Gunas  and self esteem in normal adults through a randomized comparative study.To study the efficacy of yoga on asanas, pranayama, meditation, notional correction, and devotional sessions. The comparison group practised mild to moderate physical exercises (PE). Both groups had supervised practices for one hour daily, six days a week, for eight weeks.Of the 1228 persons who attended motivational lectures, 226 subjects aged 18–71 years, of both sexes, who satisfied the inclusion and exclusion criteria, and who consented to participate in the study were randomly allocated into two groups. The Yoga (Y) group practised an integrated yoga module that included Guna  was assessed before and after eight weeks using the self-administered “The ’Gita” Inventory of Personality” (GIN) to assess Sattva, Rajas, and Tamas. Self esteem in terms of competency (COM), global self esteem (GSE), moral and self esteem (MSE), social esteem (SET), family self esteem (FSE), body and physical appearance (BPA), and the lie scale (LIS) were assessed using the self esteem questionnaire (SEQ).P > 0.05 independent samples t-test). There were significant pre-post improvements in all domains in both groups (P < 0.001 paired t-test). The number of persons who showed improvement in Sattva and decrease in Tamas was significant in the Y but not in the PE group (McNemar test). The effect size for self esteem in the Y group is greater than for the PE group in three out of seven domains.The baseline scores for all domains for both the groups did not differ significantly (Gunas and self esteem in comparison to physical exercise.This randomized controlled study has shown the influence of Yoga on  The World Health Organization defines “health” as a dynamic state of complete physical, mental, social, and spiritual wellbeing and not merely as the absence of disease or infirmity. A centurGunas. The three patterns are Sattva (gentle and controlled), Rajas (violent and uncontrolled) and Tamas (dull and uncontrolled). In an ideal situation of perfect health, an individual has the complete freedom to use any of these three patterns of responses. Ill health or limited health occurs if Rajas or Tamas becomes dominant, as one loses freedom and gets habituated to either of these response patterns. Hence, the degree of positive health can be measured by a tool that can grade these three patterns of behaviour.[The Gita inventory (GIN) is now aehaviour.Yoga concepts also include another important measure of an evolving personality, which is the knowledge about one’s unlimited potential to move towards perfect harmony with Nature. This is reflected to some extent in modern psychology as self esteem with clear-cut definitions and tools for assessment· Hence, this study includes one of the standard available measures called a self esteem questionnaire (SEQ) to see iGunas and self esteem. Hence, the present study was designed to find out the effect of the Integrated Approach of Yoga Module on Gunas and self esteem in normal healthy adults through a randomized controlled trial.Whereas yoga is getting popular, the relative roles of yoga and physical exercises have not been studied with regard to their effects on Two hundred twenty-six subjects who consented to participate in the study, were randomly allocated into two groups of equal size. Inclusion criteria included (a) normal healthy volunteers, (b) both sexes, (c) age between 18–71 years, and (d) literates. Exclusion criteria: (a) subjects with any ailment, (b) substance abuse, and (c) smokers.Informed consent was obtained from all the subjects who participated in the study and also from the institutional heads where the classes were conducted. The institutional ethical committee of the parent institution had cleared the project proposal.This study had a prospective, randomized, single-blind control design to compare the efficacy of yoga (Y) with that of physical exercise (PE) as a control intervention in normal healthy volunteers in a south Indian population. Motivational lectures were arranged in public centers such as colleges, health clubs, Rotary clubs, Lions clubs, and apartment complexes. The classes were planned in five different centers in Bangalore City.Those who consented to participate in the study and who satisfied the inclusion and exclusion criteria were randomly allotted into two groups by using five different random number tables (different table for each center) generated from the random number generator program. After reMasking: The answered questionnaires were coded and kept away for future scoring. A psychologist who was not involved in subject allocation or supervision of the classes, scored the questionnaires that were decoded only after the scoring of both pre- and post- data was completed.Assessments were done using the following questionnaires:Gunas  from the Bhagavadgita, a traditional text of yoga, which was developed by Das in 1991. This measure of the three Gunas contains ten questions that have three response choices. This test has a test-retest of 0.60 with a confidence level of 99% and has been validated. This is a valid tool for identifying the type of personality.[Gita Inventory of Personality (GIN): The GIN inventory is based on the concept of sonality.Self-Esteem Questionnaire (SEQ): This multidimensional questionnaire was developed and standardized by Karunanidhi.Kriyas, asanas, healthy yoga diet), breathing practices with body movements, and Pranayama, meditation, devotional sessions, lectures on yoga, stress management, and lifestyle change through notional corrections for blissful awareness under all circumstances (action in relaxation). Yoga was taught by qualified yoga teachers.vs nonvegetarian diet, value of fiber etc., (b) value of exercise and health (six sessions) explaining different type of exercises, its effect on muscles, effect on joints, value of regular sport activity etc, (c) bad effects of smoking , alcohol, and other chemical abuse (two sessions), (d) effect of mental stress on health and the role of physical exercise in the management of stress. This was followed by the practice of the physical exercises for 45 minutes with enough rest in between. The sessions ended with ten minutes of relaxation (without guided instructions) in a supine position.The set of physical exercises chosen for this study were the standard practices to proviThe scoring of the questionnaires was carried out as per the instructions given in the manuals. The structures of these questionnaires are described below:Tamas, Rajas, and Sattva Gunas. The score value of weightage of an item indicating Sattva is 3, for an item indicating Rajas is 2, and for an item indicating Tamas is 1. It classifies people as being predominantly of Sattva, Rajas, or Tamas type, depending on their total score on the test. The relationship between the guna type and the score is summarized below:GIN: This inventory has ten questions to evaluate SEQ: This multidimensional self esteem questionnaire has 83 items with seven subscales in the form of statements with both positive and negative items. Thirty-two items have negative scoring. Assessment is done on a 4-point scale to evaluate competency (COMP), global self esteem (GSE), moral and self control (MSE), social esteem (SSE), family scale (FSE), body and physical appearance (BPA), and the lie scale (LIS). A higher score indicates greater predominance of that mode.Data was analyzed using SPSS version 10.0.A sample size of 164 was calculated based on previous studies that shoBaseline data for both the groups were assessed for normal distribution using the Kolmogorov Smirnov test. Independent samples’ t-test was done for checking the homogeneity of baseline scores of the two groups.The GIN data was analyzed using McNemar’s test. As the baseline values of SEQ were not normally distributed, the Wilcoxon signed ranks’ test was used to compare means within the group and the Mann Whitney U test to compare the means between the groups. As the study population had a wide age range, statistical analysis was also carried out by grouping them as juniors (age ≤ 24 years) and seniors (age > 24 years). The independent samples’ t-test for between groups’ and Paired Samples Test for within groups’ comparisons was conducted for the two age groups. The data was also analyzed using gender as a factor.Sattva, Rajas, or Tamas. The ranges are 29–30 for Sattva, 24–28 for Rajas, and Tamas for scores < 24. guna type to another after the interventions, based on this characterization.The Gita inventory of personality GIN gives a single overall score that describes the disposition of an individual towards guna type changes after intervention. To ascertain this, three different McNemar’s tests were done to check the change from the presence of a guna to its absence. Thus, the McNemar’s test was done to ascertain the significance of shifts of the number of subjects who were predominantly of nonSattva type before intervention, to the Sattva type after intervention. The same was done for nonRajas to Rajas, and from non Tamas to Tamas types.The question of interest was whether an individual’s guna types for each group is presented in Sattva type remained so after intervention. Sixty-five who were nonSattva types remained so. Fourteen subjects who were nonSattva types before, became Sattva types afterwards, whereas five who were Sattva types before, became nonSattva types after intervention. A similar interpretation holds for Rajas and Tamas data.A cross-tabulation of the shifts of the The results of the Self Esteem Questionnaire (SEQ) administered to the subjects are summarized below:Competency (COM): The PE group (scores of 43.44–45.23) (P = 0.033) and juniors in the PE group (scores of 42.34–45.07) (P = 0.035) showed a significant increase in competency. The yoga group also showed an increase but it was not significant.Global self esteem (GSE): The Y group (scores of 46.68–49.47) (P = 0.036) showed a significant increase in global self esteem. Seniors (45.53–51.25) (P = 0.030) and females (45.00 to 50.49) in the yoga group also showed significant increases. The PE group also showed an increase in global self esteem but it was not significant.Moral and self esteem (MSE): Significant changes occurred in the yoga group (scores of 34.78–37.31) (P = 0.003), seniors (34.31–39.39) (P = 0.004) and females (33.59–37.77) (P = 0.001). The PE group also showed an increase in moral and self esteem but it was not significant.Social esteem (SSE): Significant changes occurred in seniors (31.39–33.92) (P = 0.023) and females (31.28–33.41) (P = 0.006) in the yoga group. The PE group also showed an increase in social esteem but it was not significant.Family self esteem (FSE): A significant increase was noticed in seniors (34.83–38.11) (P = 0.002) and females (35.15–37.36) (P = 0.003) in the yoga group. The PE group also showed an increase in family self esteem but it was not significant.Body and physical appearance (BPA): A significant improvement was noticed in the Yoga group (24.56–26.23) (P = 0.003). Juniors (25.93–26.59) (P = 0.002) and males (26.37–25.90) (P = 0.047) in the PE group showed a significant increase.No significant correlations were found between any of the measures of the Self Esteem questionnaire and GIN according to the Pearson Correlation test.This was a randomized, controlled, prospective study in normal adults comparing the efficacy of yoga with a control group practicing physical exercises. This study has demonstrated that an eight weeks-long intervention of an integrated yoga module improved and self esteem.guna, or its absence) noticed are significant. Tamas type (P = 0.023) [Sattva type (P = 0.064) in the Yoga group. The Rajas type people however, did not change significantly. In the PE group, no significant changes are seen for any of the transition [Sattva to Sattva type, and from Tamas to non Tamas (18). The upward trend in the central tendency of the scores on the GIN seems to be quite consistent with the Gita concept. This concept proposes that the Gunas initially vary in their dominance in determining the personality of an individual (canto 14),[Gunas (canto 14)[Tamas and Rajas to Sattva, and finally goes beyond the Gunas and attains liberation (cantos 7 and 14).