Limited studies have examined the association between lung cancer and bronchiectasis (BE). This study evaluated the regional association between BE and lung cancer by analyzing the lobar location of lung cancer in patients with underlying BE.This clustered multi-level study enrolled patients who had underlying BE and were newly diagnosed with lung cancer between January 1, 2010 and May 30, 2013 in two referral hospitals in South Korea. By analyzing the presence of lung cancer and underlying BE as event variables at the level of lung lobes on chest computed tomography (CT), we evaluated the association of BE and lung cancer by the locations of the diseases.p-value = 0.001).Eighty-one patients with BE and combined lung cancer were enrolled. Within 486 lung lobes of the patients, combined BE and lung cancer in the same lobe was found in 11 lobes (2.3 %). Using the general estimating equation assuming BE as a risk factor of lung cancer, the results indicated that the prevalence of lung cancer was significantly lower in the lobes with pre-existing BE  contains supplementary material, which is available to authorized users. Chronic inflammation plays a key role in carcinogenesis via disordered necrotic cell death, subsequent epithelial proliferation, and suppressed immunity . Like otBronchiectasis (BE) is a representative chronic inflammatory airway disease characterized by abnormal and permanent dilatation of the bronchi, accompanied by high levels of inflammatory cytokines . Unlike Considering reports on the influence of inflammatory signaling in carcinogenesis, chronic inflammation caused by BE might be associated with an increased risk of lung cancer because of the local effects of chronic inflammation caused by repeated airway injury and impaired mucociliary clearance. If this postulate holds, it is reasonable to think that the incidence or prevalence of cancer should be increased close to the pre-existing BE in location , 6, 7.However, there are only limited data on an association between BE and the risk of lung cancer. A few studies reported that patients with BE had elevated levels of serum transforming growth factor-β1 (TGF-β1), which is a potential protective factor against carcinogenesis , 8, 9. IThe aim of this study was to assess the association between BE and the risk of lung cancer by analyzing the lobar location of lung cancer in patients with underlying BE.We designed this multi-center-based, retrospective, clustered, multi-level study analyzing the presence of lung cancer and BE as event variables at the level of lung lobes in patients with underlying chronic BE who were newly diagnosed with lung cancer between January 1, 2010 and May 30, 2013. We identified the patients older than 40 years with BE at two referral hospitals in South Korea: Seoul National University Boramae Medical Center and Seoul National University Hospital. Among them, the patients newly diagnosed with lung cancer in the study period were enrolled and analyzed. The flow diagram selecting study population for analyses is shown in Fig. Pre-existing BE was assessed and confirmed with chest computed tomography (CT) analyzed independently by a radiologist and a pulmonologist . If incoAmong the patients with combined emphysema, the severity of emphysema was assessed visually with CT images according to the modified Goddard scoring system , 15. SixP-values < 0.05 were recognized as indicative of statistical significance. All analyses were performed using the SPSS software, version 19.0 .Age was given as the median and interquartile range (IQR), while other continuous variables were given as the means with the standard deviations. To evaluate correlations within a subject and within lobes by repeated measures of the events (BE and lung cancer), generalized estimating equations were used and the β-value was calculated. To eliminate any possible interaction that might exist between smoking and BE, analyses were further stratified by the smoking status of the patients. In addition, since emphysema is an important risk factor for lung cancer, subgroup analyses were performed in groups classified according to the presence and severity grade of emphysema. 1/FVC ratio of 67.7 and mean predicted FEV1 of 87.9 %.Eighty-one patients with pre-existing BE were diagnosed with lung cancer during the study period. The baseline characteristics of the study participants are shown in Table Seventy-three patients (90.1 %) were diagnosed with non-small-cell lung cancer. Adenocarcinoma was the most common histological type (51.9 %), followed by squamous cell carcinoma 22.2 %) and poorly differentiated carcinoma (7.4 %). When stratified by smoking status, there was significant difference in the histologic type of lung cancer between the current/former smoker group and the never-smoker group  in the analysis of the total lung cancer patients, indicating that the prevalence of lung cancer was significantly lower in lobes with pre-existing BE (Table p = 0.021) and the never-smoker group . When evaluating the lobes stratified by the presence and severity of emphysema of the patients, prevalence of lung cancer was significantly lower in lobes with pre-existing BE in patients with no or mild emphysema . Although not statistically significant, similar trends were shown in the lobes in patients with moderate  and severe emphysema .To assess the locations of BE and lung cancer, we evaluated 486 lung lobes from 81 patients. Because 4 patients had primary tumors in 2 lobes, the total number of lobes affected with lung cancer was 85. Lung cancer most commonly involved the right upper lobe (5.6 %), followed by the right lower (4.1 %) and left upper lobe 