Advanced cancer patients experience considerable symptoms, problems, and needs. Early referral of these patients to specialised palliative care (SPC) could improve their symptoms and problems.The Danish Palliative Care Trial (DanPaCT) investigates whether patients with metastatic cancer, who report palliative needs in a screening, will benefit from being referred to ‘early SPC’.DanPaCT is a clinical, multicentre, parallel-group superiority trial with balanced randomisation (1:1). The planned sample size is 300 patients. Patients are randomised to specialised palliative care (SPC) plus standard treatment versus standard treatment. Consecutive patients from oncology departments are screened for palliative needs with a questionnaire if they: a) have metastatic cancer; b) are 18 years or above; and c) have no prior contact with SPC. Patients with palliative needs (i.e. symptoms/problems exceeding a certain threshold) according to the questionnaire are eligible. The primary outcome is the change in the patients’ primary need ). Secondary outcomes are other symptoms/problems (EORTC QLQ-C30), satisfaction with health care (FAMCARE P-16), anxiety and depression , survival, and health care costs.Only few trials have investigated the effects of SPC. To our knowledge DanPaCT is the first trial to investigate screening based ‘early SPC’ for patients with a broad spectrum of cancer diagnosis.NCT01348048Current controlled Trials  The aim of palliative care is to relieve suffering and improve quality of life in patients with a life-threatening disease . PalliatIn 2011, 38% of patients dying from cancer in Denmark had been in contact with SPC . One posA recent randomised trial investigated ‘early SPC’ plus standard treatment versus standard treatment alone -7. It shThe aim of the present paper is to describe the Danish Palliative Care Trial (DanPaCT) protocol.The trial is a clinical, multicentre, parallel-group superiority trial with balanced randomisation (1:1) conducted at six Danish SPC centres. The protocol has been approved by the local regional ethics committee  and registered at www.clinicaltrials.gov (NCT01348048).Patients from departments of oncology are randomised to SPC plus standard care versus standard care. Patients are recruited at the following hospitals: Copenhagen University Hospital , Aarhus University Hospital, Odense University Hospital, Herning Hospital, and Vejle Hospital. Information about the six SPC centres can be seen in Table Patients in contact with the oncology departments who have cancer stage four according to the ‘TNM’  classification  or cancePatients are screened with the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-C30) .The EORTC QLQ-C30  assessesPatients are defined as having a palliative need and four additional symptoms  if they:● Score at least 50% of the score corresponding to maximal symptom burden or maximally reduced functioning on at least one of the following scales in EORTC QLQ-C30: physical function, role function, emotional function, nausea and vomiting, pain, dyspnoea, or lack of appetite; AND● Have four additional symptoms  out of the 14 EORTC QLQ-C30 scales .Central randomisation via telephone is carried out by the Copenhagen Trial Unit (CTU), which is independent of the trial administration office. The allocation sequence is computer-generated 1:1 with varying block size and is kept unknown for all investigators. Randomisation is stratified by the variable ’primary need’ (see description in the section ‘Outcomes’).All randomised patients are assessed with a questionnaire , the FAMCARE-p16 questionnaire  and the The HAD  scale asFinally, we included six additional newly developed items to measure pain, three items measuring appetite loss, and three items about dyspnoea. These items were selected from the item banks of the EORTC Computerised Adaptive Testing Project ,14 and wThree months after end of the intervention information about death, use of health services and treatments are retrieved from registers by investigators who are blinded and not aware of treatment allocation.Clinical data is extracted from the medical records regarding primary tumour, sex, age, stage of cancer according to the TNM system, time of primary diagnosis, and treatment status.To describe the interventions given and the ‘palliative activity’ in both groups all treatments and contacts with the health care system are registered. This is done by reviewing the medical records from the time of randomisation until the 8-week follow-up.The primary outcome is estimated as the difference between the intervention and the control group in the change from baseline to the weighted mean of the 3- and 8-week follow-up measured as area under the curve (AUC) for the EORTC QLQ-C30 scale score that constitutes the primary need. The primary need is defined as the palliative need having the highest intensity at baseline according to the EORTC QLQ-C30. Seven different palliative needs (listed in the section on screening) are considered when defining the primary need.Secondary outcomes, estimated in the same way, are a) the remaining symptoms and problems measured by the EORTC QLQ-C30 , b) anxiety and depression measured by the HAD Scale c) the patients’ evaluation of treatment and care provided by the health care system measured by the FAMCARE-p16, d) survival, and e) economical consequences per week from the start of the trial to minimum three months after the end of the intervention.We know from previous studies (unpublished data) that the standard deviation (SD) for a difference between repeated measurements (three weeks apart) in the EORTC QLQ-C30 is 15 to 22 points. Therefore, we assume that the primary outcome has an SD of 20 points in the present trial. We wish to be able to detect a difference of 7.5 points . For some patients, the primary outcome is pain, for others it is appetite loss. The strength of this approach is that the primary outcome is relevant for all patients, and that it takes into account the multidimensionality of palliative care without summing up the different symptoms/problems, which may lead to dilution of the measurement of effect.The treatment allocation cannot be blinded for participants and staff, which is of course a limitation ,32. ThisThe trial does not include all relevant palliative needs . In addition, patients with metastatic cancer constitute a heterogeneous group, and SPC may work better for patients with some primary diagnoses than for others, and this could weaken the power of our trial. It is also possible that the various SPC centres are better at treating different symptoms, and that a high effect from one SPC centre is weakened by the others. However, the heterogeneity of patients and centres increase the generalisability of our results.When the trial started we had different inclusion criteria from what has been presented here. Originally, the patients needed to have two palliative needs instead of only one, and the definition of palliative need was originally stricter . However, after the first two months of the trial, we realised that our initial inclusion criteria was too strict. Out of the first 168 patients completing a screening questionnaire, only eight were randomised. Therefore we changed the inclusion criteria in order to make a larger proportion of patients eligible. It is the revised and final inclusion criteria which are presented in this paper. The change was approved by the local regional ethics committee, the funding body and reported to clinicaltrials.gov.The DanPaCT trial aims at investigating whether patients with metastatic cancer who report palliative needs in a screening will benefit from being referred to ‘early SPC’. We also study the economical and survival consequences of such a referral.The authors declare that they have no competing interests.ATJ, AD, TBV, JL, PS, CG, MAN, MAP, LEL, LP, PF, IJH, MG took part in designing the trial. JL, CG, MAP, PF with special competence in RCT and/or statistical analysis, and ATJ, AD, TBV, PS, MAN, LEL, LP, IJH, MG with special competence in palliative care. AD, TBV, PS, MAN, LEL, LP, MG are clinical investigators and in charge of the data collection, and ASS helped collect data. ATJ was project coordinator and MG received the funding for the study. ATJ drafted the paper and all authors read, amended and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1472-684X/12/37/prepub


Patients attended by palliative care teams: are they always comparable populations? To answer this question we have compared the basic epidemiological characteristics of patients attended by home palliative care teams (HPCT) in two autonomous regions of Spain.We carried out a coordinated analytical, observational and prospective study in two Spanish autonomous regions: Aragon and Catalonia. Data were kept during each home care visit according to patients' needs. Inclusion criteria were: advanced cancer, over 18 years old and first contact with a HPCT. The recruitment period was 6 months. Variables included were: Survival time (days), age, sex, primary disease and extension, place of residence. Functional and cognitive state, and co-morbidity. 10 signs/symptoms: asthenia, anorexia, cachexia, dysphagia, xerostomy, dyspnoea, oedemas, level of consciousness, presence of delirium, presence of pressure ulcers and some treatment data. Others variables considered were: responsible team, origin, destination when discharge, date and place of death, number of visits made and duration of monitoring. We developed a comparison between groups by Chi-squared test or the non-parametric Mann–Whitney U test and a survival analysis by Kaplan-Meier curves and the logrank test to determine differences between factors. The SPSS version 15.0 software package was used.698 patients were included, 56.2% from Aragon and 43.8% from Catalonia. 