Vitis vinifera L. is one of society’s most important agricultural crops with a broad genetic variability. The difficulty in recognizing grapevine genotypes based on ampelographic traits and secondary metabolites prompted the development of molecular markers suitable for achieving variety genetic identification.V. vinifera accessions. The analysis of the chloroplast target regions proved the inadequacy of the DNA barcoding approach at the subspecies level, and hence further DNA genotyping analyses were targeted on the sequences of five nuclear single-copy genes amplified across all of the accessions. The sequencing of the coding region of the UFGT nuclear gene  enabled the discovery of discriminant SNPs (1/34 bp) and the reconstruction of 130 V. vinifera distinct genotypes. Most of the genotypes proved to be cultivar-specific, and only few genotypes were shared by more, although strictly related, cultivars.Here, we propose a comparison between a multi-locus barcoding approach based on six chloroplast markers and a single-copy nuclear gene sequencing method using five coding regions combined with a character-based system with the aim of reconstructing cultivar-specific haplotypes and genotypes to be exploited for the molecular characterization of 157 On the whole, this technique was successful for inferring SNP-based genotypes of grapevine accessions suitable for assessing the genetic identity and ancestry of international cultivars and also useful for corroborating some hypotheses regarding the origin of local varieties, suggesting several issues of misidentification (synonymy/homonymy). Vitis is of great agronomic importance in temperate areas. Within this genus, the only European species, Vitis vinifera L., represents one of the oldest cultivated plants and is the only species extensively used in the global wine agro-industry [V. vinifera subsp. vinifera (2n = 2x = 38), and nearly all cultivars are highly heterozygous, hermaphroditic and cleistogamous, although they out-cross easily [V. vinifera subsp. sylvestris that underwent several drastic morphological and physiological changes during domestication, such as in reproductive behavior , berry and bunch size, seed and flower morphology, higher sugar content, and greater and more regular yields [In the Vitaceae family, the genus industry . The vasr yields . Althougr yields . Becauser yields ,7. Becaur yields . Despiter yields . ConsequV. vinifera to different environmental conditions, misidentification is common. Accurate characterization of grapevine germplasm relies on the choice of appropriate investigative tools. In addition to the traditional ampelography and ampelometry methods strongly influenced by plant phenology, alternative approaches based on molecular markers have been developed to guarantee the identification of both grapevines and, when possible, vine-derived products, such as juice and wine, to which morphological assays are clearly not applicable [http://www.vivc.de). Recently, an additional set of microsatellites with longer core repeats were isolated and proposed to implement grapevine genotyping to avoid common problems of allele calling [Properly recognizing grapevine cultivars is complex to achieve and, because of the high adaptability and plasticity of the species plicable . Among tplicable , a set o calling . Another calling . These D calling . The emp calling . Recentl calling . In addi calling . The ava calling ,19.http://www.barcodeoflife.org/). In a broader sense, DNA barcoding is a genomic approach based on the detection of SNPs from one or few target loci used to identify an unknown organism by matching DNA sequence recovered from the sample to a database of sequences from known organisms that have been previously described and recognized using morphological keys [V. vinifera[DNA barcoding is a technique for characterizing species of organisms using a short DNA sequence from a standard and agreed-upon position in the genome. This standardized region is then compared to a public reference library of species identifiers in order to assign unknown specimens to known species  and five wild species  used as out-groups , were supplied by certified commercial nurseries, whereas the putative V. vinifera accession Perla was obtained from Hungary. Regarding the ancient local cultivars, one hybrid (Tintoria) and 22 accessions of V. vinifera, originating from Northeastern Italy, in particular from Breganze (Vicenza) and from Euganea Hills (Padova), and maintained in the experimental farm of the University of Padova, were analyzed as particular case studies.For the molecular analysis, we sampled leaves from 164 accessions of Total genomic DNA was isolated from frozen young leaf tissues using the DNeasy extraction kit (Qiagen) according to the manufacturer’s protocol. Each DNA sample was eluted in 80 to 100 μl of 0.1× TE buffer , and the purity, integrity and quantity of all DNA samples were estimated by electrophoresis on a 0.8% agarose/1× TAE gel by comparison with a 1 Kb Plus DNA ladder (Invitrogen) of known concentration.rps16 intron and the trnH-psbA, rpl32-trnL, trnT-trnL, trnL-trnF and atpB-rbcL intergenic spacers. Standard barcodes such as rbcL and matK were discarded a priori because of the well known modest discriminatory power in resolving different but closely related species of the former [The barcoding approach was carried out by amplifying and sequencing six chloroplast markers, including the e former  and the e former ,24,25.V. vinifera EST database containing sequences related to four functional classes of genes, such as sugar metabolism, cell signaling, anthocyanin metabolism and defense related [The genotyping approach was based on three nuclear single-copy genes and two cDNA sequences (coded as ID04 and IIC08) belonging to a  related : the GAI related ; an ATP  related ; and UFG related . For SNP related ,30. Some related ,28. Addi related .Taq DNA polymerase. The primers pairs, along with the relative nucleotide sequences and the corresponding references, are supplied in Table For each chloroplast and nuclear marker, the PCR reactions were conducted in a volume of 25 μl containing 15 ng of genomic DNA as template, 1× PCR buffer , 0.2 mM dNTPs, 0.2 μM of each primer and 0.5 U of http://www.ncbi.nlm.nih.gov/BLAST) against the nucleotide databases of NCBI to check the correspondence between the sequences of the obtained amplicons with the expected sequences. Multiple sequence alignments for each marker alone and for the combined sequence derived by the five regions were performed by the software SeAl .All of the obtained chromatogram files were visualized and manually edited by means of Sequencer 4.8 . Nucleotide sites in which only a single nucleotide  was detV. vinifera cultivars as well as among V. vinifera and Vitis outgroups. The inter- and intraspecific genetic divergences were carried out within and between different V. vinifera accessions according to the Kimura-2-Parameter distance model [V. vinifera plus an outgroup of Vitis non-vinifera were delineated in the total sample. In some cases, the cultivars were reattributed to the population groups according to the main current geographical diffusion of the cultivation and the eight different regions identified were called: Local, Italy (including cultivars from Austria and Croatia), Central Europe , Spain, Portugal, Eastern Europe , Near East (including cultivars from Siria and Turkey) and Balkan Peninsula . The observed number of alleles (no) and the effective number of alleles (ne) per locus were calculated according to Kimura and Crow [V. vinifera.Measures of genetic variation were used to estimate the levels of polymorphism within ce model  using MEand Crow . The ShaV. vinifera accessions was investigated using the model-based (Bayesian) clustering algorithm implemented in the software STRUCTURE version 2.2 . This software was exploited to assign individual genotypes, predefined according to the nine geographical groups introduced previously, to clusters inferred according to marker allele combination and distribution. All simulations were carried out assuming an admixture model, with no a priori population information and with correlated allele frequencies. To evaluate the appropriate K value, the software was run ten independent times for each K value (from 1 to 10) using a burning period of 100,000 and 100,000 Markov chain Monte Carlo (MCMC) repeats. Estimation of the most likely value of K was done as recommended by Evanno et al. [The population structure of our o et al. . AccessiV. vinifera. The terms “pure”, “simple” and “compound” were employed in agreement with the terminology proposed by DeSalle et al. [Because of the intrinsic difficulty in applying chloroplast DNA barcoding at the subspecies and population levels, a second approach combining the sequencing of nuclear genes with a character-based method was developed . The infe et al. : pure inrps16 intron and the trnH-psbA, rpl32-trnL, trnT-trnL, trnL-trnF and atpB-rbcL intergenic spacers. Based on the available literature, these sequences were included in the most polymorphic regions widely used for genetic identity or molecular phylogeny studies of various plant taxa [trnH-psbA intergenic spacer was found to be not only monomorphic among different V. vinifera cultivars, but also poorly polymorphic among Vitis species, scoring only two SNPs. Additional chloroplast regions were tested by analyzing only a core subset of 30 V. vinifera accessions, including also representative samples for each Vitis species. An unexpected lack of polymorphisms was observed both at the intraspecific and interspecific level (data not shown).In a number of preliminary assays, we targeted six different chloroplast markers for barcoding grapevine accessions: the ant taxa ,43,44. Dant taxa  and refeBecause of the inadequacy of the chloroplast genome for DNA barcoding purposes, further analyses were targeted on the sequences of five nuclear single-copy genes amplified across all of the accessions.The universal primers designed on the novel nuclear gene targets proved to be highly effective in generating single and reliable amplicons, with an estimate of successful amplification equal to 100%.Vitis species and among V. vinifera accessions, respectively, with an average frequency of 1 SNP/31.00 nucleotides and 1 SNP/34.55 nucleotides, respectively . Because the occurrence of SNPs, in either homozygous or heterozygous states, had to be detected with a high degree of confidence to infer the genotype composition suitable for cultivar characterization aims, we focused our attention on the nucleotide positions with no cases of ambiguous base calling. When comparing all the genotypes, a total of 107 and 96 polymorphic sites were recorded among ly Table . Considely Table .V. vinifera accessions was investigated and, for this aim, the whole germplasm collection was split into four subgroups: i) the international cultivars; ii) the local cultivars, that will be analyzed in great detail; iii) the interspecific hybrids, Bianca that represents a V. vinifera backcross with introgressed genes from non-V. vinifera ancestors, and the local accession Tintoria; and iv) the five Vitis species used as outgroups. As reported in Figure V. vinifera accessions. The genetic diversity, computed for each of the four subgroups, was equal to 0.04, 0.01, 0.02 and 0.21, respectively. The genetic distance estimates among subgroups were 0.02 between local and international cultivars, 0.03 and 0.01 between interspecific hybrids and international cultivars and local cultivars, respectively, and 0.27, 0.26 and 0.17 between outgroups and international cultivars, local cultivars and interspecific hybrids, respectively.Genetic diversity among V. vinifera accessions varied from 1.22 to 1.63 and 1.18 to 1.29, respectively. The average estimate of the Shannon’s information index of phenotypic diversity for molecular profiles was I = 0.21 and I = 0.19 for certified and local cultivars, respectively, whereas the mean Nei’s genetic diversity, equivalent to the expected heterozygosity, was as low as H = 0.13 and H = 0.12 for certified and local cultivars, respectively , as shown in Figure V. labrusca, V. cinerea, V. berlandieri, V. rupestris and V. riparia into distinct main branches with bootstrap values higher than 75%  or different strictly related