3.9 %)  could be ignored in our study.The main strength of our study is that the presence of lung cancer and BE was assessed with chest CT, a precise means of evaluating the location of the disease at the level of the lung lobes. In addition, because we analyzed the association between the two diseases by location within patients known to have both diseases, the possible confounding factors of the risk of lung cancer in each patient , which can be an important issue when discussing the role of chronic inflammation in BE. Lastly, due to the limited data collected on the field of inflammation and carcinogenesis related BE, the validity of the potential explanations on our findings and the role of chronic inflammation might be low. Nevertheless, considering the limited data and difficulty to perform large-scaled studies on the association between BE and lung cancer, our results still would provide novel and relevant information, and motivation for further studies.Although this study was not a longitudinal study following BE patients, it is reasonable to believe that in the patients evaluated in our study, BE preceded the development of lung cancer since BE is generally accepted to be a chronic condition following infection in childhood, while lung cancer usually develops within years of the initial diagnosis . MoreoveRegionally, pre-existing BE was associated with a lower risk of the occurrence of lung cancer in the same lobe.


In general, a drug candidate is evaluated using 2D-cultured cancer cells followed by an animal model. Despite successful preclinical testing, however, most drugs that enter human clinical trials fail. The high failure rates are mainly caused by incompatibility between the responses of the current models and humans. Here, we fabricated a cancer microtissue array in a multi-well format that exhibits heterogeneous and batch-to-batch structure by continuous deposition of collagen-suspended Hela cells on a fibroblast-layered nanofibrous membrane via inkjet printing. Expression of both Matrix Metalloproteinase 2 (MMP2) and Matrix Metalloproteinase 9 (MMP9) was higher in cancer microtissues than in fibroblast-free microtissues. The fabricated microtissues were treated with an anticancer drug, and high drug resistance to doxorubicin occurred in cancer microtissues but not in fibroblast-free microtissues. These results introduce an inkjet printing fabrication method for cancer microtissue arrays, which can be used for various applications such as early drug screening and gradual 3D cancer studies. Animal models are limited in their ability to mimic extremely complex carcinogenic and physiological processes in humans and more than 90% of drugs that pass animal trials fail in the clinical trials ,2. VarioIn the drug discovery process, multiple tests are required to verify various factors such as efficacy, safety, and dose of the drug . CurrentThe tumor microenvironment is constantly evolving owing to tissue remodeling and changes in the recruitment of stromal cells including a diversity of immune cells with angiogenesis. As the tumor becomes larger, the phenotype of cancer cells changes to aggressive, and in the tumor microenvironment, the extracellular matrix also changes . In addiThis study used cervical cancer cells, which are invasive and aggressive and closely associated with matrix metalloproteinases (MMPs). In particular, MMP2 and MMP9 have been found to be the most important in the degradation of the basement membrane and extracellular matrix needed for cells to acquire invasive capabilities . In thisThe diameter distribution of the nanofibers characterized by SEM imaging a is showThe printing droplet frequency was set at 10 Hz, and the distance between the printer head and NF was maintained at 2 mm or less to minimize physical damage to the cells during printing. The piezo actuation of the inkjet printing was as shown in To fabricate cancer microtissue samples, droplets of the 0.5% collagen bioink containing cancer cells were dropped 150 times using an inkjet printer on a NF as shown in In this study, we aimed to pattern four cancer microtissue arrays  within a diameter of 10 mm. In order to insure the consistency in size of each microtissue, the same number of cells needs to be seeded at one point in designed positions. Inkjet cell printing technology was used for microtissue array fabrication since it enables high resolution patterning of specific cells with soluble biomaterials, providing an ideal environment for fabricating the biomimetic samples. The viability of printed cells compared with that of cells suspended only in medium (bioink) or medium containing 0.5% collagen (collagen-containing bioink) was evaluated through a Live/Dead assay a,b. The As shown in We next compared mono-cultured cancer microtissue and co-cultured  was added to the cancer microtissues at day 7, and the resistance of the cells to the anticancer drug was examined by screening through the Live/Dead staining method a–h. MoreEnvironmental factors have significant biochemical influences on cells . A two-dThe complex test processes and high throughput of each cell are the greatest obstacles to quantitative and in-depth molecular analysis of single cells or cell populations. The distribution of cells can be quantified by patterning cells to aid in the study of cell processes, such as reactions between individual tissues and cells. The advantage of patterning technology is the exposure of tissues to the same conditions owing to the arrangement of tissues. This study exploited inkjet printing to arrange cancer microtissues on nanofibrous membranes and analyzed the viability, size changes, and other