60.3% were males, without differences between the regions. Characteristics relative to age, sex, place of residence and extension of oncological diseases were similar for both groups. We found significant differences between the two populations relative to survival time, co-morbidity, functional state, presence and intensity of a number of symptoms and the treatments, patient monitoring and the their destination after discharge.We can conclude that palliative care teams cover different profiles of patients with regard to their co-morbidity, functional, cognitive and symptomatic states. It must be pointed that the organization of palliative care services and their experience appears to condition the profile of patients they attend. There is a need of consensus on the basic descriptors for palliative care patients in order to ensure that results will be comparable. Cicely Saunders started the modern hospice movement in 1967 with the founding of St Christopher’s Hospice in London Clark . The devThe European Association for Palliative Care (EAPC) carried out a study on the development of palliative care in European countries. The Task Force on the Development of Palliative Care in Europe, headed by Carlos Centeno and David Clark, published its results in the EAPC Atlas Of Palliative Care In Europe  in Aragon and by 5 home care support teams (PADES) in Catalonia.Sample size: A sample size of 693 patients was defined. The sample was calculated according to published recommendations of 10–15 events for each dichotomous variable, and 10–15 (n-1) for each categorical variable.Inclusion criteria: patients with advanced cancer, over 18 years of age and first contact with a palliative home care team.Survival time (days).General information: age, sex, primary disease and extension, place of residence.Clinical information: functional state , cognitive state (Pfeiffer), co-morbidity (Charlson) and 10 signs/symptoms rated according to their intensity by a categorical scale between 0 a 3 where 0 was non, 1 was slight, 2 was moderate and 3 was severe. The sings and symptoms assessed were: asthenia, anorexia, cachexia, dysphagia, dry mouth, dyspnoea, oedemas, level of consciousness, presence of delirium, presence of pressure ulcers.Treatment-related information: corticosteroids, subcutaneous butterfly needle.Activity information: responsible team, origin, destination when discharge, date and place of death, number of visits made and duration of monitoring.The analysed variables were: The categorical variables are expressed as a percentage and the quantitative variables as mean ± standard deviation. The comparison between groups was made by means of the Chi-squared test or the non-parametric Mann–Whitney U test according to the variable type.Survival analysis was made using with Kaplan-Meier curves and the logrank test to determine differences between factors. Statistical significance was defined as p < 0.05.The SPSS version 15.0 software package was used.698 patients were included, of which 56.2% were from Aragon and 43.8% were from Catalonia. 60.3% were males, without differences between the regions Figure .Figure 1Table Table Finally, Table Regarding the place of death, significant differences were seen (p < 0.001). In Aragon the proportion of patients dead at home was greater (78 vs. 41%). On the other hand, comparing the number of patients died at PCU, this was greater in Catalonia (44 vs. 4%). No significant differences were fond on the percentage of patients who died at acute hospitals between Aragon and Catalonia (18 vs. 15%).The survival time for both groups is expressed as Kaplan-Meier curves in Figure This work illustrates the differences that exist in the characteristics of patients attended by home palliative care teams in two different neighbouring regions in Spain. This work is part of broader research that has the aim of establishing the prognostic values of different symptoms and the impact of repeated measurements on prognostic models  in Trondheim, Norway, to reach consensus on the minimum set of data capable to describe the population receiving palliative care. This is currently being developed using the Delphi method.Our work corroborates the need for international consensus in which descriptors for co-morbidity, cognitive and functional state, and the presence or absence of the most prevalent symptoms are contemplated in addition to personal details and particulars of the disease. These data should possibly be complemented with information on the emotional and social/family sphere of patients and the intervention setting. We will only be able to define homogeneous groups and compare the results of our research with a more detailed profile of our patients.


There is increasing evidence that psychological constructs, such as emotional intelligence and emotional labor, play an important role in various organizational outcomes in service sector. Recently, in the “emotionally charged” healthcare field, emotional intelligence and emotional labor have both emerged as research tools, rather than just as theoretical concepts, influencing various organizational parameters including job satisfaction. The present study aimed at investigating the relationships, direct and/or indirect, between emotional intelligence, the surface acting component of emotional labor, and job satisfaction in medical staff working in tertiary healthcare.Data were collected from 130 physicians in Greece, who completed a series of self-report questionnaires including: a) the Wong Law Emotional Intelligence Scale, which assessed the four dimensions of emotional intelligence, i.e. Self-Emotion Appraisal, Others’ Emotion Appraisal, Use of Emotion, and Regulation of Emotion, b) the General Index of Job Satisfaction, and c) the Dutch Questionnaire on Emotional Labor (surface acting component).r=.42, p<.001), whereas a significant negative correlation between surface acting and job satisfaction was observed . Furthermore, Self-Emotion Appraisal was negatively correlated with surface acting . Self-Emotion Appraisal was found to influence job satisfaction both directly and indirectly through surface acting, while this indirect effect was moderated by gender. Apart from its mediating role, surface acting was also a moderator of the emotional intelligence-job satisfaction relationship. Hierarchical multiple regression analysis revealed that surface acting could predict job satisfaction over and above emotional intelligence dimensions.Emotional intelligence (Use of Emotion dimension) was significantly and positively correlated with job satisfaction (The results of the present study may contribute to the better understanding of emotion-related parameters that affect the work process with a view to increasing the quality of service in the health sector. There is increasing evidence to suggest a positive relationship between physician job satisfaction and patient satisfaction as well as health outcomes, i.e. continuity of care, lower no-show rates, and enhanced adherence to treatment -4. InterAlthough emotions constitute a common characteristic of human beings, each individual differs widely in “the ability to monitor one’s own and others’ feelings and emotions, to discriminate among them and to use this information to guide one’s thinking and actions” (i.e. EI) , p. 189]EI has emerged as an interesting topic in social and organizational psychology  and appeH1a: EI is positively related to JSH1b: Gender may moderate the positive effect of EI on JSDuring interpersonal transactions, service employees are frequently involved in the process of emotional labor, i.e. amplifying, suppressing or faking emotions to comply with organizationally desired rules and complex role demands -28. Two H2a: SA is negatively related to JSH2b: Gender moderates the negative effect of SA on JSH2c: SA may predict JS above and beyond EIEI is a critical factor in performing EL; attributes of EI, such as perception and regulation of emotion, may modify employee’s EL behaviors ,41. AlthH3: EI is negatively associated with the SA component of EL.Apart from a direct relationship between EI and JS, research has also established the mediating role of different variables, such as positive and negative affect, as well as personal accomplishment, in the EI-JS relationship ,41. AccoH4a: SA may mediate the EI-JS relationshipH4b: SA may moderate the EI-JS relationshipResearch has primarily focused on direct associations among organizational psychology variables, while empirical studies integrating the constructs of EI, JS and EL in healthcare occupational setting and particularly among physicians are very limited; thus no safe conclusions can be drawn. The present study investigated the possible direct and/or indirect links between EI, SA component of EL, and JS as well as any possible moderating role of SA and demographic variables in medical staff working in tertiary health care in Greece. Apart from the primary research hypotheses, reliability and validity of constructs were also tested.The sample included 130 physicians, 80 males and 50 females, working at the University Hospital of Patras. Participants were administered a series of self-report questionnaires. The study protocol was approved by the Hospital Research Ethics Committee (119/25.11.10) and participation was voluntary. Response rate was 86.7%.EI was measured using the Wong & Law Emotional Intelligence Scale (WLEIS)  which coJS was assessed using the Brayfield & Rothe General Index of Job Satisfaction (e.g. “I am satisfied with my job for the time being”) . The scaSurface Acting of EL was assessed using the first five items of the Dutch Questionnaire on Emotional Labor D-QEL (e.g. I put on a “mask” in order to express the right emotions for my job)  . Common method bias refers to variance that is attributable to the measurement methods used , rather than to the constructs the measures represent . Common In order to assess convergent validity of the constructs, the average variance extracted (AVE) was calculated. AVE equals the sum of all squared standardized factor loadings (obtained from CFA) divided by the number of items. Fornell and Larcker  suggesteRegarding the relationship between EI and JS, a mediated model was developed and tested, in which EI was posited to positively influence JS both directly and indirectly through EL. Subsequently, a moderated mediation model was tested , in whick times with bootstrap samples, each of which contains n cases randomly sampled with replacement from the original sample (that is a given case can be selected multiple times), where n is the size of the original sample. This process yields k estimates of the indirect effects of the independent variable (EI) on the dependent variable (JS). These k values of the indirect effects are then sorted from low to high, thus enabling the specification of the lower and upper bounds of the desired CI [To assess whether mediation was present in the general theoretical model, the significance of the indirect effects of EI on JS through EL was tested using the bias-corrected bootstrap confidence intervals (CIs). Bootstrapping is a non-parametric resampling method that can be extended to designs involving indirect effects. In the case of simple mediation, indirect effects equal the product of two unstandardized regression coefficients, one representing the effect of EI (independent variable) on EL (mediator), and the other representing the effect of EL (mediator) on JS (dependent variable) controlling for EL . Howeversired CI . MacKinnsired CI  conductesired CI , generatHierarchical multiple linear regression analysis was also performed to examine the relationships between a set of independent variables  and a dependent variable , controlling for the effects of demographic , work-related variables , and other psychological variables  on the dependent variable. Screening