Attention deficit/hyperactivity disorder (ADHD) often presents as an impairing lifelong condition in adults; yet it is currently underdiagnosed and undertreated in many European countries. This analysis examines the characteristics of adult patients with ADHD in a European (EUR) and non-European (NE) patient population.N=2017; EUR, n=1217; NE, n=800) were examined. All patients who were enrolled were included in the baseline analyses.Baseline data from the open-label treatment period of a randomized trial of atomoxetine in adult patients with ADHD (p=.0049). Scores on the Conners’ Adult ADHD Rating Scale-Investigator Rated: Screening Version with adult ADHD prompts  were comparable. The adult ADHD Quality of Life-Life Outlook and Life Productivity domain scores were significantly different between groups (p≤.0004). The EuroQol-5 Dimension United Kingdom and United States population-based index scores and Health State score were comparable between groups.The demographics for patients in the EUR and NE groups were comparable. Patients in the EUR group had a somewhat lower percentage of prior exposure to psychostimulants compared with the NE group (32.7% vs. 38.9%, Adults with ADHD in Europe present similar demographics and baseline characteristics to those outside Europe and hence, study results outside Europe may be generalizable to patients in Europe.NCT00700427Clinicaltrials.gov,  Attention deficit/hyperactivity disorder (ADHD) is a neuropsychiatric disorder that begins in childhood. This disorder persists into adulthood in around one-third to two-thirds of children with ADHD -9. EpideAttention deficit/hyperactivity disorder remains a poorly understood disorder in adults and often presents as an impairing lifelong disorder currently underdiagnosed and undertreated in many European (EUR) countries ,15,16. IOne reason for underdiagnosis and undertreatment of ADHD in adults is that ADHD symptoms differ throughout the patient’s lifespan. Adult patients experience more subtle symptoms such as impairments in executive function , difficulties in relationships, poor motor vehicle driving skills, and psychiatric comorbidities including substance abuse disorders ,17,18. ATaking the differences in diagnosis and treatment of adult ADHD in many EUR regions into account, additional information on the characteristics of adult ADHD patients within Europe is needed ,19,21. TThe purpose of this analysis was to examine the characteristics of adult patients with ADHD in a large patient population in Europe as well as those outside Europe.N=2017; EUR, n=1217 [60%]; non-European [NE], n=800 [40%]). The majority (60%) of patients in the study were from Europe; of the remaining patients, the overwhelming majority (75%) were from the US. The numbers from other countries were relatively smaller and hence, we combined them with the US as non-European. Additionally, we carefully considered in which group to include Russia, which is considered part of Europe but is also part of Asia. However, since Russia is not part of the European Union, we chose not to include Russia in the EUR group. In addition, there were only 6 patients from Russia, so most likely the influence of Russian patients, overall, was limited. The NE group consisted of patients in the US (n=602), Canada (n=60), Mexico (n=53), Puerto Rico (n=52), Argentina (n=27) and Russia (n=6). The EUR group consisted of patients in Germany (n=434), Spain (n=153), Belgium (n=137), Sweden (n=112), Austria (n=109), Netherlands (n=71), France (n=65), Finland (n=52), Italy (n=32), Denmark (n=15), United Kingdom (UK) (n=27), Switzerland (n=7), and Portugal (n=3). Any excluded medications were tapered off and/or stopped during this study period.The subjects in this analysis included adults with ADHD who participated in a multicenter, multinational, randomized withdrawal trial of atomoxetine with 3 study periods: screening/washout, open-label acute treatment, and a randomized, double-blind, placebo-controlled withdrawal. Study Period I was a screening/washout period that consisted of a minimum of 3 days and a maximum of 28 days. Study Period II was a 12-week open-label treatment period (An informed consent document (ICD) approved by an Ethical Review Board or similar body was signed by the patient and/or representative deemed appropriate, according to local laws and regulations. Informed consent was obtained before any changes were made to the patient’s medical treatment plan for the purpose of study participation and before any study procedures were performed. The study was conducted in accordance with the Declaration of Helsinki and the applicable laws and regulations of the study countries and regions. The study is currently ongoing; the primary outcome of this trial will be reported upon study completion.Eligible patients were adults  with ADHD, as established by the Conners’ Adult ADHD Diagnostic Interview for Diagnostic and Statistical Manual of Mental Disorders Fourth Edition (DSM-IV) (CAADID), who had ADHD symptoms in childhood and scored ≥2 on at least 6 items of either the inattentive and/or hyperactive/impulsive core subscales of the Conners’ Adult ADHD Rating Scale (CAARS)-Investigator Rated: Screening Version (CAARS-Inv:SV). CAARS-Inv:SV is a 30-item scale containing 2 subscales (inattentive and hyperactive/impulsive) and the ADHD index . The inaThe CGI-ADHD-S is a single-item clinician rating of the clinician’s assessment of the overall severity of the patient’s ADHD in relation to the clinician’s total experience with ADHD patients. Severity is rated on a 7-point scale  . ClinicaAll raters were trained in administration of the CAADID and CAARS-Inv:SV with adult prompts via standard training procedures . Before Exclusion criteria stated that patients should be excluded from the study if they met the following criteria: Patients met full DSM-IV-Text Revision™ (DSM-IV-TR™) diagnostic criteria for any history of bipolar disorder, current major depression, a current anxiety disorder , or any history of a psychotic disorder. Additional exclusion criteria were as follows: Patients were currently using alcohol, drugs of abuse, or any prescribed or over-the-counter medication in a manner that the investigator considered indicative of chronic abuse or met DSM-IV-TR criteria for alcohol or other substance dependence.All patients who were enrolled in the open-label acute treatment period were included in this analysis of ADHD characteristics. Data at baseline were used in the current analysis.N=2017), some comparisons were too sensitive and detected unsubstantial differences. Hence, p-values were used as references only and standardized differences were used to determine clinical relevance as described below. Data on education level difference and family history were analyzed post hoc. The overall relationship of education level to prior stimulant use was assessed with a chi-square test, while Fisher’s exact test was used to test prior stimulant use for each individual level of education. The relationship of adult ADHD Quality of Life (AAQoL) scores to education level was assessed with analysis of variance (ANOVA). All tests were 2-sided and employed a significance level of 0.05. Statistical analyses were performed using SAS version 9.1.Continuous baseline patient characteristics were summarized by mean, median, standard deviation, minimum, and maximum. Categorical baseline characteristics were summarized as percentages. Statistical comparisons were conducted using t-tests for continuous data and Fisher’s exact test or a chi-square test for categorical data; however, due to a large sample size  Index, and AAQoL scores. The standardized differences between groups were calculated with the following formula: ([the mean for the EUR group] minus [the mean for the NE group]) divided by the pooled  standard deviation, thus mirroring the calculation of Cohen’s d . The stap<.0008). The CAARS-Inv:SV total score was significantly different (p<.0001), and it seemed to be due to the lower scores in Russia (mean=27.3) compared with North America (mean=39.6) and South America (mean=42.0). The CGI-ADHD-S analysis was not significantly different across regions (p=.0761) and neither was the AAQoL total score (p=.2662). Only CAARS-Inv:SV total score showed any potentially meaningful differences among North America, South America, and Russia, while all of the others did not; also, Russia’s sample was thought to be too small (N=6) to skew the NE data as a whole, justifying the grouping of these regions. In addition, Russia's sample (N=6) was too small to be a stand-alone region.Baseline demographics were first compared among North America (N=767), South America (N=27) and Russia (N=6) to ensure homogeneity within NE, and ensure that differences between NE regions did not skew data. Age, gender, and ADHD subtype were examined but were not statistically different across the sub-regions . The CAARS-Inv:SV total score, CGI-ADHD-S score, and AAQoL total score were compared among regions. All 3 CAARS scores  were examined and all were significant (p<.0001). Mean height was 173.8 cm for EUR patients and 171.7 cm for NE patients (p<.0001). Patients in the EUR group had a lower percentage of exposure to psychostimulants (32.7%) compared with patients in the NE group . The ADHD combined subtype comprised 71.7% of the EUR group and 77.9% of the NE group, while the inattentive subtype comprised 24.5% of the EUR group and 21.0% of the NE group (p=.0001). Family history of ADHD in the patient’s mother  or father  was reported to be of similar frequency in the EUR and NE groups. Family history of ADHD in siblings was greater in the NE group (18.3%) compared with the EUR group . Family history of ADHD in children was greater in the EUR group (25.3%) compared with the NE group .The demographics for patients in the EUR region and NE regions were compared Table . The meap<.0001). The CGI-ADHD-S score at baseline was severe , which suggests that the patients had significant impairment. When evaluated with standardized differences, the CGI-ADHD-S score was moderately different .The CAARS-Inv:SV ADHD index score was statistically significantly different