characteristics of the patterned microtissues. The analysis showed that the viability of the cells was close to 100% when they were printed on a nanofibrous membrane using an inkjet printer, and the cancer microtissues produced and patterned using inkjet printing maintained their initial patterns even after culturing for one week. Such patterned cancer microtissues can be multi-screened, thus enabling simultaneous verification of the changes in the size of multiple cancer microtissues and observation of various tissues.The rapid evaporation of droplets is one of the greatest drawbacks of the inkjet cell printer. The easy evaporation of droplets in micro units makes it difficult to culture cells, and many researchers have addressed this problem by printing hydrogels in wells containing a crosslinking agent ,18,19. IIn future studies, the immunity network based on the interaction between immune cells and the fabricated cancer microtissues will be simulated, and drug tests with a sample with such an immunity network are expected to produce results that are closer to the results obtained from the human body. The significance of this study is the simulation of in vitro cancer tissues in drug tests and the production of highly reliable samples. The failure rates of clinical trials are expected to decrease as the reactions to drugs would better replicate those in the human body, and this will have positive effects on pharmaceutical discovery processes with low success rates.NF was fabricated by a previously reported electrospinning method ,21. Brie2 at 37 °C for 2 min. After culturing, the detached cells were collected in a 15-mL conical tube into which culture medium was added, diluted 10 times to neutralize the trypsin, and centrifuged for 3 min at 1200 rpm. The cells obtained after removal of the supernatant were mixed with the culture medium and then used in the experiment.Fibroblasts  and HPV18-positive cervical cancer cells  were cultured with a medium containing 10% FBS and 1% Pen Strep in a 100-mm Petri dish . When cell confluency reached 80%, the cells were washed three times with PBS and treated with 2 mL of trypsin-EDTA  to produce single-cell units before culturing in 5% COThe fibroblasts  and bioink was verified. To examine the effects of the bioink on the droplets, the culture medium with or without 0.5% collagen was mixed with HeLa cells  was used in this experiment according to the manufacturer’s recommended procedure. In brief, 20 μL of 2 mM EthD-1 stock solution enclosed in the product was added to 10 mL of PBS and mixed by vortexing. Then, 5 μL of 4 mM calcein AM stock solution was added to the mixed solution, which was vortexed again to produce a live/dead solution. The samples were washed out three times with PBS and treated with the live/dead solution on the NF. Then, the specimen was cultured at room temperature, i.e., 20 °C, for 40 min.Specifically, to compare the viability of printed cells on dried glass and wetted nanofibrous membrane , the priThe sample was fixed by treatment with 4% paraformaldehyde for 20 min at room temperature and then washed three times with PBS to remove the paraformaldehyde. The washed sample was treated with 0.1% Triton X-100 for 15 min at room temperature to ensure permeability and then washed out with PBS three times. BSA buffer (1%) was used as the blocking buffer, and after treatment for 1 h at room temperature, the sample was washed with PBS three times. Then, the specific antibodies  were diluted in PBS at a ratio of 1:500. The primary and secondary antibodies were applied to the sample for 1 h at room temperature without light exposure.Human MMP2  and MMP9  ELISA kits were used to measure the level of MMP2 and MMP9. The procedure was followed the manufacturer’s instructions. To summarize, 100 μL of the standard sample, which was the benchmark, and 100 μL of the specific experimental sample to be measured in this experiment were added to the well plates and cultured for 150 min at room temperature. Then, the solution was removed and the plates were washed with distilled water and PBS-Triton. Then, 100 μL of biotinylated  detection antibody was added to the well plates and mixed carefully for 1 h at room temperature. The solution was removed and the well plates were washed again with distilled water and PBS-Triton. Then, 100 μL of HRP–streptavidin solution was added to each well plate and carefully mixed for 45 min at room temperature. The well plates were washed with distilled water and PBS-Triton again, and 100 μL of TMB one-step substrate reagent was added to each well plate and carefully mixed for 30 min at room temperature without light exposure. Finally, 50 μL of the stop solution was added to each well plate and the absorbance at 450 nm was measured using a microreader. The amount of MMP in the cancer microtissue sample was compared with that in the standard sample.2 at 37 °C. Then, the amounts of MMP2 and MMP9 expressed after one and two days of administration were measured with ELISA, and a Live/Dead assay was used to examine the drug resistance of the fabricated cancer tissues.Doxorubicin  was used to verify the drug resistance of the fabricated samples. The doxorubicin was diluted to 0.1, 1.0, and 2.0 μM in cell culture medium and added to the day-7 co-cultured samples, after which further culture was performed in 5% COp < 0.01, ** p < 0.005, *** p < 0.001.All of the data were presented as the mean ± standard deviation (SD). Statistical significance was defined as * This study fabricated a cancer microtissue array by inkjet printing cancer cells on NF on which fibroblasts were cultured. The cancer microtissues fabricated by printing cells on NF with a bioink containing 0.5% collagen showed the highest performance. The shapes of the cell aggregates were maintained well when the printed cancer cells were co-cultured with fibroblasts, and the tissues maintained their shapes and sizes with no significant variations until day 7 after production. The patterned cancer microtissues could be distinguished by staining of HPV18 in the fibroblast-layered microtissue, and their three-dimensional structures were verified using frozen sections, SEM, and confocal microscopy. The fibroblast-layered microtissue showed higher expression of MMP2 and MMP9 compared with the monocultured microtissue and higher resistance to doxorubicin.