of the raw data before they were analyzed included detection of univariate and multivariate outliers . A search was also conducted, focused on residuals, to check for violations of the assumptions of normality, equality of variance (homoscedasticity), and linearity. Independence of error terms and sequential correlation of adjacent errors was tested through the Durbin-Watson statistic. This test statistic can vary between 0 and 4, has an acceptable range of values from 1.50 to 2.50, with a value of 2 meaning that the residuals are uncorrelated. The presence of multicollinearity was detected through inspection of the tolerance (<.10) associated with each independent variable .n=80) were males. Approximately 71% of physicians were between 30 and 39 years old, and 13.1% were between 40 and 49. Slightly over half of respondents (50.8%) were married. All of them were six year university graduates and 27.7% were PhD holders. Physicians were employed in internal medicine (48.4%), laboratory (30.8%), and surgical (20.8%) sector; 69% of them were occupied as residents. Mean value of days of duty, including weekends, in a month was 6 .Of all participants, 61.5% (2(33)= 74.84, p< .01  factor did not account for most of the variance (23.36% in the unrotated solution and 13.65% in the solution after varimax rotation). Thus, no general factor that accounted for most of the covariance among the variables was apparent. Despite the fact that this procedure is widely used to test common method bias, it has several limitations . Consequd models ), CFI= .2) between UOE and ROE, as well as than the shared variance between UOE and each one of the rest of the constructs. The additional finding that the estimated correlations between the factors were not excessively high  further indicated discriminant validity.Regarding convergent validity for the other factors , as shown in Table r= .42, p< .001), while doctors who demonstrated higher levels of SA derived less JS . Hypotheses 1a and 2a were supported. In addition, EI (SEA dimension) was negatively correlated with SA , supporting Hypothesis 3. Correlations among the four dimensions of EI were statistically significant , from SEA to SA , and from SA to JS . More specifically concerning SEA, the direction of the signs of the path coefficients was consistent with the interpretation that higher SEA led to lower SA (mediator), which in turn led to higher JS.Among the direct effects, significant paths were found from UOE to JS , while the indirect effect exerted through SA was equal to B= .214, SE= .106 . This led to the rejection of the null hypothesis that the indirect effect was zero, given that the corresponding 95% CI did not contain zero. These results did not change substantially when gender and days of duty were included as covariates in the model. No other significant indirect path was found from other EI components  to JS through SA.Regarding the indirect effects, SEA was posited to influence JS both directly and indirectly through SA Figure . In the B= .521, SE= .258, p= .046)  indirect effect of SEA on JS through SA was presumed to be moderated by gender. The statistically significant interaction between SEA and gender in the model for SA implied that the indirect effect of SEA on JS was moderated by gender . There was also a significant negative relationship between SA and JS. Using the Johnson-Neyman technique, we found that the moderating effects of SA were significant at 5% level for any value of it greater than 4.401 for SEA, and for values below −1.567 for OEA. Moderation analysis for UOE and ROE revealed no statistically significant results.Regarding the moderating role of SA in the relationship between EI and JS, neither the interaction between ROE and SA, nor the interaction of UOE with SA were significant, but the interaction between SEA (and OEA) and SA was. The effects of SEA and OEA on JS were not significant, while their interaction with SA was significant  were entered first as independent variables, the work-related variables  were added in the second step, the EI variables were entered afterwards, while SA was entered in the fourth step.B= −1.138) means that survey physicians who have high SA scores have lower JS, controlling for the other independent variables. The model R2 when only the demographic variables were in the model was equal to .027. There was a statistically significant improvement (R2 change= .182) in the relationship between the set of independent variables and the dependent variable, when the SA variable was included. The proportion of variance in the dependent variable explained by the independent variables was 23.2%. The Durbin-Watson statistic was equal to 2.00, a value within the acceptable range of values from 1.50 to 2.50. Multicollinearity was not detected, as none of the independent variables had a small (<.10) tolerance value.Table B= .894) means that survey physicians who have high UOE scores have high JS as well, controlling for the other independent variables. The model R2 when only the demographic variables were in the model was equal to .027. There was a statistically significant improvement (R2 change=.165) in the relationship between the set of independent variables and the dependent variable, when the SA variable was included. The proportion of variance in the dependent variable explained by the independent variables was 33.9%. The Durbin-Watson statistic was equal to 1.84, a value within the acceptable range of values from 1.50 to 2.50. Multicollinearity was not detected, as none of the independent variables had a small (< .10) tolerance value. In addition, it should be noted that SA was the only significant predictor of JS, when the other dimensions of EI, namely OEA and ROE which both had positive regression coefficients in the equation, were introduced as independent variables. Thus, Hypothesis 2c was supported.Table The results of this study indicate that physicians with higher EI  have higher levels of JS. This finding is in accordance with a growing number of studies, showing a positive correlation between EI and JS ,14,19,41Additionally, a negative correlation between SA of EL and JS was observed, i.e. the more physicians displayed an appropriate but not felt emotion in their interpersonal relationships with colleagues and patients, the less satisfied with their job they were. It has been supported that EL can undermine JS by increasing emotional demands, thereby contributing to increased levels of stress and psychological distress as well as symptoms of depression of the employee -32. The Our findings confirm the mediating role of SA in the relation between SEA dimension of EI and JS. In the present study, the supported model of partial mediation, i.e. only a part of the total effect of EI on JS is due to SA, is not surprising as EI is also considered to have a direct effect on JS. On the other hand, other variables such as positive and negative affect , and selSA was also found to moderate EI-JS relation. With increased SA, physicians with low SEA scores had relatively higher JS compared with those with high SEA scores. As far as OEA dimension of EI is concerned, with decreased SA scores, physicians with low OEA scores had relatively low JS compared with those with high OEA scores. Hochschild  supporteAlthough moderation and mediation are distinct processes, a variable may function both as a moderator and a mediator in a single functional relation . HoweverGender was not found to moderate the direct effect of SA on JS. However, the indirect effect of SEA on JS, via SA, was moderated by gender, with this positive effect being larger for male physicians than their female counterparts. According to previous studies, females are more likely to experience job dissatisfaction when engaged in SA ; on the Research has revealed a negative relationship between EI and SA ,42. In tThe use of self-report measures, which may result in response bias  and in overstatement of the relationships between the examined constructs , does seElucidating interactions between emotion-related constructs and job satisfaction is critical to developing support programs and communication-skill training courses that may facilitate emotional appraisal and emotional regulation, reduce the related individual and organizational costs, and contribute to the improvement of health care quality. In addition, personality constructs (i.e. EI) might be used as predictive variables for health care managers in order to recruit physicians who would be most effective in the emotionally “charged” hospital environment . EmotionDespite the extensive literature on EI and JS, scant research has integrated EI with SA and JS, particularly in the hospital workplace. Most empirical studies, in health care environment, have examined the role of emotion-related constructs in the “nursing framework” , althougIn conclusion, emotionally intelligent physicians seem to be more satisfied with their job and this positive relation is moderated and partially mediated by SA component of EL. Additionally, the more physicians display an appropriate but not felt emotion in their interpersonal relationships with colleagues and patients, the less satisfied with their job they are. The findings of the present study could help to clarify aspects of the emotional dimensions of health care with a view to improving the quality of service in the health sector.EI: Emotional Intelligence; EL: Emotional Labor; SA: Surface Acting; JS: Job Satisfaction; OEA: Others’ Emotion Appraisal; ROE: Regulation of Emotion; SEA: Self-Emotion Appraisal dimension; UOE: Use of Emotion; WLEIS: Wong Law Emotional Intelligence Scale; CFA: Confirmatory Factor Analysis; AVE: Average Variance Extracted; CR: Construct Reliability; SD: Standard Deviation; SE: Standard error; CI: Confidence interval.The authors declare that they have no competing interests.The present study was carried out by all authors working collaboratively. AP conceived the study, collected data, performed statistical analysis, and wrote the first draft of the paper. FA performed advanced statistical analyses, participated in data interpretation, and revised the paper. EM contributed to the design and analysis of the data. DN participated in data interpretation and was involved in revising the manuscript critically. All authors have contributed to, seen and approved the manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1472-6963/12/463/prepub