between groups, as were the investigator-rated Hyperactivity-Impulsivity and Inattention subscale scores, and total ADHD symptom score Table . The scop≤.0004), with the NE group having a higher score on Life Outlook  and the EUR group having a higher score on Life Productivity, . Life Outlook and Life Productivity section scores were not clinically meaningfully different using standardized differences .The AAQoL total score was also comparable between groups . The AAQoL total score had a 0.8-point difference between groups ; the AAQoL total score and section score can range from 0 to 100. Psychological Health  and Relationships  section scores were not significantly different between the EUR and NE groups. The differences between EUR and NE groups on the Life Outlook and Life Productivity section scores were significantly different (p≤.0003), but the differences were very small between groups and not clinically meaningful when calculated with standardized differences  [p<.0001). When the standardized difference was examined (-0.253), the differences between groups on the EQ-5D UK and US population-based index scores were not clinically meaningful.The EQ-5D UK population-based index score and US population-based index score were statistically significantly different ( -0.143) . The HeaThere were some statistically significant differences between the EUR and NE groups in education (highest grade completed) Table . As compp=.411). Only some college and university education were significantly related to prior stimulant use. Patients who reported their highest education level as some college were more likely to report prior stimulant use . Prior stimulant use was reported in fewer patients with university education compared to no prior stimulant use .To determine if education level was the cause of the difference in prior stimulant use between EUR and NE, education level  was compared with respect to prior exposure to psychostimulants. Overall, prior stimulant use was not related to education level (p≤.001); however, both scores were affected by a few outliers. There was no substantial difference across education levels in any AAQoL measure.We further examined whether the difference in level of education as opposed to region was responsible for the differences between groups in AAQoL scores. The Life Outlook score and Life Productivity score were significantly different among education levels (p<.001) and generalized anxiety disorder , and current diagnosis of depressive disorder , dysthymic disorder , and social phobia .The summary of present and lifetime diagnosis of comorbid diseases at baseline is shown in Table N=2017) made finding statistically significant differences more likely, but many of these were small in absolute magnitude and were not clinically meaningful.This analysis of adults with ADHD was the first randomized clinical trial of this size analyzing patient characteristics across multiple countries. Results of these analyses of adults with ADHD in the EUR and NE regions indicate that the characteristics of adult patients with ADHD are comparable between the regions. There were some subtle differences, but further evaluation indicates consistency between the EUR and NE groups. The large sample size , but comparable with scores observed in previous US adult ADHD studies -32. The The AAQoL Life Outlook and Life Productivity section scores were statistically significantly different, but arguably of questionable clinical significance. The EQ-5D UK population-based index score, US population-based index score, and Health State score were statistically significantly different, but also arguably of questionable clinical significance.The NE group primarily included North American countries. Since it also included a small number of patients from Russia and Argentina, a sensitivity analysis was performed to test whether removal of Russian (n=6) and Argentinian (n=27) patient data from the NE data set would change the conclusions of the manuscript; results from this analysis confirmed that, if data from these 33 patients were removed from the NE data set, none of the conclusions would change. Therefore, we kept Russia and Argentina in the NE group to be complete.The major difference between the EUR and NE groups was prior exposure to psychostimulants. This difference may be due in part to differences in treatment in the EUR and NE regions. In some parts of Europe the use of stimulants to treat adults with ADHD has been controversial and stimulants are not approved for use in adults with ADHD . The 200Current and lifetime diagnoses of comorbid diseases at baseline were comparable. This may be due in part to the exclusion criteria, which stated that patients should be excluded from the study if they met the criteria for several comorbid conditions. Childhood and adulthood diagnoses of ADHD were also comparable across regions. This could be due in part to the inclusion criteria stating that, to be eligible for the study, patients must meet DSM-IV-TR criteria for current ADHD and for a historical diagnosis of ADHD during childhood, as assessed by the CAADID.The findings of these analyses on baseline characteristics of the adult ADHD patient in the EUR and NE regions were similar to the conclusion of the previous analyses on the characteristics of children and adolescents with ADHD outside North America ,35. In PN=2017), some comparisons between groups were statistically significant despite the absolute differences being small and not clinically meaningful; hence, p-values were used as references only, and interpretation of data was based on the magnitude of the findings rather than the p-value. Finally, this study did not look at treatment effects. Despite the limitations of this study, this analysis serves to help define/clarify who the adult ADHD patient is not only in the US, but across several countries.Several limitations of our study must be acknowledged. This is a clinical trial patient population that is based on inclusion and exclusion criteria. Due to the homogeneity of the sampling method, the data may not be representative of patients with comorbidities. Though, community-based studies on the prevalence of adult ADHD as part of the World Health Organization World Mental Health Survey found fairly similar prevalence rates of adult ADHD throughout the countries that were surveyed (mean = 3.4% range = 1.2% to 7.3%) . There iIn summary, the results reported here show that the characteristics of adult ADHD patients are generally comparable across EUR and NE regions. Although studies in the EUR population may be needed to address specific issues, the results suggest that research findings in adults with ADHD in NE regions can be generalized to adult patients with ADHD in the EUR region.Doctors Upadhyaya, Tanaka, Escobar, and Allen are full-time employees of Eli Lilly and Company and stockholders of Eli Lilly and Company. Dr. Arsenault and Mr. Williams are full-time employees of PharmaNet/i3, an inVentiv Health Company. Dr. Arsenault is also a former employee of, and minor stockholder in, Eli Lilly and Company.Dr. Adler has received royalty payments (as an inventor) from New York University. He receives/d grant research support from Abbott Laboratories, Bristol-Myers Squibb, Chelsea Therapeutics, Merck & Co., Inc., Novartis Pharmaceuticals Corporation, Shire, Eli Lilly and Company, Ortho-McNeil/Janssen/Johnson & Johnson, New River Pharmaceuticals, Cephalon Inc, Organon, and National Institute of Drug Abuse. He is/has been on the advisory board and consulted for Alcobra Pharmaceuticals, AstraZeneca, Shire, Eli Lilly and Company, Mindsite, Major League Baseball, and i3 Research. He is/has been a consultant for Epi-Q, INC Research, United Biosource, Otsuka, Major League Baseball Players Association, Ortho-McNeil/Janssen/Johnson & Johnson, Psychogenics, and Theravance.Dr. Casas has received travel grants from Eli Lilly and Company, Janssen Cilag, Shire, and Laboratorios Rubió. He receives/d grant research support from Janssen Cilag, Shire, Laboratorios Rubió, and Eli Lilly and Company. He is/has been on the advisory board for Janssen Cilag, Shire, Laboratorios Rubió, and Eli Lilly and Company. He is/has been a consultant for Janssen Cilag, Shire, Laboratorios Rubió, and Eli Lilly and Company.Dr Kutzelnigg has received travel grants from Eli Lilly and Company, Affiris AG, Novartis Pharmaceuticals Corporation, and AstraZeneca and payment for lectures including service on speakers’ bureaus from Eli Lilly and Company, Novartis Pharmaceuticals Corporation, and Affiris AG, and serves as a consultant for Eli Lilly and Company.HU made substantial contributions to the analysis and interpretation of the data, was involved in drafting the manuscript and revising the intellectual content of this manuscript. LAA made substantial contributions to the analysis and interpretation of the data, was involved in drafting the manuscript and revising the intellectual content of this manuscript. MC was involved in drafting the manuscript and revising the intellectual content of this manuscript. AK made substantial contributions to the analysis and interpretation of the data, was involved in drafting the manuscript and revising the intellectual content of this manuscript. YT made substantial contributions to the design of the study, performed the statistical analysis, and was involved in drafting the manuscript and revising the intellectual content of this manuscript. DW performed the statistical analysis, and was involved in drafting the manuscript and revising the intellectual content of this manuscript. JA was involved in drafting the manuscript and revising the intellectual content of this manuscript. RE made substantial contributions to the design of the study, analysis and interpretation of the data, and was involved in drafting the manuscript and revising the intellectual content of this manuscript. AJA made substantial contributions to the design of the study, analysis and interpretation of the data, and was involved in drafting the manuscript and revising the intellectual content of this manuscript. All authors read and approved the final manuscript.