This study investigates if laboratory data can be used to assess whether physician-retesting patterns are in line with established guidelines, and if these guidelines identify deteriorating patients in a timely manner. A total of 7594 patients with high cholesterol were studied, along with 2764 patients with diabetes. More than 90% of borderline high cholesterol patients are retested within the 3 year recommended period, however less than 75% of pre-diabetic patients have repeated tests within the suggested 1-year time frame. Patients with borderline high cholesterol typically progress to full high cholesterol in 2–3 years, and pre-diabetic patients progress to full diabetes in 1–2 years. Data from routinely ordered laboratory tests can be used to monitor adherence to clinical guidelines. These data may also be useful in the design of adaptive testing strategies that reduce unnecessary testing, while ensuring that patient deterioration is identified in a timely manner. Established guidelines for testing of total serum cholesterol for hypercholesterolemia are appropriate and are well-adhered to, whereas guidelines for glycated hemoglobin A1c testing for type 2 diabetes mellitus could be improved to bring them in line with current practice and avoid unnecessary testing. CVD costs the United States more than $315 billion annually, consuming almost one in every six dollars spent on healthcare2. Prevention of CVD would markedly decreases costs to the health system, and would improve quality of life at a population level.Cardiovascular disease (CVD), including ischemic heart disease and stroke, is the primary cause of death worldwide, leading to 32% of all deaths worldwide in the year 20134, and are easily diagnosable with simple laboratory tests5. To identify at-risk patients in the United States, professional organizations publish screening guidelines outlining the utilization of laboratory testing. Well-established guidelines are in place for screening of both hypercholesterolemia and diabetes . All methods were performed in accordance with guidelines and regulations for research involving patient data, as provided by the Stanford University IRB and the Center for Bioinformatics Research. Informed consent was not required for this study. All data from STRIDE is compliant with the Health Insurance Portability and Accountability Act (HIPAA); all information that could lead to identification of a study participant has been removed by a third party before it is accessed by any researcher involved in this study.The Stanford Translational Research Integrated Database Environment (STRIDE) was the primary source of data used for this project19, and are shown in Table We extracted laboratory data related for two tests of interest, namely total serum cholesterol, and glycated hemoglobin A1c. These tests defined two cohorts of patients, a high glycated hemoglobin A1c cohort, at risk of developing type 2 diabetes mellitus, and a high total serum cholesterol cohort, at risk of developing hypercholesterolemia. First, all patients with at least one result for the test of interest were selected. This study examines the time taken for a patient to progress from a pre-disease state, such as borderline hypercholesterolemia or pre-diabetes, to a full disease state; therefore inclusion in the cohort required at least one test result in the pre-disease range before a test result in the full-disease range. The pre-disease and full-disease test result ranges are defined using published guidelinesThe first investigation determined the time elapsed between the first recorded pre-disease test result and the next follow up test. This “time to retest” was compared with the recommended retest interval for patients in the pre-disease range. Patients were stratified into three groups based on the value of their first pre-disease test result.The second investigation examined the time between the first pre-disease result and the transition to a full disease state, with patients stratified by test result value as before.This study was approved by Stanford University’s Institutional Review Board prior to data collection.All data and associated protocols used in this study are available to readers. Please contact the corresponding author.Figure Figure The pattern of repeat testing of total serum cholesterol levels shows that the guidelines in place for this test are being well adhered to in practice. Repeat tests are almost always within the recommended 3 years for borderline hypercholesterolemia patients, with over 91% of patients being retested within this period. The guidelines that are in place are fulfilling their purpose, ensuring that the 71.8% of patients who transition to a full disease state within 3 years are identified in a timely manner.The guideline for repeat testing of glycated hemoglobin A1c levels is not well followed in practice, with only 73% of the patient cohort having a repeat test within the recommended 12 months. However, only 