Over the years, reports implicate improper anti-malarial use as a major contributor of morbidity and mortality amongst millions of residents in malaria endemic areas, Kenya included. However, there are limited reports on improper use of Artemisinin-based Combination Therapy (ACT) which is a first-line drug in the treatment of malaria in Kenya. Knowing this is important for ensured sustainable cure rates and also protection against the emergence of resistant malarial parasites. We therefore investigated ACT adherence level, factors associated with non-adherence and accessibility in households (n = 297) in rural location of Southeast Alego location in Siaya County in western Kenya.ACT Adherence level was assessed with reference to the duration of treatment and number of tablets taken. Using systematic random sampling technique, a questionnaire was administered to a particular household member who had the most recent malaria episode (<2 weeks) and used ACT for cure. Parents/caretakers provided information for children aged <13 years. Key Informant Interviews (KIIs) were also conducted with healthcare providers and private dispensing chemist operators.P = 0.011), education level (P < 0.01), ability to read (P < 0.01) and household (HH) monthly income (P = 0.002) significantly affected the level of ACT adherence. Consistently, logistic regression model demonstrated that low age , higher education level , ability to read  and higher income  were associated with ACT adherence. In addition, about 52.9% of the respondents reported that ACT was not always available at the source and that drug availability (P = 0.020) and distance to drug source (P < 0.01) significantly affected accessibility.Adherence to ACT prescription remained low at 42.1% and 57.9% among individuals above 13 and less than 13 years, respectively. Stratification by demographic and socio-economic characteristics in relation to ACT adherence revealed that age (This study demonstrates that more than half of those who get ACT prescription do not take recommended dose and that accessibility is of concern. The findings of this study suggest a potential need to improve accessibility and also initiate programmatic interventions to encourage patient-centred care. Plasmodium falciparum infection . The interview was carried out using structured pre-tested questionnaire, administered to the particular family member who had malaria and used the anti-malarial drugs in the household. However, in children below <13 years, parents/caretakers or a legal guardian provided the information. Using multi-stage and systematic random sampling, households with recent malaria episodes (two weeks prior to interview date) were established. In each sub-location in the study area, a sample proportion to the total household size was sampled and interviewed. Particular emphasis was on the most recent episode of self/presumptive or laboratory diagnosed malaria in the household within the last two weeks.Prior to the actual study, field assistants’/enumerators (n = 4) who are residents of Southeast Alego location and with a minimum of fourth form level of formal education were interviewed and recruited. The enumerators were fluent in English, Swahili and Luo languages. Training of the research assistants on survey interviewing techniques was performed for one day, followed by another day of pre-testing of survey tools and methodologies in Pap Nyadiel village, Masumbi sub-location (a neighboring region exhibiting the same characteristics as the study site). This village was then excluded during the main data collection. Based on the experiences and results of the pre-test, further re-training and refining of techniques of interviewing and modification of research tool was done. The research assistants used drug charts containing samples of commonly used anti-malarial medicines to aid recall and validate reports, remaining packages or tablets were reviewed where possible. Hospital cards were also reviewed to determine the duration of treatment. Data was collected by the researcher and field assistants. Qualitative data was also collected through KIIs with healthcare providers and chemist shop owners. Written informed consent was provided by the study participants or, where participants were children, a parent or guardian.P ≤0.050. Data collected by KIIs was organized into themes and analyzed.Statistical analyses were performed using Statistical Packages for Social Sciences . Descriptive analysis was then conducted to determine adherence level to ACT with reference to duration of treatment and number of tablets taken in relation to the age of the patient as recommended by the Ministry of Public Health and Sanitation and Ministry of Medical Services in Kenya  did not have any formal education, 188 (48.5%) had primary education, 116 29.9%) had secondary education, 37 (9.5%) had post-secondary education, while 7 (1.8%) were still in school. A higher proportion of the respondents (68.3%) were able to read, while 31.7% were unable to read the written prescription .Out of those who used ACT , 278/297 (93.6%) obtained the drugs from government institutions, 14/297 (4.7%) were given the drugs by friend/neighbor/relative, 3/297 (1.0%) bought them from pharmacy/shop and 2/297 (0.7%) used left-over medicine in the house. Since the study mainly focused on ACT, distance to the source of ACT was measured based on the time taken to reach ACT source while walking. The respondents who used <30 minutes were 44.8% while 55.2% used >30 minutes.In the context of the current study, adherence was defined as abiding by the recommended dose and period of usage of ACT. In order to assess level of adherence to ACT use, the number of tablets taken in relation to age and days of treatment were evaluated. Results revealed that most of the respondents who took ACT [215/297 (~72.0%)] had the recommended number of tablets according to their ages while others [82/297 (~28.0%)] either took less or more than the recommended number.Duration of treatment was also assessed and results demonstrate that 161 (54.0%) took ACT within the recommended 3 days, 22 (8.0%) within <3 days while 114 (38.0%) within >3 days. When combined (duration of treatment and number of tablets taken), adherence level was found to be 140 (47.0%) for adhered and 157 (53.0%) for non-adherence.P = 0.011). However, gender, marital status, HH head, and HH size were comparable between the ACT adherents and non-adherents   head, and HH size] and adherence was also conducted. Chi-square analyses revealed that age significantly differed between the ACT adherents and non-adherents (P < 0.01), monthly income (P = 0.002) and ability to read (P < 0.01) significantly differed between adherents and non-adherents (Table P = 0.094)  adhered as opposed to respondents who were ≥13 years (42.1%) (Table P = 0.017), higher education level , ability to read  and higher income  were associated with ACT adherence , socio-economic  and environmental factors . The above factors were regressed against the outcome variable; adherence. The full regression model of the demographic factors revealed that age was a significant factor in determining ACT adherence since many respondents 57.9%) who were <13 years  and distance to drug source (P < 0.01) significantly varied in the sub-locations  to reach the source of ACT. Moreover, 52.9% of the respondents reported that ACT was not always available at the source. Further analyses revealed that drug availability . In addition, the dispensing chemist operators reported that as a result of the high costs, they do not stock a lot of ACT, since they end up expiring on the shelves. However, there were ACT (generics) which retail at KShs. 40 in one chemist, and these were affordable to a majority of the study population.In addition, acceptability level to ACT in treatment of malaria was also examined with reference to the respondents’ perception on its usage. The results revealed that acceptability was high (95.4%) since only 4.4% of those who used ACT were not content with it. Others complained of the number of tablets taken 28.7%), duration of treatment (9.5%) and the smell, taste and color (29.1%) to be discouraging, however, they said that when taken, it cures malaria  at source to be significantly associated with ACT adherence. On the household source of income, it was demonstrated that families which had salaries and who were self employed adhered more compared to those that relied on farming. This could be attributed to the fact that, the salaried respondents had some level of formal education and could therefore read the prescriptions. Economically, farming in this area was less productive and this could also limit the ability of the households to purchase ACT if unavailable from the government health facilities. The results presented here, however, show that gender, household head, household size and marital status did not influence adherence to ACT prescription. Consistently, a previous study carried out in Turkey to determine knowledge on malaria and behaviour in an endemic rural area demonstrated no relationships between adherence and race, gender, educational experience, household head and marital status . HoweverA further assessment of socio-economic factors that could influence adherence revealed that household monthly income, education level and ability to read influenced adherence. This is because majority of households with income of more than KShs. 9,000 ($112) per month took correct dosages as opposed to those with income of below KShs. 4,500 ($56) or between KShs. 4,500-9,000 ($56-112). These results are comparable with a study in Tanzania in which it was demonstrated that children from relatively poorer households were less likely to be adherent to prescription as compared to those from wealthier families . In the Assessment of environmental factors that can influence drug adherence revealed that availability at source influenced pattern of adherence. Availability of drugs determines which drugs are obtainable for use at the source. Majority of the respondents mainly relied on government health institutions as source of these drugs. This is because most of the respondents were relatively poor and could not afford to buy these drugs at the retail pharmacies or visit a private clinic. Government health facilities are not reliable sources of the drug since most of them suffer ‘a drug is out of stock syndrome’ and this could be a possible reason for non-adherence. However, when given at these government health institutions, they are given full dose unlike when they buy the drugs independently. These findings are, however, inconsistent with those of a study carried out in southern Ethiopia on self-treatment of malaria in rural communities, where anti-malarial drugs were bought from markets or any shops because it was close to home (43.6%), the drugs were available (25.8%), the shops were easily accessible (20.9%), and waiting time was short (11.5%) . MoreoveAssessment of accessibility of ACT revealed that availability of the drug was low since ACT was not always available at its source and majority covered longer distance to the source. These results are comparable to previous ones in Cambodia in which access to ACT in remote areas