cultivars . In detail, in the case of Regina the genotype was shared by closely related cultivars, as Razaki, a Regina from Greece and the two Italian cultivars of Regina. Similar results were obtained in the case of the Pinot family, where the two accessions of Pinot Noir (570 and 556), Pinot Blanc and Pinot Gris showed the same CA pattern, for the group of Moscato, which included Moscato Bianco and Moscato Giallo, and for the group of Cannonao. In only one case it was difficult to find a correlation among the cultivars sharing the same pattern of CA: the two cultivars Fiano and Petit Verdot do not share the ancestors, the geographic origin  or the berry colour .Only a few genotypes corresponded to more than one modern cultivar, with a maximum of four cultivars per genotype. It is worth noting that the more numerous genotypes generally grouped either several accessions of the same cultivars  and in both of the cell layers for Pinot Blanc (white berry). These kinds of somatic mutations are very common in grapevine and contribute to the high incidence of genetic variability. Because of the origin of this mutation, probably the only way to resolve the genetic recognition of these three cultivars would be the individuation of a marker map for the gene controlling berry colour and the mutation responsible for the colour change. Even if UFGT belongs to the biosynthetic pathway of anthocyanins, a retrotransposon-induced mutation in the transcription factor-coding gene VvmybA1 is the molecular basis of the white coloration, as demonstrated by Pereira et al. [V. vinifera accessions. Despite these considerations, it is very difficult to reconstruct the pedigree and develop hypotheses about offspring relationships. In fact, sequencing of nuclear markers proved to be a valid genomic tool to distinguish species and, in large extension, cultivars. Nevertheless, the exploitation of this technique to infer offspring relationships seems risky because of the limited number of available SNPs.Considering all the certified samples, 121 genotypes were discovered: five were able to distinguish the wild a et al.  and Furia et al. . Thus, tV. vinifera and V. non-vinifera, followed by the distinction of intra-specific clusters within cultivated grapevine accessions. Nevertheless, the analysis of overall data revealed that there is no relationship between the cultivation area of the cultivars and the genomic composition. Only the wild Vitis species were clustered in a specific sub-group, together with the Perla accession, whereas all the cultivars were assigned almost in equal proportion of membership to the three V. vinifera sub-groups identified revealing an admixed origin. Regarding Perla, although the analysis was conducted considering this accession a V. vinifera cultivar, our results highlighted a different origin more compatible with an interspecific pedigree. In fact two different accessions, generally called Perla, are commercially available: Perla of Csaba, a V. vinifera variety, and Perla of Zala, an interspecific hybrid between Perla of Csaba and Eger2 cultivar deriving from Villard Blanc, a France hybrid whose genetic patrimony derives from several V. non-vinifera. The genomic composition of this variety supports the hypothesis that our material belongs to the Perla of Zala cultivar. Similarly to Perla, also Bianca cultivar showed a considerable contribution of the V. non-vinifera species, even if with less extension, to its nucleotide composition supporting in this way its interspecific origin. In fact, Bianca is a hybrid deriving from the backcross of the French V. vinifera cultivar Villard Blanc with its ancestors, which include germplasm of V. aestivalis, V. berlandieri, V. cinerea, V. lincecumii and V. rupestris, accessions used to introduce the resistance genes of the North America grapes [Using STRUCTURE software, it was possible to identify four putative subpopulations and to probabilistically assign individuals to the corresponding clusters on the basis of their genotypes. Similarly to what reported by Emanuelli et al. , a strata grapes .Once specific genotypes were identified among the international cultivars used as standard references, an additional sampling of ancient local varieties typical of northeastern Italy was performed to include them in the analysis. Characterizing this local germplasm, which represents a valuable genetic resource for the region, would be the first step of a conservation policy aimed at the preservation and valorization of old native cultivars. The identification and description of this local patrimony represents not only a valuable resource for the territory, because some local cultivars still constitute the basis of famous regional wines such as Gruaja or Marzemina, but also a potential source of genetic variability exploitable for genetic improvement programs (breeding schemes assisted by molecular markers), providing the information required for the correlation of molecular markers with phenotypic distinctive traits of grapevine cultivars. The employment of our varietal germplasm collection can be considered an explorative assay to test the effectiveness of sequencing nuclear genes to examine the genetic identity of samples, eventually resolving cases of synonymy and homonymy, and to compare the results emerging from nuclear genes with those previously obtained by using nuclear and chloroplast SSR markers ,45.V. vinifera local cultivars, of which three were registered in the Italian Catalogue and the other eight were not. For those genotypes that clustered many cultivars at the same time, cases of synonymy can be hypothesized. For instance, the cultivars Corbinona and Corbinella proved to share the same nuclear composition, confirming former results obtained by nuclear and chloroplast SSR markers that demonstrated synonymy, except for one allele, between these two cultivars [V. vinifera accessions. In fact, this cultivar on the basis of chloroplast SSR markers showed tight relationships with American grapevine species [Among the 23 local cultivars employed in this study, five are registered in the Italian Catalogue of Cultivated Varieties: Pignola, Marzemina Bianca, Marzemina Nera, Raboso Piave and Raboso Veronese. The other cultivars were developed in the Veneto regional area, where they are best adapted and still cultivated, thus belonging to a genetic patrimony that needs to be characterized, preserved and valorized. By means of SNP markers, it was possible to reconstruct specific genotypes for the Tintoria hybrid and for 11 ultivars . A similultivars . In the ultivars  and sequ species  and the V. vinifera genotypes of which 115 belonging to international cultivars and 15 to local varieties. DNA sequencing, based on nuclear markers, proved to be very effective in distinguishing grapevine cultivars, except in the case of closely related cultivars such as within the Pinot family, or to reflect the phylogeographic history of the biotypes, as in the case of the Regina or Cannonao groups. The large portion of the UFGT gene assayed in this study proved to be the most polymorphic and discriminant marker and thus it deserves deep attention because our data suggest that the coding region of this single-copy nuclear gene alone is sufficiently informative for a single-locus sequence genotyping analysis applied at the intraspecies level for assessing grapevine cultivar identity and ancestry.Concluding, the high number of genotypes obtained so far demonstrates that the nuclear genome is variable enough to function as a source of diagnostic markers for characterization issues, allowing the genetic authentication of 130 http://www.ncbi.nlm.nih.gov/BLAST: Basic Local Alignment Search Tool; Available from: Vitis International Variety Catalogue (VIVC); Available from: http://www.vivc.de.Authors declare to have any competing interests in this manuscript.Financial competing interests: In the past five years, authors did not receive reimbursements, fees, funding, or salary from an organization that may in any way gain or lose financially from the publication of this manuscript, neither we will not receive any in the future. Any organization is financing our manuscript. We do not hold any stocks or shares in an organization that may in any way gain or lose financially from the publication of this manuscript, neither we will hold any in the future. We do not hold and we are not applying for any patents relating to the content of the manuscript. We have not received reimbursements, fees, funding, or salary from an organization that holds or has applied for patents relating to the content of the manuscript. None of the authors have any other financial competing interests.Non-financial competing interests: Authors do not have any non-financial competing interests  to declare in relation to this manuscript.SN performed all the experiments, analyzed the sequence data and wrote the first draft of the manuscript. GB conceived the study, designed the experiments, and collaborated to data analysis, and preparation and revision of the manuscript. JK and DE supervised the DNA barcoding work and revised the manuscript. ML devised the study, collaborated to the selection of plant materials and to the preparation of the manuscript. All authors read and approved the final manuscript.List of 164 grapevine entries with the common name of the cultivars along with the origin area, source of genetic germplasm and destination of the berry.Click here for fileProportions of membership to the four inferred clusters of each individual grapevine accession pre-attributed to different subgroups according to their geographical origin.Click here for fileNeighbour-Joining full tree based on Kimura 2-parameter including all 159 grapevine entries of Vitis vinifera, rooted using as outgroup the accessions from V. labrusca, V. cinerea, V. berlandieri, V. rupestris and V. riparia species.Click here for fileSingle nucleotide polymorphisms (107 CAs) identified in the five target nuclear regions with information on the composition of genotypes found across all grapevine (Vitis spp.) entries.Click here for file


Angioleiomyoma is a benign soft-tissue tumor originating from vascular smooth muscle, and is rare in the head and neck. The present study retrospectively examined a cohort of patients with head and neck angioleiomyoma treated at the West China Hospital of Stomatology, and also subjected archived tissues to modern immunohistochemical analysis. In total, 21 patients were treated for angioleiomyoma between 1978 and 2012 at the West China Hospital of Stomatology, Sichuan University . Medical records were examined and paraffin block sections were cut and stained with hematoxylin and eosin, Masson’s trichrome stain and Van Gieson stain, prior to being subjected to immunohistochemical analysis to re-evaluate and confirm the diagnoses. Angioleiomyomas were found to account for only 0.18% of the benign head and neck tumors in the patients presenting to the hospital over the past 34 years. The diagnosis was more common in males  and the mean age at diagnosis was 42.5 years. The most common sites were the buccal mucosa, parotid gland and palate. More than half of the tumors (61.9%) were >2 cm in diameter. Five tumors presented with pain and/or tenderness. The histological subtype was reported as solid in five cases, venous in six, cavernous in nine and venous-cavernous in one. Three tumors exhibited nerve neurofibrils. All tumors were excised with no subsequent recurrence. Cytological and imaging examinations were not useful for pre-operative diagnosis. Angioleiomyoma is a benign tumor that causes limited morbidity. Surgical excision is the only effective treatment and recurrence is rare. The present study revealed that nerves were present in a small proportion (14.3%) of tumors. It was hypothesized that the compression of nerves accompanying numerous blood vessels in the tumor may cause pain, particularly in venous- and cavernous-type angioleiomyomas. Angioleiomyoma, also termed vascular or dermal angiomyoma, is an uncommon benign soft tissue tumor –3, comprAngioleiomyomas comprise vascular endothelial and smooth muscle cells ,10. MoriThe present study retrospectively examined the clinical features, characteristics and management of all head and neck angioleiomyomas that were treated between 1978 and 2012 at the West