48% of the cohort transitions from pre-diabetes to full type 2 diabetes mellitus within this period.If we consider the pattern seen in the repeat testing of total serum cholesterol levels to be ideal , the recommended time to retesting of glycated hemoglobin A1c should be extended to 1000 days. This would reduce the number of recommended tests during this period from three to one, reducing costs and inconvenience to patients, while still identifying most patients who progress to full type 2 diabetes mellitus in a timely manner.20. Extending the recommended time to retest for patients with glycated hemoglobin A1c values in this range would bring the guidelines in line with practice, without impacting the ability to identify patient deterioration.An adaptive testing strategy could be implemented, where re-test time is dependent on the first test result. Only 63.3% of patients with an initial pre-disease glycated hemoglobin A1c value between 5.7% and 6% currently receive a repeat test within the recommended 12 months, and only 33.7% transition to full type 2 diabetes mellitus within this period. This result may be reflection of the “wisdom of the crowd”, in that physicians already know the low probability of transitioning to full disease state after an initial low resultPractice-based evidence shows that established guidelines for screening of hypercholesterolemia are well-suited, but that guidelines for type 2 diabetes mellitus could be improved to remove unnecessary testing. An adaptive testing strategy would bring guidelines in line with actual practice, removing the recommendation for annual testing without impacting identification of patient transitions. Ultimately, the methods outlined in this proof-of-concept study may be extended to other routinely performed screening laboratory tests. Thus, laboratory data represents a valuable opportunity to identify the efficacy of screening guidelines and devise adaptive testing strategies.


It is well established that drastic declines in physical activity (PA) occur during young adults’ transition into university; however, our understanding of contextual and environmental factors as it relates to young adults’ PA is limited.The purpose of our study was to examine the feasibility of using wrist-worn accelerometers and the use of ecological momentary assessment (EMA) to assess the context and momentary correlates of PA on multiple occasions each day during first-year university.First-year university students were asked to participate in the study. The participants completed a brief questionnaire and were subsequently asked to wear an ActiGraph GT9X-Link accelerometer and respond to a series of EMA prompts (7/day) via their phones for 5 consecutive days.A total of 96 first-year university students with smartphones agreed to participate in the study . Overall, there was good compliance for wearing the accelerometers, with 91% (78/86) of the participants having ≥2 days of ≥10 hours of wear time . Students were generally active, averaging 10,895 steps/day (SD 3413) or 1123.23 activity counts/min (SD 356.10). Compliance to EMA prompts was less desirable, with 64% (55/86) of the participants having usable EMA data (responding to a minimum of ≥3 days of 3 prompts/day or ≥4 days of 2 prompts/day), and only 47% (26/55) of these participants were considered to have excellent EMA compliance (responding to ≥5 days of 4 prompts/day or ≥ 4 days of 5 prompts/day).This study represents one of the first studies to use an intensive real-time data capture strategy to examine time-varying correlates of PA among first-year university students. These data will aim to describe the physical and social contexts in which PA occurs and examine the relationships between momentary correlates of PA among the first-year university students. Overall, current results suggest that wrist-worn accelerometers and EMA are feasible methods for data collection among the young adult population; however, more work is needed to understand how to improve upon compliance to a real-time data capture method such as EMA. There is mounting evidence that engagement in habitual moderate-to-vigorous aerobic physical activity (MVPA) provides many physiological and psychosocial benefits as well as attenuates the risk of over 25 chronic health conditions -3. In CaBefore effective interventions can be designed and applied, salient determinants of PA and the specific contexts in which PA occurs must be well understood. Current evidence suggests that self-efficacy, behavioral intentions, past behavior, time constraints, and changing academic pressures are important factors related to PA behaviors in young adults transitioning to university or college ,21-25. TTraditional methods examining salient determinants of PA use self-report surveys, requiring respondents to retrospectively report their perceptions, thoughts, and feelings related to general PA over a predetermined period of time . A major limitation of these self-reported measures is the presence of social desirability and recall biases ,28. SelfEcological momentary assessments (EMA) have become increasingly popular as a real-time data capture method in PA research. Although the method itself is not entirely new, as there are many examples of researchers using diaries and logs to record momentary feeling states and behaviors ,35, the The emergence of objective PA measurement using devices such as accelerometers has also become increasingly popular due to their ability to capture the occurrence, duration, and intensity of PA . More reThe purpose of this study was to explore the feasibility of using wrist-worn accelerometers and using EMA as a