was determined and shown to be low . AnotherIn addition, the current results revealed that ACT is affordable at government health institutions. Patients aged 5 years and below are treated free of charge and those above 5 years are charged an average of KShs. 40, after which they are issued with Artemesinin Lumefantrine (AL) and analgesics. Most respondents cannot purchase the same drugs in pharmacy outlets since the prices are KShs. 250 (~$4) as compared to the KShs. 40 ($0.5) in government health institutions. The issue on high costs could also explain the reason why most of the respondents reported that when ACT is not available at the health facility, they buy cheaper alternative anti-malarials or just analgesics and wait until ACT are available. Other studies have also revealed that reduced charges at health facilities can improve accessibility ,31,32.P. falciparum malaria, which demonstrated favourable tolerability, high efficacy and adequate parasitological response to ACT in general and in particular to the standard 6-dose regimen [Furthermore, ACT acceptability in treatment of malaria was high in this study since only 4.4% of those who used ACT said that they were not content with its usage. Majority reported that ACT was effective in treatment of malaria with a small proportion believing that it was not effective. The results are consistent with those of clinical trials on ACT in the treatment of multi-drug resistant and acute  regimen ,34. The  regimen .The study was based on both self-reported and medically-diagnosed episodes of malaria experienced in the previous two weeks prior to the interview. Hence, we could not verify the authenticity of the information obtained from the respondents. Secondly, the case-specific definition of malaria could not be ascertained in this study, since some sought to over-the-counter drugs when they had symptoms similar to those of malaria. Moreover, there was recall bias in this report. Participants were asked questions based on a two-week recall period. Some of the participants would therefore, not vividly remember whether they actually had malaria/fever or how they took the drugs in the last two weeks preceding the interview. To increase accuracy on duration of treatment, hospital cards were reviewed and the drug sachets observed and number of tablets remaining or taken were counted. This certainly affected the quality of this study. However, the two week recall period is the reference period used by WHO surveys and has been adopted by many researchers for similar surveys. Therefore, findings in this report are of comparable quality. Similarly, structured interview-based studies are limited by the pre-determined responses, which are susceptible to response bias. However, attempts were made to minimize this potential source of bias by testing the tool, training field assistants in its administration, and amending it to make the wording familiar and culturally-appropriate. Finally, not asking study participants how they took Co-Artem or what advice they were given about how to take their Co-Artem was the other major limitation of the study since we could not asses the level of failure rates as a result of these components. This follows previous observations that absorption of hydrophobic lipophilic lumefantrine is greatly increased by a small amount of fat (1.2 g) co-administration  and failThis study has shown that the key challenge in changing malaria treatment policy to ACT is patients’ adherence to drug prescription and ensuring adequate access to ACT in poor rural settings where communities have limited health care services. Adherence level was low in the study area and there is potential need for interventions to improve patient adherence. Patient-centered care will be vital to encourage adherence to new treatment algorithms developed in response to the changing malaria environment in Kenya. Behaviour-change-communication (BCC) programmes should be initiated to aid in awareness creation on the consequence of non-adherence -39. MoniThe authors declare that they have no competing interests.OEO, GA, ER and CO designed, carried out the survey studies in the rural population and participated in the drafting of the manuscript. GOO, WO, RW, CAW, TW, JMO, SG, and SBA performed the statistical analyses and participated in the drafting of the manuscript. All authors read and approved the final manuscript.Department of Public Health, Maseno University, Maseno, Kenya (CAW); University of Minnesota, Centre for Global Health Research, Kenya Medical Research Institute, Kisumu, Kenya (GA); Senior Lecturer in Department of Pathology, Kenyatta University, Nairobi, Kenya (TW); Senior Lecturer in Department of Biochemistry and Biotechnology, Kenyatta University, Nairobi, Kenya (GOO); Senior Lecturer at the Department of Nursing, Masinde Muliro University of Science and Technology (JMO); Associate Professor and Dean, Faculty of Arts and Social Sciences (FASS), Maseno University, Maseno, Kenya (SG); Lecturer, Department of Biochemistry, Maseno University, Nairobi, Kenya (SBA and WO); Doctoral student at the Department of Biochemistry and Biotechnology, Kenyatta University, Nairobi, Kenya (ER); Director, School of Public Health and Community Development, Maseno University, Maseno, Kenya (CO).There is no conflict of interest for any of the authors of the manuscript due to commercial or other affiliations. The study was approved by the ethical and scientific review committees at Maseno University.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2334/12/143/prepub


Background: Gonadotropin-releasing hormone (GnRH) is a reproductive key hormone. The GnRH analogues are widely used in in vitro fertilization and treatment of sex hormone-depended cancers induced by the materials used in chemotherapeutic agents.Objective: The aim of this study is to evaluate the effects of cyclophosphamide and decapeptyl  on histomorphometry and stereology of testicular tissue as well as gonadotropic and gonadal hormones indices in mice.Materials and Methods: For this study, 24 adult male Balb/C strain mice were divided in four groups; first, cyclophosphamide (65 mg/kg/body weight (BW)), second, decapeptyl (0.05 mg/kg/BW), third, decapeptyl at first, and after 10 days of cyclophosphamide injection, and control group was received same volume of sterile saline. In order to evaluate the tissue changes in testes of the mice, sections were prepared and stained with Hematoxylin-Eosine, Periodic Acid Schief's (PAS) and Oil-Red-O staining techniques.Results: The cyclophosphamide causes histomorphologic changes in the testicular tissue; whereas such changes by decapeptyl were comparatively mild. The morphometric results revealed significant reduction in diameters of seminiferous tubules (p=0.02), and the stereological results confirmed significant differences in spermatogenesis (SI) as well as rate of tubal differentiation (TDI) indices between experimental and control groups (p=0.001). In addition, the morphometric findings proved that, there are significant decrease (p=0.001) in thicknesses of epithelia and stereologic result revealed reduction in number of cell layers in both decapeptyl and chemotherapy groups, but the decrements of these parameters were significant (p=0.02) in later group. In groups that had received cyclophosphamide, and decapeptyl alone, the LH and testosterone levels were decreased significantly (p=0.03), whereas in those that had received decapeptyl along with cyclophosphamide, the LH and FSH levels showed a decline but the level of testosterone increased.Conclusion: These results demonstrated that, analogue of GnRH i.e., decapeptyl protect morphologic, morphometric, and stereologic alterations of the testes tissue, as well as gonadotropic and gonadal hormonal changes preceding cyclophosphamide treatment in male mice.This article extracted from M.Sc. thesis. (Afsaneh Niakani) The gonadotropic releasing hormone (GnRH) plays a vital role in the control of reproduction by stimulating the release of pituitary luteinizing hormone (LH) and follicle-stimulating hormone (FSH), . There aStorehouse formulations of GnRH antagonists such as cetrorelix and cyclophosphamide could become an important addition to the clinical armamentarium. Infertility represents one of the main long-term consequences of combination chemotherapy given for cancer disease, and other malignancies , 11. Sinet al tested this hypothesis using a murine model and concluded that an agonistic analogue of GnRH appeared to protect male mice from the gonadal damage normally produced by cyclophosphamide , relative humidity (50±10%) and light (12h light/dark). They were fed with a standard pellet diet and had free access to water. For this experimental study, 24 adult and apparently healthy male Balb C/ mice with average weight of 20.00±3.00 gr were obtained from animal house of Veterinary School of Urmia University. They were housed in a specific pathogen-free environment under standard conditions of temperature  agonist (Decapeptyl) was extended by phosphate buffer saline (PBS). A depot formulation of the LHRH antagonist vial containing the 200mg powder of cyclophosphamide which is solved in 100 ml of distilled water. After adding saline (Distilled water), the vial was given severely shakes till the powder is completely resolved and a clear, colorless solution is formed. Group 1 was received a single cyclophosphamide (65 mg/kg BW) injection through intraperitoneal route. Group 2 was received a single dose of Decapeptyl (0.05 mg/kg BW) through intraperitoneal route. Group 3 was received an intraperitoneal injection of decapeptyl (0.05 mg/kg BW) at first, and 10 days after be given single dose of cyclophosphamide (65 mg/kg BW). Group 4 was received an intraperitoneal injection of the vehicle (sterile distilled water). 