In traditional epidemiological studies, participants are likely motivated by perceived benefits, feelings of accomplishment, and belonging. No study has explored motives for participation in a Web-based cohort and the associated participant characteristics, although such information is useful for enhancing recruitment and improving cohort retention.We aimed to evaluate the relationships between motives for participation and sociodemographic, health, and lifestyle characteristics of participants in the NutriNet-Santé Web-based cohort, designed to identify nutritional risk or protective factors for chronic diseases.The motives for participation were assessed using a specifically developed questionnaire administered approximately 2 years after baseline. A total of 6352 completed the motives questionnaire . We studied the associations between motives (dependent variables) and individual characteristics with multivariate multinomial logistic regression models providing odds ratios and 95% confidence intervals.In total, 46.45% (2951/6352) of participants reported that they would not have enrolled if the study had not been conducted on the Internet, whereas 28.75% (1826/6352) were not sure. Men , individuals aged 26-35 years , and obese participants  were more inclined to be motivated by the Internet aspect. Compared with younger adults and managerial staff, individuals >55 years  and employees/manual workers were less likely motivated by the Internet aspect . Regarding reasons for participation, 61.37% (3898/6352) reported participating to help advance public health research on chronic disease prevention; 22.24% (1413/6352) to help advance nutrition-focused research; 6.89% (438/6352) in response to the call from the media, after being encouraged by a close friend/associate, or a medical provider. Individuals >45 years (vs younger participants) were more likely , whereas overweight and obese participants (vs nonobese participants) were less likely to participate in the study for reasons related to helping public health research on chronic disease prevention . Exclusive public funding of the study was important for 67.02% (4257/6352) of the participants. Men  and persons >55 years  were more likely to consider the exclusive public funding as very important.The use of the Internet, the willingness to help advance public health research, and the study being publicly funded were key motives for participating in the Web-based NutriNet-Santé cohort. These motives differed by sociodemographic profile and obesity, yet were not associated with lifestyle or health status. These findings can help improve the retention strategies in Web-based cohorts, particularly during decisive study periods when principal exposure information is collected. The successful implementation of very large population-based cohort studies involving collection of comprehensive, high-quality dietary, lifestyle, and health data is both a priority and a challenge in nutritional epidemiology ,2. Such Yet Web-based prospective cohort studies are still in their infancy . WhereasVoluntariness refers to the voluntary motivational nature of a person’s participation from the initial decision to participate through the course of the study, and is influenced by external and internal factors . In tradThe NutriNet-Santé study was launched in May 2009 in France to investigate multiple facets of the relationship between nutrition and health along with determinants of dietary behavior . This isParticipants were part of the NutriNet-Santé Study, a large Web-based prospective observational cohort. It is implemented in a general population targeting Internet-using adult volunteers aged 18 years and older. The design, methods, and rationale have been described elsewhere . EligiblNumerous scientific studies have highlighted the role of nutrition as a protective factor or a risk of many common diseases in France, as in all industrialized countries, such as cancer, cardiovascular diseases, obesity, type 2 diabetes, dyslipidemia, and hypertension. Nutrition is not the only determinant of these health problems. Indeed, genetic, biological, and environmental factors are involved in the onset of these diseases. To highlight the specific role of nutritional factors in health, the development of cohort studies with very large populations  is essential as they permit to accurately measure food intake, but also take into account other determinants, such as physical activity, weight, smoking, and family history of disease. The purpose of our study is to identify nutritional risk factors or protective factors for these diseases, which is an essential step in establishing dietary recommendations to prevent the risk of disease and improve the health of the current and future generations. This is the ambitious goal of the NutriNet-Santé study and that is why researchers need you.During each multimedia recruitment campaign and during the enrollment process, participants are informed that follow-up over at least 10 years is planned.Previous findings showed that most of the participants enrolled after hearing about the study on television because this medium entails the widest reach . In partTo be included, participants have to fill in on the website an initial set of questionnaires assessing dietary intake, physical activity, anthropometrics, lifestyle, and socioeconomic conditions along with health status. Participants were informed by email that, after inclusion, they would be asked to complete the same questionnaires each year as part of their follow-up. In addition, they are invited to fill in a complementary questionnaire each month. Aspects related to convenience of participation  and confidentiality were also emphasized. In addition, a system of boosting motivation and retention was implemented. In order to forge a sense of community that helps advance research, participants receive a NutriNet-Santé membership card at inclusion and a certificate on completion of each follow-up year/wave. They also receive monthly email with scientific information regarding health and nutrition, and invitations to press conferences about the study results. For purposes of retention, free screening tests for cholesterol, triglycerides, and diabetes are offered to participants .All baseline questionnaires were first pilot-tested and compared with traditional administration methods (paper-and-pencil versions or interviews by a dietitian) -32. HealThis study was conducted according to guidelines laid down in the Declaration of Helsinki, and all procedures were approved by the Institutional Review Board of the French Institute for Health and Medical Research (IRB Inserm no: 0000388FWA00005831) and the Commission Nationale Informatique et Libertés (CNIL no: 908450 and no: 909216). Written electronic informed consent to participate in the study was obtained from all participants.Participants were asked, “Would you have participated in the NutriNet-Santé study if it were not Internet-based?” . We also asked the participants, “What was your main reason for participating in the NutriNet-Santé study?” The response options for the different motives were classified into 2 general categories: (1) intrinsic motives for participation, including, to help advance public health research on chronic disease prevention, to help advance nutrition research, to receive regular scientific information about health and nutrition, out of curiosity, to belong to a group, or other motives and (2) extrinsic motives, including in response to the call from the media, from a close friend/associate, or from a medical provider. Finally, we asked participants, “Is the fact that the study is exclusively funded by public sources important for your participation?” .At baseline, sociodemographic, lifestyle, and health characteristics were self-reported. Participants indicated their alcohol consumption frequency and quantity over the previous 7 days. Alcohol intake was calculated by multiplying the alcohol content  of each beverage  by the standard ethanol weight content. Body mass index (BMI) was assessed using self-reported height and weight. Status regarding type 2 diabetes, hypertension, and hypercholesterolemia was provided by participants by answering the following question: “Have you been or are you currently being treated for type 2 diabetes / hypertension / hypercholesterolemia?” If the participant answered yes, he/she completed the information by self-reporting the year of diagnosis and current use of medication.The present analyses focused on data from a random sample of participants in the NutriNet-Santé cohort who had completed the questionnaire assessing their participation motives and who had no missing sociodemographic, lifestyle, anthropometric, or health status data. These characteristics were compared between participants included in our analysis and those who had stopped participating within 6 months after their enrollment , using a chi-square goodness-of-fit test. The possible reasons for participation were grouped into the following 4 categories: (1) to help advance public health research on chronic disease prevention, (2) to help advance nutrition research, (3) in response to the call from the media, from a close friend/associate or from a medical provider, and (4) other motives . Perceptions/attitudes toward the public funding of the study were categorized into 3 groups: very important, important, and not important.2, 25≤ BMI <30 kg/m2, and BMI ≥30 kg/m2, respectively [P value set at <.05. A more conservative P value of.01 was also used for estimating the robustness of the results. Statistical analyses were performed using SAS software version 9.3 .According to French recommendations , male drectively . Gender,A total of 6556 of 15,000 persons completed the motives questionnaire . We excluded 61 individuals with missing data regarding the socioeconomic characteristics, 135 participants with missing data regarding weight or height, and 11 participants with missing data regarding alcohol consumption; therefore, data from 6352 participants was available for analysis. At the time of the administration of the questionnaire about motives, the mean duration of participation in the cohort for the participants included in this analysis was 20 months (SD 4.00) and the median was 23 months (range 1-24). Characteristics of the sample are presented in Compared with nonrespondents , the percentages of individuals older than 55 years and of managerial staff were higher among participants included in this analysis, whereas the percentage of individuals with at least 1 child at home was lower (data not shown). Compared with participants who stopped participating within 6 months after their inclusion in the cohort , the percentages of individuals older than 45 years, of married persons, managerial staff, persons with high educational level, individuals who reported hypertension, and those who reported hypercholesterolemia were higher among participants included in this analysis, whereas the percentages of individuals with at least 1 child at home, manual workers/employees, infrequent alcohol consumers, smokers, and obese individuals were lower .Among participants, 46.45% (2951/6352) reported that they would not have enrolled had the study not been conducted on the Internet, whereas 28.75% (1826/6352) were not sure .P value of.01 was used.Compared to women, men were more inclined to be motivated by the Internet aspect . IndividRegarding reasons for participation, 61.37% (3898/6352) reported participating to help advance public health research on chronic disease prevention; 22.24% (1413/6352) to help advance nutrition-focused research; 6.89% (438/6352) in response to a call from the media, a close friend/relative, or a medical professional; and 9.50% (603/6352) for other reasons . Unlike P value of .01 was used.Exclusive public funding for the study was important for two-thirds of the participants. Among them, half  considered it as very important . CompareProfiles of participants in a Web-based epidemiological cohort have rarely been studied ,10-16 anOur findings revealed that almost half of the participants reported that Internet use was a decisive reason for participation. In fact, this element exerted a stronger influence among men, persons younger than 35 years, individuals of higher socioeconomic status, those without children at home, moderate alcohol consumers, and obese persons. Our results are concordant with previous studies that compared sociodemographic and lifestyle characteristics of participants who used Web-based questionnaires with those of participants who used paper-and-pencil instruments ,14. TherIn addition, our study indicated that participation in an exclusively Web-based nutrition cohort was driven mainly by a desire to help advance research on chronic disease prevention or nutrition, especially among older participants, those with normal weight, and those who lived with a partner. Our results are also consistent with existing knowledge regarding motives for participation in volunteer-based cohorts on health and nutrition, which do not use the Internet ,26-28. TTwo-thirds of our sample found the use of Internet for completion of the questionnaires to be a benefit, given its flexibility, whereas less than 1% found it to be complex. Also, one-quarter of participants felt more comfortable filling in the questionnaires on the website rather than face to face with an investigator. On the other hand, only 22% visited sections of the website of the study regarding news and progress of the study. Thus, in Web-based studies, the reduced participant burden   should hParticipation in the study for altruistic reasons may be reinforced by the public nature of the research. Indeed, two-thirds of the participants considered the exclusive public funding as important or very important, with the link being particularly pronounced in men, older adults, and individuals of higher socioeconomic status. This finding is not surprising in a European context in which the majority of cohort studies are funded by public organizations. Indeed, 94% of French participants in an opinion survey conducted in the general French population reported that a large part of biomedical research needs to be funded by public funding, and 80% of responders feared that the increased participation of private funding in public research could undermine the independence of research and is damaging to certain research areas deemed less profitable . In turnOur study has several limitations. First, responders were older and belonged to higher socioeconomic strata than nonrespondents, which might have led to an underestimation of the observed associations. Moreover, our result suggests that the influence of weight status on participation is open to question because participants in a long-term cohort are likely to be particularly health conscious and interested in nutritional issues. In addition, results may reflect the motives of participants accustomed to the study rather than their motives for enrollment in the Web-based cohort because the questions about motives were asked approximately 2 years after baseline. However, key information on exposure and potential confounding factors was collected during the first 2 years of participation in the cohort. Thus, a focus on the motives of those participants who actively participated 2 years after their inclusion is useful in terms of retention strategies during decisive periods of data collection in Web-based cohorts. In addition, the percentage distributions of the given reasons for participation could be biased due the use of a predefined list of response options. However, the participants had the opportunity to choose the “other” response option and to specify the exact reason for participation. Another limitation was the lack of information on reasons for declining participation because the call for participation was not delivered to a predefined list of individuals. Finally, anthropometric status was assessed by self-reporting and may have led to misclassification. However, in a separate validation study that used data from a subsample of 2513 participants, we compared self-reported and measured height and weight (and the resulting BMI) . In partOur study highlighted that the reliance on the Internet, the willingness to help advance public health research, and the exclusive public funding of the study were key motives for participation in this exclusively Web-based cohort. In addition, these motives for participation differed by sociodemographic profile and BMI, but not by lifestyle or health status. These findings can help improve retention of diverse population samples, particularly during important data collection periods.