data-capture tool to better understand the salient correlates of PA for young adults who recently transitioned from high school into university.The sample used in this study consisted of 86 first-year university students living in university residences as a part of the MovingU study. The mean age of the sample was 18.31 years (SD 0.51), primarily white  or Asian students , with a relatively equal proportion of males  and females  see . To be eAll interested students were first provided with a detailed description of the study purposes and requirements. Participants who provided written consent were then asked to complete a Web-based questionnaire using an Android tablet. Once completed, participants were asked to download on their smartphone (iPhone or Android) the mobile EMA (mEMA) app designed and developed by illumavu Inc . Each paAccelerometry is an objective method of assessing free-living PA and an established method for measuring activity . ParticiParticipants received 7 EMA prompts per day over the 5-day study period, resulting in 35 prompts in total. Using a random-sampling signal-contingent schedule, participants were asked to respond to prompts whenever a notification was sent to their device (taking approximately 1 to 2 minutes to complete). Consistent with several previous EMA studies ,46, eachcompliance, perceived burden, and compensation.Following the 5-day study period, all participants were invited to voluntarily complete an anonymous Web-based questionnaire assessing the acceptability and receptivity of our EMA study. An invitation to participate was emailed to all participating students, including a link to the questionnaire on the Web. A total of 47 of the 86 study participants (55% response rate) completed the brief 10-item questionnaire related to ComplianceThree questions were asked related to participants’ general compliance to wearing the accelerometer or completing the EMA prompts. For example, we asked, “How often were you able to wear the accelerometer watch?” with responses ranging from 0=I didn’t wear it to 4=I wore it all the time; and “On average, how many prompts per day did you respond to?” with responses ranging from 0=none to 4=5 or more.Perceived BurdenTwo questions sought feedback regarding the perceived study burden, asking, “What did you think about the number of prompts that you received each day?” with the response options of 0=far too few, 1=somewhat too few, 2=just right, 3=somewhat too many, and 4=far too many; and “What did you think about the 5 days of being prompted?” with the response of 0=5 days was appropriate or 1=5 days was too long.Compensation, generous for the time required.There were 5 items that asked about compensation and participants’ overall motivation to participate in the study. For example, there was a question that asked, “What did you think of the study compensation or gift card amount?” Response options included 0=wasn’t worth my time, 1=too little for my time, 2=fair, 3=good for the time required, and 4= very good Descriptive statistics were used to summarize the demographic characteristics of the study sample, compliance rates of both accelerometer wear and EMA prompt responses, as well as responses to the process evaluation survey. Statistical analyses were conducted using SPSS version 22.A total of 98 students initially provided written consent to participate in the study. There were 2 students who provided formal withdrawal, 1 student due to smartphone incapability with the mEMA app and 1 student because of expressed participant burden. There were 10 students who expressed interest and provided written consent, but for one reason or another did not take part in any of the data collection activities . Details of the sample characteristics for all participants are shown in Of the 86 participants, a total of 91% (78/86) wore the activity monitor for at least two days for 10 or more hours on each those days see . The majOf the 86 participants in our sample, only 55 (64%) provided what we estimated to be usable data for analyses . Among those with usable data based on compliance, nearly half of the participants  had excellent EMA compliance (defined as having 5 days of 4 or more prompts each day or having 4 days of 5 or more prompts each day), approximately one-third  had fair compliance (defined as responding to 4 days of 3 or more prompts per day or at least 3 days including 1 weekend day of 4 or more prompts per day), and 20% (11/55) have only met the minimum compliance requirements. The average number of prompts that participants with minimum compliance responded to over the 5 days was 19.6 . A complete breakdown of compliance rates for EMA responses are shown in Of the 78 participants with valid accelerometry data, 64% (50/78) met the minimum compliance threshold of EMA responses. There were 5 participants who had compliant EMA data but did not have compliant accelerometer data, and a total of 3 participants who were noncompliant for both EMA responses and accelerometer wear.Among the 47 participants who completed the process evaluation survey, 91% (43/47) self-reported wearing the accelerometer most or all of the time and 89%  reported answering 3 or more EMA prompts a day. In terms of the compensation, only 2% (1/47) reported that the gift card amount was either too little for the time required in the study or was not worth their time. However, at least 75% (35/47) reported that they would have responded to more EMA prompts if they were provided with more compensation for their time. The majority of participants, 51% (24/47) and 96% (45/47), reported that the number of prompts they received each day and the number of days of