30 days after commence of experiment, all animals in 4 groups at first were anesthetized by Ether Vapor, and then their blood collected through intracardial route. Then immediately the serum of the samples were separated and put in deep freeze for further investigations. In the second step, after expire of all mice, their abdominal region were cut opened and their testes taken out and put in Bouin’s solution for fixation. Histologic and histomorphometric experimentset al formula , all the morphometric parameters including; diameters and epithelial thicknesses of semniferous tubules (SFTs), were recorded. The diameters of seminiferous tubule were measured by using Soudamani  formula . TubulesL= length (large diameter) and B= width . For spermatogenesis index (SI), transect of each 100 fields in each group were studied with light microscopy. The number of tubules containing spermatozoa and spermatids were counted. For the calculation of tubule differentiation index (TDI), 200 cross-sections of seminiferous tubules were randomly analyzed in each mouse (one hundred per testis). TDI is the percentage of seminiferous tubules containing at least four differentiated germ cells .et al procedure : for the identification and qualification of polysaccharides and inert mucous compounds in testicular tissues, the formalin fixed and paraffin embedding technique was used , were carried out on blood serum by using an ELISA technique, and testosterone assay were carried out on blood serum by ELISA kit. For the LH intra-assay and inter-assay, if frequency of repetition was 24, the amount of SD  was 0.53 and 0.45, respectively. For FSH intra-assay and inter-assay, if the frequency of repetition was 24, the amount of SD was 0.14 and 0.45 IU/L, respectively.Statistical analysisResults are expressed as Mean±SE. Differences between groups were assessed by the analysis of variance (ANOVA) using the SPSS software package for Windows. Statistical significance between groups was determined by Tukey multiple comparison post hoc test and the p<0.05 were considered to be statistically significant.Histomorphological findingsIn the control group, all histomorphological features in the seminiferous tubules (SFTs) were normal and no abnormality was observed . In testIn test group 3, which received cyclophosphsmide+ decapeptyl, the degenerative and destructive sings were declined in comparison to test group 1 . In the In test group 1, which received cyclophosphamide at rate of 65 mg/kg BW, the degenerative and destructive sings were higher than other groups and the population of all cell types, including spermatogonia types A and B, spermatocytes, spermatids and spermatozoa were significantly reduced . In testIn test group 3, which received cyclophosphsmide + decapeptyl, the degenerative and destructive sings were declined in comparison to test group 1, however here a little histological changes were present . In contIn test group 2, which received decapeptyl at rate of 0/05mg/kg BW, no evident changes in the seminiferous tubules and leydig's cells were seen . In testMorphometric findingsThere were significant decrease (p=001) in thicknesses of epithelia in both decapeptyl and chemotherapy groups, but the decrements of these parameters were significant (p=0.02) in later group. The group which received cyclophosphamide, were showing significantly (p=0.02) decrease in the mean diameter of SFTs in comparison to the controls. Meanwhile, in decapeptyl treated group sharp increase in this parameter was evident . The group which received cyclophosphamide, were showed significantly (p=0.001) decrease in TDI in comparison to the controls. Meanwhile, in decapeptyl treated group sharp increase in this parameter was evident, and in cyclophosphamide+ decapeptyl group the restoration of this parameter was reached to the level of controls . In all Hormonal assaysThere was not significant (p>0.05) alterations in the levels of FSH in control and different test groups . There wThere was significant (p=0.03) decrease in the level of testosterone in group which received cyclophosphamide, whereas there was significant (p=0.03) increase in the level of this hormone in decapeptyl group in comparison to the all other groups .For assessment and confirmation of the cyclophosphamide and decapeptyl  effects on the stereology of testicular tissue as well as gonadotropic and gonadal hormones indices in mice, this study was planned and performed. The results confirmed that, cyclophosphamide causes histomorphologic changes in the testicular tissue; whereas by the uses of decapeptyl, the changes were comparatively milder. The morphometric as well as stereological results were revealed significant reduction in diameters of seminiferous tubules, spermatogenesis (SI) as well as rate of tubal differentiation (TDI) indices in experimental groups, but these reductions were enhanced in group which received cyclophosphamide alone. The reductions in the levels of the FSH in test groups in comparison to controls were not significant, whereas, the levels of LH, in all of test groups particularly, in those received the cyclophosphamide alone, were highly reduced. The level of testosterone in group which received the cyclophosphamide alone was highly reduced, but in test group which received the decapeptyl alone, was highly increased. The level of testosterone in group which received cyclophosphamide plus decapeptyl almost increased to level in control group.et al the chemotherapy affecting the spermatogenic functions of testicular tissue, and the fast dividing cells in this tissue including spermatogonia are more susceptible to this cytotoxic possessions  and control groups, but significant difference in lumen diameter, thickness of epithelium and the number of cell layers in seminiferrous tubules are obvious  in testes. Reduced hypothalamic sensitivity to negative feedback effects of androgens increases GnRH secretion and consequently the amount of gonadotropin and androgen secretion increases which cause testicular growth and the incidence of other secondary sex characteristics . DecapepGnRH analogues with continuous stimulation of GnRH secretion, inhibits the decrement in secretion of LH and FSH hormones . A GnRH et al cross connections in the active parts of chromosomes are damage in chemotherapy (According to Masta otherapy . Evidencotherapy . Men treotherapy . Since totherapy , 39.In most of the cases, azoospermia and oligospermia are consequents of cancer therapy in males. According to Howell and Shalet, the germinal epithelium in the testis is more vulnerable to chemotherapy than those of mature adult cells . The resThe damages caused by chemotherapy or radiation therapy could be on somatic cells of the testis, like as Sertoli and leydig’s cells . Our resAccording to previous reports , 43 and The present study showed that, chemotherapy with cyclophosphamide in male mice cause changes in the testes histology and treatment with decapeptyl brings about protection of seminiferous tubules.The authors declare that there are no conflicts of interest in this study.


We investigated the association between heart rate and its variability with the parameters that assess vascular, renal and cardiac target organ damage.A cross-sectional study was performed including a consecutive sample of 360 hypertensive patients without heart rate lowering drugs . Heart rate (HR) and its standard deviation (HRV) in clinical and 24-hour ambulatory monitoring were evaluated. Renal damage was assessed by glomerular filtration rate and albumin/creatinine ratio; vascular damage by carotid intima-media thickness and ankle/brachial index; and cardiac damage by the Cornell voltage-duration product and left ventricular mass index.There was a positive correlation between ambulatory, but not clinical, heart rate and its standard deviation with glomerular filtration rate, and a negative correlation with carotid intima-media thickness, and night/day ratio of systolic and diastolic blood pressure. There was no correlation with albumin/creatinine ratio, ankle/brachial index, Cornell voltage-duration product or left ventricular mass index. In the multiple linear regression analysis, after adjusting for age, the association of glomerular filtration rate and intima-media thickness with ambulatory heart rate and its standard deviation was lost. According to the logistic regression analysis, the predictors of any target organ damage were age (OR = 1.034 and 1.033) and night/day systolic blood pressure ratio (OR = 1.425 and 1.512). Neither 24 HR nor 24 HRV reached statistical significance.High ambulatory heart rate and its variability, but not clinical HR, are associated with decreased carotid intima-media thickness and a higher glomerular filtration rate, although this is lost after adjusting for age.NCT01325064ClinicalTrials.gov:  Traditionally, high heart rate (HR) at rest has been directly associated with a risk of cardiovascular (CV) disorders, both in the general and in the elderly population , as wellThe aim of the present study therefore was to assess the association between office and ambulatory HR and its variability with the parameters that assess the presence of vascular, renal and cardiac target organ damage.This was a cross-sectional study performed in a primary care setting. We included 360 hypertensive patients without heart rate lowering drugs, aged 30-80 years, and seen in their primary care clinics between January 2008 and June 2010 through consecutive sampling. All patients enrolled agreed to take part in the study. The protocol was approved by an independent ethics committee of Salamanca University Hospital , and all participants signed the corresponding informed consent forms.Sample size calculation indicated that the 360 patients included in the study were sufficient to detect a minimum correlation coefficient between heart rate or its variability and subclinical organ damage parameters of 0.15 in a two-sided test, with a significance level of 0.05 and a power of 0.81.Clinical blood pressure and heart rate measurements were obtained by performing three measurements of systolic blood pressure (SBP) and diastolic blood pressure (DBP), with a validated sphygmomanometer, OMRON M7 model , following the recommendations of the ESH . For theAmbulatory blood pressure monitoring (ABPM) was performed on a day of standard activity with a cuff adequate for the size of the patient's arm. A control system, the Spacelabs 90207 model , was used and validated according to the protocol of the British Hypertension Society . Of the The electrocardiography examination was performed with a General Electric MAC 3.500 ECG System  that automatically measures the voltage and duration of waves and estimates the criteria of the Cornell voltage-duration product (Cornell VDP)  to assesKidney damage was assessed by measuring the glomerular filtration rate estimated (eGFR) by the CKD-EPI (Chronic Kidney Disease Epidemiology Collaboration) equation  and protCarotid ultrasonography to assess IMT was performed by two investigators trained for this before starting the study. The reliability of which was evaluated before the study began using the intraclass correlation coefficient, which showed values of 0.974 (95%CI: 0.935 - 0.990) for intra-observer agreement on repeated measurements in 20 subjects, and 0.897 (95%CI:0.740 - 0.959) for inter-observer agreement. According to the Bland-Altman analysis, the limit of inter-observer agreement was 0.022 (95%CI: -0.053 - 0.098) and the limit of intra-observer agreement was 0.012 (95%CI: -0.034 - 0.059). A Sonosite Micromax ultrasound device paired with a 5-10 MHz multifrequency high-resolution linear transducer with Sonocal software  was used for performing automatic measurements of IMT for optimizing reproducibility. Measurements were taken from the common carotid artery after the examination of a 10-mm longitudinal