[Sattva and a decrease in Tamas after eight weeks of integrated yoga practices, but not after PE, is clearly demonstrated in this study.McNemar’s test, a nonparametric test, is used to determine if the changes of yoga group (predominance of a = 0.023)  and a maansition . Thus, ianto 14), but thatcanto 14) and ulti and 14). This treGita a guna indicates a specific behavioral style. Sattva indicates purity, wisdom, bliss, serenity, love of knowledge, spiritual excellence, and such other noble and sublime qualities. Rajas indicates egoism, activity, restlessness, and hankering after mundane things such as wealth, power, valor, and comforts. Tamas implies qualities such as bias, heedlessness, and inertia, besides perversion in taste, thought and action.[Rajas and Tamas are said to be the manifestations of a violent state of mind in which a person lacks mastery over upsurges of emotions and impulsive behavior. Yoga is known to be useful in promoting positive health at the physical, mental, social, emotional, and spiritual domains, which results in becoming energetic, confident, masterful over the sense organs, possessing harmony and coordination between right and left brain functions, as well as becoming stress-free. These are attributed to the calmness of the mind leading to forbearance and stability of the nervous system,[Sattva -dominant person.Furthermore, in the famous scriptural text, the d action. Rajas ans system, which armahamantra (chanting of a specific pious chant) and the Vedic Personality Inventory in a three-armed, randomized, prospective, controlled study on 62 volunteers. They showed that the mahamantra group had increased Sattva and decreased Tamas with no significant change in Rajas scores, which is also a measure of the three Gunas. In their study, they also showed a significant reduction in stress, anxiety, and depression after a month of chanting mahamantra, 20 minutes daily for four weeks. The present study has also demonstrated a significant improvement in Sattva and Tamas scores and a reduction in Rajas in females and seniors, which was not found in the earlier study conducted by Dasa. This difference would be because of the inclusion of Asanas and Pranayama in addition to the meditation technique in the present study, whereas the mahamantra study was mainly a form of meditation.A similar study by Dasa was condIn the self esteem components, the Yoga group showed significant increases in GSE, MSE, and BPA whereas the physical exercises group showed significant increases in only one subscale of self esteem—COM . AlthougAn analysis based on gender showed significant changes in Y group females for GSE, MSE, SSE, and FSE and for PE group females for COM. In males, significant changes were observed in BPA in the PE Group. Age analysis showed differences within the two age groups (≤ 24 and > 24 years). The older group showed better changes than the younger group within the Yoga group. In the younger age group, most significant changes observed in the PE group were for COM and BPA. In the older group, significant changes observed in the Yoga group were for GSE, MSE, SSE, and FSE .pranayama, and the systematic breathing during asanas regularizes the breathing mechanism, trains the proper use of abdominal and chest muscles, and also improves the vital capacity and stamina, which in turn can influence better self esteem.[Relatively better changes in the Y group (compared to PE) can be noted in the GSC  and MSC  domains . The praf esteem. Yogic brf esteem.et al. studied the efficacy of exercise-based intervention of eight weeks’ duration in a population of Australian employees and showed that the intervention significantly improved the QoL in comparison to a waiting list control group (measured by SF-20). They showed an improvement of 12.8% in physical functioning, 9.90% in general health, 44.50% in vitality, and 15.90% in mental health scores.[COM , BPA  in younger groups and BPA in males were significantly improved in the PE group. Atlantis h scores.Gunas  and self esteem. These findings reveal that Yoga has greater influence on holistic personality growth (Gunas) when compared to routine physical exercise. Hence, it can be considered independently to promote quality of life and health, prevent chronic diseases, and to promote socio-economic development.Thus, Yoga helps in the improvement in Finally, the fact that there were no significant correlations between the Gita Inventory and the parameters of the Self Esteem questionnaire is noteworthy. This lack of correlation between the two instruments shows that they measure orthogonal qualities.Furthermore, we can observe that, like physical exercise, Yoga is traditionally acceptable in India, is easy and cost-effective to perform, and has become popular around the globe. Yet another point of this design is a matched intervention in the form of exercises. However, a third group with no intervention would have given greater insights to the comparisons.Gunas, with accompanying promotion of positive health and self esteem. This study thus provides scientific evidence to consider yoga as an independent practice that can be beneficial in improving one’s quality of life.In summary, this randomized interventional study has shown that the improvement in the Yoga group is more when compared to the physical exercises’ group for all the


P = 0.026) and decreased the ratios of TC/HDL-c and LDL-c/HDL-c . The placebo intake did not significantly change the blood lipid profile. In the initial 43 participants with dyslipidemia, 76.7% of them were diagnosed with “Spleen deficiency” and 58.1% with “Liver qi stagnation.” The intake of hawthorn fruit and Chinese kiwifruit extract compound may increase the serum levels of HDL-c and decrease the ratios of TC/HDL-c and LDL-c/HDL-c, therefore, may reduce the risk of cardiovascular disease.The clinical efficacy of the Chinese therapeutic food  on dyslipidemia was evaluated in this placebo-controlled, double blind, paired clinical trial conducted in Melbourne, Australia. Forty-three participants diagnosed with moderate dyslipidemia and met the study criteria were randomly assigned to Group A or B, with baseline characteristics matched. Twenty-seven participants completed all the tests, the blood lipid profile including total cholesterol (TC), high-density lipoprotein cholesterol (HDL-c), low-density lipoprotein cholesterol (LDL-c), and triglycerides (TG) was analysed. The traditional Chinese medicine diagnosis was made based on participants' symptoms and signs. The results indicate that a four-week intake of the compound increased the serum HDL-c levels by 5% ( Atherosclerosis and subsequent cardiovascular disease (CVD) are common and have high mortality. Dyslipidemia is considered to be responsible for the development of atherosclerosis through blood lipid accumulation and oxidation , 2. The Shan Zha) is known in traditional Chinese medicine (TCM) for its effects on reducing food stagnancy and blood stasis. As herbal medicine, it is also used to treat dyslipidemia, angina pectoris, and hypertension [Zhong Hua Mi Hou Tao) originated from China and its various cultivars have been widely consumed globally. Previous studies have shown that the Chinese kiwifruit cultivar used in the supplement for this study appears to be antiatherogenic [Chinese therapeutic food may make a valuable contribution to a more balanced diet. They have been used widely with acknowledged safety in Chinese history, and recipes based on herbal dietary therapy are accepted extensively nowadays for the prevention and treatment of heart diseases . Chinesertension . Chineseerogenic , 9.This study evaluated the efficacy of the selected Chinese therapeutic food supplement for the treatment of dyslipidemia in Australia and compared the outcomes with the previous study conducted in China .A placebo-controlled, double-blind, paired research design was used in the present study, based upon a previous study with positive outcomes . Among tThis study was approved by the Human Research Ethics Committee of Victoria University, Melbourne, Australia. It was registered with the Australian-New Zealand Clinical Trials Registry. The Therapeutic Food Administration (TGA) was notified of this trial.In this present study, the heavy metal contents in the compound were analysed by the Australian National Measurement Institute and were found to be safe for human consumption. The pesticide concentrations of the supplements used in this study were also analysed at Victoria University and found to be safe for human consumption.All participants met the following criteria before enrollment:have lived in Australia for the past 10 years,diagnosed with moderate dyslipidemia, in which fasting serum LDL-c level within 3.2–4.6 mmol/L (125–180 mg/dL) or TG 2.0–2.9 mmol/L (180–250 mg/dL), according to Adult Treatment Panel III [aged 40–70 years and with blood pressure lower than 159/99 mmHg  or pregnancy,not have taken other supplements or medicine which may influence blood lipid levels in the past 3 months,not allergic to the extract of the therapeutic food or wheat germ,cool, which means that intake of kiwifruit may give rise to or deteriorate fluid retention for people with very weak digestive system and cold nature; hawthorn