prompting, respectively, were appropriate. Only 4% (2/47) reported that 5 days of prompting was too long, but 34% (16/47) reported that there were either somewhat or far too many prompts.Given the drastic declines in PA during the emerging adulthood period, it is becoming increasingly important to intervene before individuals form stable unhealthy behavioral patterns. Considering the ubiquitous nature of smartphones combined with the accessibility of accelerometry, there is a unique opportunity to collect precise estimates of PA and greater ecologically valid measurements of the salient PA influences to inform the design of interventions. This study demonstrated that it is feasible to combine methods of wrist-worn accelerometers and a mobile EMA app among first-year university students; however, more can be done to improve compliance.The compliance rate for the accelerometers was good to excellent, with 91% of the sample providing valid accelerometry data. The proportion of our sample providing valid accelerometry data is comparable with that of waist-worn accelerometers used in the 2007-2009 Canadian Health Measures Survey. Additionally, the average number of steps per day, 10,895, is similar to the population average in Canada . The simThe compliance rate for accelerometer wear, however, was considerably better than the compliance rate for EMA responses. Among the 86 participants in the study, only 55 responded for 3 or more days of 3 or more prompts per day or for 4 days of at least 2 prompts each day. This compliance rate somewhat aligns with the information obtained on the process evaluation survey, indicating that one-third of respondents thought there were too many prompts; however, critically, it is considerably lower than the compliance from a late adolescent sample from Southern California . This diAnother difference between our study design and the Dunton et al  study waFinally, the role of compensation may be something that can help to improve compliance rates. Although the vast majority of participants indicated their satisfaction with the compensation provided, over 75% reported that their compliance could be improved with increasing value of compensation per prompt. Interestingly, fewer respondents indicated they would improve their response rate if offered larger and guaranteed compensation regardless of the number of prompts they answered. The study by Dunton et al  compensaThere are a number of limitations associated with this study. First, the issue of generalizability of the sample must be acknowledged. The sample in this study included a relatively small and homogeneous group of students living on campus, and relatively passive recruitment methods were used. In addition to a response bias, our findings may not be generalizable to the entire first-year university student population, particularly for those who do not live on campus. Second, as this study took place at a university, the lower compliance rate may be due to the students’ inability to answer prompts being given during class times. More research aimed at understanding factors related to overall compliance and compliance during certain times of the day is needed. Third, EMA compliance rates may be partly attributed to a lack of familiarity with the app, as the push notification that sent the EMA survey to the participants required participants to navigate into the app when prompted. This may not have been entirely intuitive for participants. Fourth, it may be possible that our single, brief 5-day data collection period is not representative of the student’s typical routine. It may have been a particularly busy week for students that may be impacting compliance, thus further studies using multiple EMA collection periods are needed. Finally, we acknowledge that the response rate for the process evaluation survey was low, with less than half the sample providing feedback related to the acceptability and receptivity of using EMA in university students. The low response rate may be in part due to the anonymity of the survey and no compensation being given to respond. Given that they were completed anonymously, individual responses cannot be matched to their objectively measured compliance rate, although the vast majority of respondents reported being largely compliant to both the accelerometer wear and EMA responses. This is indicative of a response bias, and warrants caution when interpreting the process evaluation results.Overall, the MovingU study represents one of the first studies to use an intensive data recruitment strategy through the use of EMA, aimed at understanding the factors related to PA during students’ transition from high school into university. Current results suggest that wrist-worn accelerometry is a feasible method to assess objective PA among the young adult population, but that more work is needed to understand how to increase compliance to real-time data capture methods such as EMA. A greater understanding of the predictors of compliance to the EMA and accelerometer protocol in a population of emerging adults will inform the design of the next large-scale EMA study. Future work will then explore some of the time-varying and time-invariant predictors of EMA compliance, as well as begin to examine how PA correlates measured multiple times each day across the 5-day study period relate to objectively assessed PA in these first-year university students. With enhanced knowledge regarding the salient predictors of PA in an emerging adult population, we can move toward designing interventions that target these predictors to have a larger impact on PA behavior change during this major life transition.