Background: Exposure to metals has been implicated in the pathogenesis of Parkinson disease (PD).Objectives: We sought to examine in a large prospective study of female nurses whether exposure to airborne metals was associated with risk of PD.Methods: We linked the U.S. Environmental Protection Agency (EPA)’s Air Toxics tract-level data with the Nurses’ Health Study, a prospective cohort of female nurses. Over the course of 18 years of follow-up from 1990 through 2008, we identified 425 incident cases of PD. We examined the association of risk of PD with the following metals that were part of the first U.S. EPA collections in 1990, 1996, and 1999: arsenic, antimony, cadmium, chromium, lead, manganese, mercury, and nickel. To estimate hazard ratios (HRs) and 95% CIs, we used the Cox proportional hazards model, adjusting for age, smoking, and population density.Results: In adjusted models, the HR for the highest compared with the lowest quartile of each metal ranged from 0.78  for chromium to 1.33  for mercury.Conclusions: Overall, we found limited evidence for the association between adulthood ambient exposure to metals and risk of PD. The results for mercury need to be confirmed in future studies.http://dx.doi.org/10.1289/ehp.1307218Citation: Palacios N, Fitzgerald K, Roberts AL, Hart JE, Weisskopf MG, Schwarzschild MA, Ascherio A, Laden F. 2014. A prospective analysis of airborne metal exposures and risk of Parkinson disease in the Nurses’ Health Study Cohort. Environ Health Perspect 122:933–938;  Parkinson disease (PD) is the second most prevalent neurodegenerative disorder, after Alzheimer disease . ExposurThere has also been some evidence of onset of PD following occupational  as well To our knowledge, to date only two epidemiologic studies have assessed exposure to airborne metals and PD in nonoccupational cohorts. A case–control study in Canada by In this study, we examined the association between census tract–level air emissions of antimony, arsenic, cadmium, chromium, lead, manganese, mercury, and nickel, and risk of PD in a large prospective cohort of female nurses.Study population. This study was conducted using data from the Nurses’ Health Study (NHS), an ongoing prospective cohort of female nurses initiated in 1976 and followed with biennial questionnaires collecting residential location and information on lifestyle factors and health outcomes. Residential locations were available throughout follow-up, which corresponds to exposure during adulthood in this cohort. At the initiation of the cohort in 1976, the 121,701 study participants were between 30 and 55 years of age and resided in 11 states . For each follow-up cycle, the rate of follow up has been > 90%. Information on state, county, and census tract of residence was derived from the residential address updated every 2 years. Detailed description of the cohort is provided elsewhere  (s (NATA) . NATA ins (NATA) . NATA uss (NATA) , which es (NATA) . We useds (NATA) , we perfStatistical analyses. We used Cox proportional hazards models adjusted for age in months (crude model), as well as a multivariable model adjusted additionally for smoking (one variable defined as never/past/current and another continuous pack-years variable at baseline) and census tract–level population density  to calculate hazard ratios (HRs) for the association between exposure to airborne metals and risk of PD. We also conducted sensitivity analyses further adjusting for tract-level income (quartiles). Person-years of follow-up were calculated from baseline in 1990, through the end of follow-up (30 June 2008), death, or date of PD onset, whichever occurred earlier. The relationship between PD onset and metals exposure was examined for each metal individually, coded in quartiles (using cutoffs based on the exposure distribution over the entire study period), or continuously in separate models. Because smoking has been established as protective against PD based in multiple epidemiologic studies . All analyses were conducted at the 0.05 alpha level, and all tests were two-sided. Between the study baseline in 1990 and the end of the study in 2008, we confirmed 425 cases of PD with data available on metal exposures. ptrend = 0.10)].Metals exposures were not significantly associated with PD  in age-aptrend = 0.14) in these analyses (data not shown).Because at the census tract level total metal exposure was correlated with income , we condptrend = 0.04) but not among ever-smokers ; the p-value for interaction with smoking was not significant (pinteraction = 0.29). We did not observe evidence of interactions between smoking and any of the other metals in the study.In analyses stratified by smoking , we did pinteraction = 0.06) consistent with evidence of a negative association among those living in less densely populated counties versus a weak positive association in highly populated counties. For most of the metals in the study, the relative risks among participants living in urban counties were higher than among those living in rural counties, although none of the other interaction tests were significant. The relative risk was particularly high for mercury exposure among those living in urban counties , although risk was also elevated in the low population density group  and the p-value did not indicate an interaction (pinteraction = 0.86).In analyses stratified by population density , we obseIn this prospective cohort study of female nurses, we did not observe a statistically significant association between U.S. EPA HAP-modeled concentrations overall and risk of PD. In adjusted models, the HR for the highest compared with the lowest quartiles of each metal ranged from 0.78  for chromium to 1.33  for mercury. The association with mercury was stronger in nonsmokers as well as among participants living in urban counties.To our knowledge, to date only two studies have addressed ambient air pollution and risk of PD. In Hamilton, Ontario, Canada, in a case–control study designed to examine the association between traffic pollution in general and PD, pinteraction of 0.06, none of the other tests for interaction were significant. Also, our study included only women, and all the participants were nurses. We cannot, therefore, exclude the possibility that our results would have been different had our study focused on men or on individuals occupationally exposed to pesticides or other chemicals. An interaction between manganese-containing fungicides and paraquat, for example, has been reported in animal models of PD (In one study, ls of PD . Likewisls of PD .The association between exposure to mercury and PD in the present study is supported by some  but not One limitation of our work is that the levels of airborne metals were not measured directly, but rather were based on linkage with the U.S. EPA HAP-modeled concentrations. The use of census tract–level modeled estimates of air pollution may have obscured a true association between airborne metals and PD. Additionally, PD is thought to have a long preclinical period, so the ideal measure of exposure would have been a cumulative lifetime exposure to airborne metals. However, only HAPSs measures in 1990, 1996, and 1999 were available, and according to the The strengths of this study include its large size and a long, prospective follow-up, which included a large number of PD cases confirmed through neurologist medical record review. The study area included the whole contiguous United States, allowing for a wide range of exposure values for the airborne metals of interest. Among the limitations, our study included only women who were unlikely to be occupationally exposed to metals, pesticides, or other toxicants that might interact with metals. However, this aspect of our study is also an advantage because this is one of the few studies of airborne metal exposure in a nonoccupational cohort.Overall, we found little evidence that airborne metal exposures were associated with PD in this large prospective cohort of female nurses. There was limited evidence of an association between mercury exposure and PD, particularly among never-smokers and among participants living in counties with populations ≥ 250,000 persons. The results suggest that exposure to airborne metals is by itself unlikely to be a major cause of PD among U.S. women without occupational exposures to metals. The lack of association with most metals in this study as well the observed association with mercury needs to be confirmed in future studies.