Ampulex dementor Ohl n. sp. was selected. The name, derived from the ‘soul sucking’ dementors from the popular Harry Potter books is an allusion to the wasps' behavior to selectively paralyze its cockroach prey. In this example, public voting on a scientific name has been shown to be an appropriate way to link museum visitors emotionally to biodiversity and its discovery.Taxonomy, the science of describing and naming of the living world, is recognized as an important and relevant field in modern biological science. While there is wide agreement on the importance of a complete inventory of all organisms on Earth, the public is partly unaware of the amount of known and unknown biodiversity. Out of the enormous number of undescribed  species in natural history museum collections, we selected an attractive example of a wasp, which was presented to museum visitors at a special museum event. We asked 300 visitors to vote on a name for the new species and out of four preselected options,  Taxonomy is an interesting and popular endeavor. It has recently been the subject of a lively discussion on how to improve its standing and perception in science and society th century, taxonomic names have been formed on the basis of Latin or Greek words Since the beginning of formal taxonomic description in the 18http://www.gti-kontaktstelle.de/en and was the national organiser of the World Wide Views on Biodiversity in Germany in September 2012: http://www.wwviews-biodiversity.naturkundemuseum-berlin.de/). Here we report on another activity not only to inform visitors about taxonomy, but also to connect people emotionally to biodiversity and its discovery. During a Berlin-wide “Long Night of the Museums” (LNoM) in 2012, we set up several activities in order to inform visitors about the rules, principles and also the pleasures of naming newly discovered species. We also invited museum visitors to vote on the name of an undescribed species of wasp, which we herein formally describe.It seems to be widely unknown within society that the majority of global species richness still awaits discovery The digital images of the holotype were taken with a Canon 6D SLR camera attached to a Leica MZ 12.5 dissecting microscope. Multifocus photographs were focused and captured manually and subsequently stacked using the software package Helicon Focus 5.3.http://zoobank.org/”. The LSID for this publication is: urn:lsid:zoobank.org:pub:B0F2FFEC-A89E-4A99-B39A-C30C26260B65. The electronic edition of this work was published in a journal with an ISSN, and has been archived and is available from the following digital repositories: PubMed Central, LOCKSS.The electronic edition of this article conforms to the requirements of the amended International Code of Zoological Nomenclature, and hence the new names contained herein are available under that Code from the electronic edition of this article. This published work and the nomenclatural acts it contains have been registered in ZooBank, the online registration system for the ICZN. The ZooBank LSIDs (Life Science Identifiers) can be resolved and the associated information viewed through any standard web browser by appending the LSID to the prefix “Ampulex dementor Ohl n. sp., the candidate species names for the public voting listed in Except for One of three families of “Sphecidae” (commonly referred to as digger wasps), which are one of the most diverse groups of Aculeata (stinging wasps).The Diagnosis section of a formal species description includes the characters of the new described species, which distinguishes it from similar and usually closely related species.The Etymology section of a species description explains the formation, derivation and grammatical status of the new name.An acronym for Life Science Identifier. An LSID is a uniform resource name in a specific format to locate pieces of information in the web. In zoological nomenclature, LSID's are used as globally unique identifiers for registration entries in Zoobank, the official registry for zoological nomenclature.This is a set of rules and recommendations, which as conventions rule the formal scientific naming, name formation and name handling for organisms treated as animals.This phrase is used here in terms of the International Code of Zoological Nomenclature as a piece of scientific work, which meets a set of specific criteria to make a new name officially available.One or more particular specimens, on which a formal species description is based. A holotype is an individual specimen, either the only available specimen or selected out of a series, to which a given species name is attached. If one species is later considered to be composed of actually more than one species, the species, to which the holotype belongs, keeps the previous name.Ampulex Jurine from Thailand in the family Ampulicidae. It belongs to an ant-mimicking group of species with attractive coloration and rather bizarre habitus , which has become popular for successfully being cultured in zoos and privately Ampulicidae, or cockroach wasps, comprise 200 already named species in six genera, which occur mainly in tropical habitats of all continents Ampulex with a general ant-like appearance and red-black coloration with marked wings. It is most similar to another species in the genus, described from Sri Lanka . The two have the first two upper plates (terga) of the metasoma (the body section behind the waps-waist) markedly shining, but the sides of the second tergum is dull due to numerous tiny dimples (micropunctures). The two species can be readily distinguished by the vertex, the area of the upper head mainly behind the three simple eyes (ocelli), which is microsculptured and dull in both species, but with only a few indistinct larger punctures in the new species and many, deep and clearly defined punctures in A. ceylonica. The two are also different in the morphology of the frons, the head area below the three ocelli. In the new species, the frons has markedly developed longitudinal wrinkles (rugulae) for almost all of its length, whereas in A. ceylonica, the frons is indistinctly wrinkled near the lower margin of the frons. Finally, the new species is known from Thailand only, whereas A. ceylonica has been exclusively recorded from Sri Lanka.The new species exhibits some characters unique within the group of species in th “Long Night of the Museums” (“Lange Nacht der Museen”) (LNoM) (http://archiv.lange-nacht-der-museen.de/30/). Seventy museums all over the city provided guided tours behind the scenes and a wide variety of more than 350 special events. In total, more than 30,000 visitors attended the LNoM, and the MfN alone had 5,226 visitors.In January 2012, Berlin museums organized the 30Special events in the MfN comprised guided tours through the scientific collections and various displays in the exhibition hall, which provided information on entomology, geology, history of science, specific information for children and others. We set up an information desk that offered opportunities for visitors to learn about nomenclature. As an example, we demonstrated the basic principles of patronyms by transforming the visitors' personal name into a formal scientific name for a hypothetical species.Ampulex from Thailand. We informed the visitors, that we intended to describe and name it and that they were asked to vote for the species name to be published. We handed out a ballot with a few explanations on the necessity to select an appropriate name for the newly discovered wasp. In order to avoid large numbers of linguistically incorrectly formed and, thus, inappropriate names, we decided to provide a list of four preselected names. These four names were selected to represent different linguistic kinds of names, but in all cases, we made sure that the names were meaningfully and comprehensibly derived from the species to be described  and Twitter (https://twitter.com/MfNBerlin). During and after the LNoM, people were informed that the result would be announced over the same channels.In addition to the printed program for the LNoM, the MfN informed potential visitors about the possibility to vote for a name of a new animal species in advance on its homepage and using social media like Facebook (http://www.nhm.ac.uk/hosted-sites/iczn/code/). Names as linguistic tags for information on a species are arbitrarily formed, but may have an etymological meaning.Society should be concerned not only with the loss of biodiversity but also with its still unexplored richness. Current trends towards an integrative taxonomy, which incorporates a large variety of mainly molecular methods The two parts of the process of species description are fundamentally different and require specific background knowledge to be accessed by non-experts. Species delimitation in modern integrative taxonomy is mostly based on large comparative collections housed in natural history museums, genetic data and morphological information often gained by high-technology imaging systems like μ-computer tomography In contrast, the naming aspect of taxonomy is different and particularly suitable for communicating the process of species discovery to the public. Based on our experiences, ‘public naming’ of newly discovered species is a suitable means of visitor participation in one of the core disciplines of a natural history museum, the discovery of biodiversity. Today's rules for the formation of scientific names are still partly based on the principles of classical languages, e.g., names are usually Latinized in terms of their endings. It can be expected that the widely decreasing knowledge of classical Latin and Greek in society might serve as a psychological hindrance with regards to engagement in taxonomy. However, it can easily be demonstrated that the formation of names based on modern linguistic elements is an easy task and requires knowledge of very few rules. As an example, we have latinized visitor names together with the visitors to form patronyms.Megapenthes lugens . The underlying expectation was that such an initiative would raise awareness of a part of Britain's fauna, which is poorly known and often overlooked by the public. The competition was later expanded to the naming of ten endangered species of organisms in Britain, and the judging panel received more than 3,000 entries. The results were made public by “The Guardian” only a few weeks later, and the naming initiative has been received as a way to build up “a cultural connection that will help their conservation cause” There are other approaches for involving the public in biological naming processes, which have raised broad publicity. One was a competition for common names of endangered species in Britain, another is the auctioning or selling of naming rights. In 2010, the British newspaper “The Guardian” in collaboration with “Natural England”, a non-departmental public body of the UK government responsible for protecting and developing England's natural environment, and the Oxford University Museum of Natural History, has launched a similar, but in many respects different initiative th century, new species have frequently been named after sponsors of the expedition which found the unnamed specimens or after other people supporting the authors' research. In this context, dedicated species names have always been exploited to bring the sponsors' name to the public in order to bind sponsors to the organisms named after them and, often more relevant, to the describing researcher or to the conservation project in the relevant area. Naming species after sponsors has always been accompanied by the expectation that the sponsor will continue funding the project or the scientist. From here it is only a short step to sell or auction naming rights Callicebus aureipalatii Wallace, 2005. The entire sum of money raised was