section at 1 cm away from the bifurcation. We performed measurements of the anterior or proximal walls and of the posterior or distal walls in the lateral, anterior and posterior projections, following an axis perpendicular to the artery to discriminate two lines, one for the intima-blood interface and the other for the media-adventitious interface. Six measurements were obtained of the right carotid and another six of the left carotid, using mean values (mean IMT) and maximum values (maximum IMT) calculated by the software automatically. The measurements were obtained following the recommendations of the Manheim Carotid Intima-Media Thickness Consensus . Mean IMThis parameter was evaluated using the ankle-brachial index (ABI) and was performed in the morning in patients who had not consumed coffee or tobacco for at least 8 hours prior to measurement in an ambient temperature of 22-24°C. With the feet uncovered and the patient in a supine position after 20 min of rest, the pressure in the upper and lower extremities was measured using a portable Minidop Es-100Vx Doppler system . The probe was applied at posterior tibial artery at an angle of approximately 60° relative to the direction of blood flow. The transducer's cuff was quickly inflated on each ankle to about 30 mm Hg above the systolic pressure, and the pressure was then allowed to descend (by about 2 mmHg per second) until the first sound corresponding to the systolic pressure was heard. Blood pressure was also measured in both arms . The ABI was calculated separately for each foot by dividing the higher of the two systolic pressures in the ankle by the higher of the two systolic pressures in the arm. Target organ damage was considered present if the ABI was lower than 0.9  and missContinuous variables were expressed as the mean ± standard deviation (SD), while qualitative variables were expressed on the basis of their frequency distribution. The Pearson correlation coefficient was used to estimate the relationship between quantitative variables. The multivariate analysis involved eighteen multiple linear regression models with mean IMT (nine models) and CKD-EPI (nine models) as dependent variables. We included as independent variables, clinical HR, 24-hour HR, awake HR, sleep HR, 24-hour HRV, awake HRV, sleep HRV, N/D HR ratio and N/D HRV ratio, one in each model, and age as the adjusted variable. Logistic regression analysis was performed, including as dependent variable the absence "0" or presence "1" of any TOD and as independent variables, using the enter method, age, gender, antihypertensive drugs, systolic N/D (night/day) ratio, office systolic blood pressure, waist circumference, atherogenic index , smoking, diabetes mellitus and 24-hour HR in the first model and 24-hour HRV in the second model. An α risk of 0.05 was established as the limit of statistical significance. The SPSS/PC+ version 15.0  statistical package was used throughout.Table Tables These correlations were stronger in diabetics patients and the subgroup without antihypertensive treatments and weaker in the subgroup with antihypertensive drugs, losing statistical significance in some of the correlations of HR and HRV with IMT and systolic and diastolic blood pressure night/day ratio. The statistics signification of the association found between HR and HRV with IMT and eFGR was lost after adjusting for age.2.Figure According to the logistic regression analysis Table , the preThe data obtained in our study suggest that there is an association between ambulatory, but not clinical, HR and its variability with respect to IMT and eGFR, whereas no association was observed with respect to albumin/creatinine index, Cornell VDP, LVMI or ABI in patients without heart rate lowering drugs. However, this association is lost after adjusting for age. On the other hand, the variable with the greatest capacity to predict the presence or absence of target organ damage was night/day systolic ratio, without HR or HRV reaching statistical significance in the logistic regression models.The association found with ambulatory HR but not with office HR could be due to white coat phenomenon that increases and modify the basal HR in the office.The association between HR and its variability with respect to the development of target organ damage or vascular conditions has not been clearly established. Barrios et al.  noted thFácila et al.  studied Gottsäter et al.  found a Brotman et al.  noted anMartini et al.  found a They also concluded that there is a continuous negative association between left ventricular mass and HRV, while Cuspidi et al.  found siFinally, in our study the most important predictive variable of damage to any target organ was the night/day systolic ratio (OR = 1.418). A fact that had already been suggested in 1997 by Mancia et al. , indicatThe main limitation of this study is its cross-sectional design, which precludes longitudinal analysis between HR, HRV and TOD. Another limitation is the selection of the study population, since sampling was performed consecutively with pragmatic and broad inclusion criteria; thus, the study population included hypertensive patients, some with diabetes and hyperlipidemia, and many patients receiving drug therapy (not HR lowering drugs). This could modify blood pressure levels and thus limit the validity of some results. Consequently, the heterogeneity of the sample could lead to some limitations when interpreting the results, though it is quite similar to the distribution of the general population of hypertensive patients with some cardiovascular risk factors.In conclusion, high ambulatory HR and its variability, but not clinical HR, were associated with a decreased carotid intima-media thickness and a higher glomerular filtration rate, although it was lost when adjusted for age. We found no association of HR with albumin/creatinine ratio, Cornell VDP, left ventricular mass index or ankle/brachial index. In summary, the data from this study indicate that the associations found between HR and its variability with the parameters that assess target organ damage is mediated principally by age. This would be contrary to consider the HR as an independent risk factor for the appearance of TOD.However, given the discrepancies found in the literature, we consider that further prospective studies are needed in order to determine the association between HR and its variability with cardiovascular risk in the early stages of hypertension and prior to the development of TOD.The authors declare that they have no competing interests.AGG and LGO devised the study, designed the protocol, participated in fund raising, and prepared the draft manuscript. CPA collaborated in protocol design and data interpretation. JIRR, ERS and CAC participated in study design, data collection, and manuscript review. MAGM participated in protocol design, fund raising, analysis of results, and final review of manuscript. Finally, all authors reviewed and approved the final version of the manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2261/12/19/prepub


In HIV-infected patients, combination antiretroviral therapy (cART) is associated with clinical lipodystrophy (CL) and metabolic abnormalities (MA). This study aimed to evaluate the prevalence of the metabolic syndrome (MS) and its components, and to determine whether patients with or without CL had a different prevalence of MA.We evaluated 345 HIV-infected patients on cART using two different MS definitions (NCEP-ATPIII-2005 and IDF-2005) and the Framingham risk score.CL was present in 58.7% of the patients. The prevalence of the MS was 52.2% (ATPIII) and 43.2% (IDF), and it was not significantly different between patients with (W) or without (WT) CL, regardless of the definition used . Moderate concordance was observed between the 2 definitions  and after gender stratification there was good concordance in women . Patients with CL had lower waist circumference and HDL-C and higher triglycerides levels. In women, CL was significantly associated with MS, hypertriglyceridemia and low HDL cholesterol independently of age, cART and BMI. Patients with CL had a significantly higher risk of coronary heart disease at 10 years, measured by the Framingham risk score, than patients without CL. Those with CL and with MS had higher frequencies of moderate and high risk categories than those without MS.The prevalence of the MS was high in these HIV-infected patients with an age average of 40 years and this finding could explain why HIV patients have an increased risk for cardiovascular disease (CVD). Combination antiretroviral therapy (cART) has changed the course of HIV infection, leading to a significant reduction in AIDS related morbidity and mortality . HoweverThe Metabolic syndrome (MS), a common condition in the general population, refers to a constellation of cardiovascular disease (CVD) risk factors, including increased waist circumference (WC), glucose and lipid metabolism disorders, and hypertension ,5. Each HIV-lipodystrophy is considered to be an adverse effect of cART, not limited to a specific drug or class of drugs . It seemThe aim of this study was to evaluate the prevalence of the MS and of its five individual components in HIV-infected patients on cART and to determine whether patients with or without CL had a different prevalence of MA.As part of a cross-sectional study, 345 non-institutionalized, HIV-infected Caucasian adults , on cART referred from the Infectious Diseases to the Endocrinology Out-patient Clinic of Hospital São João due to lipodystrophy or any metabolic disorders were included. Only patients on cART were included, since lipodystrophy is mainly related to ART drugs. The study protocol was approved by the Hospital's Ethical Committee and all patients provided informed consent.