fruit may cause slight diarrhoea due to its effect on reducing food stagnancy, however, it is unlikely occur in this study because kiwifruit's cool nature can be balanced by hawthorn fruit's warm nature and the nourishing effect of kiwifruit may also balance the hawthorn fruit's effect of reducing stagnancy). not have fluid retention or severe diarrhoea . They became aware of this study through public e-mails within Victoria University, posters at community health centers, local newspapers, and word of mouth.The issues pertaining to this research were reinforced and explained by the researchers at each interview. The treatment and control crossover procedure was clearly described and explained to each participant. The participants were also informed that they could withdraw from this study at any time. Each participant signed the consent form prior to recruitment. All records were kept secure and confidential and can only be accessed by the related researchers.Participants were assigned into pairs according to the baseline blood lipid levels and demographic characteristics . A random number table was used for grouping the randomly allocated participants. Participants in Group A received the treatment of the supplement for the first four weeks while participants in Group B received the control supplement (placebo) during the same period. For the second four weeks, the interventions were switched, that is, Group B received the supplement and Group A took placebo, to observe long-term treatment effects in Group A. The total duration of participation was eight weeks. Three office visits were organised during the study . Treatment effects have been considered within individual Group A and B, and also for the combination of Group A + B.A practitioner who was familiar with this type of clinical trial was invited as the third party to label the treatment and placebo powder (which were packed in the same container). The powder was assigned to match the participants' codes and groups . This practitioner was asked not to reveal relevant information to either researchers or participants until the final data analysis was completed.Blood lipid levels can be affected by lifestyle-related factors and can fluctuate over time without treatment. All participants in both the treatment and control groups were advised not to change their normal daily lifestyle during the course of this study. Thus, they were asked to complete a questionnaire as to record their diets and physical activities for the first and last three days in each phase of their participation. The questionnaire allowed the researchers to monitor the participants' diet and physical activity to determine whether there were significant changes. By completing the questionnaire, the participants were also made aware of their habits and were reminded not to make any changes during the study.Crataegus pinnatifida Bge.) and Chinese kiwifruit (Actinidia chinensis var. deliciosa). It contains the effective components haw flavone, triterpenoid, rutin, tartaric acid, citric acid, crategeolic acid, ester, glucoside, analytical lipid enzyme, carbohydrate, some saponins, polysaccharides, multiple kinds of organic acids, isoflavones, and adequate amounts of trace elements, for example, zinc (Zn) and strontium (Sr). The placebo consists of wheat germ, food dye, and citric acid, and sweetener was used as a control supplement in the same dose. Both the treatment and placebo drinking powder were provided by the supplier of the previous study in China [Hawthorn fruit compound (HFC) with an established safe and effective dosage of 10 g twice per day , 10 was in China , 10. ParBlood lipid levels including TC, TG, and HDL-c were assayed during pre-, mid- (at the end of 4th week), and posttreatment periods. The LDL-c level was calculated using the Friedewald equation : LDL-c =Blood samples were taken in the Outpatient Department of the appointed hospitals with Melbourne Health Shared Pathology Service (MHSPS), including Royal Melbourne Hospital, Footscray Western Hospital, and Sunshine Hospital. All blood tests were performed in the Melbourne Health Shared Pathology Laboratory by the appointed staff. Enzymatic and spectrophotometric methods were used for the study assays. Participants were asked to fast 12 hours before the blood sample collection.Participants' symptom information was collected using the standard TCM diagnostic methods, including inspection, asking questions, listening, smelling, and palpation. The occurrence of certain symptoms and signs indicates certain patterns of disharmony, which was determined at every visit of assessment.t-test using a software program SPSS 18.0 to determine the differences between pre- and postinterventions, and P < 0.05 was accepted as being significant.The data were analysed through the application of paired Twenty-seven of the 43 participants completed all the treatment and placebo intervention applicable to this study in eight weeks . There iP = 0.09). When combining the treatment results from both groups (Group A + B), it was found that the overall increase of HDL-c is statistically significant .Tables P = 0.032) and in Group A + B (P = 0.012). The results indicate that HFC can effectively lower the ratio of TC/HDL-c, an informative marker of atherosclerosis.P = 0.047) in Group B without the impact of HFC treatment  and postplacebo in Group A. However, an increase of the TC/HDL-c ratio is statistically significant (reatment . This maP > 0.05)  .P > 0.05), which indicates that the placebo intake did not have a significant impact on the LDL-c level in this study (Again there is an insignificant increase of the LDL-c level comparing the pre- and postplacebo intake in both Group A and Group B (is study .P = 0.044).Similar to the ratio of TC/HDL-c, the ratio of LDL-c/HDL-c provides a more informative marker for CVD risk than the individual value of LDL-c and HDL-c. There is a decreasing trend of the LDL-c/HDL-c ratio after the treatment in Group A and Group B . When coP = 0.04, There is an insignificant increase of LDL-c/HDL-c ratio comparing posttreatment and postplacebo in Group A. However, in Group B, without the impact of HFC treatment, the ratio increased significantly after the placebo intake . Symptoms and signs which may be relevant to Spleen deficiency are prevalent in all the participants. For example, more than half of the participants complained of abdominal symptoms before participation; 37.3% of them had loose stool, diarrhea, or occasional constipation and diarrhea; 39.5% of them prefer a warm condition to a cool one. In addition, 48.8% of the participants had teeth marks on their tongues and more than half had weak pulse. These signs on the tongue and the pulse are usually indicative of Spleen deficiency. It was found that 58.1% of the participants were diagnosed of Liver qi stagnation. 55.8% of the participants complained of stress and 51.2% of them had wiry pulse, which supports the Liver qi stagnation diagnosis.Among the 43 participants who were initially recruited, the TCM In the present study, the four-week intake of HFC appears to effectively increase the serum levels of HDL-c by 5% (Group A + B) for the 27 participants. Compared with the previous clinical study on this compound , which h⩾5% decrease in atheroma volume) occurred only in patients achieving both low levels of LDL-c (<2.26 mmol/L) and an increase of 7.5% in HDL-c with lipid lowering therapy [Epidemiologic studies have demonstrated a high cardiovascular risk at low levels of HDL-c regardless of the LDL-c levels . Substan therapy .According to Ma et al. , the comIn this present study, HFC induced a significant decrease of the TC/HDL-c ratio and LDL-c/HDL-c ratio. However, no significant effects on serum TC, LDL-c, and TG were found. Such outcomes are consistent with the previous study .Although the LDL-c is considered as the primary treatment target for lipid management , 18, theAnother relevant study showed that HFC significantly reduced serum levels of LDL-c, TG, and the LDL-c/HDL-c ratio in atherosclerotic mice, and this effect was comparable with the control of statins therapy .−10%), TG (−12%), LDL-c (−18%), and increasing HDL-c (+7%). Statistically, the design and results of the previous study was used to predict the statistical power of the present study. The power calculation indicated that 62 participants were needed to achieve overall statistically significant outcomes. The insignificant results of LDL-c and TG levels in this study may be due to the low number of participants.In the previous clinical study conducted by Chen et al. , the HFCIn the present study, the Australian participants originated from more than 10 countries or areas (not including East Asia), which reflects the fact of the composition of Melbourne population, however, this may also affect the research outcomes because of the diversity of genetic factors and culture-related lifestyles. Classification of participants by different lipoprotein subgroups or relevant genotypes was unavailable. It is difficult to determine whether there was a detectable diet-gene interaction involved in the study or not. In the case of disparities of blood lipid level and CVD risk, evidence on their relationships with ethnic features is not convincing.In Chen et al. study , the HFCSpleen deficiency and Liver qi stagnation were recognized as major root causes of abnormal blood lipid metabolism [The above TCM findings are consistent with previous research in which tabolism , 21. Thitabolism . Howeverblood and phlegm stagnation in TCM. It is noted that 32.6% of the participants have the purple tongue body, a typical sign indicating blood stasis. However, the prevalence of phlegm and blood stagnation pattern is not as high compared to Spleen deficiency in the participants with moderate dyslipidemia. Therefore, the pattern of blood and phlegm stagnation may need to be identified in severe dyslipidemia cases.Long-term or severe dyslipidemia have also been viewed as a condition or pattern of heat-related symptoms and signs, that is, 51.2% of the participants complained of thirst or dry mouth, 34.9% with red tongue tip or yellow tongue coating, and 44.2% with tongue coating fissure. This heat pattern was also reported by Fu and Xu [Spleen deficiency may also result in thirst as the fluid cannot be transformed sufficiently and be transported upward to nourish the mouth, about one third of the participants were diagnosed of Heart heat pattern or Stomach yin deficiency pattern, respectively. Heat patterns in patients with dyslipidemia have not been emphasized in previous TCM research. Possible TCM mechanisms may involve the qi stagnation and phlegm accumulation which can generate heat, resembling the heat-generating process of compost; the heat may in turn deteriorate lipid metabolism by overheating fluid into the thick and pathological phlegm. According to the TCM theory, kiwifruit, with the cool nature, can remove heat and nourish yin [heat patterns. Further study is needed to explore the optimized the TCM treatment for people with dyslipidemia and heat pattern. The utilization of Chinese therapeutic food according to the TCM differential diagnosis can be explored as a tailored treatment of diet-related conditions.Another finding of this study is that many participants had u and Xu  in theirrish yin . Thus, tSpleen deficiency” and “Liver qi stagnation.”Intake of the Chinese therapeutic food, specifically the hawthorn fruit compound, has shown a positive effect on increasing serum HDL-c levels and decreasing ratios of TC/HDL-c and LDL-c/HDL-c, which indicates an improvement of the blood lipid profile. As a dietary therapy, this compound can be considered for the treatment of hyperlipidemia and the prevention of atherosclerosis, and such effects need to be further explored. The major TCM patterns observed in this moderately dyslipidemic participants' group include “