provided to the Bolivian Park Service to run the Madidi National Park. Due to the large amount of money and a casino involved, this unusual example of auctioning naming rights has received much attention from the public. Many taxonomists around the world have successfully auctioned naming rights for their newly discovered species, most of them for significantly smaller amounts of money. In 1998, a German non-profit initiative named “BIOPAT” set up an internet broking platform for selling naming rights Since the 17Our public voting of a taxonomic name was received very positively. Visitors were highly interested and during the event spent a significant amount of time asking for details and listening to explanations. We prepared 300 ballots in advance, of which about 90% were returned . Even thThe new species is named after the “dementors”, which are fictional characters of the wizarding world in the popular “Harry Potter” book series by the writer Joanne K. Rowling. These creatures are said to suck out every good feeling, every happy memory and the free will of anybody getting too near.Ampulex on the behavior of its cockroach prey. After being stung by the wasp, specific behaviors of the cockroach are inhibited (e.g. escape behavior) while others are unaffected (e.g. locomotion). The wasp grabs the partly paralyzed cockroach by one of the antennae and guides it to a suitable oviposition location, the prey following the wasp in a docile manner. This is a unique strategy of behavioral modulation of a prey by a wasp's sting The dementor's fictional behavior and effects reminded us of the effect of the stinging behavior of Ampulex dementor belongs in a group of species, which are characterized by black head and metasoma in combination with a mostly red mesosoma . Ampulex dementor is most similar to A. ceylonica Krombein, 1979 from Sri Lanka: Both species have shining terga I and II . Total length (excluding appendages) 9.6–10.9 mm (n = 2).Black, the following light red: mandible, most of clypeus, prothorax, mesothorax , the posterolateral corners of mesoscutum and the ventral surface of the mesopleuron beneath omaulus and sternaulus, upper half of metapleuron, propodeum, most or all of hindcoxa and all trochanters, tibiae , all tarsi; propodeal spines and petiole whitish, metasomal segments IV and V dark brown, VI pale brown. Forewing slightly yellowish, with dark marking in marginal cell, distal half of first and complete second submarginal cells, and distal half of discoidal cell II, and small infumate spot at apex of submedial cell. Hindwing hyaline.Head elongate behind eyes, completely microsculptured, dull. Frons with irregular, longitudinal rugulae and with shallow, shining carina along midline, entire from clypeus to midocellus. Vertex with a few, irregularly scattered, shallow punctures. Gena impunctate. Mandible unmodified. Compound eye surrounded by carina, which is strongest at level of frons, diverging above, lower interocular distance across toruli about 0.75x upper interocular distance across hindocelli. Flagellomere I slightly shorter than II and III combined.Pronotum microsculptured, impunctate, with sharp, median furrow and a pair of acute tubercles anterolaterally. Mesonotum micropunctate, shining, with irregularly interspersed macropunctures, notauli irregularly punctate, mesopleuron similar, macropunctures subcontiguous on upper half, 1–2 puncture diameter apart on lower half, sternaulus und omaulus coarsely punctate, scutelleum similar to mesonotum, with a few macropunctures posterolaterally. Propodeal dorsum coarsely areolate, with a median and four lateral longitudinal ridges, connected by several tranverse carinae, with truncate median process at posterior margin, posterolateral spines long, slender, curved, propodeal sides above metapleural sulcus and posterior propodeal declivity coarsely areolate, propodeal side below metapleural sulcus shining.Forewing submarginal cell bent away from wing margin for most of its length, pointed distally, continued by a non-pigmented vein to wing tip. First intersubmarginal veinlet lacking, so that submarginal cells I and II fused to form a markedly long cell. First recurrent vein meeting combined submarginal cells I and II almost medially, second recurrent vein meeting (apparent) submarginal cell II in basal one-fourth. Hindwing media diverging at cu-a.Legs long and slender, femora markedly swollen medially (fore and midlegs) or basally (hindleg). Tarsomeres IV with ventral mat of fine pubescence, short, tarsomeres V inserted dorsally at base of IV.Petiole almost evenly tubular, about as long as tergum I in dorsal view. Tergum I with sides diverging toward tergum II, not nodose, with constriction between terga I and II. Tergum I and II shining, virtually impuncate, except for densely, finely punctate posterolateral corner of II. Punctation of tergum III finer and denser than on posterolateral corner of tergum II, becoming increasingly indistinct on following terga. Sternum II markedly convex, with strong transverse groove subbasally, very finely, densely micropunctate. Following sterna microsculptured. Metasomal segments V and VI compressed laterally.Holotype, female. T2448. Thailand, Phetchabun, Khao Kho NP, mix deciduous forest, 16°32.539′N 101°2.483′E, 524 m, pan traps, 10–11 June 2007, S. Chachumnan & S. Singtong .Paratype: same data as holotype, except for: T2447, 9–10 June 2007 .Kan. Dist., Udawattakele Sanct., 2 and 9 Feb 1979, det. K.V. Krombein Ampulex ruficornis (Cameron): Thailand, Phuket, det. M. Ohl ; Sri Lanka, Colombo, det. K.V. Krombein Ampulex from Thailand and Singapore belonging to the ant-mimicking group with black-red coloration have been studied, some of which have been provided by the TIGER-project and are currently deposited in the Museum für Naturkunde, Berlin, Germany, and some are in the collection of the Smithsonian Institution, Washington, USA. They probably belong to three or four undescribed species, but some of them are singletons. Whereas the identity of Ampulex dementor as an undescribed species can be safely deduced from the original description and the examination of available material of the other known species in the group, the status of the unidentified material is less clear and can only be elucidated after studying the types of some of the species from Southeast Asia described by Cameron and Tsuneki.37 specimens of http://www.zoobank.org):Life Science Identifiers (LSID), issued by Zoobank (Author: urn:lsid:zoobank.org:author:878259F2-C3C6-4264-B04A-C397E01E5C8EPublication: urn:lsid:zoobank.org:pub:B0F2FFEC-A89E-4A99-B39A-C30C26260B65Species-group name: urn:lsid:zoobank.org:act:1358BB4F-FCA2-4463-A11C-E063A55C7B15Uniform Resource Identifiers (URI), issued by the Museum für Naturkunde, Berlin (MfN), linking to type and drawer images of the digital collection of the MfN:http://coll.mfn-berlin.de/u/MfN_Hym_Amp_I00001Holotype: http://coll.mfn-berlin.de/u/MfN_Hym_Amp_I00002Paratype: http://coll.mfn-berlin.de/u/MfN_Hym_Amp_D0003MfN insect drawer containing the paratype:


Appropriate sedation benefits patients by reducing the stress response, but it requires an appropriate method of assessment to adjust the dosage of sedatives. The aim of this study was to compare the difference in the sedation of mechanically ventilated patients undergoing flexible bronchoscopy (FB) monitored by auditory-evoked potentials (AEPs) or the Ramsay sedation scale (RSS).In a prospective, randomized, controlled study, all patients who underwent FB with propofol sedation were monitored and their sedation adjusted. During FB, one group was monitored by AEP and another group was monitored by RSS. The propofol dosage was adjusted by the nursing staff during examination to maintain the Alaris AEP index (AAI) value between 25 and 40 in the AEP group and the RSS at 5 or 6 in the RSS group. Before FB and during FB, the AAI, heart rate (HR), and mean arterial pressure (MAP) were recorded every 5 min. The percentages of time at the sedation target and the propofol dosages were calculated.P < 0.001). During FB, the RSS group had a significantly higher AAI (P = 0.011), HR (P < 0.001), and MAP (P < 0.001) than the AEP group.Nineteen patients received AEP monitoring and 18 patients received RSS monitoring. The percentage of time at the sedation target during FB was significantly higher in the AEP monitoring group  than in the RSS group , (In mechanically ventilated patients undergoing FB, AEP monitoring resulted in less variation in AAI, HR, and MAP, and a higher percentage of time at the sedation target than RSS monitoring.NCT01448811.ClinicalTrials.gov  A patient who undergoes bronchoscopy frequently suffers from pain, cough, and dyspnea, and may remember the procedure as an unpleasant experience ,2. SedatBetween March 2007 and March 2008, a prospective, randomized, controlled trial was conducted at the adult ICU of a tertiary medical center with 77 adult ICU beds. The Institutional Review Board of the Kaohsiung Veterans General Hospital  approved the trial and consent forms. The patients or their next of kin provided informed consent. Procedures were performed in accordance with the Helsinki Declaration.Mechanically ventilated patients in the ICU, aged 18 or over, who needed a FB and did not have contraindications for FB were eligible for this study. Patients needed a FB if they had abnormal chest radiography findings such as a mass, nodule, or collapse, inflammation in the lung that needed evaluation of a possible lung infection; blood in the sputum; or foreign body in the airway. Exclusion criteria included patients with pacemakers, neuromuscular blockade, neuromuscular diseases with motor dysfunction, neurological disease, encephalopathy, hypothermia, hyperthermia, propofol allergy, or hearing difficulties. After applying the inclusion and exclusion criteria, 37 patients were randomized to the AEP group or the RSS group by software that generated a random number without blocking  was determined by continuous electrocardiography. All patients were ventilated using the assisted-controlled mode and were monitored with pulse oximetry. One hundred percent inspired oxygen was supplied to maintain an arterial oxygen saturation greater than 90% during the intervention. Before the FB, all patients were connected to the AEP monitor . The electrodes were positioned at the mid-forehead, the left forehead, and the left mastoid after the skin was cleaned with alcohol. The target of sedation adopted deep sedation because most FB procedures were advanced diagnostic or therapeutic bronchoscopy procedures. All procedures were administered to mechanically ventilated patients in the ICU. Transbronchial brushing, biopsy, or lavages were administered to patients with pneumonia or lung tumor. Foreign removal was administered to one patient with foreign body aspiration. The target of AAI level was between 25 and 40 and the target RSS value  was 5 orAn experienced respiratory physician performed the FB. The distal end of the endotracheal tube was connected to an adaptor that allowed the maintenance of mechanical ventilation during the procedure. Flexible bronchoscopy began when the AAI level was controlled between 25 and 40 and the RSS was at 5 or 6. The bronchoscope was passed into the trachea through the adaptor and endotracheal tube. Topical lidocaine 2% was used by the spray-as-you-go technique on the bronchial mucosa during the FB examination. The AAI, HR, and MAP were recorded every 5 minutes during bronchoscopy. In the AEP monitoring group, trained ICU nurses adjusted the propofol dosage based on the AAI levels. If AAI was greater than 40, propofol was increased; if the AAI was less than 25, the dosage was decreased. In the RSS monitoring group, trained ICU nurses adjusted the propofol dosage based on the RSS level. The RSS was controlled