China Hospital of Stomatology, Sichuan University . Where possible, archived tissue was subjected to modern immunohistochemical diagnostic techniques.Patient records and analysis. In total, 21 patients have been diagnosed with angioleiomyoma at the West China Hospital of Stomatology over the past 34 years. The records of these patients were examined and recorded, including data on age, gender, presenting symptoms and their duration, clinical features, investigations and method of diagnosis, tumor location and size, original diagnosis and Morimoto’s pathological classification, and subsequent management and surveillance . ArchiveThe patients diagnosed with angioleiomyomas accounted for 0.18%  of all benign head and neck tumors, 0.17%  of all benign salivary gland tumors and 91.3% (21 out of 23) of all leiomyomas during the 34-year study period.The clinical characteristics of the present cohort and details of the disease are shown in Fine-needle aspiration (FNA) was undertaken in five patients, and revealed blood and cast-off cells, indicating the presence of hemangiomas. Enhanced computed tomography (ECT) of the head and neck was performed in three cases and Doppler ultrasonography in seven. An example of an ECT image is shown in All patients underwent excision of the tumor. Those with tumors in the parotid gland also underwent parotidectomy. Intraoperatively, the tumors were found to be well circumscribed. One tumor had a partial capsule, however, the remainder had complete capsules. Their cut surfaces were gray-white, brown or dark red. The follow-up duration was 6–81 months, during which, no local recurrences were observed .Microscopically, the lesions consisted of a proliferation of smooth muscle cells and numerous blood vessels of varying size that were surrounded by smooth muscle bundles. The spindle-shaped cells were characterized by elongated, cigar-like nuclei and an eosinophilic cytoplasm. Smooth muscle bundles with collagen fibers exhibited an interlacing and swirling arrangement. The abundant blood vessels, with thin or thick walls and circular, slit-like or stellate lumens, were of varying size between tumors and in different areas of the same tumor. In certain cases, neoplastic cells were arranged around vessels that were lined with endothelial cells containing basophilic nuclei. Out of the 21 tumors, five were solid, six venous, nine cavernous and one venous-cavernous . It was Immunohistochemical analysis revealed that the spindle-shaped tumor cells were diffusely reactive to α-actin smooth muscle and vimentin, and focally reactive to desmin. Endothelial cells in tumor vessels stained positively for CD34. In three cases, a few small neurons that stained positively for S-100 were evident close to the capsule (two cases) or interstitium  A larger group of extremity tumors that are frequently painful and predominantly of the solid type; and ii) a smaller group of painless tumors on the head that are predominantly 75%) of the venous type 5% of the,23. One ofibrils . The preThe pre-operative diagnosis of head and neck angioleiomyomas is challenging . FNA and− and S-100−), myofibroma  and myopericytoma  , certain benign mesenchymal tumors , pleomorphic adenomas and cysts ,3,9. Hisd S100−) . It is pd S100−) . Angioled S100−) . Immunohd S100−) . A strenIn the present study, one patient had undergone laser therapy at a local hospital prior to referral, however, the tumor recurred one year later. In accordance with the literature, the present study concluded that surgical resection along the tumor capsule is the most effective treatment for all head and neck angioleiomyomas ,9,13, asIn conclusion, it is extremely rare for an angioleiomyoma to present in the head or neck; such cases comprised only 0.18% of the cases at the West China Hospital of Stomatology, a specialist institution, over 34 years. The diagnosis could only be made pre-operatively if a biopsy was undertaken; pre-operative cytological and imaging investigations were not fruitful in any of the cases. At present, surgical excision is the only effective treatment and recurrence is rare. In the present study, three tumors that contained neurofibrils were identified. Angioleiomyoma is a benign tumor and surgery is almost always curative, and although it is rare in the head and neck, it is important to recognize that it can only be reliably diagnosed prior to surgery by biopsy.


Because consequences of pediatric overweight and obesity are largely psychosocial, the aim of this study was to describe health related quality of life (HRQoL), the prevalence of overweight and obesity, and to examine the relationships between HRQoL and body mass index (BMI), age, and gender in a Norwegian sample of schoolchildren. In addition, because children are dependent upon their parents’ judgment of their condition, the aim was also to compare child- and parent-reported HRQoL and BMI, age, and gender.This cross-sectional study involved 1238 children (8–18 years) and 828 parents. HRQoL was measured with the Norwegian version of the KIDSCREEN-52, child and parent version. Child BMI was calculated based on objective measures of height and weight, and adjusted for age and gender. Multiple regressions were used to determine how variations in BMI, age, and gender affected child- and parent-reported HRQoL.HRQoL decreased significantly with age and girls had lower HRQoL than boys on the majority of the KIDSCREEN subscales. Of the total sample, approximately 16% were overweight and 3% were obese. BMI contributed significantly to explaining the variations in the KIDSCREEN subscales of Physical well-being and Self-perception. Higher BMI was associated with lower HRQoL scores. Although there were significant differences between child and parent ratings on most KIDSCREEN subscales, the direction of the differences varied. In some scales, parents rated their child’s HRQoL higher than the child, and in some scales lower. Increasing age of the child seems to increase the differences, while gender and the child being overweight and/or obese affected the differences to a smaller extent.This study showed that almost 20% of the children and adolescents in a representative Norwegian school sample were overweight or obese. Age and gender were the most significant factors associated with variations in HRQoL in the sample; however, increasing BMI added to the negative effect of other factors. The study also found substantial differences between the child and parent ratings of the child’s HRQoL. Misinterpretations of the child’s well-being might result in less targeted actions to improve the child’s HRQoL. Overweight and obesity are a serious public health problem, associated with various impairments and medical disorders -3. The pBecause consequences of pediatric obesity are largely psychosocial, the exploration of health related quality of life (HRQoL) seems relevant to understanding the effect of overweight and obesity on children and adolescents. HRQoL is generally conceptualized as a multidimensional construct that includes the individuals’ subjective perspective on physical, psychological, social, and functional aspects of health . The mulEmerging research suggests that treatment-seeking populations of overweight children have poorer quality of life than overweight children in community samples ,24. KnowTo describe HRQoL and the prevalence of overweight and obesity.To examine the relationship between HRQoL and overweight/obesity, gender, and age.To examine the relationship between child- and parent-reported HRQoL and overweight/obesity, gender, and age.The aims of this study in a representative school sample of children (8–18 years) in Eastern Norway were as follows.In addition, the psychometric properties of the parent version of the Norwegian KIDSCREEN-52 were evaluated.A cross-sectional study was conducted in an eastern region of Norway with about 1.7 million inhabitants , and a child population (8–18 years) of about 230,000. The sampling was planned and conducted in cooperation with Statistics Norway. First, all schools in the region were stratified according to population density, school size, and school level. We randomly selected two schools from each stratum, and non-responding schools were replaced by schools selected according to the same criteria. From the cluster sample of 20 schools, we selected classes that covered grades 3, 5, 7, and 9 in elementary schools, and grades 1 and 3 in secondary schools. We invited the children and adolescents to participate after their schools agreed to be part of the study. We recruited 1675 children and adolescents aged 8–18 years, and gave them and their teachers standard verbal and written information about the study one week before they participated. A signed informed consent was obtained from the parents, and a signed written informed assent was taken from the eligible children. Students completed the self-report instruments in their classrooms during school hours, and the investigator and the teacher were present to provide assistance when needed. For the grade 3 elementary schoolchildren, the investigator read the questionnaire aloud to the class. Those who were absent from school on the day of the study were not included. Of the 1675 eligible children and adolescents, 258 (15%) did not provide written permission from their parents, 148 (9%) were absent from school on the day of the study, and 31 (2%) did not want to participate. Hence, 1238 children and adolescents participated, for an overall response rate of 74%. The response rate varied across schools from 55% to 96%. In addition, 828 parents (67% of the responding children) answered the questionnaires. The study was reviewed and approved by the Regional Research Ethics Committee of Norway.The first part of the questionnaire recorded demographic details of nationality, gender, date of birth, cohabitant status, parental marital status, and school year. The parental marital status was dichotomized as two parents (married or cohabiting) or single parent .The Norwegian version of the KIDSCREEN-52 was used to measure HRQoL. The KIDSCREEN questionnaire is a generic HRQoL instrument based on a multidimensional HRQoL construct . The queBMI was calculated for each individual by dividing their weight in kilograms by their height in square meters. Age- and gender-specific BMI cut-off values, proposed by the International Obesity Task Force, were used to categorize the adolescents as overweight or obese . BMI < 2The analyses were conducted using SPSS (20.0) and AMOS (20.0). Descriptive statistics for the variables of BMI, age, gender, and HRQoL are presented as means and SDs or as frequencies and percentages. Pearson’s correlations were calculated to examine the relationships between each of the 10 KIDSCREEN scales (child-reported) and the independent variables. After examining the bivariate relationships and considering whether schools differed on the dependent variable and whether clustering should therefore be taken into account, multiple regressions were used to determine how variations in BMI, age, and gender affected child-reported HRQoL. Finally, the data from the parent reports and the corresponding child reports were merged; with the differences between child and parent reports on each of the KIDSCREEN scales put into the models as the dependent variable, and regression was performed to detect differences in how parents and children report on children’s HRQoL when BMI, age, and gender vary.2), adjusted goodness-of-fit index (AGFI), Tucker–Lewis index (TLI), comparative fit index (CFI), and the root mean square error of approximation (RMSEA). Acceptable goodness of fit was defined as [2 (sensitive to sample size); AGFI > 0.90 (acceptable) ≥ 0.98 (good); TLI > 0.90 (acceptable), ≥ 0.95 (good); CFI > 0.90 (acceptable) ≥ 0.95 (good); RMSEA < 0.05 (close fit) ≤ 0.08 (fair).Mean, standard deviations, measures of skewness and kurtosis, and floor and ceiling effects were calculated for each scale of the KIDSCREEN-52 proxy version. Reliablity is expressed by Cronbach’s alpha and was computed for the 10 KIDSCREEN scales. Alpha coefficient of .70 or above was considered acceptable. To test how well the KIDSCREEN-52 proxy version fit the data, confirmatory factor analysis (CFA) was conducted, using structural equation modeling (SEM) analysis. CFA models were tested