The National Clinical Database (NCD) of Japan was established in April, 2010 with ten surgical subspecialty societies on the platform of the Japan Surgical Society. Registrations began in 2011 and over 4,000,000 cases from more than 4100 facilities were registered over a 3-year period. The gastroenterological section of the NCD collaborates with the American College of Surgeons’ National Surgical Quality Improvement Program, which shares a similar goal of developing a standardized surgical database for surgical quality improvement, with similar variables for risk adjustment. Risk models of mortality for eight procedures; namely, esophagectomy, partial/total gastrectomy, right hemicolectomy, low anterior resection, hepatectomy, pancreaticoduodenectomy, and surgery for acute diffuse peritonitis, have been established, and feedback reports to participants will be implemented. The outcome measures of this study were 30-day mortality and operative mortality. In this review, we examine the eight risk models, compare the procedural outcomes, outline the feedback reporting, and discuss the future evolution of the NCD. Until recently, no nationwide data on cancer were available in the field of gastroenterological surgery in Japan. In 2006, the Japanese Society of Gastroenterological Surgery (JSGS) formed a committee to devise a database to track surgical patients treated in Japan over the 3 years from 2006 to 2008, and reported relatively low mortality rates for the major surgical procedures , 2. The The gastroenterological section of the NCD collaborates with the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) , which sSubmitting cases to the NCD is a prerequisite for all member institutions of the JSS and JSGS, and only registered cases can be used for board certification . To assuhttp://www.site.acsnsqip.org/wp-content/uploads/2013/10/ACSNSQIP.PUF_.UserGuide.2012.pdf#search=‘user+guide+for+the+2012+ACS+NSQIP). The potential independent variables include patient demographics, pre-existing comorbidities, preoperative laboratory values, and perioperative data. The demographic variables include age, sex, smoking status, and drinking status. Patients were categorized according to whether they were brought to hospital directly, by ambulance. General factors such as the patient’s body mass index (BMI) and preoperative functional status, defined as independent, partially dependent, or totally dependent, according to their ability to perform activities of daily living (ADL) in the 30 days prior to surgery and immediately before surgery, were also considered. We evaluated the physical status classification by the American Society of Anesthesiologists (ASA) and considered pre-existing comorbidities, including the cardiovascular status, respiratory status, renal status, hematological status, oncological status, preoperative blood transfusion, chronic steroid use, ascites, sepsis, diabetes, open wound, and pregnancy. The laboratory parameters included in the analysis were the white blood cell count, hemoglobin level, hematocrit, platelet count, prothrombin time, and activated partial thromboplastin time, as well as the serum levels of albumin, total bilirubin, aspartate amino transferase, alanine aminotransferase, alkaline phosphatase, urea nitrogen, creatinine, sodium, hemoglobin A1c, and C-reactive protein. The length of surgery, intraoperative blood loss, amount of transfusion, and any accident during the operation were also considered.The NCD variables are almost identical to those applied in the ACS-NSQIP  value for inclusion of 0.05. A “goodness-of-fit” test was performed to assess how well the model could discriminate between patient survival and death. The receiver operating characteristic (ROC) curves for the 30-day and operative mortalities were created for the validation dataset. An ROC curve is a plot of a test’s true-positive rate (sensitivity) versus its false-positive rate (1—specificity). Model calibration, being the degree to which the observed outcomes matched the predicted outcomes from the model across a group of patients, was examined by comparing the observed and predicted averages with each of 10 equally sized subgroups, arranged in the order of increasing patient risk.The outcome measures of this study were 30-day mortality and operative mortality. The former was defined as death within 30 days of surgery, regardless of the patient’s geographical location, even if the patient had been discharged from hospital. The latter was defined as death within the index hospitalization period, regardless of the length of hospital stay (up to 90 days), as well as any death after discharge, up to 30 days after surgery. Data were randomly assigned into two subsets that were split 80/20: the first, for model development, and the second, for validation. The two sets of logistic models  were constructed for dataset development using step-wise selection of the predictors with a probability . Among these cases, approximately 120,000 were used to create the risk models. Table The 30-day mortality and operative mortality risk models for the eight procedures were created, and the C-index for those in the validation data sets was as follows: Eso, 0.767/0.742; TG, 0.811/0.824; DG, 0.785/0.798; RHC, 0.836/0.854; LAR, 0.75/0.766; HX, 0.714/0.761; PD, 0.675/0.725; and ADP, 0.851/0.852, respectively . The real-time feedback system gives the predicted mortality of patients simultaneously with data input. Standardized information on patient risk and predicted mortality can be reformulated as case reports and shared at conferences.The NCD will soon be able to provide data on each facility’s severity-adjusted clinical performance (benchmark), which can be compared with national data Fig. a. CumulaMore than 4,000,000 cases were retrieved from the NCD during the 3 years before April 2013. The number of esophagectomy and pneumonectomy cases registered in the NCD accounted for approximately 95 % of all cases registered in the Regional Bureau of Health and Welfare. Thus, most cases in Japan appear to be captured by the NCD system. This NCD project started with support from Health and Labor Sciences Research Grants by the Ministry of Health Labour and Welfare  and considerable funding from the JSGS and JSS. Participating institutions can now use the database system at no cost; however, it is mandatory for the institutions to participate in the benchmarking project when applying for the board certification system. Currently, the board certification system is operating adequately on the web for surgical society members and allows members to obtain information on their cases being used to assess a member’s qualifications for certification during a certain period. Any applicant who has a sufficient number of cases for application no longer needs to write case reports. All participating healthcare professionals use information acquired from the NCD. Moreover, the board certification system itself can be revalidated using the surgical improvement program of the NCD.]A previous study by Hall et al.  showed tIn the gastroenterological section, risk models of mortality for the eight procedures were created to enable feedback. Simultaneously, risk models of morbidities for the eight procedures are being created to enable feedback for the next year. Currently, the database system is built up to enable efficient provision of benchmark reports to each institute. The benefits and costs can now be shared with the relevant stakeholders. A participation fee depending on the number of cases for retrieval is expected to be charged by the NCD to each hospital. Research grants from various sources are also expected to support clinical investigations using the NCD data.To avoid burdening physicians, the NCD allows data entry by other medical staff members. The NCD data entry privileges allow people other than physicians to enter the data. An appropriate educational system for data managers would be mandatory to maintain the accuracy of data and reduce the burden on physicians. This could be achieved by holding an annual data manager educational meeting and eventually introducing an e-learning system. The JSGS is planning to create an audit committee separately from the NCD, with the goal of achieving accurate data inputs and of educating data managers.The NCD generalizes site-specific cancer registries by taking advantage of their excellent organizing ability. Some site-specific cancer registries have already been combined with the NCD . CooperaCurrently, quality assessment of hospitals is being carried out using the Diagnosis Procedure Combination (DPC) data from the participating hospitals , 18. ThePublic reporting and transparency are being demanded by multiple stakeholders , 20. AltIn 2012, the ACS-NSQIP partnered with the Centers for Medicare and Medicaid Services (CMS) to promote public reporting and transparency of surgical outcomes . Althoug


P=0.032). Furthermore, the two eyes of most NL monkeys remained isometropic, whereas 3 of 4 AL monkeys developed myopic anisometropia more than -2.0D. At adolescence, eyes of AL monkeys showed significant myopic anisometropia compared with eyes of NL monkeys  and controls . All differences in refraction were associated with parallel changes in axial dimensions. Our results suggest that exposure to natural outdoor light might have an effect to reduced hyperopic defocus-induced myopia. Also, the data imply that early life exposure to sunlight may help to maintain normal development of emmetropization later in life, and thus lower the risk of myopic anisometropia in adolescent monkey.Exposure to sunlight has recently been postulated as responsible for the effect that more time spent outdoors protects children from myopia, while early life exposure to natural light was reported to be possibly related to onset of myopia during childhood. In this study, we had two aims: to determine whether increasing natural light exposure has a protective effect on hyperopic defocus-induced myopia, and to observe whether early postnatal exposure to natural light causes increased risk of refractive error in adolescence. Eight rhesus monkeys (aged 20-30 days) were treated monocularly with hyperopic-defocus (-3.0D lens) and divided randomly into two groups: AL group (n=4), reared under Artificial (indoor) Lighting (08:00-20:00); and NL group (n=4), exposed to Natural (outdoor) Light for 3 hours per day (11:00-14:00), and to indoor lighting for the rest of the light phase. After being reared with lenses for ca. 190 days, all monkeys were returned to unrestricted vision until the age of 3 years. Another eight age-matched monkeys, reared with unrestricted vision under artificial lighting since birth, were employed as controls. The ocular refraction, corneal curvature and axial dimensions were measured before lens-wearing (at 23±3 days of age), monthly during the light phase, and at the age of puberty (at 1185+3 days of age). During the lens-wearing treatment, infant monkeys in the NL group were more hyperopic than those in the AL group (F=5.726,  Myopia is a common eye disorder, which is often considered to arise from complex interactions between genetic makeup and environment , 2. The It is well known that the development of refraction is an active and visually guided process, called emmetropization, for matching eye length to optical power, although a genetically determined “set-point” of emmetropization may also be involved , 8. EmmeBesides optic defocus, many other environmental factors, some of which can last for extended periods of time, can also affect the emmetropization process. Ambient light is one such factor. Studies have shown that a greater time spent outdoors, independent of physical activities, had a protective effect against childhood myopia., 19. NatThe use of the animals was approved by the Committee on the Ethics of Animal Experiments of the Sun Yat-sen University on June 30, 2010 ((Macaca mulatta)  and topical application of one drop of 0.4% oxybuprocaine hydrochlorid. In addition, one to two drops of 0.3% tobramycin were used after each examination to avoid ocular