EXPAREL (bupivacaine extended-release liposome injection), DepoFoam bupivacaine, is in development for prolonged postsurgical analgesia. Repeat-dose toxicity studies were conducted in rabbits and dogs to compare the potential local and systemic toxicities of EXPAREL and bupivacaine HCl (Bsol), and the reversibility of any effects. Dogs tolerated much larger doses than rabbits. EXPAREL-related minimal-to-moderate granulomatous inflammation was noted at the injection sites. In recovery animals, the granulomatous inflammation was observed less frequently and was characterized by an increased number of multinucleated giant cells. These effects were considered a normal response to liposomes and nonadverse. Rabbits are more sensitive than dogs. In rabbits, convulsions were noted with EXPAREL and more frequently with Bsol; a NOAEL was not identified. In dogs, EXPAREL was well tolerated (NOAEL > 30 mg/kg/dose). The cumulative exposure of EXPAREL in these studies is well in excess of the proposed maximum single-dose exposure that is intended in humans. The investigational drug EXPAREL  is a multivesicular liposomal formulation of bupivacaine being developed for postsurgical analgesia  blood and/or tissue concentrations of bupivacaine compared to bupivacaine HCl (Bsol) and therefore may provide a safer alternative to current therapies. Systemic reactions to bupivacaine mainly involve the central nervous (CNS) and/or cardiovascular (CV) systems . These eWhen given in sufficiently large doses, liposomal formulations may be irritating to subcutaneous (sc) tissues, causing nonspecific local reactions. Particularly during repeated exposure, the presence of exogenous lipid materials in the sc space may serve as a nidus for the development of a foreign body type reaction in surrounding tissues. Therefore, it seems possible that prolonged, repeated exposure to EXPAREL could intensify the degree of sensitivity to bupivacaine and/or DepoFoam particles particularly in rabbits, because of the thinness of the skin layer and relative absence of sc fat.As part of the nonclinical development program, the safety of repeat-dose administration of EXPAREL compared to Bsol was evaluated in two species in accordance with International Conference on Harmonization (ICH) guidelines. These multiple-dose studies in rabbits and dogs  were designed to complement single-dose toxicology testing  in the same species, in which animals were exposed to the same amount of drug. Groups of animals were given EXPAREL at a dose level of 9 mg/kg, 18 mg/kg, or 30 mg/kg in comparison with Bsol 9 mg/kg (7.5 mg/mL), or saline via sc twice weekly injection. These studies included evaluation of both local effects as well as the usual broad range of systemic effects. It was possible to meaningfully compare the toxicology findings and concurrent systemic exposure in rabbits and dogs since the same protocol in a whole-body system, assay methodology, and data acquisition systems were used. The clinical relevance of the toxicology results was evaluated in relation to the intended clinical use of EXPAREL (single dose) in patients.The DepoFoam drug delivery system is a proprietary, injectable technology that provides a sustained release of therapeutic compounds. The DepoFoam system consists of microscopic, polyhedral, lipid-based particles composed of numerous nonconcentric, aqueous chambers containing the drug in solution. Each chamber in this multivesicular liposome is separated from adjacent chambers by lipid membranes , 10.The DepoFoam particle components are naturally occurring or synthetic analogues of common lipids, including phospholipids, cholesterol, and triglycerides. EXPAREL , 15 mg/mL and 25 mg/mL (expressed as anhydrous bupivacaine base), was provided by Pacira Pharmaceuticals, Inc., San Diego, Calif. In the higher-concentration EXPAREL system (25 mg/mL), the multivesicular liposome particle concentrations were increased from approximately 35–40% of the total suspension volume, to approximately 60–70% total suspension volume.  Sensorcaine-MPF  was supplied by AstraZeneca, Wilmington, Del. Saline (0.9% sodium chloride injection USP) was supplied by Abbott Laboratories, North Chicago, Ill. New Zealand White rabbits and Beagle dogs were supplied by Covance Research Products, Kalamazoo, Michigan, and Marshall BioResources, North Rose, NY, respectively. The animals were 5–8 months (rabbit) and 4 months (dog) of age on arrival. The animals were acclimated for a period of at least one week. The animals received LabDiet .All protocols were reviewed and approved by the Institutional Animal Care and Use Committee (IACUC) of MPI Research, Inc., Auxvasse, Mo, for compliance with regulations prior to study initiation. These studies were conducted according to ICH guidelines and in accordance with Good Laboratory Practices principles as set forth by the United States Food and Drug Administration (FDA), 21 CFR Part 58.The repeat-dose studies were designed to use the fewest number of animals possible, consistent with the objective of the studies, with particular consideration to eliminating the impact of surgical intervention on the normal behavior or pattern of study animals.N = 3/sex/group) were given EXPAREL at 9, 18, or 30 mg/kg/dose of a more highly concentrated formulation , Bsol 9 mg/kg/dose (7.5 mg/mL), or saline via sc twice weekly injection. Each dose was administered by bolus injection.Groups of animals , maximum projected clinical dose, and published literature discussed here.The selection of the highest dose is based on an EXPAREL dose of 30 mg/kg given up to the limits of solubility (25 mg/mL). For the 30 mg/kg dose, the injection volume of 1.2 mL/kg was calculated based on the supplied concentration of 25 mg/mL. It should be noted that the studies were not designed to study specifically volume effects. Greater volume of more concentrated drug was necessary to achieve the highest dose level of EXPAREL 30 mg/kg. Smaller volumes or more dilute suspension of bupivacaine were used at lower EXPAREL dose levels. Both the highest volume delivered (1.2 mL/kg) and the highest dose administered (9 mg/kg) of bupivacaine HCl were evaluated. The 9 mg/kg dose was based upon the published intr-avenous (iv) lethality of 5–11 mg/kg for bupivacaine [The dose sites were alternated between two scapular regions so that the studies could be performed without the potential concern of injection site irritation obscuring or otherwise compromising the ability to discern systemic effects resulting from treatment-related observations. Specifically, the twice weekly doses were rotated at two different sites to the right of the dorsal midline (site 1) and to the left of the dorsal midline (site 2). The borders of the sites on opposite sides of the midline had at least two inches to ensure that there was no cross contamination between the sites. The dose was administered on Days 1, 8, 15, and 22 (site 1) and on Days 4, 11, 18, and 25 (site 2). An individual site was dosed once every 3 days. The study design takes into consideration the slow egress of the lipid components from the injection sites as previously shown in research studies (data not shown). The repeat dose administration studies with EXPAREL were designed with an intermittent dosing schedule to allow enough time for dose egress from the injection sites between each dose administration and minimize the risk of plasma drug accumulation while providing sufficient exposure. The twice weekly dosing schedule  was selected based on computer-based simulations using WinNonlin (assuming linear kinetics) which suggested continuous exposure of bupivacaine with no or minimal accumulation over the course of the study. The simulated profile was derived from actual single dose data (high dose only) and extrapolated to twice weekly administration (data not shown).N = 3/sex/group/period).Following 25 days of administration, three anima-ls/sex/group were maintained for a 4-week treatment-free recovery period. At the end of the dosing (Day 25) and recovery period (Day 50), animals were sacrificed , organ weight, full histopathologic tissue evaluation, and toxicokinetics on Day 1 (first dose) and Day 25 (last day of dosing) (through 72 hours postdose). EKG was performed prior to dosing and during the last week of dosing (Day 22) and the last week of the recovery period (Day 50).  Any observable involuntary movements were noted. Special attention was paid to signs of CNS disturbances and seizures  Microscopic examination of fixed hematoxylin and eosin-stained paraffin sections was performed on the sites of injection and other protocol-specified tissues. A four-step grading system was used to define gradable lesions for comparison between dose groups . 