for each of the 10 scales and for the complete KIDSCREEN measure using the sums of each scale. The latter analysis was conducted with sum indicators for all ten scales and for the first nine scales (excluding bullying). CFA provides goodness-of-fit tests and allows alternative models to be tested. Acceptable goodness-of-fit values indicate the construct validity of a model, and the literature contains various recommendations about the type, number, and cutoff values for goodness of fit that are required to be reported. The following goodness-of-fit indices were used in this study: chi-square  and overweight and obese (BMI ≥ 25). As shown in Table 5 and oveTo examine further how BMI, age, and gender were associated with HRQoL, multiple linear regression analyses were performed with each KIDSCREEN subscale as dependent variables. Multilevel analysis was considered because data were collected at schools. However, we decided to use linear regression of three reasons. First, the grouping was weak for eight scales (.01 < ICC < .10) and only moderate for two of the scales (ICC ≥ .16). Second, the level 1 variables explained only a small amount of level 1 (1% to 9%), but a large part (52% to 91%) of the level 2 variance. This is because class and age are highly collinear and therefore a bit misleading. Third, our focus was on explained variance of HRQoL, and not on variation of regression coefficients.2 and the unique contributions of each of the independent variables. In model 1, R2 varied between 0.011 and 0.228, meaning that gender and age accounted for 1–23% of the variance in the KIDSCREEN subscales. Age made the biggest contribution in all subscales. However, it is noticeable that gender explained 8% of the variance in the Self-perception subscale, which was the largest contribution of gender in this model. Adding interaction between gender and age increased the explained variance significantly, but to a small extent, in the subscales of Physical well-being, Mood, Self-perception, and Autonomy. Adding BMI resulted in negligible changes in the explained variance. However, BMI contributed significantly but weakly to explaining variations in the subscales of Physical well-being and Self-perception.The independent variables were entered stepwise into the model: gender, age, interaction between gender and age, and finally, BMI. Table 2 was significant for all scales except Self-perception and Parent relations. This may be because of the relatively large sample.Reliability of the subscales in the parent version of the KIDSCREEN-52 was confirmed by acceptable levels of Cronbach’s alpha for all scales Table . Table 3To assess how parents rated their child’s HRQoL in relation to the child’s own estimates, parent proxy reports were compared with the children’s reports and the mean differences between them were calculated. Complete data on parent–child pairs were found for 639 cases. Each KIDSCREEN scale with more than three items were examined for measurement invariance. The measurement differences between parents and children were consistently small enough to compare parents and children. Overall, there are substantial significant differences between parents and children in most KIDSCREEN subscales Table . HoweverConsistent with previous findings ,39, HRQoNationwide data on BMI across age groups during childhood in Norway were not available. However, the Norwegian Growth Study (representative nationwide data on 8-year-old children) , the BerBMI was not found to be a strong explanatory factor for variations in HRQoL in this study. However, findings from other studies are confirmed, with an inverse relationship between BMI and HRQoL in the subscales of Physical well-being and Self-perception ,19,24. TThe Norwegian parent proxy version of the KIDSCREEN-52, used here to study the effect of age, gender, and BMI on differences in parent–child reports on HRQoL, appears to be a valid and reliable measure, supporting the findings of a number of studies . In the This study showed that almost 20% of the children and adolescents in a representative Norwegian school sample were overweight or obese. Age and gender were the most significant factors to consider regarding variations in HRQoL; however, increasing BMI added to the negative effect of other factors, and thus must be taken seriously when children’s HRQoL is evaluated. The study also shows that there are substantial differences between the ratings of children and parents of the children’s HRQoL. Misinterpretations of children’s well-being might result in less targeted actions to improve children’s HRQoL.


Sudden sensorineural hearing-loss (SSNHL) patients constitute approximately 2–3% of referrals to ear, nose and throat (ENT) clinics. Several predisposing factors have been proposed for this condition; one of which is vascular disorders and perfusion compromise. In this research the atherosclerotic changes and their known risk factors are studied in SSNHL patients.Thirty SSNHL patients and 30 controls were evaluated with regard to cardiovascular risks including history, heart examination, blood pressure, body mass index, waist circumference, electrocardiogram, blood sugar, triglycerides, cholesterol, high-sensitivity C-reactive protein (HSCRP); also, carotid artery color Doppler study was undertaken to measure intima media thickness(IMT).IMT and HSCRP showed an increased risk in the case group compared with the controls (P= 0.005 & P=0.001). However, waist circumference, history of smoking, fasting blood sugar, lipid profile, and electrocardiogram revealed no significant difference between the two groups. Interestingly, blood pressure and body mass index were higher in the controls in this study.Sudden sensorineural hearing loss may be associated with subclinical atherosclerosis. Sudden sensorineural hearing loss (SSNHL) is defined as loss of hearing of over 30 dB in three sequential frequencies occurring within 3 days ,2. The a Different mechanisms are thought to lead to this condition including viral infections, vascular obstruction, autoimmunity, and rupture of the endocochlear membranes -7. In 10On the other hand, there are some known risk factors for atherosclerosis including age, gender, obesity, blood pressure, lipid profile, high-sensitivity C-reactive protein (HSCRP), and smoking -12. Atherosclerotic changes in the carotid artery are also an important indicator of risk of stroke or myocardial infarction (MI).Because vascular factors have been proposed to be a possible underlying mechanism of this condition, we examined atherosclerosis risk factors in SSNHL patients in this study. In this cross-sectional study, patients with sudden sensorineural hearing loss admitted at Ghaem Hospital, a tertiary teaching medical center, between September 2011 and September 2012 were selected. These patients were visited in the otolaryngology clinics because of their hearing loss within the first three days of the beginning of their symptoms. The control group did not suffer from any known cardiovascular or neurological conditions or hearing problems. They were selected from a large healthy community and underwent a thorough history, physical examination and doppler exam of upper neck on an outpatient basis. They were matched in terms of age, gender, and residence (the area they lived) on a person-to-person basis. All patients went through a comprehensive evaluation for possible etiologies such as brain tumors and infectious diseases as well as rheumatologic, autoimmune, traumatic and hematologic causes; and those with known etiologies  were excluded from the study. All those in the study and the control groups were taken complete history (including smoking history by pack years unit), beside examination from the point of clinical as well as microscopic evaluation by an ear, nose, and throat (ENT) specialist, and also underwent audiometry. Then, they were examined by a cardiologist and underwent a history and physical examination including body mass index (BMI), waist circumference and blood pressure assessment . Hypertension defined by blood pressure more than 140/90 mmHg. An electrocardiogram (ECG) was also performed.Next, all cases and controls were examined by a neurologist and given doppler sonography of the upper neck blood vessels, using a Medison instrument (SONOACE 8000 EX). In order to measure the intima media thickness (IMT), proper magnification on the carotid artery wall was first obtained; then, in the area of the carotid bifurcation between the distal part of the common carotid artery and the proximal part of the internal carotid, IMT was measured on both sides using an automated measurement mode.Serum tests, including high-density lipoprotein (HDL), low-density lipoprotein (LDL), total cholesterol, triglycerides (TG), fasting blood sugar (FBS), and high-sensitivity C-reactive protein (HSCRP) were performed on all patients, just when they were admitted(before initiation of the medications such as corticosteroid)and the controls.Statistical analysisAll results were analyzed using SPSS, Absolute numbers and percentages were computed to describe data. Data were expressed as mean ± SD for continuous variables Categorical variables were compared between two groups using the chi square test and the mean of two independent groups were compared using Independent T test. For adjusting the confounders, variables were entered into the binary logistic regression model and OR (Odds Ratio) with 95% confidence intervals (CI) calculated. A P-value less than 0.05 were considered as statistically significant.This study was approved by the Ethics Committee of Mashhad University of Medical Sciences.This study was performed in 30 patients suffering from SSNHL compared with 30 non-SSNHL controls. The mean age of the study group was 45±12.7 years . There were 15 male and 15 female patients. The control group consisted of 13 men and 17 women with a mean age of 45±11.8 years. Sixteen (53.3%) patients had a right-ear involvement and 14 (46.7%) a left-ear involvement. There was no significant difference between the study and the control groups in terms of age (P= 0.29) and gender (P=0.29).The average speech reception threshold in the case group (the worse ear) was 86.17Mean BMI was 25.32 ± 4.4 in the case group and 26.49 ±4.9 in the controls, which were not significantly different (P = 0.40); but there was no significant difference in terms of waist circumference. Smoking frequency was 16.7% in the study group and 10% in the control group, which showed no statistically significant difference (P=0.93). Hypertension was seen in 7.16% of the study group and 40% of the control group, which was a statistically significant difference (P= 0.045). Mean HSCRP levels were markedly higher in the study group than in the control group, and blood sugar and lipid levels, although higher in the study group than in the control group, showed no statistically significant difference .The results of the Doppler study showed that the mean IMT in the right carotid bulb, the right internal carotid, and the left internal carotid  were significantly higher in the study group than in the control group .After adjusting hypertension as a confounding factor among two groups by logistic regression analysis we found that increases in the IMT in Bulb-R., ICA-R, ICA-L and bulb-L are the independent risk factors for sudden hearing loss.We also considered the cutoff point of 0.6 mm for intima thickness to compare cases and controls. After hypertension as a confounding factor was entered into the model separately for each location , only the odds ratio for IMT more than 0.6 mm in the right carotid bulb was statistically significant . Cardiovascular and neurological physical examinations in all the subjects were normal, while ECGs showed old ischemic changes in two individuals (one in each group). SSNHL is one of the most important ENT conditions, manifesting itself as sudden loss of hearing, sometimes with vertigo and tinnitus. SSNHL patients tend to range across all age groups. Various background factors seem to play an etiopathogenic role, including viral, vascular, and immunologic etiologies, but as the actual cause is hard to identify in most cases, the condition is considered idiopathic. Due to Although when it is treated quickly, there is probably a good chance of some recovery, there is a need for further