infection.All of the infant monkeys were fitted with lightweight helmets, provided by Dr. Earl L. Smith 3rd , at approximately 20–30 days of age, incorporating a -3.0D spectacle lens over the right eye and a zero-power lens over the left eye for hyperopic anisometropia. The lenses were worn continuously, except when removed for cleaning or eye examination, for about 190 days. The details of the maintenance of the lens have been described elsewhere.After wearing the lens, the animals were randomly divided into two groups (n = 4 monkeys in each group): A) AL  monkeys were kept under fluorescent lamps . Illuminance at the level of the monkeys’ eyes was 100-200lux, and the main output wavelengths were 453nm, 545nm and 611nm. B) NL  monkeys were exposed to natural outdoor light for 3 hours, from 11:00 to 14:00 each day, and were housed in the same indoor setting as the AL monkeys during the rest of the light phase. As the weather changed, the intensity of the sunlight was not stable. A photometer  was used to determine the illuminance at the level of the animals’ eyes at 30-minutes intervals, every day of treatment. When it was cloudy, the light intensity varied from 6,000 to 10,000 lux; but when it was sunny, the illuminance could reach 60,000 to 70,000 lux. Throughout the course of the experiment, the average highest light intensity ranged from 25,000 to 40,000lux. In addition, the spectrum of the sunlight is across most of the electromagnetic spectrum, spanning a range of 200nm to about 1mm.To examine whether the early life exposure to sunlight would associate with the onset of refractive errors, all of the helmets were removed after the last biometry measurements of experiment A, at approximately 215±3 days of age. Then, the monkeys regained unrestricted vision and were raised in the same laboratory room (without exposure to outdoor light) until they were about 3 years old (1185 ± 3 days of age). That age in monkeys can be considered to be equivalent to 12 years of age in humans, well into the age range when school myopia frequently develops in children. Comparison data were available from eight 3-years-old monkeys reared from birth with unrestricted vision, under the standard indoor lights and conditions described above.The spherical equivalent refractive error, corneal curvatures, and axial dimensions of each eye of each monkey were measured before lens-wearing (at 23±3 days of age), monthly during the lens-wearing treatment period, and at the age of puberty (at 1185+3 days of age). To make these measurements, the monkeys were anesthetized with a combination of ketamine hydrochloride + acepromazine maleate . Retinoscopy was performed by two experienced optometrists using a streak retinoscope and hand-held trial lens, after topical application of three drops of 0.5% tropicamide for cycloplegia. Mean spherical equivalent spectacle-plane refractive correction was recorded for a given eye’s refractive status. Corneal curvature was assessed using a handheld videotopographer . The axial dimensions were measured by A-scan ultrasonography ; the 11-MHz transducer was placed in direct contact with the cornea, following topical anesthesia with one drop of 0.4% oxybuprocaine hydrochloride. The details of these determinations have been reported previously. All thet-tests were used to compare intraocular differences between NL group and AL group at the start and the end of lens-rearing period respectively. In experiment B, a paired-samples t Test was used to assess the interocular differences. One-way ANOVAs were employed to analyze interocular inference of measured ocular parameters among the three groups, and least-significant difference tests were further applied in post hoc multiple Comparisons. Pearson’s correlation analysis was used to examine the relationship between refractive status and vitreous chamber depth. All measurements were analyzed on computer .Mann-Whitney U test were used to compare the median of refraction and vitreous chamber depth between the two groups at the start of lens-rearing treatment. Since the lens-rearing regimen altered emmetropization process in both eyes of every animal in experiment A, each individual eye was recorded and treated as an independent sample. However, considering the emmetropization in the two eyes of the animals may not be totally independent, a linear mixed model, which is a useful approach allowing correlation in observations, was used to compare the longitudinal change of refractive errors and vitreous chamber depth in the two groups. To further assess the effect of different ambient light on defocus-induced myopia, all data are presented as mean intrerocular differences, i.e. differences between treated eye and fellow eye. Independent-samples P = 0.032), whereas no statistical difference was found in the rate of vitreous chamber elongation . However, because the average value of vitreous chamber depth was greater in the NL group at the start of treatment , the same amount of refraction need more change in axial length  and corneal power  between both groups at the start and the end of lens-rearing treatment . Over the next 190 days of unilateral hyperopic-defocus regimen, three of four infant monkeys under artificial lighting developed myopic anisometropia more than 2.0D, although the refractive errors in individual monkeys fluctuated over time and reached maximum anisometropia at variable times—ranging from 90 to 150 lens-rearing days .At the start of lens-rearing treatment, the refractive status, corneal power, and vitreous chamber depth of the two eyes in each infant monkey were very similar. There were no between-group differences in these ocular parameters , possibly for the same reason as that for the development of anisometropia (previous paragraph).Previous studies have shown that negative lens-induced myopia in animal models is generally axial in nature. Fig t = 1.452; P = 0.197;190 days).The interocular differences in corneal power in both groups Fig  and 2F wt test indicated that refractive states , vitreous chamber depth  and corneal power  for the right and left eye of all control animals were well matched. Therefore, we analyzed only the data of the right eyes in this control group. Although the mean refractive errors of monkeys in the artificial lighting group seemed to be more myopic in comparison to monkeys in the other two groups , vitreous chamber depth , or corneal power  among the three groups . Assessment by a paired-sample o groups , One-waye groups .However, it is interesting that the absolute anisometropia (i.e. the difference of maximum and minimum refraction) in 3-year-old monkeys that were treated by monocular hyperopic-defocus during infancy under artificial lighting was significantly greater and more myopic than that in monkeys in the NL group  or the 3-year-old control group  at the same 3-year-old end-point. As illustrated in 2 = 0.769, P<0.0001). Furthermore, Fig In all groups of monkeys, absolute myopic anisometropia was associated with a difference (excessive increase) in vitreous chamber depth : r2 = 0.per se, rather than other factors, is responsible for the anti-myopia effect of time spent outdoors, possibly due to a synergy between high lighting levels and an abundance of short-wavelength light. Consequently, in the first part of this study we compared refractive development and defocus-induced myopia in monocular lens-wearing infant rhesus monkeys, reared under ordinary artificial indoor lighting, with that in monkeys exposed to sunlight, to investigate the effects of sunlight on refractive development.A number of recent epidemiological studies have suggested that greater time spent outdoors has protective effect on the incidence and progression of school myopia , 31–34. In order to observe the general effect of sunlight on refractive development, we pooled the data from both eyes of the animals in the same group. Recent studies demonstrated that unilateral lens treatment can influence eye growth and refractive development also in the untreated contralateral eye , 36. Butper se. However, in another study, Smith et al. observed that the same illumination protocol had no effect on the compensation for and recovery from myopia induced by -3.0D [There are numerous ways in which sunlight affect the development of refraction or prevention of myopia. As mentioned above, optical defocus has been identified as one of regulators in emmetropization, which is actively guided by visual processes—mainly in the retina. Nonetheless, other visual stimulus properties—including light intensity, spectral components, spatial and temporal contrast and perhaps others that are still not recognized,—can modulate the process. Since sunlight is different from artificial light used in our study being up to 100 times higher luminance and richer in shorter wavelengths, it is likely that both of these factors contribute to the beneficial effects of sunlight on refractive development. With respect to high ambient light intensity, rearing chicks with 10,000lux lighting delayed the time of emmetropization and conserved hyperopia , and a rby -3.0D .Are there apparent differences between the study of Smith et al. (2013) and the present one that might explain the difference in results? Yes, clearly there were several significant differences between conditions in these two studies. One difference was the mean light level: the illuminances in Smith’s study averaged 25,000lux whereas the illuminance of sunlight in our study varied widely, from 6,000lux to 70,000lux, and the mean illuminance was higher, from 25,000 to 40,000lux. Some evidence has indicated that higher light intensities have specific effects on ocular growth: for example, Asbby et al. have repHowever, not all evidence supports the hypothesis that exposure to sunlight could prevent the development of myopia. For instance, a large study in Israel including 276,911 adolescents found that young adults born in the summer had a higher prevalence of moderate and severe myopia in comparison to those born in the winter, suggesting that increased exposure to sunlight early in life is a risk factor for developing myopia later in life. Two subIt has been documented in a variety of animals that the induced anisometropia produced by unilateral negative lens-treatment early in life can be eliminated after the restoration of unrestricted vision , 46, 47.On the other hand, the same unilateral lens-rearing protocol under sunlight did not cause significant myopic anisometropia as those monkeys grew into adolescence. Why was that? Again we suggest that this could be due to the difference in luminance and spectral component between the sunlight and the artificial light used in the study: The fluorescent light lacks variety in luminance intensity and has discontinuous spectral makeup, which is a mixture of three wavelengths including 453nm, 545nm and 611nm, while the light level of sunlight changed with time and weather, and the spectrum contains all wavelengths of visible light. Changes in both luminance and color contrast have been demonstrated to contribute to the discrimination process that the eye determines the sign of defocus , though In conclusion, our study demonstrates that exposure to natural light has an effect to reduce hyperopic defocus-induced myopia, supporting a role for sunlight in protection against myopia by outdoor activity in school-aged children. Further, we present evidence indicating that exposure to sunlight early in life promotes normal emmetropization in later in life, and thus lower the risk of myopic anisometropia in adolescent monkey. However, there are limitations in our study , and there is still much to be learned about the mechanism(s) by which exposure to sunlight prevents the development of myopia, further studies with larger scale and more details in basic lighting parameters are needed in the future.S1 File(PDF)Click here for additional data file.S2 File(PDF)Click here for additional data file.S3 File(PDF)Click here for additional data file.S4 File(PDF)Click here for additional data file.S5 File(PDF)Click here for additional data file.