3 EDTA and stored on an ice block until centrifuged. Each sample was 0.5–1 mL. The test animals were not fasted before blood collection unless collection times coincide with clinical pathology collections. The plasma samples were stored frozen at approximately −70°C until analyzed.Toxicokinetic samples were collected from the 3 animals/sex/group designated for a 4-week recovery period. Blood samples were taken from the jugular veins in these groups on Day 1 and on Day 25, at 0 (predose), and at 0.5, 1, 2, 4, 8, 12, 24, 48, and 72 hours after dosing. Samples were placed in tubes containing K3EDTA plasma in the concentrations ranging from 10.0 to 10,000 ng/mL. The PK parameters were evaluated by a noncompartmental model using WinNonlin, version 5.0 . The PK parameters were maximum plasma concentration (C max), time at which the C max occurred (t max), and area under the plasma concentration, time data (AUC 0-t). The half-life (t 1/2) was calculated in the late phase of plasma concentration versus time curve. Plasma concentrations of bupivacaine were measured by MPI Analytical, Mattawan, Mich, using a validated LC-MS/MS method. The assay is selective for the quantification of bupivacaine in rabbit and dog KThere were no test article-related effects on body weight, food consumption, hematology, coagulation, clinical chemistries, urinalysis, or organ weight endpoints.One female died on Day 19 one day after receiving the sixth dose of EXPAREL (30 mg/kg). In the last scheduled observations, the animal was normal. Microscopically, no cause of death was determined. In addition to the changes seen at the injection sites in all the EXPAREL groups , this animal presented with microscopic findings consisting of splenic, lymph node, and thymic lymphoid depletion. This stress-associated lymphoid depletion is a common finding in animals that die on study and is associated with physiological stress. Additionally, a small amount of material consistent with food matter was seen in the lungs, due most likely to perimortem aspiration as there was no associated inflammation. It should be noted that as a result, since this rabbit was normally part of the recovery group, there were only two of the three females surviving though the recovery period.When comparing with the same dose of EXPAREL, Bsol (9 mg/kg) was associated with a more frequent incidence of tremors/convulsions  . While cMacroscopically (Day 26), increased incidence of mild-to-moderate red discoloration and swelling/thickening of both of the injection sites was noted in animals of both sexes at the 30 mg/kg dose of EXPAREL. Red discoloration and swelling/thickening were also noted at a low incidence in the 9 and 18 mg/kg dose groups, but these local reactions were comparable to Bsol or control saline group. In recovery animals, mild red discoloration was seen at a low incidence in all three EXPAREL-dosed males at all the dose levels and in 1/3 female receiving EXPAREL 30 mg/kg. These changes were, for the most part, correlated with the microscopic findings of hemorrhage (HEM) and neovascularization (NV) outlined below. Test article-related microscopic findings (H&E staining) were seen in both the sc injection sites, at all dose levels of EXPAREL in the majority of animals after repeated dosing. Microscopic findings consisted primarily of HEM, NV, vacuolated (foamy) macrophages (VMs), and inflammation (chronic-active or subacute). There was no consistent dose-dependent response seen, except in increased numbers of VMs at higher dose levels. This finding consisted of individual VMs with finely vacuolated, foamy cytoplasm forming aggregates, and/or extending along fascial planes, with rare small numbers of lymphocytes and/or plasma cells and no significant numbers of multinucleated giant cells (GCs). All findings were minimal-to-mild/moderate. None of the changes above were seen in either saline or Bsol group .Injection site lesions resolved to some degree at recovery, although minimal to mild HEM, VMs, NV, and inflammation were all present in low numbers in recovery animal. The presence of VMs appeared to resolve in a dose-dependent manner with none seen in males at the 9 mg/kg dose or in females at the 9 or 18 mg/kg dose of EXPAREL. There were no test article-related effects on clinical observations, body weight, food consumption, hematology, coagulation, clinical chemistries, urinalysis, or organ weight endpoints. There were no EKG abnormalities caused by EXPAREL, Bsol, or saline.When compared to Bsol or saline control group, the only notable findings were EXPAREL-related macroscopic and microscopic observations in the injection sites of both male and females (Days 26 and 54).Swollen or thickened injection sites were noted in a low number of terminal and recovery animals. Often, there was no microscopic correlate to the red discoloration at the injection sites. In rare occasions, the red discoloration corresponded with HEM, edema, and/or sc subacute inflammation. This macroscopic finding was considered to be a result of physical trauma from the injection procedure and not associated with treatment.On both Day 26 and Day 54, minimal-to-moderate Gi was observed in the sc tissue of male and female dogs. Similar microscopic findings were not observed in Bsol or saline control group .On Day 26, Gi was characterized by numerous VMs and fewer lymphocytes, plasma cells, and/or GCs formed by fused Macs with abundant cytoplasm and nuclei scattered irregularly throughout the cytoplasm. The Gi was commonly associated with edema and/or mineralization. The mineral deposits were commonly surrounded by GCs. On Day 54, Gi was observed less frequently and was characterized by an increased number of GCs sometimes associated with mineralization, but not edema. In one male receiving EXPAREL 9 mg/kg, minimal edema not associated with inflammation was noted. In the EXPAREL groups, minimal-to-mild signs of hemorrhage, acute inflammation, erosion, epidermal exudates, and/or subacute inflammation were observed sporadically at the injection site of some terminal and recovery animals. The subacute inflammation was primarily associated with hair follicles and rarely surrounded intralesional mites consistent with Demodex canis. These findings were considered procedural. C max (↓ 4 fold) and AUC (↓ 5 fold) for all dose levels for EXPAREL (rabbit versus dog). The same observation was made for Bsol with lower C max (↓ 4-9 fold) and AUC (↓ 4 fold).The pharmacokinetic results are shown in Tables Systemic exposure in female rabbits on Day 25 tended to be larger than that in males (data not shown). In dogs, there was not marked or consistent gender difference with regard to the PK parameters for bupivacaine. The PK results indicate that rabbits and dogs were exposed to bupivacaine in a dose-related  manner after twice weekly repeated dosing of EXPAREL, at doses ranging from 9 to 30 mg/kg. The degree of accumulation for EXPAREL upon repeat dosing was no greater than two- to threefold which indicate minimal-to-moderate carryover from the previous dose Tables  and 3. C max was on the order of two- to threefold compared to Bsol after the first dose. The accumulation was more evident at the 30 mg/kg dose in rabbits compared to dogs. In both species, the kinetic release profile was consistent with sustained release of the drug from the delivery system at the site of administration Figures , and 4. When interpreting toxicology results, consideration has to be given to the particular sensitivity of the species to local reactions. The rabbit is, as a general rule, more sensitive than other species to the action of most substances . The senAlso, when assessing the potential existence of cumulative systemic effects of bupivacaine, the resulting plasma kinetics is an important safety consideration because systemic absorption of bupivacaine causing rapid high peaks are associated with a more pronounced risk of CNS and CV effects. A brief review of the literature is provided below.The toxic response of bupivacaine is characterized by a complex interaction between the CNS and CV systems. The response, at least in part, depends on how fast the drug is administered, and the resultant blood/tissue concentrations in target tissues are affected. Particularly, injection of repeated doses of local anesthetics may cause significant increases in plasma levels with each repeated dose due to slow accumulation of the drug or its metabolites or to slow metabolic degradation. It is difficult to determine the relationship between plasma levels and toxicity when the summated response originates from tissues with different sensitivities, for example, cardiac muscles, neural tissues. In animals (and humans), adverse effects associated with bupivacaine are generally dose-related and most often are due to acutely high plasma levels resulting from rapid absorption of bupivacaine at the intended site of action, overdosage , diminished tolerance, or unintentional intravascular injection , 14, 15.μg/mL produce a progression of CNS symptoms, including headache and numbness; with increased plasma concentrations, convulsions may occur [In humans, dose-limiting effects generally occur more frequently with bupivacaine doses in the higher ranges. Plasma concentrations of bupivacaine ranging from 3 to 5 ay occur , 16. In ay occur , 18. LarCardiotoxicity is less easy to study in man, as the clinical signs are not usually seen until the CNS toxicity is marked. However, CV collapse and even death can occur from low dose of bupivacaine without significant CNS toxicity, possibly as a result of the sudden onset of ventricular fibrillation , 20. DurAcute toxicity of bupivacaine has been reported in mice, rats, rabbits, dogs, pigs, sheep, and monkeys. Endpoints studied includes CNS (convulsions) and CVS toxicity , muscle degeneration and regeneration (particularly in rats), and maternal and fetal toxicity during delivery (mostly in sheep) –38. Neurotoxicity manifesting as convulsions is a well-recognized complication of the administration of bupivacaine  in both animals and humans. CNS toxicity is characterized by a two-stage pathophysiologic process. Shivering, muscle twitching, and tremors precede tonic-clonic seizure activity as increased plasma levels of bupivacaine preferentially block inhibitory central pathways, leaving excitatory neurons unopposed. Convulsions may occur due to absolute overdose, inadvertent iv injection or because of accidental early tourniquet release in iv regional anesthesia . The seiThere are a number of limitations to some published in vivo studies since they were performed in anesthetized animals with the complicating effects of anesthesia and surgery, and bupivacaine was administered at toxic doses which did not allow to evaluate the absolute CNS and/or CV effects. Although there is no generally agreed standard model of toxicity, whole-system models are generally considered more clinically relevant than others. However, the data acquired are complicated by PK/PD interactions at different organ system, progressive  response, and intrinsic control mechanisms. As a result, the dose response may be discontinued and nonlinear . CNS effects are generally assumed to precede CV toxicity; this notion was primarily derived from studies over the past several decades comparing doses causing disappearance of pulsative blood pressure and onset of convulsions effects in sheep . This raIn a recent published report, the utility of site-directed delivery systems to differentiate between CNS and CV system effects has been emphasized . The autIn rabbits, the mean convulsive doses  and mean lethal