investigation into the pathogenesis of this condition in view of its morbidity. Several possible hypotheses have been suggested to explain the vascular involvement, including sudden nature of the onset of the disease ; histopathological changes due to vascular obstruction ; the facOn the other hand, atherosclerosis is a pathologic condition based on inflammatory vascular changes throughout the body. There are several traditional risk factors like diabetes mellitus, hypertension, smoking and dyslipidemia that cause atherosclerosis. Some predisposing factors like aging and family history of premature coronary artery diseases (CAD) may accelerate these changes. Based on paraclinical data, HSCRP is a known predictor of atherosclerosis and acute coronary events. The intima media thickness (IMT) is also a helpful marker based on carotid intimal thickness to predict atherosclerotic changes throughout the body. Quantitative assessment of atherosclerosis was performed by Eugene in the early 1980s. Pignoli This technique provides information about atherosclerotic changes which cannot be obtained through angiography or MRI. B-Mode sonography has shown that an increase in IMT directly correlates with risk of MI and stroke, especially in older patients without a history of cardiovascular conditions .IMT measurements at different sites of the carotid arteries have been performed in different groups, and have shown that the common carotid artery IMT (CCA IMT) is a good predictor of stroke, and that the internal carotid artery IMT (ICA IMT) is a good predictor of MI. EpidemiIn view of the mean IMT in this study group, which differed significantly from that of the control group, atherosclerosis may be considered an important factor in these patients; however, IMT values were lower than the risk threshold of 1 mm. On the other hand, as atherosclerosis is a whole-body phenomenon, changes of as little as 0.1 mm in small vessels such as the labyrinthine artery (which is only 0.5 mm in diameter) can deleteriously influence the blood flow . Also, ACiccone et al studied flow-mediated dilation (FMD) of the brachial artery, which is an early index of subclinical atherosclerosis, and found it to be significantly lower in patients experiencing sudden deafness; in their study IMT values of carotid artery were also within the normal range .Inflammatory biomarkers are believed to have important role in the pathophysiology of SSNHL. Recent The American Heart Association and the US Centers for Disease Control and Prevention have recently offered a strategy for the practical use of CRP; CRP levels of less than 1 mg/l indicate low cardiovascular risk, 1–3 mg/l moderate risk and over 3 mg/l high risk ,24. In crandomly chosen individuals, rather biased toward the atherosclerosis risk factors. And this was due to the limitation of doing upper neck doppler exam in all the controls. This selection bias accounts for the high prevalence of hypertension in the controls. However, the results in a non-biased control group are expected to emphasize our findings more markedly. Considering the role of inflammation in atherosclerosis, the authors believe the pathophysiology of SSNHL may be closely connected to the vascular background of the inner ear; this impression certainly needs further investigations to clarify the details of this relationship.In the end the authors would like to emphasize that, as mentioned in the methodology section, the controls of this study were not truly There are several pieces of evidence indicating that vascular atherosclerotic changes may be important in the pathophysiology of SSNHL, at least in a number of patients. HSCRP and IMT are the new findings proposed in this paper.


Introduction. Medial temporal lobe atrophy assessment via magnetic resonance imaging (MRI) has been proposed in recent criteria as an in vivo diagnostic biomarker of Alzheimer's disease (AD). However, practical application of these criteria in a clinical setting will require automated MRI analysis techniques. To this end, we wished to validate our automated, high-dimensional morphometry technique to the hypothetical prediction of future clinical status from baseline data in a cohort of subjects in a large, multicentric setting, compared to currently known clinical status for these subjects. Materials and Methods. The study group consisted of 214 controls, 371 mild cognitive impairment (147 having progressed to probable AD and 224 stable), and 181 probable AD from the Alzheimer's Disease Neuroimaging Initiative, with data acquired on 58 different 1.5 T scanners. We measured the sensitivity and specificity of our technique in a hierarchical fashion, first testing the effect of intensity standardization, then between different volumes of interest, and finally its generalizability for a large, multicentric cohort. Results. We obtained 73.2% prediction accuracy with 79.5% sensitivity for the prediction of MCI progression to clinically probable AD. The positive predictive value was 81.6% for MCI progressing on average within 1.5 (0.3 s.d.) year. Conclusion. With high accuracy, the technique's ability to identify discriminant medial temporal lobe atrophy has been demonstrated in a large, multicentric environment. It is suitable as an aid for clinical diagnostic of AD. In vivo biomarkers of disease progression, both chemical and imaging, lie at the heart of these criteria.Early identification of patients most at risk of progression to dementia due to Alzheimer's disease (AD) remains a crucial clinical and research issue. To address this concern new criteria have been proposed to increase diagnostic certainty and better identify individuals in a prodromal state, mild cognitive impairment (MCI) due to AD –3. In viThe earliest AD-associated brain alterations, according to histopathological staging , occur iThe most validated procedure to estimate MTA relies on expert manual outlining  of individual or ensembles of structures on high resolution T1-weighted MRI, following an established set of anatomical landmarks . While mThere has been renewed enthusiasm recently over the performance of multi-atlas or template-based approaches for automated segmentation –16. OverOur methodology is set within this context. It incorporates local estimates of both tissue composition and deformation within a specific volume of interest (VOI) centered on the medial temporal lobes , providiClinical application of any one of these automated methodologies require that techniques maintain the same level of performance in a multicentric setting, where large interscanner variations become inevitable due to MRI physics , even thAn ideal dataset for this purpose is the Alzheimer's Disease Neuroimaging Initiative (ADNI) study . For theOur general objective is to assess the accuracy of our automated high-dimensional morphometry technique to the hypothetical prediction of future clinical status from MRI when examining previously acquired data in a cohort of MCI subjects from the large, multicentric ADNI dataset, compared to the currently known clinical status for these subjects, under various conditions.that intensity standardization and tissue classification improve the system's robustness and hence performance, in a multicentric setting;that a medial temporal lobe VOI is the best for the differentiation of CTRL from either probable AD or MCI progressing to probable AD, as opposed to whole-brain VOIs ;that the methodology remains highly accurate even with large, ostensibly heterogeneous datasets.Specifically, we will want to test the following hypotheses, which would need to hold true for any methodology:Proving or disproving these hypotheses would constitute significant contributions that could be further employed in other, similar research endeavors.http://www.adni-info.org/). The institutional review boards of all participating institutions approved the procedures for this study. Written informed consent was obtained from all participants or surrogates. More information about the ADNI investigators is given in Acknowledgment.Each participant from the ADNI cohort was formally evaluated using eligibility criteria that are described in detail elsewhere . The ADNI was launched in 2003 by the National Institute on Aging (NIA), the National Institute of Biomedical Imaging and Bioengineering (NIBIB), the Food and Drug Administration (FDA), private pharmaceutical companies, and nonprofit organizations, as a $60 million, 5-year public-private partnership. The primary goal of ADNI has been to test whether serial magnetic resonance imaging (MRI), positron emission tomography (PET), other biological markers, and clinical and neuropsychological assessment can be combined to measure the progression of mild cognitive impairment (MCI) and early Alzheimer's disease (AD). Determination of sensitive and specific markers of very early AD progression is intended to aid researchers and clinicians to develop new treatments and monitor their effectiveness, as well as lessening the time and cost of clinical trials. The principle investigator of this initiative is Michael W. Weiner, M.D., VA Medical Center and University of California, San Francisco. ADNI is the result of efforts of many coinvestigators from a broad range of academic institutions and private corporations, and subjects have been recruited from over 50 sites across the U.S. and Canada. The initial goal of ADNI was to recruit 800 adults, ages 55 to 90, to participate in the research—approximately 200 cognitively normal older individuals to be followed for 3 years, 400 people with MCI to be followed for 3 years, and 200 people with early AD to be followed for 2 years. For up-to-date information see http://www.adni-info.org/.) study were as follows:CTRL: MMSE scores  between MCI subjects: MMSE scores between 24 and 30 (inclusive), a memory complaint, have objective memory loss measured by education adjusted scores on Wechsler Memory Scale Logical Memory II , a CDR oMild AD: MMSE scores between 20 and 26 (inclusive), CDR of 0.5 or 1.0, and meets NINCDS/ADRDA criteria for probable AD .Inclusion criteria to the ADNI (Data used in the preparation of this article were obtained from the Alzheimer's Disease Neuroimaging Initiative (ADNI) database  long-term clinical assessment; and (d) no conversion (CTRL) or regression  in terms of final diagnostic.From the complete ADNI dataset of 822 subjects at baseline, we selected individuals for theeria cf. : (a) valIn fine, the Study Group was composed of 200 CTRL, 179 patients with Mild AD, and 381 MCI subjects  using a 3D T1-weighted MP-RAGE protocol or its equivalent [MRI data for alluivalent .http://www.bic.mni.mcgill.ca/) conversion; (b) raw scanner intensity inhomogeneity correction [3 isotropic grid; (g) intensity standardization and tissue classification  DICOM to MINC  noirrection ; (d) linrrection , maximizrrection ; (f) restion see  to the rThe reference image was an unbiased standard magnetic resonance imaging template brain volume for a young adult population, created using data from the ICBM project .We did not perform distortion correction, nor selected images corrected for distortion from the ADNI distribution website. We assessed—albeit visually—that our fully affine linear registration, centered on the medial temporal lobe, was sufficient to remove most of the effects.cf. The problem of multicentric acquisitions is to ensure that similar intensities will have analogous tissue meaning in the images across scanners. In this study we tested three intensity features: (i) T1-weighted intensities, scaled to match the mean level of the reference image . After global linear registration of the subject's image to the reference, a piecewise linear mapping function is computed based on the intensity correspondences obtained for each tissue, thereby implicitly binding histogram matching to tissue correspondence . The foThe GM probability maps were obtained by feeding intensity images to a neural network classifier , which pWe visually inspected and compared all standardized images and GM probability maps for quality control.Following the conclusions of Pelaez-Coca et al. , we test Study Group, in effect testing for generalizability. Further, to benchmark our technique with the literature, we used the Comparison Group, in effect the same subjects used in the Cuingnet study [All of the previous