T. brucei, T. cruzi, Leishmania spp., and E. histolytica parasites.Iron is the fourth most abundant element on Earth and the most abundant metal in the human body. This element is crucial for life because almost all organisms need iron for several biological activities. This is the case with pathogenic organisms, which are at the vanguard in the battle with the human host for iron. The latest regulates Fe concentration through several iron-containing proteins, such as transferrin. The transferrin receptor transports iron to each cell that needs it and maintains it away from pathogens. Parasites have developed several strategies to obtain iron as the expression of specific transferrin receptors localized on plasma membrane, internalized through endocytosis. Signal transduction pathways related to the activation of the receptor have functional importance in proliferation. The study of transferrin receptors and other proteins with action in the signaling networks is important because these proteins could be used as therapeutic targets due to their specificity or to differences with the human counterpart. In this work, we describe proteins that participate in signal transduction processes, especially those that involve transferrin endocytosis, and we compare these processes with those found in Iron (Fe) is a cofactor of a variety of proteins with important functions for almost all living organisms, prokaryotes, and eukaryotes. Fe is important for several biological processes, such as breathing, oxygen transport, the tricarboxylic acid cycle, gene regulation, and DNA synthesis ; however2+ and Fe3+. Haem Fe from haemoproteins is an important Fe source in omnivores; this is more easily absorbed than nonhaem Fe from vegetables and grains [In a normal diet, Fe absorption is approximately 1.5 mg every day. Fe absorption is accomplished through complex mechanisms that are carried out by enterocytes in the upper part of the gut, the duodenum, and the proximal jejunum. The Fe absorbed can be nonhaem Fe or haem Fe. The Fe absorption mechanism involves several import proteins for the two ionic forms of iron, Fed grains .2+ to Fe3+ by ferroxidases, such as ceruloplasmin, and followed by the loading of Fe3+ onto transferrin (Tf). These proteins are able to regulate iron efflux and consequently iron absorption, because overexpression of ferroportin1 is induced by cellular Fe and is suppressed by hepcidin, which inhibits Fe efflux through binding to and induction of the degradation of ferroportin1 [In the enterocyte, Fe can have several destinations. The Fe destination depends on the iron pool inside the cell. Therefore, Fe can be exported from cells to the circulatory system or can be accumulated inside the cell. For Fe that is exported to the circulatory system, a protein specific for this purpose, ferroportin1, has been identified. Ferroportin1 is a multipass protein found in the basolateral membrane of enterocytes. Once exported by ferroportin1, Fe must be transformed in a process coupled by reoxidation of Feoportin1 .Cellular Fe metabolism is regulated by Fe itself. When Fe is at low concentrations, iron regulatory proteins 1 and 2 (IRP1 and IRP2), which are components of posttranscriptional regulation, bind to iron responsive elements (IREs) present in the untranslated regions of the mRNAs encoding TfR1, stabilizing it and increasing the number of receptors in the membrane and Fe levels; when Fe levels are high, ferritin synthesis increases, and the receptor mRNA is destabilized, leading to low Fe entry –9.In the blood, Fe bound to Tf, which is the main protein for transporting Fe in plasma, regulates Fe levels in biological fluids. Although Fe is the most essential nutrient for almost all organisms, it has a poor bioavailability and very low solubility and is not found free in nature; therefore, all organisms have invested significant efforts in obtaining Fe.3+-binding protein, which is found in blood plasma, lymph, and other body fluids and has as its primary function the transportation of Fe to all cells. Another function of Tf is to keep free Fe at a very low concentration, approximately 10−18 M, avoiding the high potential risk of damage and depriving pathogens of Fe, which they require for growth. Tf has an important impact in the defense against infections [Fe exported to the serum is scavenged by Tf, a glycosylated Fe3+). Tf binds one Fe3+ ion in each of the two lobes; the C-terminal lobe binds Fe more tightly and releases it more slowly. Iron binding requires binding of a carbonate/bicarbonate anion in a synergistic way. A complete series of reviews about Tf have been published recently in a special issue of Biochimica et Biophysica Acta (BBA), general subjects entitled Transferrins:Molecular mechanisms of iron transport and disorders 1820(3), 2012.Tf is a single polypeptide of about 80 kDa with two homologous lobes  connected by a short center region. Normally, only 30% of the binding sites of the protein are occupied by ferric Fe ; thus, the biological function of the specific receptors is to bind Tf on the cell surface and ingest it. TfRs are a member of the family of tyrosine kinase-linked receptors that possess an intrinsic tyrosine kinase involved in signaling pathways.Two TfRs have been described in mammals, TfR1 with high-affinity uptake for holoTf and currently the most studied and TfR2 that binds Tf with a 25-fold lower affinity; both TfRs are homodimeric transmembrane glycoproteins that are specific for Fe-loaded Tf (holoTf) . TfR2 shμmol/L, TfR1 mediates Tf internalization, but at high Tf concentrations, low affinity uptake of holoTf that is not mediated by TfR1 has been observed. TfR2 has been proposed as a receptor that participates in this low affinity uptake, but this receptor is expressed in only a few organs, and the low affinity uptake is found in more cells. Other proteins are responsible for binding and internalize Tf with low affinity, such as the proteoglycans via fluid phase endocytosis in hepatocytes and glyceraldehyde-3-phosphate dehydrogenase (GAPDH) on the macrophage cell surface [At low Tf concentrations of <0.3  surface , 18, 19. surface , 21.TfR1 is a homodimer linked by two disulfide bridges with a molecular mass of 190 kDa. The receptor is formed by 3 domains: transmembrane, cytoplasmic, and extracellular, which is the larger one and contains the Tf binding site , 22.Tf internalized by both high and low affinity uptake receptors is transported to early endosomes as described below. Once Tf binds to the extracellular domain of the TfR on the plasma membrane, it changes conformation and dimerizes, and this change allows the activation of kinase activity, and it becomes phosphorylated. The Tf-TfR complex enters the endocytic pathway via endocytosis mediated by clathrin-coated pits. The action of dynamin is crucial for the fission of pits from the plasma membrane and the formation of coated vesicles. The Tf-TfR complex is transported to a unique endosomal compartment where acidification (pH lower than 5.6) leads to the release of ferric iron in 2-3 min .Successively, Tf without Fe (apoTf) bound to the receptor is transported to the plasma membrane via endocytic recycling compartments (ERC). The receptor becomes dephosphorylated, and apoTf is released outside the cell in order to bind new Fe , 17, 24.Tf, through the TfR, acts as a growth factor. Therefore, its function is important for the regulation of embryogenesis, cell growth, motility, proliferation, differentiation, glucose metabolism, and apoptosis and is determined by its trafficking through the endosomal pathway . Leishmania, and it has been demonstrated that this parasite developed strategies to increase the presence of Tf inside the parasitophorous vacuole where Leishmania lives. These elaborated systems of Fe obtained by TfR expression ensure their success as parasites, host colonization, and the establishment of the infection.In the same way as in mammalian cells, TfR from parasites increases the uptake of Tf, and in consequence of Fe, through the expression of a specific receptor or binding protein that is associated with the course of the infection. TfRs are very important determinants of virulence in pathogens, and depending from the environment where the infection takes place the receptor is or is not expressed. In this sense, parasites in blood vessels express TfR to bind Tf present in this environment, even more in other environments where the presence of this receptor will not be expected: like inside cells, some parasites express TfR, such asA successful infection by pathogens relies on the host colonization. Colonization depends on the availability of nutrients and growth factors, such as Fe. The relationship between parasitic organisms and their hosts is especially complex, because the hosts must obtain Fe from the diet and fulfil their own Fe needs and at the same time sequester this nutrient away from invading pathogens. Tf is the iron-containing protein that fulfils this activity, but protozoan parasites do not express Tf or Tf-like proteins that help them to acquire Fe. As these organisms are highly dependent on a plentiful supply of host Fe, they have developed mechanisms to acquire this metal by multiple and divergent pathways or steal it from host Fe deposition sites , 28.These mechanisms include the secretion of specific Tf proteases, the presence of reductases that capture host Fe-containing proteins, or through specific TfR or Tf binding proteins . The pre Plasmodium spp. [ Tritrichomonas [ Trypanosoma brucei [ Trypanosoma cruzi [ Leishmania spp. [ Entamoeba histolytica [TfRs have been described inium spp. , 31, Trichomonas , trypanoa brucei , Trypanoma cruzi  and Leisnia spp. , and thetolytica . It is rThe use of specific receptors to obtain growth factors or nutrients ensures temporal prolongation of signal transduction initiated upon ligand binding at the plasma membrane and continued after internalization. In this review, the TfRs from parasites, mainly those with signal