doses of bupivacaine  were determined after slow iv infusion of 0.32 mL/min for 20 minutes, or until the animals died. The clinical signs were salivation, tonic and clonic convulsions, and respiratory arrest. After eight injections of bupivacaine given sc at 30-minute intervals, a dose of 6 mg/kg produced convulsions in 2/5 rabbits while no effects were seen at 5 mg/kg . MetabolIn addition, cardiac toxicity is a well-recognized complication of the administration of bupivacaine  in both animals and humans –49. ElecRabbits have been reported to be more sensitive to the cardiotoxicity of bupivacaine than other animals . It seemIn our studies, dogs tolerated much larger doses of EXPAREL than rabbits. A no-observable-adverse-effect level (NOAEL) dose for EXPAREL or Bsol was not achieved in rabbits. The tonic and/or clonic seizure activity seen with EXPAREL at 9 and 18 mg/kg as well with Bsol, although at lower frequency, were associated with bupivacaine and not the liposomal formulation. Complete recovery was observed after each dose indicating that these effects were reversible. It is our opinion that the major factors involved in the dramatic results seen in the rabbit compared to the dog were its susceptibility to bupivacaine. Under these stringent conditions, the test system was overwhelmed, which presumably contributed to the adverse effects. The exaggerated response achieved in rabbits was somewhat expected based on literature review, and, in some respect, mimics adverse reactions that could occur as a result of intravascular infusion and/or acute overdosing of bupivacaine. It is unclear why no convulsions were seen at the higher dose level of EXPAREL 30 mg/kg. Apparently, there is a toxicity threshold for concentration and exposure time, such that when surpassed, irreparable damage to target organs is produced. The lack of a clear dose response may reflect a differential expression of potassium channels, and, perhaps, compensatory mechanism(s) involving differential blockade and/or stimulation of excitory/inhibitory pathways, which could lead to a disproportional and nonlinear response.The day after receiving EXPAREL at a dosage of 30 mg/kg/dose given sc at biweekly intervals for a total dose of 30 mg/kg/dose × 6 injections = 180 mg/kg, one female rabbit was found dead. All other animals survived the duration of the study even those receiving a total dose 30 mg/kg/dose × 8 injections = 240 mg/kg in which the dose exposure was larger higher on a cumulative basis, and plasma concentrations were present for a longer period. The experimental conditions did not allow determination of the cause of death. It is possible that if this animal had been monitored constantly, earlier detection of delayed toxicity may have been possible. Intravascular injection is unlikely to have been an etiology in our case since the animal appeared normal on the day of dose administration. Considering the susceptibility of rabbits to cardiotoxicity and the fact that, after several repeat injections of EXPAREL, the compartments, being nearly saturated, may reach potentially toxic concentrations, led us to speculate that the lethality may have been caused by hypotension, respiratory distress, CV collapse, and/or sudden fatal ventricular tachycardia and fibrillation with or without hypoxia or acidosis. In recovery rabbits, the local reactions resolved to some degree, although minimal to mild HEM (hemorrhage), VMs, NV, and inflammation were present in few animals. The HEM, NV, and inflammation (chronic-active or subacute) seen in the EXPAREL-treated animals were possibly adverse effects although there was no clear evidence of a chronic response to EXPAREL consistent with a harmful response to the immune system. Some of the local inflammatory reactions may be caused by overt irritation produced by prolonged bupivacaine exposure –53. TherIn dogs, the NOAEL was >30 mg/kg/dose. The low-grade Gi  observed with EXPAREL-dosed groups only decreased in severity, yet persisted in the recovery animals, and therefore was not considered reversible. The mineral deposits, commonly surrounded by GCs, were considered evidence of small amounts of foreign matter, presumably DepoFoam particles in the loose connective tissues of the sc space. With the low incidence and severity, these soft tissues changes are compatible with a foreign body type reaction following exposure to the tissue of the test article. The character of the soft tissue reaction was nonspecific and did not indicate any special toxic effect per se. In each species, the highest dose was administered via application of a concentrated formulation of EXPAREL (25 mg/mL); the formulation of 25 mg/mL was intended to maximize the delivery of EXPAREL to the site of absorption and was used to increase exposure of local tissues to relatively higher concentrations of both vehicle and drug. Despite the documented actions of bupivacaine on the musculoskeletal system, normal function of this system was not affected—even at both lipid and bupivacaine concentration 1.7 times higher than the undiluted EXPAREL formulation.C max (↓4 fold) and AUC (↓5 fold) for all dose levels for EXPAREL (rabbit versus dog). The same observation was made for Bsol with lower C max(↓4–9 fold) and AUC (↓4 fold), perhaps because differences in tissue binding, vascular uptake, and hepatic clearance affect drug distribution. After repeat exposure, the modest accumulation of bupivacaine in rabbit plasma suggested that the highly concentrated formulation of EXPAREL was not cleared completely before the next dose was administered, as would be expected from its prolonged absorption from the injection sites. Notably, EXPAREL revealed a predictable sustained release profile in both species even at high doses. Notably, species difference was observed with lower In contrast, dogs appeared to process bupivacaine similarly after the first dose and after the last dose; this finding is consistent with a lack of toxicity reported in this experimental model. The gradual input afforded by EXPAREL allowed enough time for the body to absorb bupivacaine and processed it without overwhelming the system even when massive doses were administered. In summary, we have identified a species difference as reflected in the greater incidence of local and systemic reactions in rabbits compared to dogs. In both species, EXPAREL was irritating to extravascular soft tissue when given in large amounts in excess of the clinical dosage. All microscopic changes at the injection sites were minimal to mild/moderate. Similar microscopic findings were not observed in Bsol or saline control group. In rabbits, the systemic reactions (tremors/convulsions) were attributed to an exaggerated response to bupivacaine and were more frequently observed with Bsol. As a result, a NOAEL was not identified in rabbits. The local reactions were expected consequences of EXPAREL, due to the deposition of foreign matter in the loose connective tissues of the subcutaneous space. The most important consideration in the findings from these studies is the potential implications on human risk. While the mechanism(s) that contributed to convulsions in this study cannot be identified with certainty, the toxicological effects of EXPAREL in rabbits, presumably, are a reflection of a low rate, threshold-sensitive phenomenon that is not operative, and/or anticipated in humans under actual condition of exposure . In the repeat-dose 28-day studies, the dosing methodology was selected to maximize exposure conditions. Under these conditions, the total cumulative dose of bupivacaine was regarded as excessive relative to the intended single-dose administration in the clinic, that is, the dosing regimen far exceeded the number of doses humans will receive. In dogs, no effects were noted. In rabbits, convulsions and one death were noted. The death was recorded in a female rabbit one day after receiving six injections of EXPAREL 30 mg/kg subcutaneously at biweekly intervals, which correspond to a total cumulative dose of 30 mg/kg × 6 doses = 180 mg/kg). Given the fact there was no dose-related response, the death may have been either incidental and/or related to excess responsiveness to bupivacaine action, that is, the lethality may have been caused by sudden fatal ventricular tachycardia and fibrillation leading to cardiac arrest as discussed above. There is no compelling evidence for this being due to the cumulative EXPAREL material per se that was injected. There is no evidence that the negative outcome in this animal is related to the specific formulation of bupivacaine used (EXPAREL) and/or the vehicle itself, but rather this extreme finding was considered to be incidental and/or most likely attributed to the sensitivity of this particular animal to the toxic effects of bupivacaine. The dog findings appear to be clinically more relevant than the rabbit, since humans usually do not experience severe effects unless very high doses of bupivacaine are given. However, caution must be emphasized since this may not be always the case. For example, patients with underlying pathology  may have higher sensitivity to the toxic effects of bupivacaine and structural analogs .It is our opinion that the major factors involved in the dramatic results seen in the rabbit were due to physiol-ogical variations and species susceptibility to bupivacaine. Alteration in regional blood flow, hemodynamic instability, and a more rapid drug uptake along with a slow egress in target tissue may render rabbits more susceptible to drug accumulation and increase the risk of overt toxicity with prolonged administration of repeated doses. In summary, the nature and level of the findings in rabbits did not present a clinically significant safety concern since EXPAREL will be administered as a single-dose by local infiltration in a clinical setting. The relevance of the rabbit observations in terms of correlating to humans is limited, since this model uses excessive dosage relative to the intended clinical dose. The lack of significant toxicology effects in a second model may provide a higher level of comfort that EXPAREL does not pose a significant health risk especially after single dose administration. These studies however draw attention to the potential complications which may occur whenever bupivacaine in any form is used.Taken together, the data demonstrate that rabbits are more susceptible to bupivacaine toxicity than dogs. EXPAREL was well tolerated in dogs during twice weekly administration for a total of 8 doses over the course of the study (cumulative NOAEL dose = 240 mg/kg). In this species, there was no indication of local or systemic complications over the course of the study. In contrast, a NOAEL was not identified in rabbits.