tests were done using the completeet study   image intensities within the VOI as a proxy of local tissue composition and (ii) image determinants as a proxy of local tissue differences. We then expressed the Training Group data as coordinates in the new principal components space, and we assessed normality of the univariate distributions of coordinates along any principal component via Shapiro-Wilk statistics and rejected nonnormal distributions.Next, we generated from the Training Group for the classification task at hand . To complete the analysis, we projected the Testing Group in the same principal components space, and used the discrimination function to obtain independent assessment of the system's accuracy. To ensure we did not have a particular bias related to random group assignments in the Study Group, we repeated the random assignment process ten times.We used support vector machines with a linear kernel to select the discriminatory variables from the projected data forming the best discriminating function in theWe performed modeling, statistical, and classification analyses using MATLAB .The reference standard for classification consisted of the latest, longitudinal clinical assessment available through ADNI. Study Group and within the cubic-shaped VOI.Testing first for robustness, using either the T1-weighted intensities (Step 2.5(d)), standardized T1-weighted intensities (Step  2.5(g)) or the GM probability maps following intensity standardization (Step  2.5(h)), in the Anatomical or Global VOIs, in the Study Group and with the best intensity feature obtained in the previous step.Testing next for spatial sensitivity, using either the cubic-shaped, Study Group and the Cuingnet Comparison Group, in the best VOI and with the best intensity feature obtained from previous steps.Testing finally for comparison, using both the ADNIWe tested our three hypotheses in a hierarchical fashion, namely, as follows.The final reported results are averaged over all trials for accuracy, sensitivity, and specificity. We further employed McNemar's test using exact binomial probability calculations to assess the significance of the difference between the two correlated proportions of the truth table .The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.The first phase of the ADNI study was closed for recruitment on October 23, 2008. Study Group  for each diagnostic subgroup are reported in We used principal components analysis to reduce the dimensionality of subjects' data to generate two linear variation models of image intensities and local volume differences as proxies of tissue composition and deformations. For both models, we retained features that explained 68% of the variance of the input data. Study Group was 77.9% (189/243), sensitivity 76.3% (90/118), and specificity 79.2% (99/125). By using McNemar's Test , the difference is not significant. Results for the discrimination of CTRL from MCI-P . Finally, results for the discrimination of MCI-P from MCI-NP .The best results were obtained with the GM probability maps see . In termom MCI-P  were 72.m MCI-NP  were 62.To test the influence of VOI, we retrained the system using GM probability maps and determinant information in each of the three VOIs. In each case we retained features that explained 68% of the variance of the input data.The best results in terms of accuracy for discrimination were obtained using the same cubic-shaped VOI as in  Study Group and averaged over 10-fold. For comparison and benchmarking purposes, we used the best technique from previous test and applied it to the Cuingnet Comparison Group, which was split only once in the same Training/Testing sets as their original article. Results show accuracy for discrimination of CTRL from probable AD of 78.7% (107/136), sensitivity 72.5% (50/69), and specificity 85.1% (57/67) . Results for the discrimination of CTRL from MCI-P were 59.4% (60/101), sensitivity 82.4% (28/34), and specificity 47.8% (32/67) . Finally, discrimination of MCI-P from MCI-NP were 66.0% (64/97), sensitivity 2.94% (1/34), and specificity 100% (63/63) .All of the previous results were obtained with the more inclusive (57/67) . These r (32/67) . McNemar (63/63) . McNemarWe wished to assess the ability of our T1-weighted MRI classification technique to the retrospective, cross-sectional prediction of future clinical status in a cohort of subjects within the large, multi-centric ADNI cohort, under various conditions.Our technique achieved a high level of performance for the discrimination of probable AD from CTRL, achieving 79% accuracy on a comparative, benchmarked cohort, and 78% in a nearly twice-larger dataset. These results are statistically comparable to the clinical diagnostic (as per McNemar's test) and thus support the use of machine-learning techniques such as ours as biomarkers of medial temporal lobe atrophy within expanded criteria for the diagnostic of probable AD, such as proposed by McKhann et al. . The tecWe explored in A number of previous reports have explored the topic of MR-based classification and prediction , 24–26. Our results are in line with this previous literature but are best compared to studies using similar datasets. Therefore, the benchmarking study by Cuingnet et al.  is especA substantial limitation of this study and, so far for all studies based on the ADNI dataset, remains the lack of histopathological confirmation for AD cases and MCI progression. Even though the longitudinal followup duration was substantial, our results do not equate perfectly with predicting AD, as the clinical assessment is not inherently 100% accurate. The length of followup is also expected to bias the results as more MCI subjects are expected to progress to clinically probable AD.It should also be noted that we used a reference image created from the ICBM project. The choice of a reference image has been shown for other techniques to have a significant outcome on final results. We have tested this hypothesis early on (results not shown) using various templates, including age-related templates and did not uncover appreciable differences for the discrimination tasks that we explored. However, this cannot be construed as a general rule, since the choice of template may influence other discrimination tasks and should therefore be verified each time.k-fold validation is one such well-known method. The unavoidable downside to this approach is that slightly different information is collected for each fold. Thus, in a strict statistical sense, it is likely that the results are an overestimation of the classification rate on generalized data.Finally, albeit the ADNI dataset is large, we must use machine-learning approaches to optimize training/testing, and Our results indicate that our completely automated technique is able to extract critical individualized diagnostic information from standardized MRI acquisitions, obtainable in a clinical setting.


Habitat fragmentation is one of the principal causes of biodiversity loss and hence understanding its impacts on community assembly and disassembly is an important topic in ecology. We studied the relationships between fragmentation and community assembly processes in the land-bridge island system of Thousand Island Lake in East China. We focused on the changes in species diversity and phylogenetic diversity that occurred between life stages of woody plants growing on these islands. The observed diversities were compared with the expected diversities from random null models to characterize assembly processes. Regression tree analysis was used to illustrate the relationships between island attributes and community assembly processes. We found that different assembly processes predominate in the seedlings-to-saplings life-stage transition (SS) vs. the saplings-to-trees transition (ST). Island area was the main attribute driving the assembly process in SS. In ST, island isolation was more important. Within a fragmented landscape, the factors driving community assembly processes were found to differ between life stage transitions. Environmental filtering had a strong effect on the seedlings-to-saplings life-stage transition. Habitat isolation and dispersal limitation influenced all plant life stages, but had a weaker effect on communities than area. These findings add to our understanding of the processes driving community assembly and species coexistence in the context of pervasive and widespread habitat loss and fragmentation. SI =ZD) of SD in saplings minus that in seedlings as:Dobs.sap and Dobs.see are the observed diversity indices of saplings and seedlings, respectively, and Dran.sap and Dran.see are the diversity indices derived from the random communities. Significance was based on one-tailed t-tests. We analyzed the shift of SD between trees and saplings using the same methods as for the shift between saplings and seedlings. Positive values of ZD indicate increasing standardized SD from the younger life stage to the older stage, corresponding to a species-level overdispersion assembly process. Conversely negative ZD values indicate a clustering assembly process.We used species richness (number of species) as the index of species diversity (SD). We evaluated if SD is shifting across the different plant life stages. Using the R package “vegan” , we compZD of PD was also calculated as described above for SD and negative and positive values reflect phylogenetic overdispersion and clustering, respectively. Spearman’s rank correlation was used to test the relationship between SD and PD.We used Faith’s PD to assess phylogenetic diversity (PD). Under this metric, PD is the sum of the phylogenetic branch lengths linking together all species present in the focal community ,50. We tAll the phylogenetic metrics were calculated by the R packages “picante” ,52.We used a hierarchical regression tree analysis to evaluate the effects of the island attributes linked to habitat fragmentation on the patterns of community assembly between the different life stages. As a non-parametric method, the regression tree is robust to many types of data such as nonlinear relationships and missing values . It is tThe densities of trees, saplings and seedlings were 1441, 13184 and 244 individuals per hectare, respectively, on the 29 study islands with a total area of 1258.7 ha . And theR = 0.98, P<0.001; Sapling: R = 0.99, P<0.001; Seedling: R = 0.90, P<0.001) by Spearman’s correlation analysis.Species diversity (SD) and phylogenetic diversity (PD) differed across the three life stages of plants on islands in TIL. As expected and in accord with previous studies –57, therZD) in SS decreased on all islands and mainland. However, the standardized SD in ST decreased on 4 islands and mainland, but increased on the other 25 islands. We also found that most plant communities (25 islands) exhibited opposing trends of SD in SS vs. ST comparisons  can work in parallel ,59, and et al. [On most of the TIL study islands, we found that the changes in SD and PD differed between SS and ST transitions . SD and et al.  even fouet al. –32. The et al.  and thatThe results of the regression tree analyses help to distinguish the contribution of environmental filtering and dispersal limitation on community assembly on these islands. Area loss is commonly thought to be the most significant factor affecting biodiversity and community assembly in fragmented landscape, and can in fact mask other effects linked to habitat fragmentation . The resIsolation also had an important effect by decreasing the connectivity of the fragmented landscape. In this study, isolation was the most important factor in the ST transition , but onlCompetition was the main mechanism driving the community assembly on the surrounding mainland. We speculate that the habitat quality of surrounding mainland was poor leading to intense competition for resources. Distinct from the assembly process on islands, plant community assembly on the mainland exhibited a monotonic process across life stages further suggesting that fragmentation changed the plant community assembly ,15,62,63Habitat fragmentation can change ecological patterns, processes, and interactions in plant communities ,32, inclS1 Table(XLSX)Click here for additional data file.S2 Table(DOCX)Click here for additional data file.S3 Table(DOCX)Click here for additional data file.