transduction studies, have been included and compared with what is known in mammalian cells.Trypanosoma brucei. African trypanosomiasis is caused by the protozoan Trypanosoma brucei. This is a very important disease, because millions of people are at risk of infection and because current chemotherapies are toxic [re toxic , 38. Glossina). The initial infection is in the gut of the fly (procyclic stage). The infection travels to the salivary glands, and the parasite differentiates into the epimastigote stage and then to the metacyclic stage. This is the stage in which the parasite is injected into the mammalian host. The parasite lives within the mammalian bloodstream as its slender form, and when it is necessary, the parasite transforms into the stumpy form as a prelude to another insect infection [The cell cycle of this protozoan consists of two general stages, one in humans and the other in the insect vector, the tsetse fly (genusnfection . In the  T. brucei express a Tf receptor (TbTfR) that mediates Tf endocytosis at the plasma membrane; this receptor has already been identified and is structurally completely different from the host TfR [ TbTfR is formed by a complex of the proteins encoded by two expression site-associated genes, ESAG6 and ESAG7. ESAG6 has a glycosylphosphatidylinositol (GPI) anchor that attaches the receptor to the plasma membrane. The binding of Tf requires the association of both ESAG proteins [Therefore, bloodstream forms ofhost TfR , 40, 41.proteins , 43. ESAproteins . This prMost trypanosomatid protozoa have a specific structure that allows uptake of nutrients at a specific membrane site, named the flagellar pocket. This is a cell membrane invagination from which the flagellum emerges. In this structure, endocytosis of Tf takes place . The mol TbTfR anchored to membrane by the GPI tail, it is internalized by clathrin-dependent endocytosis. The low pH of the endosome allows the release of Fe from Tf. Tf at this pH has a low affinity for the TbTfR [ T. brucei cysteine-protease rhodesain or cathepsin L activity (TbCATL) and TbCATB (T. brucei cathepsin B) [ TbTfR is recycled to the cell surface to bind new Tf and the Fe associated with it [When Tf binds to thehe TbTfR  and is repsin B) , 46. TbT with it , 47. The TbTfR has a low-specificity for Tf, the parasite can use Tf from different sources providing the parasite the opportunity to increase its number of hosts, including humans and cattle [The TfR is of great importance for parasite adaptability and for the ability to colonize several hosts. Becaused cattle , 48. TheTrypanosoma cruzi. T. cruzi is an intracellular protozoan, the causal agent of South American trypanosomiasis or Chagas disease, which infects 8 million people in Latin America [ America . T. brucei parasite, T. cruzi infects humans and invertebrates hosts during defined stages of the life cycle. The invertebrate host is the triatomine bug that ingests trypomastigotes present in the bloodstream of an infected mammalian host when it feeds. In the gut of the vector, the parasites transform into epimastigotes and migrate to the posterior gut. Then, they transform into infective trypomastigotes, and the vector inoculates them subcutaneously into the mammalian host with infective feces. Once inside, parasites invade several kinds of cells through a lysosome-mediated mechanism, differentiating into amastigotes that replicate and transform into trypomastigotes causing host cell lysis that releases parasites into the bloodstream; the parasites are then capable of invading other cells or infecting vectors that make a meal of the host [Similar to thethe host .T. cruzi amastigotes growing in cell-free medium and epimastigotes require high concentrations of Fe to survive, and curiously in these stages, they are able to obtain Fe from human Tf. Amastigotes present specific TfR in the flagellar pocket [ TcTfR presents structural homology with human TfR, with a 200 kDa molecular mass, and Tf is internalized by receptor-mediated endocytosis. However, in the epimastigote stage of the life cycle, the parasite ingests Tf at the cytostome/cytopharynx through a TfR [r pocket  that aregh a TfR . This stgh a TfR . The pargh a TfR , 53. T. brucei should not be excluded; the cholesterol-dependent pathway could be a secondary endocytic process, because inhibition of this pathway did not reduce cell proliferation [Despite the fact that this parasite has clathrin that could participate in endocytosis , 55, morferation , 56. Corferation . It woulLeishmania spp. The leishmaniases and fatal visceral leishmaniases are diseases with a large spectrum of clinical symptoms in mammals and are caused by at least 20 pathogenic obligate intracellular species that include Leishmania major, L. infantum, L. braziliensis, L. mexicana, L. amazoniensis, L. tropica, and L. donovani. Approximately 2 million new cases occur every year with an estimated 150 million people infected worldwide [orldwide , 59.The infection starts with the bite of an infected sand fly (dipteran insects) that inoculates metacyclic promastigotes (infective form) into a mammalian host. After being phagocytosed by macrophages, the parasites are found inside parasitophorous vacuoles (PVs); these acidic structures are similar to phagolysosomes and contain certain lysosomal enzymes. Inside the PVs, promastigotes transform into amastigotes. The parasites replicate and induce cell lysis; released parasites can be phagocytosed by adjacent macrophages or infect the surrounding cells. Sandflies become infected by ingesting infected cells during blood meals; amastigotes transform into promastigotes in the gut and then migrate to the proboscis for a new round of infection , 61. L. infantum (LiTfR) and L. major (LmTfR) were described as an integral membrane monomeric glycoprotein of 70 kDa that is structurally different from the mammalian receptor [ L. chagasi, promastigotes and amastigotes, the binding of Tf is through nonspecific and saturable Tf binding proteins [Once the parasites are released and before the promastigotes are phagocytosed, they could be encountering Tf from the bloodstream; thus, the expression of a specific receptor would be useful. The presence of a specific and saturable TfR similar to the mammalian TfR was described in promastigotes. The TfRs ofreceptor . In bothproteins . UnfortuLeishmania amastigotes are usually the form internalized by the mammalian host cell, but in the case of L. amazoniensis promastigotes [ Leishmania parasites have developed several strategies for surviving inside the mammalian host. One strategy consists of fusion of the PV with several individual vacuoles and fusion of the resultant vacuoles with compartments of the endolysosomal system. This was discovered because proteins specific for each of the vacuoles are found associated with PVs [ Leishmania species, because in L. mexicana-infected macrophages Tf was not present in the PV [stigotes , they cawith PVs , 63. In with PVs ; furthern the PV ; howeverLeishmanial infection would also affect the TfR recycling regulation on macrophages , resulti Leishmania intracellular parasites, it is delivered to the cysteine proteinase-rich compartments, where this protein is degraded [Once the Tf is endocytosed bydegraded .3+ into Fe2+ for transmembrane transport and allowing Fe to be internalized by the parasite [ Leishmania.Another strategy to obtain iron inside the acidic PV from the Tf-TfR complex could present a similar behaviour as in the endosomes; that is, the Tf loses affinity for Fe and remains attached to the receptor and iron release could be facilitated via Tf degradation by cysteine proteases secreted by living amastigotes or released by the lysis of the dead parasites . Then, tparasite , 61, 65.Entamoeba histolytica. E. histolytica is a parasitic protozoan of humans. It causes amoebiasis, a global disease characterized by dysentery and intestinal ulcer production. Under certain conditions, the parasite is able to invade the liver, lungs, and brain. E. histolytica infects 500 million people, causes disease in 50 million people, and causes death in 100,000 people each year [ach year .E. histolytica has an absolute necessity of Fe. This need in the bowel can be sustained by bacteria or phagocytosed red blood cells or through endocytosis of Fe-containing proteins from the host. During invasive amoebiasis, the Fe source is Tf in the bloodstream and liver; in this organ, the use of ferritin, an Fe-storage protein, would be useful for the parasite. EhTfbps of 70, 96, and 140 kDa molecular mass as previously described [The amoeba has developed two specific mechanisms for obtaining Fe from Tf , 67 to e EhTfbps identified present structural homology with the human TfR, because this is recognized with an anti-human TfR antibody. Similarly, T. cruzi Tf receptor is recognized with the same antibody, while TbTfRs are different proteins not recognized by human TfR antibodies. EhTfbps form a complex with holoTf and are endocytosed with the participation of clathrin [Theclathrin , 69, 70. EhTfbp was identified as enzyme acetaldehyde/alcohol dehydrogenase-2 (EhADH2) [ EhTfbps have not been identified (70 and 140 kDa). This enzyme is essential for the growth and survival of E. histolytica and allows the parasite to obtain energy through glucose fermentation and to convert acetyl-CoA into ethanol. This enzyme binds extracellular matrix proteins and is found on the cell surface and in the cytoplasm [The 96 kDa(EhADH2) . The othytoplasm . This pr Ehmeth enzyme that catalyzes DNA methylation [In this parasite, other glycolytic enzymes have been described with several functions, such as enolase, which interacts with the activity of thehylation . Staphylococcus aureus and Staphylococcus epidermidis, bacteria capable of removing Fe from Tf via a receptor-mediated process [α-enolase, lactate dehydrogenase, and hexokinase [As previously described, surface-localized GAPDH has a novel function with TfR in human and murine macrophage cell lines . GAPDH i