at 5 or 6. Alaris AEP index monitoring was also administered to the RSS monitoring group. However, the AEP monitor was shielded and the trained ICU nurses who adjusted the propofol dosage were unaware of the AAI levels. The AAI levels were censored and recorded if the RSS, HR and MAP were checked. Each adjustment increased or decreased 10%–20% infusion doses of propofol . The meaThe primary endpoint of this study was to compare the differences in the AAI between the AAI monitoring group and the RSS monitoring group. The secondary endpoint was to compare the differences between the AAI monitoring group and the RSS monitoring group in the HR; MAP; times of propofol dosages adjustment; time to the first propofol dosages adjustment; mean propofol dosage during the examination; percentage of change in the propofol dosage from the baseline dose; percentage of time at the sedation target; percentage of AAI level greater than 40; and occurrence of significant hypotension.The percentage of time at the sedation target is defined as the percentage of minutes in which a patient maintains an adequate or desired level of sedation, based on the assessment method used . The equWe performed a power calculation to determine the ideal sample size. A minimum of 18 patients was required in each group to detect a difference in the HR with a power of 90% and a confidence interval of 95%. This was based on a previous study involving HR and different sedation levels during FB .All data were analyzed by SPSS version 12.0 . The data were presented as the mean ± standard deviation (SD), the median [interquartile range], or the number and percentages.U test was used to compare continuous variables. The chi-square test or Fisher’s exact test was used to compare dichotomous variables, depending on the expected frequency of occurrence. The correlation between the AAI and the RSS, HR, and MAP were analyzed by Spearman correlation analysis. Changes in the AAI, HR, and MAP were analyzed with a generalized linear model for repeated measures by using dummy variables. A P < 0.05 was considered statistically significant.The Mann–Whitney Of the 37 patients included in the study, 19 received AEP monitoring and 18 received RSS monitoring , HR (P <0.001) and MAP (P < 0.001) in the RSS group than in the AEP group during the course of the FB examination. Significant differences in the AAI, HR, and MAP between the two groups were present after 20 min, 10 min, 10 min, respectively, after the examination began (P < 0.05) . The Spearman correlation coefficients between the AAI and the RSS, HR, and MAP were -0.949, 0.255, and 0.337, respectively. The RSS had the best correlation with the AAI.Figure This study showed that, when FB was administered to mechanically ventilated patients, the patients who underwent AEP monitoring had a significantly higher percentage of time at the sedation target, compared with patients who underwent RSS monitoring. During the course of the FB examination, patients monitored with AEP used higher sedative dosages and had less change in the AAI, compared with patients monitored with RSS. Patients monitored with RSS had a higher percentage of AAI levels greater than 40, indicating that most of these patients were inadequately sedated and the goal of deep sedation was not reached most of the time.Undersedation can result in tachycardia and hypertension, which can lead to adverse outcomes in ICU patients ,19. The Flexible bronchoscopy is an important tool for the diagnosis of pulmonary disease, especially infectious pneumonia . HoweverSome studies have shown that AEP is correlated well with the RSS in nonparalyzed patients ,22,23. OThe advantages of the RSS are that it can be performed at the bedside and it is easily reproducible ,25. HoweAuditory-evoked potential monitoring has the advantages of continuous monitoring without inter-rater variation in interpretation, and it can be used in patients receiving neuromuscular blockades . AuditorThe ideal level of sedation varies for different situations, and the adjustment of dosage should always be considered when a patient’s needs change ,18. FreqSeveral limitations exist in this study. First, patients with neuromuscular blockades were not included. The RSS is a numerical scale of motor responsiveness that is graduated in accordance with increasing depth of sedation. Therefore, it cannot evaluate the level of sedation accurately in patients with neuromuscular blockade. In this study, we therefore excluded paralyzed patients to avoid inaccuracy. Second, patient movement can cause EMG artifacts and affect the AAI levels. To avoid EMG artifacts, as much as possible we did not move patients or administer to them a clinical stimulus during the study period. Third, all patients were supported by mechanical ventilation. Thus, the results may not be generalized to patients without mechanical ventilation. Furthermore, we studied patients receiving FB in this study. Different procedures in the ICU may have different characteristics and need a different assessment procedure. Further studies are needed for other invasive procedures to determine the appropriate sedative assessment tool in the ICU patients.Compared with RSS monitoring, AEP monitoring provided better sedation monitoring and allowed a more appropriate sedative adjustment to reach the sedative goal in mechanically ventilated patients undergoing FB. Patients monitored with AEP have a significantly higher percentage of time at the sedation target and less variation in the AAI, HR, and MAP, compared with patients monitored with RSS.AAI: Alaris auditory-evoked potential index; AEP: Auditory-evoked potentials; EMG: Electromyography; FB: Flexible bronchoscopy; HR: Heart rate; ICU: Intensive care unit; MAP: Mean arterial pressure; MLAEP: Middle latency auditory-evoked potential; RSS: Ramsay sedation scale.The authors have no competing interests to declare.C-WH was the main contributor to the study design, data interpretation, and manuscript drafting. S-FS contributed to data acquisition and analysis and manuscript revision. K-AC and D-LL contributed to the execution of the study, and K-FW contributed to the statistical analysis of data. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2466/14/15/prepub


Vertebral fractures, the most common type of osteoporotic fractures, are associated with increased risk of subsequent fracture, morbidity, and mortality. The aim of this study was to examine the contribution of important risk factors to the variability in vertebral fracture risk.2) at the hip was measured by DXA. Lifestyle information was collected by questionnaires. Multivariable logistic regression model, with anthropometric and lifestyle factors included, was used to assess the association between each or combined risk factors and vertebral fracture risk. Population attributable risk was estimated for combined risk factors in the final multivariable model.Vertebral fracture was ascertained by VFA method  in 2887 men and women, aged between 38 and 87 years, in the population-based Tromsø Study 2007/2008. Bone mineral density , after adjusting for age. In women and men, respectively, approximately 46% and 33% of vertebral fracture risk was attributable to advancing age (more than 70 years) and low BMD (less than 0.85 g/cm2), with the latter having a greater effect than the former.In both sexes, age  and BMD  were independent risk factors for vertebral fracture. At BMD levels higher than 0.85 g/cmThese data confirm that age and BMD are major risk factors for vertebral fracture risk. However, in both sexes the two factors accounted for less than half of fracture risk. The identification of individuals with vertebral fracture is still a challenge. Fragility fracture is highly prevalent in the general population, and is increasingly becoming a public health concern ,2. From Norway is among the countries in the world with the highest incidence of fragility fractures, including hip  and forehttp://www.tromsostudy.com). Details of study design have been described elsewhere [The present study is part of the on-going Tromsø Study . Daily phantom measurements were performed throughout the survey. Three technicians did the scanning according to a standardized protocol, and one of them performed the quality assessment of the total material afterwards. The short term in vivo precision error was 1.2 and 1.7% for total hip and femoral neck measurements, respectively [BMD expressed as g/cmectively . For theData on lifestyle variables were collected through questionnaires in both phases of the study. The questionnaires obtained information, among other, on smoking habits, physical activity, self-perceived health, and education. Smoking status was classified into three categories, namely: present, former, and never. These were further grouped into two categories: former and never smokers were categorized as “not smoking” and smokers as “smoking”. The question on leisure time physical activity level during the last year had four alternatives from sedentary (mostly tranquil activities), moderate (lightly active at least four hours a week), active (vigorously active at least four hours a week) and highly active . The sedentary and moderate active were categorized into one “low active group”, and the active and highly active into one “high active” group. Five levels of self-perceived health  were categorized into two, good (very good and good) and poor. Five levels of education were categorized into three levels: 1) primary school only (i.e. seven years), 2) up to four years more than primary school, and 3) more than four years after primary school.Each individual was classified as having a vertebral fracture if there was a presence of at least one fracture as described in the “Ascertainment of vertebral fracture” section. The association between sex and vertebral fracture risk was assessed by Chi-square statistics. Univariate analyses (Chi-square statistics or Independent sample T-tests) were used to examine the association between baseline characteristics and vertebral fracture risk in women and men. Logistic regression was used to assess the association between each risk factors and vertebral fracture risk in women and men separately, adjusting for age. Odds ratio (OR) of fracture ) was estimated per standard deviation (SD) of continuous risk factors ). Multivariable logistic regression analysis was used to assess the association between each significant or combined risk factors and vertebral fracture risk. Testing for interaction was done by including the product of sex and BMD and sex and age in the model. The final and most optimal model was found using backward selection procedures. In order to assess the impact of risk factors on vertebral fracture, we estimated the population attributable risk fraction (PAR) for combined risk factors in the “final” multivariable model, for women and men separately. In this study context, PAR represents the proportion of vertebral fractures that can be attributed to a risk factor, if there is a causal relationship between the risk factor and fracture . HoweverThe study cohort included 2887 individuals (1206 men and 1681 women) aged between 38 and 87 years, with the majority being post-menopausal (women) or aged 50+ years.Overall, approximately 64% of men and 61% of women reported good health status, with a majority (more than 78%) in the sedentary or moderately physical activity group.Vertebral fracture was found in 166 (13.8%) men and 199 (11.8%) women (p = 0.07). Baseline characteristics of participants stratified by fracture status and sex are shown in Table 2 decrease), and in women only BMD  and weight   , after adjusting for age.Because sex was not associated with the prevalence of vertebral fractures in any age group p > 0.12) .A multivariable logistic regression model was