A farming environment confers strong protection against allergy development. We have previously shown that farming mothers consume more full-fat dairy than control mothers, who instead consume more low-fat dairy, margarine, and oils; margarine and oil intake was associated with increased risk of allergy development in their children.The aims of this study were to investigate the differences in diet between children in farming and control families at 1 year of age, to investigate the relation between the diets of the mothers and their children, and to relate the children's diet to allergy development.n=28) and from control families in the same rural area (n=37) was assessed by 24-h dietary recalls, followed by 24-h food diaries. Allergy was diagnosed by pediatricians at 3 years of age using strict predefined criteria.The diet of 1-year-old children from dairy farming families (Farm children had a higher intake of farm milk, whole cream, cholesterol, saturated fat, and fat in total and tended to eat more butter, while controls consumed more carbohydrates and poultry and tended to eat more margarine. Farm children also had higher intakes of homemade porridge/gruel, oily fish, and iodine. The intake of butter and whole milk in children and mothers correlated significantly in farm families but not in controls. A weak negative association was found between seafood intake and allergy development, while allergy was positively associated with the intake of pork as well as zinc in the control group; these intakes also correlated with each other.Consistent with mothers in farming families, the children consumed more full-fat dairy and saturated fat than did controls, but this could not be linked to the low risk of allergy in the farming group. Seafood intake might protect against allergy development, in accordance with earlier findings. The incidence of allergy has increased during the last decades in countries with a Western lifestyle. A reduced exposure to microbes has been proposed to explain the increase , 2, but Children who grow up on farms have considerably fewer allergies than those who grow up in the countryside, but not on a farm . ContactThe aim of this study was to investigate whether the diet at 1 year of age differed between children raised on small dairy farms and control children in rural non-farming families, and whether the children's diet resembled those of their mothers. A second aim was to examine the relation between the diet at 1 year of age and subsequent allergy development.The FARMFLORA birth cohort includes 65 children from the Skaraborg County in the Southwestern part of Sweden, 28 of whom are being raised on small family-owned dairy farms, while 37 are controls living in the same rural area but not on farms, all included in this study. The recruitment of the pregnant women took place at maternity clinics between September 2005 and May 2008. Children who were born within the span of gestational weeks 36–42 were included in the study. Written consent was obtained from both parents and the study was approved by the Regional Ethics Committee in Gothenburg (No. 363-05).At the age of 1 year 10–14 months), the parents of the children were asked to complete a 24-h dietary recall followed by a 24-h food diary of their children's diet. The 24-h recalls were performed unannounced and followed a pre-decided interview protocol based on the five-step multiple-pass method developed by the United States Department of Agriculture .No data of the children's weights were collected at 1 year of age. Instead, a reference weight of Swedish 1-year-old children (10.25 kg)  was usedAt the ages of 1.5 and 3 years, the children were examined by pediatricians to diagnose allergic rhinoconjuctivitis, asthma, and/or food allergies according to predefined protocols . AllergiOrthogonal Projections to Latent Structures with Discriminant Analysis (OPLS-DA)  was usedU test was used for the evaluation of differences in dietary intake between farmers and controls and healthy and allergic children. For categorical variables, a χ2-test or Fishers’ exact test was used. Correlations were made using Spearman's rho. Two-tailed P-values <0.05 were used as the limit of significance. The univariable analyses were performed using SPSS .Due to a non-normal distribution of variables, a non-parametric Mann–Whitney P≤0.2 in a univariable analysis of healthy versus allergic children.Logistic regression was used for multivariable analysis . Variables were included as covariates in adjusted models if n=28) and control (n=37) children are shown in Characteristics of farm . Of these, one child (in the farm group) received substantial amounts of breast milk at this age and consumed only 712 kJ per day from foods other than breast milk. The duration of exclusive breastfeeding tended to be longer in farm children compared to control children , although the duration of any breastfeeding did not differ .All 65 children had either the 24-h dietary recall and/or the 24-h food diary completed; 74% completed both the recall and diary, 14% completed only the dietary recall and 12% only the food diary, with no difference between farming and control families or between families with healthy or allergic children. The median energy intake of all children was 4,202 kJ from foods, excluding breast milk, and did not differ significantly between farm and control children or healthy and subsequently allergic children. The children had a median energy intake per body weight of 0.41 MJ/kg, which exceeded the current recommendations of 0.33 MJ/kg . Five faA broad variety of foods in the children's diets were reported. Food items consumed by less than 25% of the children were not included in the tables and figures; such items were olive oil, low-fat cream, lean fish, shellfish, game/lamb, nuts/seeds, peanuts, soft drinks, mashed potatoes from powder, muesli/granola, coconut milk, vegetable based milk, mushrooms, ketchup/chili sauce, whey cheese, and mayonnaise dressing.P<0.001), whole cream (P=0.02), oily fish (P=0.02), and homemade porridge/gruel (P=0.05) than did controls, while the latter group consumed more poultry , while controls tended to consume more margarine , cholesterol (P=0.02), the fatty acids 4:0–10:0 (P=0.01), 14:0 (P=0.02), 18:0 (P=0.02), saturated fatty acids in total (P=0.02), as well as the fatty acids 16:1 (P=0.01) and arachidonic acid (P=0.04) compared to controls, who instead consumed more carbohydrates , seafood , legumes , and charcuteries . When energy-adjusted intakes were analyzed, negative correlations were found also for butter , cheese , milk , pork , vegetables , and fruit .Further, the correlations between the absolute intake of iron and different foods in the children's diet were analyzed to evaluate the main contributors of iron to their diet. The children's intake of bought porridge was the only food item or food group that correlated positively with the children's iron intake  and lactation  and tended to correlate with the intake also during lactation , but not whole cream, during pregnancy and tended to correlate with the maternal intake of whole cream during lactation . The farm children's intake of margarine correlated with their mothers’ intake of margarine during lactation ; the intakes of oily fish did not correlate at all. In the control group, no significant correlations were found between the children's intake of full-fat milk and cream, butter, margarine, and oily fish and their mothers’ intake of these foods. Thus, the farming families were characterized by a common diet rich in full-fat dairy products, while no ‘family pattern’ could be detected in the control families.Our hypothesis was that the diets of the pregnant and lactating mother and child living on a farm resemble each other and differ from those of non-farming families. Correlations were made between the maternal and child intake of foods that differed significantly between farm and control families, either in the children's or the mothers’ diets. Absolute intakes of the children's diet were used for correlations to the maternal intakes, as they were previously reported as absolute values . The farP=0.02) and exclusive  breastfeeding was observed in the allergic group compared to the healthy group, although no significant differences were found for the rate of breastfeeding at 1 year of age . Significant differences in the diets of healthy and allergic children are displayed in P=0.02) and tended to eat less pork , while the lower intake of pork became significant . Similar results were obtained when energy-adjusted values were used in the calculation ; no correlation was found between seafood and the maternal intake of margarine and oils. Also, no correlations were found between pork and serum EPA or margarine and oil intake.One farm child (4%) and 10 control children (32%) were diagnosed as allergic by the age of 3 years . The allP=0.052; . Since o P=0.02; . Additio 9% vs. 1%, P=0.13We have previously shown that farm mothers in the FARMFLORA birth cohort consume more saturated fat and full-fat dairy products during pregnancy and lactation, while control mothers consume more margarine and oils . In thisDespite the farm mothers’ higher intake of full-fat milk during lactation observed in our previous study , we coulThe children's intake of nutrients did not differ substantially between farm and control children. The majority of the children had intakes of vitamin D, iodine, and selenium that were considerably lower than current recommendations  . AlthougThe intake of seafood at 1 year of age was negatively associated with being allergic at 3 years of age. The early intake of fish has previously been associated with protection against allergy development , 23, 24.In contrast to seafood, the intake of pork was positively associated with allergy development. No substantial decrease in the odds ratio for pork and allergy was observed when adjusted for potential covariates in logistic regression. One could suspect that the consumption of more pork may result in the consumption of less fish, but no correlations were found between the children's pork and fish intakes. However, the odds ratio for the association of pork intake and allergy was moderate (1.37), and there are no previous reports of pork consumption as a risk factor for allergy development; hence, the finding should be interpreted with caution. Further, the intake of zinc was higher in children who later developed allergy than in healthy children. Correlations were made in retrospect between pork intake and dietary zinc content, and we found that these were positively correlated. Hence, the association between pork and allergy may be mediated by zinc. However, although zinc has immunomodulatory properties and could play a role in allergy development, there are no previous reports of positive associations between zinc and allergy, to the best of our knowledge.The dietary pattern of a higher intake of full-fat dairy, including farm milk, which characterized the farm children in our study, was not related to allergy protection. However, unpasteurized milk has been associated with a lower risk of allergy in a number of studies , 12. In We could show a similar dietary pattern in farm children and their mothers, including more full-fat dairy, fat in total, and saturated fatty acids compared to control infants, who instead tended to consume more margarine; this pattern was, however, not linked to the protective effect on allergy development of growing up on a farm. However, the farm children consumed more oily fish, and a weak negative association between seafood intake and allergy development was found; the pork intake and zinc content of the diet were instead correlated with one another and were positively associated with the risk of allergy development in the control infants.