process . Interes process , 73, 74. process  due to txokinase . E. histolytica has to compete with bacteria for Fe, other nutrients, and space in the intestinal microenvironment, and intra- or extracellular trypanosomatids in the mammalian host must obtain Fe and other nutrients that are present in very low concentrations. In addition, these parasites must sense several stressors to regulate the different stages of their life cycle to evade host defenses or control their invasive behaviour. Upon invasion, parasites continue to face a battery of challenges that require the ability to adhere and obtain sufficient nutrients. The survival of these parasites within their host requires a profound ability to sense and respond to environmental challenges, and utilization of an extensive signaling network may therefore be very useful.The life cycle of protozoan parasites suggests why these organisms require an extensive network of cell surface signaling molecules. For example,Despite the fact that there is much information about TfR signaling pathways in mammalian cells, very little information is available in protozoan parasites, despite the fact that this pathway regulates proliferation and cell growth. In describing these pathways, the emphasis will be placed on the Tf-TfR complex in mammalian cells and the way in which information travels from the cell surface to the cytosol in comparison with that observed in protozoa.Tf trafficking of information inside the cell and initiation of several signaling pathways are very well defined in mammalian cells: (1) trafficking and insertion of membrane vesicles, (2) inositol-1,4,5-triphosphate and diacylglycerol signaling pathway, (3) MAPK signaling pathway, and (4) growth factors signaling pathway .2) in the plasma membrane, which induces the recruitment of clathrin and its adaptor protein AP-2 [The initial signal propagation is in the plasma membrane for endocytosis and then through the endocytic compartments , 75–79. ein AP-2 , 81. Theein AP-2 –85 that ein AP-2  to be poein AP-2 , 78, 86.Vesicle formation results in spatial and temporal compartmentalization that is controlled by Rab proteins, members of the small GTPase family, which are involved in transmitting signals and providing the identity of the endosome. Tf-TfR complexes accumulate in early endosomes that are specifically marked with Rab5, early endosome antigen 1 (EEA1) , 87, andActin regulators  and othe T. brucei, the Tf-TbTfR complex is endocytosed in clathrin-coated vesicles [ TbEpsinR, instead of AP-2 from mammals, promotes clathrin assembly. Additionally, in trypanosomes the endocytosis and scission of the clathrin-coated pits are independent of dynamin [Invesicles , and its dynamin  , and TbRab11 [ T. cruzi and Leishmania, where Rab5, identified based on its homology with TbRab5 [ T. brucei in the invertebrate host, the two Rab5 isoforms occupy the same compartment and have similar effects but in the fluid-phase endocytosis. The differences in endocytic regulation between the two stages of the parasite life cycle show the different mechanisms for surviving in two different hosts: insects and mammals [Endocytosis in unicellular parasitic protozoa is regulated by the Rab family of proteins. In TcRAb11 . In T. br pocket  in a rec TbRab11 . A similh TbRab5  and Rab1h TbRab5 , but it  mammals , 104. E. histolytica, EhRab11A and EhRab11B may be participating in the recycling of receptors, because these Rab11s are observed in cells during Fe starvation conditions and in the beginning of the encystation process [ EhRab11s participate in secretion of cysteine proteases [In the parasite process –108; in roteases . Leishmania, Rab7 protein promotes fusion with the late endosome during trafficking [ LdRab7 is present in Golgi cisternae, and E. histolytica EhRab7A is found in endosomes [ EhRabX3 [Infficking , but LdRndosomes . In the ndosomes , 75% of  EhRabX3 , for whi2+ signaling plays a key role in controlling the process of cell proliferation. Tf bound to TfR, a type of tyrosine kinase-linked receptor, stimulates the formation of inositol-1,4,5-triphosphate (InsP3) and diacylglycerol (DAG) through the hydrolysis of phosphatidylinositol-4,5-diphosphate  by phospholipase C (PLC). The released DAG has an important role activating protein kinase C (PKC) and the InsP3 diffuses into the cytosol to activate InsP3 receptors to release Ca2+ stored in the endoplasmic reticulum. The InsP3/Ca2+ signaling system controls many different cellular processes, such as proliferation [The inositol-1,4,5-triphosphate and diacylglycerol signaling pathway is another important signaling pathway activated by Tf internalization. In this pathway, Caferation –116. T. brucei and Leishmania. In these parasites, Tf internalization is specifically regulated by glycosylphosphatidylinositol-phospholipase C (GPI-PLC). This enzyme is expressed in the bloodstream form of T. brucei. During transformation to the insect stage, GPI-PLC contributes to the release of VSG from the plasma membrane. A new function of the enzyme has been described as a signaling protein that stimulates endocytosis. Similar to that observed in mammalian cells, the products of the enzyme activity are DAG and inositolphosphoglycans (IPG). DAG regulation of Tf internalization depends on proteins with specific domains to act as DAG receptors with protein tyrosine kinase (PTK) and ubiquitin ligase domains [This kind of signaling pathway has been described only in domains . Through domains , 118  pathway that consists of activation of tyrosine kinase-linked receptors, resulting in the phosphorylation of extracellular signal-regulated kinases 1/2 (ERK1/2) that then translocate into the nucleus. This pathway often begins with Ras, another member of the small GTPase family, and its function is the control of many cellular processes, particularly those related to cell proliferation. T. brucei and Leishmania MAPKs have been described: mitogen-activated protein kinase (LMPK) of L. mexicana [ TbMAPK2 of T. brucei [ E. histolytica, two components of the MAPK signaling pathway have been identified in the E. histolytica genome [Variability in the levels of expression or activity of MAPKs has been correlated with the proliferation, development, or cell cycle progression of many protozoan parasites. Along these lines,mexicana  and TbMA. brucei . In the a genome . MAPK bea genome   or PI4K and PI-related kinases with some functions in regulating cell proliferation, such as apoptosis, mitosis, cytokinesis, membrane trafficking, and cytoskeletal organization. The most important component, PI3K, generates the second messenger phosphatidylinositol-3,4,5-trisphosphate (PI3P) that in turn activates both phosphoinositide-dependent kinase 1 (PDK1) and protein kinase B (PKB) that translocate into the nucleus. PI3K confers the mobility needed for clathrin-coated membranes through the microtubule motor machinery , 122.In this sense, PI3K contributes to sending information to the target of rapamycin (TOR) signaling pathway, named because it is inhibited by the drug rapamycin, which is a potent inhibitor of cell proliferation. TOR is a serine/threonine protein kinase, which operates as a nutrient-sensitive cell cycle checkpoint controlling protein synthesis. The activity of TOR is switched off and cell proliferation ceases under conditions of low concentrations of amino acids or when energy is limiting. This kinase is organized into two complexes, TOR1 and TOR2. T. brucei, T. cruzi, Leishmania major, L. braziliensis, L. infantum, and E. histolytica genomes established the presence of several PIKs and PI3Ks, so they have been proposed as a novel signaling pathway [A genetic screen of the pathway , 112. T. brucei and T. cruzi was described, and cellular localization was determined in order to define the function, because the localization of signaling molecules is related to their function and specificity. In T. brucei, TbTOR1 was observed inside the nucleus and TbTOR2 was associated with the endoplasmic reticulum and mitochondria. In T. cruzi, TcTOR1 was absent from the nucleus and was observed close to reservosomes, and TcTOR2 was found dispersed in the cytosol around TcTOR1. These differences in localization suggest a new function of the TOR complex as a result of the high genome plasticity observed in T. cruzi originating from different events of intragenic recombination [In the kinase TOR, the functions are well conserved in eukaryotes with some differences in cellular localization. The presence of the TOR1 and TOR2 complexes inbination . Differe E. histolytica. Unfortunately, the role of these proteins in the endocytosis of Tf and signaling pathways has not been studied.Several PI3Ks , 125, 30Further studies are necessary to comprehend the role of these proteins in order to understand the Fe acquisition system of Tf and Fe metabolism in these important parasites.The importance of effective Fe uptake has been demonstrated for virulence in several pathogens, and although substantial progress has been made, there is surprisingly little information available about the signal transduction pathways induced by Tf endocytosis in order to obtain Fe. Although the broad picture suggests similarities with the mammalian host, there are many gaps in our understanding of these processes. The identification of signaling proteins will be useful to identify new factors that are essential for parasite adaptation to the host environment.To date, it has been difficult to compare signal transduction processes in the studied organisms, but it is possible that they are very similar, and as was observed, this similitude may be conserved in intra- and extracellular parasites, despite the fact that they confront Fe absence in different ways.The differences observed between several proteins and their equivalents in mammals could be used as therapeutic targets that may help treat diseases produced by these parasites, which has implications for biomedical research to develop new chemotherapeutic strategies.


