropy of the character types, and hierarchy depth of programs. These analyses reveal the disorderly naming conventions of P2P IPTV programs. The analysis results can help to purify and extract useful information from chaotic names for better retrieval and accelerate automatic sorting of program and establishment of IPTV repository. In order to represent popularity of programs and to predict user behavior and popularity of hot programs over a period, we also put forward an analytical model of hot programs. Peer-to-Peer P2P) applications take advantage of resources such as storage, CPU cycles, content, or human presence available at the edge of the Internet to provide a service . With thP applicaP2P IPTV, also called P2P streaming, emerged recently as a novel framework to deliver TV programs or live events to a large number of viewers over the Internet. With the rapid large-scale popularization of broadband technology, P2P IPTV becomes the disruptive IP communication technology, which greatly revolutionizes people's lives and entertainment . SeveralThere are more and more P2P IPTV applications in the Internet now. And it is difficult to measure the applications because they use proprietary protocols. Source codes or official documents are scarcely published. However, the measurement of P2P IPTV applications is an important problem for the management and development of IPTV and several researchers have tried to address this issue. But none of them focused on program-list and its distribution of P2P IPTV. In this paper, we proposed a distributed multiprotocol crawler (DMP-Crawler) for collecting program resources in P2P IPTV networks. Moreover, we analyzed the characteristics of these IPTV programs and presented an analytical model of hot programs. The model can be used to infer the popular drama IPTV users at some time.The remainder of this paper is structured as follows. Internet Protocol Television (IPTV) denotes the transport of live streams and recorded movies or video clips by means of advanced packet-switched Internet technologies . ITU-T dOver the past decade, P2P technology has been a promising solution for the distribution of large-scale media and a large amount of P2P IPTV systems have been developed and widely deployed on the Internet. In this paper, we defined P2P IPTV as a technology that enabled users to transmit and receive multimedia services including television, video, audio, text, and graphic through P2P overlay networks with support for QoS/QoE, security, mobility, interactivity, and reliability. Through P2P IPTV, users can enjoy IPTV services anywhere. Now P2P IPTV applications are changing the way that we watch TV and movies.In 2000, Chu et al. proposed End System Multicast (ESM) , the firA typical P2P IPTV application is comprised of five components: media collection server (MCS), media distribution server (MDS), program-list server (PLS), tracker server , and end system . As illustrated in MCS gathers video data in two ways. Firstly, for live program, MCS gets video data from video grabber. Secondly, for video on demand (VoD), MCS reads video file directly, encodes video data according to some coding methods, and uploads the data to MDS.When coding data of a video, MCS will generate the related program name, program GUID , play link, category, and so forth and register the information in PLS. At the same time, MDS will register program GUID in TS.After receiving live data, MDS will distribute them to IPTV network. After receiving VoD data, MDS will store them firstly and distribute them when clients request them. We have introduced the video distribution protocol in detail in 2012 .The local peer requests the latest program-list file from PLS and updates it immediately after lunching the IPTV client. The list of program consists of program name, program GUID which is the most important identification of signal communication among peers, program descriptions, and so forth.After the local peer selects one program to watch videos, the peer registers itself to the tracker server and sends multiple query messages to the server to retrieve a small set of partner peers who are watching the same program. The information of partner peers includes IP address, TCP port, and UDP port. Upon receiving the initial list of partner peers, the local peer uses this seed peer list to harvest additional lists by periodically probing active peers which maintain a list of peers.After harvesting enough peers, the peer tries to connect the active ones or MDS to request video data for playback of the appointed program and launches a local media player  to play the video. To deal with the churn of peers, the local peer needs to actively seek new peers from its existing partners to update peer list. At the same time, it also rebroadcasts its current peer list to its partner peers.Our work is focused on P2P IPTV measurement has been extensively studied. The measuring methods can be classified into two types: passive tracing and active tracing approach.The passive approach is performed by deploying code at suitable points in the network infrastructure. The passive approach does not increase the network traffic. And it is often used to analyze and identify P2P IPTV traffic from general Internet traffic with the known behaviors . It is also used to capture IPTV traces and grasp the P2P IPTV application. Du et al.  and Tan In the active approach, the special crawler, like an ordinary client, is adopted to inject test packets into P2P IPTV network or send packets to servers and peers. Then the crawler follows packets and measures characters of IPTV network. Hei et al.  carried Most of existing research work surveyed the P2P IPTV network-centric metrics  or user-centric metrics . Our studies were primarily focused on program-list distribution of P2P IPTV applications because program resource distribution was very important to P2P IPTV applications. Our work surveyed the P2P IPTV content-centric metrics which were useful for prediction and