Obesity in children has increased in recent years throughout the world and is associated with adverse health consequences. Early interventions, including appropriate pedagogy strategies, are important for a successful intervention program. The aim of this study was to assess changes in body mass index, the ability to perform sport activities, behavior in the classroom and academic performance following one year of a health-wellness intervention program in obese youth.The CEMHaVi program included 37 obese children (19 girls and 18 boys). Participants received an intervention program consisting of physical activity and health education. Assessment included body mass index, academic performance, classroom performance and ability to perform sport activities. Paired t tests were used to assess the effects of intervention, and chi square was used to assess inter-action between measures.Findings of the study suggest significant decrease in Z scores of Body Mass Index and an improvement of academic performance, classroom behavior and the ability to perform sport activities (p < 0.05). Chi square testing showed significant positive inter-actions between body mass index, classroom behavior and academic performance.Results following year one of CEMHaVi showed that a program of physical activity and health education had positive effects on obesity, behavior in the classroom and the ability to perform sport activities in obese adolescents. Significant inter-action in changes between variables was observed. Findings are important for designing intervention models to improve health in obese youth. Adolediseases . Consequdiseases , onset odiseases ,9, frequdiseases ,11.In addition to physical consequences, obesity in youth is also associated with cognitive and psycho-social maladaptive behaviors. Li et al. showed an association between overweight and decreased cognitive function among children and adolescents that leads to poor quality of life, increased illness, incompetence, and low self esteem . Low selEarly interventions, including appropriate pedagogy strategies, are important for a successful program. Exercise is one of the factors which contributes to long term weight maintenance . PhysicaFew studies of diet restriction have been undertaken in children. Protein-sparing and hypo caloric balanced diets have been evaluated for safety and effectiveness for children in outpatient weight reduction . Data suCombining diet and physical activity has not been recommended because of the consequences of decreased energy intake with increased energy expenditure. Ebbeling & Rodriguez suggest that exercise offers metabolic benefits for obese children during diet-induced weight loss . LongituThe aim of the present study was to assess changes in ability to perform sport activity, classroom behavior and academic performance following one year of a health-wellness intervention using the Conative Educational Model in obese youth.th percentile, 7 to 17 years of age, non-genetic obesity, and a normal clinical examination including normal growth and psychomotor development. Aims and objectives were carefully explained to each subject prior to intervention. Written informed consent was obtained from subjects and parents. The study was approved by the Lille University Research Ethics Committee . All procedures were performed in accordance with ethical standards of the Helsinki Declaration of 1975, as revised in 2008, and the European Good Clinical Practices. Data were collected at baseline and at the end of year one.Thirty-seven subjects, 19 girls and 18 boys from Dunkerque, France participated in the study. Selected physical characteristics are presented in Table CEMHaVi is a unique program of exercise and health education developed by Applied Physiology Laboratory of University of Littoral Cote d’Opale  and Dunkerque medical community.CEMHaVi consisted of one hour every three months for health education and two hours per week of physical activity in the university gymnasium using the Conative Educational Model ,19.Health education was adopted from PATH  translated into French ,20. A maimpetus which lead one’s actions. This model allows the resarcher to identify conative stages through observation of child’s practice, and to assess progress or evolution in the three components  forming the model. The summation of these three components is called “guiding principle” which organize five conative stages, from novice (1) to expert (5) [The conative educational approach is based on the idea of conative curriculum which models a sense given by to one’s actions . Identifpert (5) . SubjectBody mass was measured without shoes and heavy outer garments to the nearest 0.1 kg using an electronic scale . Height was measured without shoes to the nearest 0.1 cm using a standard physician’s scale. Body Mass Index (BMI) was calculated by Weight (kg)/Height (m²), and was converted to Z-score of BMI.Ability to perform sport activities was assessed by only a CEMHaVi researcher with scales for team sports, e.g. soccer, handball, basketball, etc. and net sports, e.g. tennis, badminton, volleyball. The five levels in conative curriculum are described in Table Academic performance was assessed by questionnaire interview between a researcher from CEMHaVi and the teacher. The questionnaire was comprised of two components: 1) notation and, 2) life in the classroom. The notation score was calculated from the formula: general mean of pupil/general mean of classroom × 100. The individual pupil mean of note includes different disciplines, e.g. mathematics, physiology, French, etc. Each pupil has a note score in each discipline between 0 and 20. In the end, the teacher sums the note of each discipline and calculated the general mean of pupil. According to the general mean of class, the pupil has a score class ranking. Classroom performance consisted of measures of self-esteem, self evaluation of academic performance, and ability to work alone. Interviews were scheduled with the teacher at baseline and following year one for each subject.t tests to assess the effects of the intervention program. Measures included academic performance, Z-score of BMI, and the stage of conative curriculum. The chi square test was used to assess the interactions between these three variables during the intervention program. A p values < 0.05 were taken to be significant with a 95% confidence interval.Data were analyzed using the Statistical Package for the Social Sciences, Windows 11.5 , Excel 2003  and Sphinx . Means were calculated at baseline and following intervention and were compared by paired Significant improvements were observed in Z score of BMI and ability to perform team and net sports Table , and beh2 = 57.14, df = 2, p < 0.001), increased ability to perform sports and improvement of academic performance, , and increased academic performance and improved classroom behavior traits . Finally, a strong interaction was found between decreased Z-score of BMI and increased in sport activity .Significant chi square findings suggest an interaction between decreased Z-score of BMI and improvement in classroom behavior traits (To the best of our knowledge, the present study is the first to assess changes in academic performance, classroom behavior and ability to perform sport activities following a one year health-wellness program in obese youth using the Conative Educational Model. Results of the present study suggest that the conative model had a positive impact and that a strong inter-action exists in changes among measures.Significant decrease in Z score of BMI was important because of the association between obesity and cardiovascular disease, metabolic syndrome or type 2 diabetes . SeveralKrukowski et al. suggest that psychosocial variables, such as weight-based teasing, be considered in future research examining the impact of childhood obesity on school performance and the effect of health intervention studies . IncreasTo reinforce self esteem and classroom performance, the CEMHaVi program used the Conative Educational Model . ExercisOne of the limitations of the present study is the absence of a control group. Because of time limitations and financial constraints a randomized control group was not possible. However, the study has pre-test/post-test design and the group participants act as their own control subjects. Nevertheless, it would be preferable to develop this program with a control group in order to have more rigorous methodology, and to increase the number of participants for statistical power. Therefore, the present study is a pilot and its findings are preliminary, but encouraging.Results following year one of CEMHaVi showed a close relationship between BMI, academic performance and ability to perform sport activity. Of greatest importance is that Z-score of BMI decreases proportionally to improved behavior and quality of life in classroom and ability to work alone. Results also showed a positive inter-action between academic performance and the ability to perform sport activities. Finally, the positive effect of academic performance on behavior traits in the classroom demonstrates in obese youth that increased academic performance results in better integration into classroom. These results are particularly favorable for obese youth to improve their general health state, both physical and mental.The authors declare that they have no competing interests.J. Mikulovic, L Béghin, J. Vanhelst conceived the idea. J. Vanhelst and P Fardy wrote the first and subsequent drafts. G. Bui-Xuan helped developed the ideas. All authors read and approved the final manuscript.There are no funding sources for the work.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2458/12/416/prepub


Objectives. Human placental extract (HPE) has begun to be used in Korea in various ways to improve health, even though evidence-based data is insufficient. This study investigated the effects of HPE on health status in elderly Koreans. Design. Randomized, single-blind, and case-control study design. Setting and Participants. Thirty-nine community-dwelling healthy Koreans ≥65 years of age. Intervention. The participants were randomly categorized into a placebo group (n = 17) and HPE group (n = 22). The HPE group received abdominal subcutaneous injections of HPE for 8 weeks. The placebo group was injected with normal saline. Measurements. The degree of health status was surveyed by the Korean health status measure for the elderly (KoHSME V1.0) at baseline and the end of the study. Results. In the HPE group, the scores of physical function, sexual life, and general heath perception at the end of the study period were significantly improved from baseline , while the health status of the placebo group remained unchanged during the study period. There was a significant difference over the study period between the two groups in the mean change of the physical function score (P = .036). Conclusion. A HPE injection regimen can improve the health status in elderly Koreans. Human placenta has been a historical folk remedy in Oriental countries. In Japan, the hydrolysate of human placenta, which contains therapeutic compounds, has long been refined as human placental extract (HPE). In Korea, HPE has been approved for the improvement of liver function and menopausal symptoms since its importation from Japan in 2003. In Korea, HPE has been approved and is now widely used for improvement of fatigue, skin whitening, and antiaging. Despite this popularity, the efficacy of HPE has not been sufficiently researched.Studies using animal models have provided evidence for liver function improvement and skin whitening attributes of HPE by liver regeneration and antimelanocyte activity –5. ImproWith the aim of investigating HPE in more rigorous detail, the present randomized controlled trial was undertaken to determine the influence of HPE on the health status in elderly Koreans.This study was approved by the Institutional Review Board of Ajou University Hospital, Suwon, Republic of Korea (AJIRB-CRO-05-211).A public notice posted on the notice board of Ajou University Hospital between May and July, 2006, recruited research participants. Details of the study were explained to potential volunteers prior to obtaining informed consent.Initial screening included past/current medical history and a physical examination. Eligible participants were Koreans ≥65 years of age. Subjects with history of chronic renal disease were excluded if their plasma creatinine levels exceeded 1.5 mg/dL, if they had history of liver cirrhosis or other hemmorhogic diseases, history of any cancer, or history of taking medications such as thrombolytic agents. Forty-two subjects  were selected. The sample size calculations were based on the assumptions of a standardized effect size of 0.90, statistical power of 95%, and a (1-sided) type I error 5%. To meet these assumptions, 42 patients were required.The hydrolysate of human placenta  has been previously described . It is an = 18) or HPE (n = 22) for 8 weeks. Participants were injected with the appropriate preparation in the following schedule: 4 mL twice weekly for the first 2 weeks, 2 mL twice a week for the next 2 weeks, and 2 mL once weekly for the last 4 weeks. Each participant visited the hospital 12 times during the 8-week study for the injection, and the total amount injected was 32 mL. All subjects had their eyes covered during injection to blind them to the identity of the injected preparation. Health status was assessed by a questionnaire and metabolic parameters including cardiovascular risk factors that were measured at baseline and after 8 weeks.The subjects were randomly assigned to receive subcutaneous injection of either placebo   was usedγ-GTP). Metabolic parameters were measured exactly as described previously [Body measurement and metabolic parameters were similar to those of our prior study , includieviously . InsulinP value <0.05 indicated statistical significance.Statistical analyses utilized SPSS for windows, version 11.5 . A nonparametric test was used to compare HPE with placebo at baseline and the end of the study . Wilcoxon-signed rank test was used to assess the change in each group at the beginning and end of the study period. All values are shown as mean ± standard deviation (SD). A One subject in the placebo group did not complete the study, withdrawing for a personal reason. Thirty-nine participants completed the study (22 in the HPE group and 17 in the placebo group).There were no significant differences between the HPE and placebo groups at baseline concerning gender, age, BMI, prevalence/nature of cardiovascular diseases, use of antihypertensive medication, use of oral hypoglycemic agents for diabetes, and use of medication for hyperlipidemia . LaboratP = 0.036, P < 0.001, All mean KoHSME scores did not differ significantly between the HPE and placebo groups at baseline. In the HPE group, the mean scores of physical function, sexual function, and general health perception at the end of the study period were significantly improved from those at baseline . AlthougThere were no significant changes in the risk factors of cardiovascular disease in the two groups during the study period, including blood pressure, fasting plasma glucose, insulin, insulin resistance index , lipid levels , and high sensitivity C-reactive protein level .The proportion of the elderly in Korean society and globally is increasing rapidly as advances in medical science permit a longer life. With an extended life span, the quality of life and health status of the elderly, especially concerning depression and physical function, have become very important issues. Depression in elderly people is an important cause of weight loss, cognitive dysfunction, and death –11.In the present study, health status improved in elderly Koreans (≥65-years-of-age) when they received an 8-week regimen of HPE injections. Improvements noted in general physical function in accord with the improved physiologic function and depressive mood were improved at the end of the study period, while these aspects were unchanged in the placebo group. Aging has been linked to increased inflammation . The demThe present study also assessed the influence of HPE on sexual functioning. Although IGF-1 was not changed, the noted improvement in sexual function may have reflected the general physiologic function improvement mediated by HPE. HPE displays anti-inflammatory activity that is the same as diclofenac . The lesThe current study is limited by the small number of participants, the use of only Koreans, and the lack of a long-term assessment. Further studies must address these shortcomings before the significance of the present findings can be verified. Also, the effectiveness of HPE treatment needs to be explored further in a global approach, in terms of different cultures and habits. Despite the limitations, the study is notable for the demonstration of improved health status in elderly Koreans who received HPE for 8 weeks.