conducted to search for independent risk factors for each sex separately, and the results are shown in Table In line with other studies ,22,33, wAt the highest BMD levels, the risk of vertebral fracture at given age was greater in men than in women. Few population-based studies have included vertebral fracture assessment in both women and men. It is therefore difficult to compare the present sex-related vertebral fracture risk. There has been some controversy in the literature about whether there is a higher risk of vertebral fractures in women than in men. Our finding of non-significant difference in vertebral fracture risk between men and women (before adjustment of age and BMD) is not consistent with a previous review which suggested that the incidence of vertebral fractures in men is about one third to one half of that in women , but of Several other studies report, similar to the present study, that low BMD measured at the femoral sites are associated with prevalent radiographic vertebral fractures ,22,28. WThe present findings should be viewed within the context of strengths and potential limitations. The Tromsø Study is a population-based, longitudinal study with a high participation rate. The present study is a cross-sectional survey within the framework of the Tromsø Study, where vertebral morphometry was done for the first time. Because of its cross-sectional design, causal inference cannot be drawn from the findings and the results will need confirmation within a longitudinal design. For logistic reasons, we did not perform quality control using x-ray technology. It is, however, reported that DXA scans are more precise in measuring moderate and severe than mild deformities , and 99%Advancing age and declining BMD are independent determinants of vertebral fracture risk in women and men, but accounting for less than half of the total risk. The predictive value of prevalent vertebral fractures on subsequent vertebral fractures and other types of fractures should be explored in longitudinal studies.The authors declare that they have no competing interests.Study concept and design: NE, SW, AJS; Acquisition of data: NE, SW, NDN, LAA; Analyses and interpretation of data: SW, NE, LAA, AJS, JC, JAE; Statistical analyses: SW, NE, LAA, TN; Critical revision of the manuscript: SW, LAA, AJS, JC, NDN, TN, JAE, NE. All authors read and approved the final manuscript.Contributions of the authors to the manuscript included The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2474/13/163/prepub


Background. Despite evidence of the potential importance of the role of health and lifestyle behaviours in multiple sclerosis (MS) outcomes, there has not been a significant focus on this area of research. Aim. We aimed to recruit an international sample of people with MS at baseline and over a five-year timeframe, examine their health and lifestyle behaviours, and determine the relationship of these behaviours to self-reported disability, disease activity, and quality of life. Methods. People with MS were recruited through web 2.0 platforms including interactive websites, social media, blogs, and forums and completed a comprehensive, multifaceted online questionnaire incorporating validated and researcher-derived tools. Results. 2519 participants met inclusion criteria for this study. This paper describes the study methodology in detail and provides an overview of baseline participant demographics, clinical characteristics, summary outcome variables, and health and lifestyle behaviours. The sample described is unique due to the nature of recruitment through online media and due to the engagement of the group, which appears to be well informed and proactive in lifestyle modification. Conclusion. This sample provides a sound platform to undertake novel exploratory analyses of the association between a variety of lifestyle factors and MS outcomes. Multiple sclerosis (MS) is a chronic, debilitating neurological condition that affects an estimated two million people worldwide. Despite decades of research, the aetiology of MS and factors that affect disease progression and relapse rate are still debated . SymptomSeveral large national MS registries collect longitudinal data on patient outcomes and measure the effectiveness of a range of therapies . EpidemiWe aimed to recruit followers of online media engaging people with MS and examine in detail their health and lifestyle behaviours and determine the relationship of these factors to self-reported disability, disease activity, and quality of life, with a follow-up period of five years. For many people with chronic diseases, the internet is an important tool for self-education, emotional support, and practical advice from people facing similar challenges . Web 2.0This study provides a snapshot of current lifestyle and risk-modifying behaviours of a large international group of people with MS, as well as an ongoing platform for analysing the association between these variables and disease progression, that have not previously been examined in detail. They will also help to inform future research, and people with MS, of the potential contribution of lifestyle to their health-related quality of life, disease activity, and physical disability. This paper reports in detail the methodology of the study and an overview of the characteristics of participants recruited. Future studies will seek to analyse and report associations between lifestyle variables and disease data in detail.http://www.overcomingmultiplesclerosis.org; “OMS”). Two members of the research team (GJ and EH) systematically identified Facebook groups and pages with over 500 members or followers, designed for people with MS. On a weekly, or biweekly basis (depending on site traffic), the researchers invited people with MS to take part in the study and posted a link to the survey. Members of the OMS website were informed of the study by email and invited to participate. This was followed up with several reminders over the course of the recruitment period. Moderators of several popular MS blogs were contacted and asked to post information about the survey on their websites. Several MS societies were emailed and asked to promote the study through their websites or social media. The response to these requests was positive, and many people continued to voluntarily promote the study through their own online networks, contacts, and communities, creating a snowball effect.This survey, collecting the baseline data for the health outcomes and lifestyle interventions in a sample of people with multiple sclerosis (HOLISM) study, was conducted using the online software SurveyMonkey. A webpage was created, inviting people to take part in the study, with a description of the study aims. Online recruitment for the study took place over a 15-week period, using websites, a mailing list, and web 2.0 platforms such as blogs, forums, Facebook, and Twitter. The principle investigator (GJ) had developed an online presence in the MS community over the 12 years prior to the study due to his extensive work advocating for lifestyle modification and integrated MS management, including moderating a website dedicated to this field . The survey consisted of a maximum of 163 questions, taking around 40 minutes to complete, although skip logic enabled participants to avoid some questions not relevant to them. Three members of the research team searched and reviewed validated tools for use in the survey. Where possible, a tool was chosen that was psychometrically sound and had been tested in a similar study . Some quThe survey consisted of the following domains.Sociodemographics. This domain consisted of items collecting data on age, gender, current location, country of birth, parents' countries of birth, cultural background, marital status, number of children, employment, education, height, and weight. All sociodemographic items were multiple choice. Cultural background was categorised according to the Australian standard classification of cultural and ethnic groups [c groups , with anDiagnostic History. This included confirmation of MS diagnosis by a medical doctor, year of diagnosis, first year of symptoms, diagnostic investigations undertaken, number of brain and spinal lesions, and subtype of MS on diagnosis/currently. Some of these items were modified from the North American Research Committee on Multiple Sclerosis (NARCOMS) enrolment questionnaire. Although only people with a formal diagnosis of MS were invited to participate, to improve the validity of self-report, those who could not confirm their diagnosis but had clinically isolated syndrome or “possible MS” were still able to complete the questionnaire. However, for the purpose of this paper, analyses were only performed for those self-reporting a confirmed diagnosis of MS.Disease Activity. This was determined through participant's reported relapse rate  in the last 12 months and the last 5 years; number of relapses treated with steroids and whether currently experiencing symptoms due to recent relapse. A five-year annualised relapse rate was derived by dividing the number of relapses over five years by the number of years of disease with an upper limit of five. Level of Disability. The patient-determined disease steps  is an efficient method of assessing the presence of comorbidities in the absence of medical record review [d review . It alsod review . For theHealth-Related Quality of Life. The multiple sclerosis quality of life-54 (MSQOL-54) is a measure of health-related quality of life (HRQOL) that was developed from the RAND 36-item health survey (SF-36) and supplemented with 18 additional items. The MSQOL-54 consists of 52 items distributed into 12 scales and two single items, which give rise to two composite scores—the physical and mental health composites. Internal consistency reliability estimates for the 12 multi-item scales ranged from 0.75 to 0.96 in a sample of 179 patients with multiple sclerosis [clerosis . Test-reclerosis –28, and clerosis , depressclerosis , and sexclerosis , as wellDietary Habits. The diet habits questionnaire (DHQ) is a 22-item dietary assessment tool, validated in an Australian cardiac disease population [pulation . It asseSmoking and Alcohol. Frequency and number of alcoholic drinks were measured with examples of a standard drink provided. Other items were current smoking status, number of cigarettes smoked, and year quit, if previously smoked. Medication Use. A list of 24 disease modifying drugs (DMDs) and other common MS medications including generic and trade names were provided, and participants were asked to indicate current and previous use, including length of time taken. In addition, participants were asked to indicate whether they took prescription, over-the-counter, or herbal agents for 10 symptomatic conditions: depression, anxiety, headaches, other pain, fatigue, difficulty sleeping, bladder problems, bowel problems, spasticity, and “other”. Sunlight and Vitamin D. A total of seven researcher-devised items explored participants' average weekly frequency of sun exposure, current vitamin D supplementation and dosage, serum vitamin D level, and recency of test. Adequate sun exposure was considered to be 10–15 minutes of sunlight on a day with UV index of 7 (more or less if the UV index is lower or higher).Omega-3. Items included both the type and daily dosage of omega-3 supplementation used on average in the last 12 months. Types of omega-3 included fish oil, high strength fish oil, flaxseed oil, and “other” free-text responses.Exercise. The international physical activity questionnaire (IPAQ) is a 7-day recall of frequency and duration of vigorous and moderate activity participation: walking and sitting [ sitting . Items c sitting , 33. Stress Management. Four researcher-devised items measured the weekly frequency