To investigate time-dependent predictors of institutionalization in old age using a longitudinal approach.In a representative survey of the German general population aged 75 years and older predictors of institutionalization were observed every 1.5 years over six waves. Conditional fixed-effects logistic regressions  were performed to estimate the effects of marital status, depression, dementia, and physical impairments  on the risk of admission to old-age home or nursing home. By exploiting the longitudinal data structure using panel econometric models, we were able to control for unobserved heterogeneity such as genetic predisposition and personality traits.The probability of institutionalization increased significantly with occurrence of widowhood, depression, dementia, as well as walking and hearing impairments. In particular, the occurrence of widowhood (OR = 78.3), dementia (OR = 154.1) and substantial mobility impairment (OR = 36.7) were strongly associated with institutionalization.Findings underline the strong influence of loss of spouse as well as dementia on institutionalization. This is relevant as the number of old people (a) living alone and (b) suffering from dementia is expected to increase rapidly in the next decades. Consequently, it is supposed that the demand for institutionalization among the elderly will increase considerably. Practitioners as well as policy makers should be aware of these upcoming challenges. As the Hence, in our study we analyzed time-dependent variables assumed to be relevant for institutionalization, such as deteriorations in walking performance or losing the spouse by death or divorce. Thus, we aimed at determining factors affecting the probability of transitions to NH or old-age homes in a longitudinal setting. In particular, we analysed in our main model how marital status, depression, dementia, and physical impairments  affect the probability of transitions to institutionalization. This knowledge is important in order to fully understand the causality leading to admission to NH or old age-home, respectively. This, in turn, may reveal new approaches for prevention or delay of institutionalizations which is essential as institutionalization can be viewed as a “last” and very expensive option.The ethics committees of the participating centers approved the study (reference numbers: 050/02 (University of Bonn), 2079 , 2817/2007 , 309/2007 , 2007-253E-MA , 713/02 ). The study was conducted according to the principles expressed in the Declaration of Helsinki. Written informed consent was obtained from all participants and/or from their respective guardian. Once a patient had been diagnosed with dementia, written informed consent was obtained from a proxy (e. g. spouse). Proxies provided, for example, information about basic activities of daily living of the subject if MMSE < 25.Data were derived from the German Study on Ageing, Cognition and Dementia in Primary Care Patients (AgeCoDe). This is a population based prospective cohort study. Individuals were recruited by General practitioners’ (GP) offices at six study centres  in Germany in 2003 and 2004 which is considered as baseline. Since then, patients as well as their proxies were interviewed by trained staff every 1.5 years (follow-up wave 5: 2011/2012). Individuals were included in the cohort if they fulfilled the following criteria at baseline: (i) age ≥75, (ii) absence of dementia and (iii) at least one contact with the GP during the last 12 months. Individuals were excluded if they met at least one of the following criteria: insufficient knowledge of the German language, consultations only via home visits, residence in a NH, severe illness the GP would deem fatal within 3 months, deafness, blindness, lack of ability to provide informed consent and not being a regular patient of the participating practice. Detailed information regarding the sampling frame were published elsewhere . The stuIn our analysis we draw on six waves , including 260 non-institutionalized individuals at baseline who were admitted to NH or old-age home sometime after baseline. Thereby, 41 individuals were admitted to NH or old-age home by the time of follow-up wave 1; wave 2: 47 individuals; wave 3: 56 individuals; wave 4: 50 individuals; wave 5: 66 individuals). Thus, we included solely individuals who were institutionalized sometime after baseline. We also included individuals with scores of 4/5 on the Global Deterioration Scale at baseline (n = 70) as transitions to NH or old age-home also occurred in these individuals. Among these 260 individuals, main reasons for lack of follow-up data were death (n = 71) and, to a markedly lesser extent, refused participation (n = 7).Institutionalization was defined as self-reported transition to a NH or an old-age home sometime after baseline. For individuals who died between two waves, proxy interviews were conducted with their relatives. In these interviews the last residence before death was reported.sociodemographic variables: sex, family status , age, the educational level according to the CASMIN classification which distinguishes between three levels  and havDepressive symptoms were assessed with the 15-item version of the Geriatric Depression Scale [on Scale . We dichmobility , hearing , and visual impairment  the impairments were categorized, in each case with “no impairment” as reference. The Global Deterioration Scale [dementia stage . This scale was dichotomized into dementia  and absence of dementia (otherwise). The proportion of missing values was negligible in all variables.According to the grade of on Scale  providesmorbidity score, i.e. the sum of severity ratings for conditions scored as present. This was done to account for the severity of the chronic conditions.Presence/absence of 28 chronic conditions was recorded by the GP in wave 2 upwards. Under the condition that a chronic condition was present, severity was rated by the GP on a 1 (mild) to 4 (severe) scale by the GP. We calculated a weighted count Social support (wave 2 and wave 4) was quantified using the 14-item short form of the questionnaire for social support (F-SozU K-14) designed by Fydrich et al. [h et al. . To accoPhysical and cognitive activities (wave 1 upwards) were captured by a measure adapted from a scale originally developed by Verghese et al. [e et al. . IndividFrailty (wave 4 upwards) was measured using the Clinical Frailty Scale (CSHA) [severity of dementia symptoms was assessed by the Clinical Dementia Rating (CDR) [e (CSHA) , rangingng (CDR)  (wave 3 ng (CDR)   [t score)  (baselint score)  (100 = bt score) ,27 that Conditional fixed-effects logistic regressions were used to estimate the effects of time dependent variables on institutionalization. Thus, we assume that the unobserved heterogeneity (e. g. genetic predisposition) is correlated with the explanatory variables. This leads standard random effects strategies to be inconsistent. In order to deal with heteroskedasticity and serial correlation, robust standard errors that cluster errors at the individual level were reported .To test whether fixed effects models are needed or the more efficient random effects regressions can be used instead, Hausman test was performed. It tests the null hypothesis that the coefficients estimated by the random effects estimator are the same as the coefficients estimated by the consistent fixed effects estimator. We strongly rejected the null hypothesis in each model. Consequently, fixed effects regressions are the model of choice.Since our main variables—marital status, depression, impairments in walking, hearing and vision and dementia—were measured in all waves, we thus used within-variations from all waves. Furthermore, we estimated several additional models to test the robustness of our findings. These models differ by adding predictors  or replacing variables  instead of Global Deterioration Scale). Moreover, the statistical analysis was repeated using a more strict definition of institutionalization, which excluded individuals with transitions from assisted living to NH or old-age home.The level of significance was set at p < .05. All statistical analyses were performed using Stata 13.1 .Since the baseline characteristics of institutionalized and non-institutionalized individuals with a different number of waves were compared elsewhere , we presWe ran separate regressions for women and men, and individuals with own children as well as childless individuals . Compared with total sample, findings were almost the same in women and in individuals with own children. Due to small sample size, findings in men and in childless individuals are hard to interpret.We checked the robustness (in terms of significance and effect sizes) of our variables of interest by comparing the main model  with altinstead of measures of dementia. Additionally, we estimated models with urinary and fecal incontinence (components of the Barthel Index). When the functional status  got worse, the risk of institutionalization rose significantly. However, when incontinence occurred, the risk did not increase in a significant way.All analyses were repeated with CDR or MMSE instead of Global Deterioration Scale. The effect of dementia on the risk of institutionalization was insensitive to the measure of dementia  used. Moreover, for reasons of collinearity we redid everything with functional impairment  Due to the extremely high OR for dementia see , we analMoreover, with a more strict classification of institutionalization where transitions from assisted living to NH or old-age home were not taken into account, we obtained virtually the same results. Even if we focus solely on incident dementia cases , findings almost remained the same. Altogether, findings of the additional models underlined the robustness of our main model.The risk of transitions to institutionalization increased sharply with transitions from marriage to widowhood. Moreover, the risk increased considerably with occurrence of dementia . As compared with the occurrence of dementia, it is noteworthy that the occurrence of mild cognitive impairment had a much lower impact on the risk of transitions to institutionalization. Additionally, the risk rose markedly with occurrence of walking and severe hearing impairments. Furthermore, the risk of institutionalization increased with the occurrence of severe depression in individuals.Overall, our findings based on time-dependent predictors extend previous studies that used a static set of baseline characteristics as predictors. More specifically, findings regarding functional impairment ,26,29–31Our findings regarding mobility impairments are in line with a previous study by von Bonsdorff et al. . Using aA previous study  has alsoThis is one of few longitudinal studies aimed at determining factors affecting admissions to NH or old age homes. In extension to Luppa et al. , the preConcerning the fact that our estimates might have been biased for reasons of panel attrition caused by time-dependent variables, we examined whether there were differences at baseline between individuals with complete follow-up data and individuals who dropped out sometime after baseline. The latter group was initially more severely cognitively  and functionally (IADL) impaired. Moreover, the latter group was older, more depressed, and had more impairments in walking, hearing and vision . This might lead to a downward bias.Despite the fact that model fit was decent, other factors may exist that affect the probability of admission to NH. Particularly, more research is needed to clarify the (long-term) role of social support and income. Moreover, future research is called for to disentangle the complex decision-making process regarding admissions to NH–from different perspectives.Some of these factors are inevitable in very old age, whereas other factors may be not. Therefore, our findings highlight the role of physical impairments for institutionalization. Addressing these issues in future research might open up new possibilities for delaying or preventing admission to NH in old age. This is very important as institutionalization is often seen as a “last” option.Furthermore, the role of marital status and the occurrence of dementia should be emphasized. This is crucial as (1) the number of old people living alone  and (2)