Somatic andcognitive-affective symptoms were assessed using the subscales of the BeckDepression Inventory - I (BDI-I).  of 531 participants, 62.7% were male, with a mean age 57.3 years (SD= 13.0) formales and 56.2 years (SD= 12.1) for females. Analyses of variance showed an effectof sex (p<0.001 for somatic and p=0.005 for cognitive-affective symptoms), butno effect of age. Women presented with higher mean values than men in both BDI-Isubscales: 7.1 (4.5) vs. 5.4 (4.3) for somatic, and 8.3 (7.9) vs. 6.7 (7.2) forcognitive-affective symptoms. There were no differences by age for somatic(p=0.84) or cognitive-affective symptoms (p=0.84).  women hospitalized with heart disease had more somatic and cognitive-affectivesymptoms than men. We found no association of somatic and cognitive-affectivesymptoms with age. Future research for these patients could reveal whether thesedifferences according to sex continue throughout the rehabilitation process. Despite the significant advances in treatment and control ofcardiomyopathies, they still represent a highly relevant health problem in the worldtoday. The World Health Organization (WHO) estimates that the global mortality due tocardiomyopathies will increase from 17.1 million in 2004 to 23.4 million in 2030, with alarger relative increase in countries of low and medium income. Emotional issues in person with cardiomyopathy have been studied,including studies of depression in patients in Brazil(-) and other countries(-).Cardiomyopathies are the main cause of morbidity and mortality in the world. Despitntries-.. Depression symptoms are present in one out of five persons with coronary artery disease(CAD) and in one out three persons with congestive heart failure (CHF). However, themajority of these cases are not recognized or treated appropriately. Depression isconsidered a risk factor for developing cardiovascular disease, as well as a predictorof worse outcomes among persons with established cardiomyopathy. , and present higher scores than males in self-report measures of depressionsymptoms. For age, studies have shown that there is a higher prevalence ofdepression symptoms among adults 35 to 50 years of age, with a decline in prevalence for65 years and older. Age and sex are two factors that have been studied as moderators of depression symptomsin persons with cardiomyopathy. Females tend to have a two to three times higherprobability of being diagnosed with major depressive disorder (MDD) thanmales, and prsymptoms,8. Folder,,-10. . Women tended to present higher frequency of depression symptoms than men,as well as higher rates of anxiety disorders and somatic symptoms, such as fatigue,sleep disorders, and lack of appetite. Among patients with cardiomyopathy, especially the ones with CAD, thepresence of anxiety has been observed in various studies(-). Given the frequency of reports of depression as well as other symptomsassociated with cardiomyopathy, it is of interest to determine whether the differencesbetween men and women exist when examining the specific symptom clusters of depression. Researchers have also pointed out differences between men and women diagnosed with MDDregarding perception of depressive symptoms as measured by the Beck Depression Inventory(BDI-I and BDI-II),11. Wappetite. Among  studies-13. GDespite the research on depression and cardiomyopathy, little has been examined onwhether differences exist in the presence or absence of specific depressive symptoms inthis population. Specifically, we have not found studies that investigated the role ofsex and age in the presence of somatic and cognitive-affective symptoms among personswith cardiomyopathy. This study aimed to investigate the association of somatic andcognitive-affective symptoms with sex and age among patients hospitalized with heartdisease in two public hospitals in the state of São Paulo, Brazil. Given the previousresearch, we hypothesized that women would report more symptoms in each symptom clusterthan men and that those who were older who report higher levels of each symptom thanthose who were younger. The results will help clinicians to understand the somatic andcognitive-affective symptoms profile of patients with established cardiomyopathy, byproviding information that can be used in their treatment and care, and can assist inthe mental and psychosocial rehabilitation of those patients. This study is a secondary analysis of data from two observational studies, which willbe described below.The data for this study came from two previous studies involving patientshospitalized with heart disease in two public hospitals in the state of São Paulo,Brazil, and which collected the Beck Depression Inventory - I (BDI-I) . . The data was collected from a single university hospital that servesindividuals through the public system of healthcare in Brazil. Individuals could beincluded in the study if they had a diagnosis of cardiac disease confirmed byclinical, laboratory or radiologic exam, did not have psychiatric conditions , and were hospitalized for diagnosticor therapeutic purposes due to cardiomyopathies, whether the first or a repeatedhospitalization for the diagnosis. Data for that study were collected in two phases:2005 to 2007 (203 participants), and 2010 to 2011 (100 participants). The first study was performed to culturally adapt and evaluate the psychometricproperties of the Antonovsky's sense of coherence questionnaire to the Portugueselanguage. The da. Data were collected from the same university hospital as the firststudy with additional participants from a second hospital (non-teaching institution),also within the public system of healthcare, with a similar population of patients.Individuals could participate in the study if they were being hospitalized for thefirst episode of unstable angina or acute myocardial infarction, and were in physicaland psychological condition to answer the questionnaires. Data for that study werecollected from 2006 to 2009 (253 participants). For both studies, individuals wereexcluded if they had a history of cerebral vascular accident that precluded theability to communicate with the researcher.The second study was performed to study the association between depressive symptomsand age and sex, in persons with acute coronary syndrome  hospitalized for their first cardiac event. Data w, individuals could be included if they were 18 years or older, and inthe second study were included 21 years or older individuals. In this present study, theresults are regarding all patients were age 18 or older.Regarding the age, in the first study, indivind study were inSince 25 individuals participated in both studies, we only utilized their data fromthe earliest evaluation. Therefore, the total number of participants in this analysiswas 531. Given the inclusion/exclusion criteria, the final sample can be thought ofas representative of individuals hospitalized for cardiac diseases.Both studies collected the following demographic and clinical data: sex, age inyears, marital status , paid job (yes or no), years of education, monthly family incomein Reais, diagnosis at hospital admission, and presence of comorbidities . Diagnosis athospital admission was categorized into coronary artery diseases , heart failure , or other . Somatic and cognitive-affective symptoms(15) using the adapted version to Portugueselanguage.Both studies collected information on somatic and cognitive-affective symptoms viathe subscales of the BDI-Ilanguage.. The BDI-I is an inventory composed of 21 items, where each item describes a specificbehavioral manifestation of depression. Each item has four choices of self-assessmentstatements, which are scored 0 to 3, with higher scores indicating increasing symptomseverity. Respondents are instructed to describe the way they have been feelingduring the past week. Higher sum of scores suggest higher depressionsymptoms. (17) andstudies with cardiac patients, scores on items 1 to 10 and 12 to 14  are summed to calculate the cognitive-affective symptom subscaleof the BDI-I (range 0 to 39). Likewise, items 11 and 15 to 21  are summed to calculate thesomatic symptom subscale of BDI-I (range 0 to 24). Higher scores in the subscalesmean higher somatic and cognitive-affective symptoms.Based on one review of existing factor models and item contentpatients,18, sData were analyzed using IBM SPSS version 21.0 for Windows and Mac . Descriptive analysis was used for all variables. Demographic andclinical characteristics were compared between males and females by using theChi-square test , ort-test for independent samples .To compare scores of the subscales of somatic and cognitive-affective symptoms, weused a two-way analysis of variance (ANOVA), using age and sex as factors, andincluded their interaction. The significance level was set to α=0.05.This study was approved by the Research Ethics Committee (Comitê de Ética emPesquisa) of the Hospital das Clínicas of the Faculdade de Medicina de Ribeirão Pretoda Universidade de São Paulo (Process HCRP nº. 12164/2012), and it was exempt from anew informed consent, since it was a secondary analysis of data already availablefrom previously approved studies. Men and women differed in diagnosis at hospital admission, with a higher proportion ofmen having coronary artery disease and higher proportion of women having heart failure.Men had lower proportions of arterial hypertension (p=0.01), dyslipidemia (p<0.001),and diabetes (p=0.01) than women, but were not different in obesity (p=0.93) andcerebral vascular accident (p=0.83). We found that somatic and cognitive-affective symptoms were different for the groups ofmen and women, but not different for age groups.  and our general findings are consistent with theliterature.In the literature, studies that used the BDI-I in populations with cardiac diseases didnot report the somatic and cognitive-affective subscales separately and, therefore, adirect comparison with our study is not possible. However, when taken as a single totalscore, the BDI-I showed differences between males and females in depressive symptoms forvarious studies. Somatic complaints that were different between males and females includedheadache, dizziness, back pain, nausea, muscle pain, hot and cold flashes, and feelinglump on throat. Other researchers also studied people with major depressive disorder(MDD) and found a higher likelihood that females would present with somatic depressionthan males. Fatigue and change in appetite were significantly different between menand women. Somatic symptoms have been studied for certain populations using measures other than theBDI. Among patients under treatment for depression, females reported more symptoms ofdepression overall and somatic complaints when compared to men. Somatian males. Fatigund women. . Note in In our study, age group was not a statistically significant factor in the presence ofcognitive-affective or somatic symptoms. Again, we found no studies that examinedcognitive-affective symptoms separately. However, while not statistically significant,we did see a trend where an increase of somatic and cognitive-affective symptoms wasseen for those at younger age  when compared to older age. Asimilar pattern has been observed in the people with depression in the generalpopulation,-10. N(-), including a study in the Brazilian population. It is thought that depressive symptoms in women might be related tobiological aspects, such as hormonal oscillations during their reproductive period andmenopause, as well as psychosocial aspects, such as their social and family roles. Inthe occidental culture, including the Brazilian population, women might have arelatively larger work burden than men, as they might have a professional job whilestill doing the majority of the housework, being primarily responsible for the care ofchildren, husbands, and family relatives who are sick, all of that while having a lowerlevel of education and receiving lower salaries than men. In our study, we observed ahigher percentage of men who were married, having a higher mean family income, and witha higher mean number of years of education at the time of hospitalization. It ispossible that these psychosocial factors in addition to their chronic cardiac conditionmight predispose women to more severe symptoms of depression than men.Some possible causes of differences in depressive symptoms between men and women havebeen discussed in the literature-23, ipulation. It is . Using the subscales of the BDI-I separately for patients with cardiomyopathy hasimplications for both clinical practice and research. Differentiating the type ofdepressive symptoms a person has might help in the evaluation of the severity (intensityand chronicity) of the condition, its prognostic, and possible response to treatment,especially when there are differences in the manifestation of depressive symptomsaccording to the person's characteristics. In our study, women showed higher levels ofsomatic and cognitive-affective symptoms than men. This fact might be used in thetreatment that is prescribed to them. For example, some researchers suggest that personwith elevated scores in the cognitive-affective domain might benefit from cognitivebehavior treatments, while persons with elevated somatic scores might benefit frommedication treatment. This study had some limitations. First, this is a secondary data analysis and as such,our results are of an exploratory nature. There were variables that were not availableand which we feel should be considered in future studies. For example, it would havebeen interesting to look at whether the hospitalization was the first, second, etc.While one of the studies only had people in their first hospitalization, the other studydid not have that information, and therefore, we could not associate that variable withdepressive symptoms. Using the subscales of the BDI-I in people with cardiomyopathy sampled from two publichospitals in the state of São Paulo, Brazil, we found that women had, on average, higherlevels of somatic and cognitive-affective symptoms than men. Age was not statisticallyassociated with the subscales of BDI-I. Although women in the age group of 45-54.9 yearsshowed a higher mean in both subscales, the interaction of age and sex was notstatistically significant. Treatment of patients with cardiomyopathy should include the assessment of depressivesymptoms and special care should be taken to assess depression in women, so thatdepressive symptoms are identified early and appropriate treatment is initiated.