and length of meditation practice undertaken on average over the previous 12 months, other stress reduction activities practiced by respondents (free-text option), and the self-reported efficacy of such activities, categorised.Social Support. The single item measure of social support (SIMSS) was employed to determine the number of people that provided support to participants. This item was developed by Blake and McKay (1986) and is a predictor of morbidity among women [ng women . Responsng women , 35.Fatigue. The fatigue severity scale (FSS) consists of nine fatigue-related statements rated on a seven-point scale from “disagree” to “agree” [ “agree” . It has  “agree” , 36. A m “agree” .Depression. The patient health questionnaire (PHQ-9) is a depression screening tool which has been validated in patients with MS [ with MS . The pat with MS . The PHQEngagement. Four items are asked about engagement in OMS resources and other sources of information on lifestyle and MS, such as books, websites, or educational programs (free-text response). The statistical package for the social sciences (SPSS) version 20.0 was used to calculate statistics. Univariate analyses were performed and continuous data reported using mean (95% CI) or median (IQR) and categorical data using number and percentage. Due to variation in item completion, analyses were calculated using item response as the denominator. Where possible, summary scores from validated tools were derived according to scoring instructions or as suggested in the literature. The following are explanations of how new variables and summary scores were derived for the purpose of this paper.A planned variable, “disease activity,” was derived from data reporting relapse rates (doctor diagnosed) for those with relapsing-remitting MS only. It was categorised as increasing, decreasing, or stable, where relapse rate in the preceding 12 months was higher, lower, or the same, respectively, as the 5-year annualised relapse rate. For the purpose of this paper, conditions listed in the SCQ were summed to determine the proportion of participants that had one or more comorbidity. “Other” free-text responses will be categorised and reported in a future study along with reporting of the treatment and limitations relevant to each condition. The MSQOL-54 was scored according to the scoring instructions with a set number of items required to be completed in order to give rise to the subscores, which in turn were required for calculation of the composite scores; hence, there was variability in the completion rates. Cutoff scores were set as an aggregate score ≥ 3 in the PHQ-2 to screen positive for major depression, and a mean score ≥ 4 in the FSS to indicate clinically significant fatigue, as defined in the literature. To derive both of these summary scores, full item completion was required. Based on recency of licensing and mode of action, the medications were grouped into seven categories . Free-teA total of 3053 participants consented to participate, seven of whom were pilot study participants, whose data were included in analysis. Of those that consented, 2519 had been formally diagnosed with MS and therefore met the criteria for study inclusion. 2518 of these provided contact details for followup . Of thosThe majority of respondents were women, comprising 82.2% of the sample . ParticiA median of 13 years (IQR 7–21) had passed since participants first experienced symptoms of MS, whilst participants had formally been diagnosed with MS for a median of six years (IQR 3–12), with 45.0% having being diagnosed within the previous five years . The medThe level of disability, as measured with the PDDS, was across all disability spectrums, but 31.7% reported having no symptoms or mild symptoms that return to normal after an attack: “normal” . The medn = 1382), based on diagnosis by a doctor, disease activity was decreasing for 42.0%, increasing for 31.0%, and remaining stable for 27.0%.Over the previous 12 months, relapsing-remitting participants self-reported an average of 1.09 relapses, and over the last five years, they self-reported an average of 0.97 relapses per year . This waMedian summary scores from the MSQOL-54 were 68.4 (IQR 55.0–81.65) for the overall quality of life subscore, 59.2 (IQR 42.3–77.2) for the physical health composite, and 72.0 (IQR 51.2–84.1) for the mental health composite . Using aThe following variables are a snapshot of participant responses and not comprehensive of all variables examined; these will be examined in greater detail in subsequent papers. 68.4% of participants reported having one or more of the listed comorbidities in the SCQ. At the time of the survey, 51.4% of respondents were taking a first or second generation DMD. According to the single item measure of social support, the majority (59.5%) had 2–5 people in their life that they could count on in times of difficulty, but 5.3% of the sample had no one. 38.0% of respondents did not consume dairy products, 26.7% did not consume meat products, and 21.5% consumed neither meat nor dairy. 11.7% were current smokers. Over two-thirds (67.0%) intentionally exposed themselves to the sun to try to raise their vitamin D levels, and 82.3% took vitamin D supplements. Nearly two-thirds of respondents (64.3%) took omega-3 supplements. Meditation practice was undertaken at least once per week by 676 respondents (30.0%). This is the first cross-sectional study examining health and lifestyle behaviours in a large international sample of people with MS using web 2.0 platforms. Our results suggest that the online MS community is a unique sample to study. The proportion of women that participated is an overrepresentation from the estimated incidence of 1.8 female cases for every male . StudiesIn general, participants of this study had been diagnosed recently and had a low level of disability. This concurs with results from a self-enrolling online registry—NARCOMS—that reported one-third of their participants enrolled within two years of diagnosis and also had a median disability score of 3 (1–5) on the PDDS . CompareIt has been noted that clinical outcome measures of relapse rate and disability are insufficient alone to measure the impact of MS as they do not reflect patients' experiences of the disease . MeasureWide-ranging health and lifestyle behaviours have not been studied extensively among people with MS . A surprThe MS sample described appear to be a highly engaged and proactive group of patients. This is evidenced by the method of recruitment which was self-selecting from patients utilising online resources. The preliminary data suggests that a significant number in this sample have adopted lifestyle changes, much of which they would have learned about through self-directed learning beyond the clinical setting, and which demands a great deal of self-efficacy and commitment. A surprisingly large proportion of people continued to the end of the survey despite its considerable length. This was likely aided by the fact that participants could exit and return to the survey at their leisure. The large sample size and high item completion rate might indicate that the online MS community is motivated to contribute to novel research. Much of the feedback the research team received through the survey, emails, phone calls, and online comments was very positive. Participants expressed a desire for more research exploring lifestyle factors. Personal empowerment is key to successful adoption of healthful practices; people with MS who show increased levels of activation or self-efficacy also demonstrate positive changes in their self-management behaviours , self-reRecruiting participants through web 2.0 platforms results in rapid access to a heterogeneous sample in a highly cost-effective way and may invite contribution from previously hidden populations . EngagemAlthough participants in 57 countries took part in the survey, the majority were residing in western countries where English is the primary language. This is likely a direct reflection of the sources of recruitment used by the researchers, which were mostly limited to English language, while the survey itself demanded a high level of literacy. Severe physical disability may have prevented some people with MS from taking part as they may not have been able to complete the survey without assistance. The fact that some participants were directly recruited through a website and associated forums promoting lifestyle modification may have resulted in the participation of individuals with an interest in, and more inclined to undertake, holistic disease management. As such, the findings from this study may not be generalisable to the global online MS community. When making a decision about which items to include in the survey, serious consideration was given to the time burden placed on participants, given that the survey intended to cover many different domains. Although validated tools were used where possible, and researcher-devised items were carefully constructed, with the survey piloted with a small group, there are a number of limitations to the survey. Firstly, the validated tools have not all been tested for validity and reliability across diverse MS samples. Different cultural understandings of health mean that the use of western terminology and concepts of health with a culturally diverse sample may have allowed bias. It is also unclear whether these validated tools have previously been tested in an online survey format. It is also possible that the study was more likely to select participants with a higher level of socioeconomic status due to the method of recruiting through web 2.0 platforms. Socioeconomic status of participants was not measured in the questionnaire. This is because of the international nature of the survey and difficulty correlating data across regions. A significant proportion of participants reported experiencing symptoms related to a recent relapse. It may be difficult for patients to distinguish between enduring relapse symptoms and a permanent progression of disability. This has the potential to impact other outcome variables, and future analyses will need account for this. All data were self-reported, which can lead to potential sources of bias due to over- or underreporting. This needs to be considered particularly in light of historic reporting of events which can be limited by poor recall, such as the number of relapses in the preceding five years, or poor knowledge, such as the number of lesions or vitamin D level. We were not able to verify the accuracy of these responses. Validation through medical records or physician's report would significantly increase the reliability of self-reported data. Consideration will be given to the limitations of data reliant on self-report that may be used in future analyses. Despite these limitations, some self-reported data in MS study participants have previously been found to be a reliable measure of outcomes , 63. TheIncreasingly, web 2.0 platforms are being embraced by patients and researchers alike, with the shared goal of improving patient-centred health outcomes. The characteristics described above suggest this online MS community recruited to our study is a heterogeneous and unique group who appear actively engaged and keen to contribute to research on health and lifestyle behaviour. Although there are several limitations to conducting research with online communities, this method provides efficient and rapid access to a large sample of people with MS. This study provides a sound platform to undertake exploratory analyses of lifestyle variables that have not previously been examined in such detail. The dataset will provide an important opportunity for novel research into lifestyle and health behaviours and their potential impact on MS outcomes over time.