The incidence of congenital heart disease (CHD) is continuously increasing among infants born alive nowadays, making it one of the leading causes of infant morbidity worldwide. Various studies suggest that both genetic and environmental factors lead to CHD, and therefore identifying its candidate genes and disease-markers has been one of the central topics in CHD research. By using the high-throughput genomic data of CHD which are available recently, network-based methods provide powerful alternatives of systematic analysis of complex diseases and identification of dysfunctional modules and candidate disease genes.In this paper, by modeling the information flow from source disease genes to targets of differentially expressed genes via a context-specific protein-protein interaction network, we extracted dysfunctional modules which were then validated by various types of measurements and independent datasets. Network topology analysis of these modules revealed major and auxiliary pathways and cellular processes in CHD, demonstrating the biological usefulness of the identified modules. We also prioritized a list of candidate CHD genes from these modules using a guilt-by-association approach, which are well supported by various kinds of literature and experimental evidence.We provided a network-based analysis to detect dysfunctional modules and disease genes of CHD by modeling the information transmission from source disease genes to targets of differentially expressed genes. Our method resulted in 12 modules from the constructed CHD subnetwork. We further identified and prioritized candidate disease genes of CHD from these dysfunctional modules. In conclusion, module analysis not only revealed several important findings with regard to the underlying molecular mechanisms of CHD, but also suggested the distinct network properties of causal disease genes which lead to identification of candidate CHD genes. Congenital heart disease (CHD) is among the most common human congenital defects, and is the leading cause of infant morbidity in the world ,2. AlthoTo discover molecular pathogenesis in complex disease, considerable efforts have been made to elucidate the relations between variability in gene expression and genotype -12, and In this paper, we construct a CHD subnetwork and identify dysfunctional modules by developing a novel network-based computational approach which integrates protein-protein interactions, gene coexpression profiles and causal paths from putative CHD genes to target genes. We evaluate the functional implications of our modules for phenotype classification, and further reveal their higher order topological relationships by exploring their represented biological processes and crosstalk. Results show that our modules are better disease-markers than documented pathways, and have the discriminative power stably across several independent microarray datasets. In particular, correlation analysis reveals that each module is also a group of significantly coexpressed genes; module interaction analysis characterizes the higher-order topology of these identified modules; functional enrichment and module-pathway crosstalk analysis suggests that the topology of a module is highly related to its roles in CHD. While the modules in central place of the CHD subnetwork are enriched in core CHD-related dysfunctional processes, such as anatomical structure morphogenesis, cell differentiation and cytoskeleton organization, and regulate key pathways of CHD such as cardiac muscle contraction, Notch signaling pathway and ECM (extracellular matrix)-receptor interaction, the modules in peripheral place are enriched in auxiliary processes, such as cell communication and various metabolic processes, and regulate less disease-related pathways. In addition, we find that CHD casual genes exhibit different network features, i.e. disease genes tend to have lower current flow and participate in fewer dysfunctional subnetworks than expected. Moreover, we provide a list of candidate CHD genes by module analysis, where the top ranked genes in the candidate list are all well supported by literature and experiment evidence. The results not only elucidate the functional roles of the modules on CHD, but also provide some insights into the underlying molecular mechanisms of CHD which lead to identification of candidate CHD genes.The work flow of our method of identifying dysfunctional modules is shown in Figure Totally, our method resulted in a connected CHD subnetwork consisting of 498 nodes and 2413 edges Figure . We idenp-value<0.05) compared with 1000 random gene sets of the same size  of each module with sample phenotype. The results are shown in Table p-value, and were added sequentially. The result shows that modules are consistently better in the classification accuracy than pathways and random sets, while pathways are better than random sets only for the first five features  and build logistic regression models  in a fivs Figure . To tests Figure . In crosp-value<0.05), and all of them also have significant MI at the same time. If all 12 modules are regarded as a whole and compared with 12 random gene sets, the result is also significant .Besides comparing module expression profiles under disease and control status to evaluate its synergistic differential expression, another way to utilize microarray data is to exploit gene coexpression relationships within modules and across modules. Under the well-accepted hypothesis that genes exhibiting similar expression patterns across sample status are likely to have functional relevance , we reasp-value<0.05) are shown. For each module, we defined its intra-modular connectivity as the sum of the absolute value of correlation for all its outgoing edges, and used this score to evaluate its network centrality  in Module 10, demonstrating the functional relevance of Module 10 to CHD. Module 12 . Table Utilizing our previously developed NOA  method of functional enrichment analysis , we idenodule 10 ,22. It e2 Figure  ranks 2n, NOTCH1  and JAG1, NOTCH1 , again, We have shown that modules with highest scores, being in the central place of the subnetwork, are enriched in core processes related to heart development, and that CHD genes participate in all the top ranked GO processes in a module. We then investigated the modules with lowest scores in the marginal place of subnetwork and identified their relations with CHD. Module 4  influenced by at least one module, and columns represent modules and their influence to the 85 pathways. Module 10 is the most influential and many of its influenced pathways are closely related to heart progression, such as cardiac muscle contraction, Dorso-ventral axis formation, gap junction and regulation of actin cytoskeleton. Specifically, the gap junction is very important in cardiac muscle, through which the signal to contract is efficiently passed, allowing the heart muscle cells to contract in tandem. For example, GJA1 encodes a gap junction protein, and gene conversion in GJA1 has been found in patients with CHD  = 6 equally spaced bins [a'. × and y enumerate values of a and c, p is the joint probability density function (pdf) of a' and c, and p(x) and p(y) are the marginal pdf's of a and c.Here, ced bins , and thep-value for the discriminative score, we also generated N random gene sets of the same size as each module R, aggregated their genes' expression vectors a(R) and computed their MI with phenotype S(R):To get empirical N is set as N = 1000.where K modules, then for each k ≤ K, select the first kth modules to train the classifier. Pathways and random gene sets were also used in similar manner. The final classification performance was reported as the Area Under ROC Curve , pathway activity matrix (pathways versus samples) and random gene sets (gene sets versus samples). For within-dataset experiments, each time 4/5 of the samples were implemented as the training set to build the classifier and the remaining 1/5 samples were used as testing set to evaluate the performance . Assuming that there are rve (AUC ) on the X and Y, we firstly identified the edges with two end nodes, each of which belongs to one module, and then we summed up the weights of all these connecting edges usingPrevious work  has idenM and P, we firstly identified the edges with two end nodes, each belonging to the module and the pathway, and detected the nodes in both the module and the pathway. Then we summed up the weights edges and number of nodes usingFor module-pathway crosstalk, we only considered the pathway which contains at least one gene on the CHD subnetwork in order to filter out unspecific pathways. For each module-pathway pair x∈M,Py∈|weight)| corresponds to the sum of the weight of all edges, and {e:x∈M,y∈P} are those edges that connect a pathway P and a module M. M and P, where each node is given the weight equals to 1. M and pathway P. The summation is such divided in order to normalize the size of module and pathway.where ∑p-value, we generated 1000 gene sets pairs containing the same number of nodes as the module-module or module-pathway pair, and computed their interaction scores. Random controls were generated from genes on the whole weighted PPI network, and genes in the KEGG. The significance of interaction is defined asTo get empirical N2 is set as N2 = 1000.where The authors declare that they have no competing interests.D.H., Z.P.L. and L.C. conceived the research, Z.P.L. and D.H. designed the framework and experiments, D.H. and Z.P.L. performed the experiments, D.H. and Z.P.L. drafted the manuscript, L.C. revised the manuscript and supervised the project. All authors read and approved the final manuscript.List of selected target genes and sample distance of 21 expression profiles.Click here for fileGenes in each module.Click here for filePathways enriched in CHD subnetwork using hypergeometric test. Top 12 pathways are used for classification evaluation.Click here for fileList of enriched GO terms in each module.Click here for fileNetwork view of Modules 4, 5 and 9.Click here for fileDetails of prioritizing of candidate disease genes by module analysis and robustness analysis of identified modules.Click here for file