monitoring of programs. In this paper, a distributed multiprotocol program crawler was proposed to collect various kinds of information of programs. Moreover, we also analyzed the characteristics of program resources and put forward an analytical model of hot program.In this section, we will present the basic principle of program-list distribution in P2P IPTV applications and illustrate a feasible and efficient architecture for crawling program-list.When the program-list is downloaded and extracted by an IPTV client, users can select a program to watch videos. So program-list distribution is very important in P2P IPTV applications. The program-list includes program name, categories, play-link, and descriptions. Play-link is the most important identification of signal communication among peers viewing the same program. A typical example of program metadata is shown in The client-server architecture, as shown in With the rapid increase in the number of programs, the size of program-list file becomes bigger and bigger. For example, PPTV had about 300 thousand programs in 2011, and the size of program-list file was more than 20 MB, which is a heavy burden to program-list servers and leads to bad experience to users. Some IPTV applications use compression method to decrease the file size, while others use multiple program-list files based on program categories. Furthermore, some IPTV applications encrypt program-list files to prevent hotlinking.In order to obtain program information of IPTV applications, it is necessary to summarize the principle of program-list distribution of the most of IPTV applications and decrypt the encrypt algorithm and XML metadata of program-list file.Then, an efficient distributed multiprotocol crawler (DMP-Crawler) was proposed to collect various kinds of information of programs in popular P2P IPTV applications. {Program name, IPTV application name} was used to uniquely identify a program. On the basis of crawler clients' and server's status, the crawler controller assigns tasks to multiple independent crawler clients through a task scheduling algorithm. Each crawler client periodically reports its crawling status as well as CPU and memory consumption to crawler controller.A crawler client mainly includes crawling engine, program-list crawling module, program-list extracting module, classification module, and data storage module. According to crawling task type, the crawler client invokes crawler engine, requests program-list file from program-list servers, and reports crawling status to crawler controller. When program-list file is downloaded, the crawler client extracts metadata of programs from the file, classifies these programs, and stores all information into database for further analyses.In order to understand naming rules of IPTV programs, characteristics of program naming were analyzed with statistical methods. Characteristics analysis of programs included distributions of the length of program names, the entropy of the character types, high-frequency symbols in the names, and distributions of the hierarchy depth of program names.c1  c2 ⋯ cn, Where n is the number of characters or length of PN and n = len(PN). ci   is a printable character in some coded character set, such as Chinese, English, Latin, and punctuation symbol. If len(PN) ≤ 10, the program has a short name. If 10 < len(PN) ≤ 20, the program has a medium name. If 20 < len(PN) ≤ 30, the program has a long name. If len(PN) > 30, the program has a super-long name.Program Name (PN) is composed of a serial of characters, PN = x denote the character type of program name. The set of value of x is denoted asLet a random variable se (UCD) .Uc denote the set of characters of program names, ci ∈ Uc.Let f : Uc → CharsType, every character of program name can be transformed to the corresponding character type as follows:xi ∈ CharsType, i = 1, 2, …, n.With a mapping function H(CharsType) denote the information entropy of xi, which is used to evaluate the chaos of program naming . If popularity level is between 0 and 4, median of corresponding interval is used as U. If popularity level is 5 and PPStream has not the same program, UPPTV = 3000 and UQQLive = 1800. If popularity level is 5 and PPStream has the same program, UPPTV and UQQLive are calculated byPPTV and QQLive offer 6-level popularity of programs. Every popularity level presents an interval of the number of viewers. Popularity levels of 0, 1, 2, 3, 4, and 5, respectively, represent , , , , , and [1000, + For a program, PPStream and PPfilm provide the number of its viewers, UUSee presents the ratio of its viewers, while PPTV and QQLive only offer 6-level popularity. Thus, we must normalize the number of viewers according to the number of online viewers of various IPTV applications. In June 2010, the maximum viewers of PPStream, UUSee, PPTV, and QQLive are about 20.0, 2.0, 11.0, and 6.6 million, respectively. The normalizing rules are as follows. Let's see the Meteor Shower together in that week. Moreover, the model can be used to predict popularity of hot programs in some time.In this paper, we have studied the program information collection in P2P IPTV applications. We proposed a distributed multiprotocol crawler to harvest program information of P2P IPTV applications. As far as we know, it is the first time that the detailed crawler for IPTV programs is presented. Characteristic analysis of programs was carried out. The results reveal the disorderly naming conventions of P2P IPTV program and can help to purify and extract useful information from chaos names for better retrieval. We also put forward an analytical model of hot programs to represent popularity of programs and predict user behaviors and popularity of hot programs within a period.Distribution of IPTV programs is independent and incompact, resulting in the chaos of program name, which obstructs searching and organizing programs. In the next work, we will focus on data mining of programs and establishment of IPTV repository.