Obesity is associated with an increased risk of esophageal adenocarcinoma (EAC) and a decreased risk of esophageal squamous cell carcinoma (ESCC). However, little is known about the risk of EAC and ESCC related to other metabolic risk factors. We aimed to examine the risk of EAC and ESCC in relation to metabolic risk factors, separately and combined in a prospective cohort study.The Metabolic Syndrome and Cancer cohort includes prospective cohorts in Austria, Norway and Sweden, with blood pressure, lipids, glucose and BMI available from 578 700 individuals. Relative risk (RR) for EAC and ESCC was calculated using Cox’s proportional hazards analysis for metabolic risk factors categorized into quintiles and transformed into z-scores. The standardized sum of all z-scores was used as a composite score for the metabolic syndrome (MetS).In total, 324 histologically verified cases of esophageal cancer were identified . BMI was associated with an increased risk of EAC  top versus bottom quintile) and negatively associated with the risk of ESCC (RR 0.38 (0.23-0.62)). The mean value of systolic and diastolic blood pressure (mid blood pressure) was associated with the risk of ESCC (RR 1.77 (1.37-2.29)). The composite MetS score was associated with the risk of EAC (RR 1.56 (1.19-2.05) per one unit increase of z-score) but not ESCC.In accordance with previous studies, high BMI was associated with an increased risk of EAC and a decreased risk of ESCC. An association between high blood pressure and risk of ESCC was observed but alcohol consumption is a potential confounding factor that we were not able to adjust for in the analysis. The MetS was associated with EAC but not ESCC. However this association was largely driven by the strong association between BMI and EAC. We hypothesize that this association is more likely to be explained by factors directly related to obesity than the metabolic state of the MetS, considering that no other metabolic factor than BMI was associated with EAC. Esophageal cancer is the eighth most common cancer and the sixth most common cause of cancer-related mortality worldwide . EsophagThe metabolic syndrome (MetS) is a cluster of metabolic risk factors, including obesity, hypertension, insulin resistance/hyperglycemia and dyslipidemia that has been shown to be associated with cardiovascular disease ,7. ThereThere is strong epidemiological evidence for an association between obesity and an increased risk of EAC  and a deThe aim of the present study was to investigate the association between BMI, blood pressure, glucose, cholesterol, and triglycerides, both separately and combined, and the risk of EAC and ESCC in a large prospective cohort.The Metabolic syndrome and Cancer project (Me-Can) was initiated in 2006 with the specific aim to investigate the association between components of the metabolic syndrome and overall- and site-specific cancer risk -22. The Study participants were subjected to health examination (s) between 1972 and 2005. The data collection procedure and details on measurement methods have been described in a previous publication . In brieThe seven cohorts were linked to the respective National registers for cancer diagnosis, migration status (if available) and vital status. End of follow-up was 2006 in the Swedish cohorts, 2005 in the Norwegian cohorts and 2003 in the Austrian cohorts. Migration status was available in all cohorts except for the Australian cohort . Subject-value for trend over quintiles refers to the Wald test of a linear risk estimate.Quintile cut-off values were calculated separately in groups defined by cohort and sex for BMI and mid BP ((systolic BP + diastolic BP)/2) and in groups defined by cohort, sex and categories of fasting time  for glucose, cholesterol and triglycerides. In order to reduce the risk of a reverse causation, follow-up started one year after baseline examination. Subjects were followed until the date of diagnosis of esophageal cancer, death, migration, or end of follow-up, whichever occurred first. Incident cancers at other sites were not considered a criterion for censoring. Cox proportional hazards analysis was used to calculate relative risks (RR) with 95% confidence interval (CI) for EAC and ESCC related to quintile levels of all five components of the MetS. The proportional hazards assumption was met in all analyses as verified by log-log plots. Attained age was used as the underlying time scale. All models were stratified by cohort and by categories of birth-year . Relative risks were adjusted for age at baseline as a continuous variable and for sex, smoking status and quintile levels of BMI as categorical variables. We decided to include BMI in the final model due to the association between BMI and EAC and ESCC and the well-established association between BMI and other metabolic factors. The pIn order to make the variables comparable on a continuous scale and to create a combined MetS variable, the z-score standardization was used ((exposure level – mean)/standard deviation (SD)), resulting in a z-score of the exposures with a mean of 0 and a SD of 1. Glucose and triglycerides were log-transformed before standardization, as they were skewed and had outliers. BMI and mid blood pressure were standardized separately in groups defined by cohort and sex. Log (glucose), cholesterol and log (triglycerides) were standardized in groups based on cohort, sex and fasting time. The MetS score was calculated by summarizing the five individual z-scores before standardization. Cox proportional hazards regression was used to calculate RRs for EAC and ESCC related to the continuous z-score of the exposures. Again, attained age was used as time scale and the model was stratified by cohort and birth-year categories. In the analysis of the MetS, all estimates were subsequently adjusted for sex, age at baseline and smoking status. Relative risks related to the composite MetS score were adjusted for sex, age at baseline and smoking status. Additionally, the adjusted model of individual metabolic factors  included all metabolic factors at the same time.RRs for EAC and ESCC were also assessed for all separate exposures as continuous variables . In this analysis, subjects with glucose levels > 10 mmol/l and triglycerides > 6 mmol/l were classified as outliers and excluded. RRs were adjusted for age at baseline, smoking status and all metabolic factors. Interactions between smoking and additional factors were tested by including cross-product terms in the regression models. A p-value of < 0.05 was considered to be indicative of a statistically significant interaction.In addition to quintile categorization, BMI and blood pressure variables were further categorized according to World Health Organization (WHO) criteria for obesity  and EuroIn the analysis of exposure categorized in quintiles, regression dilution ratios (RDR) were calculated based on repeated health examinations in 133,820 subjects in the full Me-Can database in order to adjust RRs for random errors in the measurement of exposure variables at baseline ,28, thisWhen more than one variable with a random error was included in the analysis such as when z-score variables were analyzed, the RDR correction was not considered appropriate. In those situations a regression calibration model (RC) was used instead ,29. WithAll statistical analyses were performed in SPSS Statistics 19.0  except calculation of RDR and regression calibration that was calculated in R, version 2.7.2.Baseline characteristics for the Me-Can cohort and cases of EAC and ESCC are presented in Table There was a statistically significant association between BMI and the risk of EAC with a clear dose–response relationship over quintiles (adjusted RR for top versus bottom quintile of BMI was 7.34 95% CI 2.88-18.68) and corresponding RDR corrected adjusted RR was 9.18 )  and corresponding RDR corrected adjusted RR was 0.34  (Table Higher mid BP was associated with an increased risk of ESCC. The adjusted RR for ESCC was 2.60 (95% CI 1.54-4.39) for top versus bottom quintile of mid BP and corresponding RDR corrected adjusted RR was 5.79  (Table There was no association between glucose, cholesterol or triglycerides and risk of ESCC Table  and 3, wThe association between metabolic factors and the risk of the two dominating types of esophageal cancer, EAC and ESCC, was investigated in this large prospective cohort study. There was a strong association between high BMI and an increased risk of EAC and a decreased risk of ESCC. Mid BP was associated with an increased risk of ESCC. The composite MetS score was associated with an increased risk of EAC but not with the risk of ESCC.The association between overweight and EAC is known from several previous studies ,30-33. ITwo different causal links between obesity and EAC can be hypothesized. One possible mechanism is through and increased risk for gastroesophageal reflux. Obesity is associated with an increased risk of gastro-esophageal reflux  which inAnother possible mechanism for the association between obesity and EAC is through a hormonal and/or metabolic systemic disequilibrium related to the MetS . The MetIn the present study, we found a statistically significant association between the surrogate score for the MetS and the risk of EAC. However, BMI was the only metabolic factor with a statistically significant association with the risk of EAC. Therefore, we consider that our findings suggest that obesity leading to gastro-esophageal reflux and esophageal dysplasia may be the more important mechanism. Nevertheless, this does not exclude a role for metabolic state related to the MetS for the development of EAC. High leptin levels and low levels of high molecular weight adipnectin have been associated with an increased risk for progression from Barrett’s esophagus to EAC after adjustment for relevant other risk factors, including BMI .The inverse association between BMI and the risk for ESCC demonstrated in the present study has been observed in several previous studies ,39,40. IWe found a strong and dose dependent association between mid BP and risk of ESCC. However, alcohol consumption is a known risk factor for hypertension  and has An association between high blood glucose and an increased risk of cancer overall has been reported in several prospective studies ,13. PropWell-designed studies on the association between blood lipids and different subtypes of esophageal cancer are lacking. A positive association between esophageal cancer and both triglycerides and low-density lipoprotein cholesterol/high-density lipoprotein cholesterol has been reported in a recent cohort study . HoweverMajor strengths of the present study are the prospective design and the large size of the cohort. The large proportion of subjects with repeated measurements in the cohort enabled us to adjust for random error in measurement of metabolic factors. National cancer registries in Sweden, Norway and Austria have a previously been demonstrated to be highly accurate ,50,51 asThis study confirms the previously described association between a high BMI and an increased risk of EAC. A significant association was found between the surrogate score for the MetS and the risk of EAC. However, considering that no other metabolic risk factors were associated with EAC risk, we hypothesize that it is not the hormonal metabolic state related to the MetS that is the probable cause of the association between BMI and EAC. More likely, other factors associated with obesity such as increased risk of gastro esophageal reflux disease may play a role. We were also able to confirm the previously described negative association between BMI and ESCC and we found a positive association between blood pressure and ESCC that, to the best of our knowledge, has never been described before. However, this finding has to be confirmed in studies where proper adjustment for alcohol consumption is possible.EAC: Esophageal adenocarcinoma; ESCC: Esophageal squamous cell carcinoma; MetS: Metabolic syndrome; BMI: Body mass index; BP: Blood pressure; WHO: World Health Organization; ESH: European Society of Hypertension; ESC: European Society of Cardiology; RR: Relative risk; CI: Confidence interval; Me-Can: The metabolic syndrome and cancer risk project; RDR: Regression dilution ratio; RC: Regression calibration.The authors declare that they have no competing of interests.BL and JM have full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: BL, DJ, TS, HC, TB, MA, CH, AE, GH, GN, HJ, RS, HU, ST, PS, JM. Acquisition of data: BL, DJ, TS, HC, TB, MA, CH, AE, GH, GN, HJ, RS, HU, ST, PS, JM. Drafting of the manuscript: BL. Critical revision of the manuscript for important intellectual content: BL, DJ, TS, HC, TB, MA, CH, AE, GH, GN, HJ, RS, HU, ST, PS, JM. Statistical analysis: BL, HJ, JM. Obtaining funding: JM, PS. Study supervision: JM, PS. All authors read approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2407/14/103/prepub