®, model TBF 300) scale and height was measured to the nearest centimetre in the standing position using a wall stadiometer .For each patient the following information was collected, using a standardized protocol: demographic data , duration of HIV infection, history of diabetes, hypertension, use of antidiabetic, antihypertensive or lipid-lowering drugs and duration of cART. Weight, height, WC and resting BP were measured as previously described . Body weNo lipodystrophy ; group 2- Isolated central fat accumulation ; group 3- Isolated lipoatrophy ; group 4- Mixed forms of lipodystrophy .Clinical lipodystrophy (CL) and central fat accumulation or abdominal prominence, were defined as previously described . All cliA venous blood sample was drawn after a 12-hour overnight fast. All the samples were analyzed at the central laboratory of our hospital. Plasma glucose, total cholesterol, HDL cholesterol (HDL-C) and triglycerides were determined using automatic standard routine enzymatic methods. Hepatitis C was diagnosed by HCV-Ab serostatus. The CD4+ cell count was determined by flow cytometry and plasma RNA-VIH was measured by a quantitative reverse transcriptase polymerase chain reaction, which had a lower limit of detection of 50 copies/mL.Two different MS definitions were used: the Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (ATPIII) modified by American Heart Association/National Heart, Lung, and Blood Institute Scientific Statement (AHA/NHLBI) in 2005  and the The Framingham cardiovascular risk score was calculated for all patients using the Framingham methodology as reported by Wilson. It incorporates age, gender, systolic blood pressure, lipids, glucose, and smoking status into a model that predicts the probability of coronary heart disease risk at 10 years .th and 75th percentiles. For comparison between quantitative variables Student-t test and the Mann-Whitney test were used when appropriate. Categorical variables were described as counts and proportions, and compared using the chi-square or Fisher's exact test. Kappa coefficients were estimated to analyze the statistical agreement between ATP III as modified by the AHA/NHLBI and IDF definitions of MS.Data were presented as mean and standard deviation (SD) for quantitative variables when normally distributed. When the variable distribution was different than the normal, it was expressed as median and respective 25Odds ratios and their respective 95% confidence intervals (CI) were computed using unconditional logistical regression models. The association between lipodystrophy and the presence of MS and its individual components was estimated after adjustment for sex, age, cART duration and BMI, whenever appropriate.Statistical analysis was performed using the SPSS version 17.0 software . All probabilities were two tailed and p values < 0.05 were regarded as significant.Of the 345 HIV-1 infected patients on cART included in this study, 58.7% presented CL. Table Regarding BMI distribution, men and women with CL, were more frequently classified as normal when compared to those without CL. Those without CL were more frequentely classified as overweight Table .In our sample, the prevalence of MS was 52.2% and 43.2%, according to ATPIII and IDF criteria, respectively. No significant differences in the prevalence of the MS were observed in patients with or without CL, regardless of the definition used table .Regarding the aggregate of the MS criteria using the ATP definition, the most frequent aggregate number was 2, except for men without CL. On the other hand, using the IDF definition, the most frequent aggregate number was 3, except for women without CL table  and 6. NConcerning the frequency of the individual ATPIII criteria for MS, we found a significantly lower prevalence of central obesity in men with CL and no other significant differences were observed. No significant differences were found in the frequency of the five IDF criteria for the MS in men table .In women with CL, using either ATPIII or IDF criteria, we found a statistically higher frequency of hypertriglyceridemia and lower HDL-C levels. According to ATPIII criteria, women with CL had a lower frequency of central obesity Table .No significant differences were found between the cumulative number MS features according to the presence of CL in both genders Table  and 6.In men, high blood pressure, high WC and the MS were more frequent in those with isolated central fat accumulation and mixed forms of lipodystrophy using either ATPIII or IDF criteria. High fasting glucose levels were significantly more frequent in patients with isolated central fat accumulation and mixed forms of lipodystrophy using ATPIII criteria and without any differences (p = 0.058) in the 4 groups of fat distribution using the IDF criteria table .In women, no significant differences were found in high blood pressure and high fasting glucose levels in the four groups of fat distribution (either ATPIII or IDF criteria). Hypertriglyceridemia, low C-HDL levels, high waist circumference and presence of the MS were more frequent in patients with isolated central fat accumulation and mixed forms of lipodystrophy using either ATPIII or IDF criteria table .Men and women with CL, after adjustment for age and cART, had significantly lower odds of having central obesity, as defined by the ATPIII criteria .In women, CL was significantly associated with higher odds of having MS as defined by IDF [OR = 5.290 (95%CI: 1.502-18.635)], hypertriglyceridemia [OR = 5.917 (95%CI: 1.50-23.349)] and low HDL cholesterol [OR = 3.990 (95%CI:1.252-12.716)], independently of age, cART and BMI tables .No significant differences were found in the five classes of the Framingham risk score between patients with or without CL (data not shown).Patients with CL had a significantly higher median risk of coronary heart disease at 10 years, measured by the Framingham risk score, than patients without CL, . Independent of the presence of CL, those with MS had a higher median of the Framingham risk score. In patients without CL, those with MS had a higher Framingham risk score median than those without MS, . Also, in patients with CL, those with MS, had a higher Framingham risk score than those without MS, .In patients with CL, we found significant differences in the Framingham risk score classes between patients with or without MS. Patients with CL and with MS had higher frequencies of moderate and high risk categories than those without MS table .To our knowledge, this is the first study conducted in HIV-infected patients focusing specifically on the role of subcutaneous adipose tissue atrophy defined by presence of CL on the prevalence of the MS. Another particularity is that all patients were on cART. Other studies analysed the presence of the MS in naïve or on cART HIV-infected patients, with sub-analyses concerning the presence of CL in patients with the MS ,14,17.per se, including genetic lipodystrophy syndromes, is associated with lipid and metabolic disturbances, and hasmany similarities with the MS [cART can induce a large spectrum of metabolic disturbances. On the other hand, lipodystrophy h the MS ,31-35. Th the MS  and its h the MS ,38. Our It is unknown if the MS is more frequent in patients with lipodystrophy compared to either with patients without lipodystrophy and not HIV-infected ,17. We fStudies of prevalence of MS in HIV-infected individuals compared with control populations revealed different prevalences of MS) -23 and iIn our sample, the prevalence of MS was lower using the IDF definition compared to the ATPIII criteria either in the total of the patients or in men with or without CL. On the other hand, in women it was higher when the IDF definition was used. This probably mirrors the fact that central obesity is a compulsory criterion for the IDF definition, and, women had a higher mean of WC. Since HIV patients despite lower WC had increased visceral fat, Capeau J proposed that a different WC cut-off is needed for HIV patients . In factNo differences in the prevalence of ATPIII or IDF defined MS between patients with and without CL were observed, like it was previously described by Estrada . In womeIn the Jericó and Mangili studies, the prevalence of MS in HIV-infected patients significantly increased with age . In our Regarding gender differences, as in our study, Mangili reported that significantly more women than men had MS .Concerning the number of MS components, in our study and according to IDF definition, we had 25% of patients with two features of MS which is lower when compared to other studies ,17. In tConcerning the prevalence of the individual features of MS, we found that the two least prevalent features were high fasting glucose level (similar to Bonfatti and Sobieszczyk) ,21 and hOur study had some limitations. We did not exclude patients with diabetes or hypertension diagnosed prior to HIV infection. We also cannot discard the influence of the pre-HIV body composition, the cumulative exposure time of each drug and the nadir value of CD4 factors that could contribute to the risk lipoatrophy or abdominal prominence that were not evaluated. It is difficult to compare results on the prevalence of MS because of the heterogeneity in populations regarding past and actual cART regimens and treatment adherence. Regarding the CD4 count we only presented the values at the time of the cross sectional evaluation, because we did not have access to the nadir value. Finally, there exists the possibility of selection bias. Some subjects in this study were referred from to Endocrinology Clinics specifically for lipodystrophy or metabolic disorders related to cART, and so we might have selected for a study population enriched for metabolic complications.In women, CL was significantly associated with the metabolic syndrome, hypertriglyceridemia and low HDL cholesterol independent of age, cART and BMI.Our data showed that among HIV patients on cART, the prevalence of MS may be remarkably high, especially when taking into account the mean age of our sample. The observation that patients with CL had a significantly higher risk of coronary heart disease at 10 years, measured by the Framingham risk score, than patients without CL and those with CL and with MS had higher frequencies of moderate and high risk categories than those with CL but without MS, emphasizes the importance of the clinical diagnosis of this condition.AHA/NHLBI: American Heart Association/National Heart, Lung, and Blood Institute Scientific Statement; ATPIII: The Third Report of Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults; BP: Blood pressure; cART - Combination antiretroviral therapy; CL: Clinical lipodystrophy; CVD: Cardiovascular disease; HIV: Human immunodeficiency virus; IDF: International Diabetes Federation; MA: Metabolic abnormalities; MS: Metabolic syndrome; NCEP: National Cholesterol Education Program; WC: Waist circumference.The authors declare that they have no competing interests.PF conceived the study, participated in its design, in the acquisition of data and drafted the manuscript; DC conceived the study, participated in its design and drafted the manuscript; SS participate in the acquisition of data and drafted the manuscript; SX participate in the acquisition of data; ACS performed the statistical analysis and revised critically the manuscript; RM participated in its design and revised critically the manuscript; EM and AS revised critically the manuscript; JLM revised the study design. All authors read and approved the final manuscript.Research Fellowship Dr. Manuel Almeida Ruas, Portuguese Society of Diabetology. Research Fellowship of the Portuguese Association for Clinical Study of AIDS. Research Grant to support doctoral studies in the area of HIV/AIDS Foundation GlaxoSmithKline of Health Sciences.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2334/11/246/prepub