However, optimal determination of somatic mutations in patient samples requires not only tumor DNA but also a germline control DNA. The importance of germline mutations in acute myeloid leukemia (AML) has recently come into special focus as being an integrated part in the new WHO classification.2 Thus, somatic mutations must be clearly distinguished from germline mutations and germline genetic variants and there is an increasing need for a good source of germline DNA when defining mutations in AML in the routine care. In research, a significant problem is that the only material that is available from an AML patient may be a biobanked vitally frozen vial taken at the diagnosis. Finding a reliable source of germline DNA is then crucial in research as well as for clinical routine. Several approaches to attain germline DNA in AML are used and have been proposed. Still, many of these approaches imply different limitations where skin biopsies and buccal swabs/washes can be hampered by contamination of leukemic cells3 as well as low amounts of DNA and the use of T cells is limited by the presence of evolutionary early somatic mutations like DNMT3A mutations that also are present in the malignant clone.4 Also, these approaches require additional sampling that has to be implemented in the routine. Remission samples are not possible to obtain for all patients as not all will achieve a complete remission and as pre-leukemic mutations may also be present in remission. Motivated by these problems, we aimed to find a reliable method to get out germline DNA from the same sample as from which the AML cells at diagnosis had been obtained. For this purpose, we choose to focus on the non-hematopoietic cell population present in the diagnostic AML bone morrow sample and hypothesized that bone marrow derived stroma cells (BMS) would fit the purpose. Our aim was also to find substantial amounts of germline DNA from each patient without contamination of leukemic cells and that this DNA could be used as a germline control for mutations found in the AML cells.The introduction of next generation sequencing (NGS) techniques has revolutionized the genetic characterization of malignant diseases.With this aim, we thawed, seeded and growed adherent cells from vitally frozen, Ficoll separated, bone marrow aspirates taken at the time of diagnosis of AML. The purpose was to eliminate leukemic cells and in parallel, obtain up to 5 μg of germline genomic DNA from non-malignant BMS. Forty-eight hours after seeding, unattached cells were washed away while BMS was attached to the bottom of the flask and were monitored by light microscopy for their ability to form colonies and retain a flattened shape. The culture was maintained in MyeloCult with 10% FBS for the first 2 weeks then in DMEM-GlutaMax and 10% FBS up to 6 weeks. For detailed description of culture procedure, DNMTT3A, EZH2, FLT3, IDH1, KRAS, NRAS, TET2, RUNX1, PTPN11, SF3B1, TP53 and U2AF1 genes .Flow cytometry was used to characterize primary AML cells and cultured BMS cells . Results5 The differentiation assay reviled that the cultured BMS cells were able to differentiate into osteoblasts and adipocyte  was performed in all cells cultures and no cells with monosomy 7 could be detected in any of the cultures from any of the six patients (DNMTT3A, EZH2, FLT3, IDH1, KRAS, NRAS, TET2, RUNX1, PTPN11, SF3B1, TP53 and U2AF1 in the BMS cells (To exclude malignant contamination of the BMS culture or presence of any of the genetic aberrations found in the AML samples in the cultured cells, genetic analysis was performed on cultured cells. A detailed description of the methods is presented in patients . For mutMS cells . The ori8 However, these mutations do not overlap with aberrations found in the malignant clone. The mechanisms for how these BMS specific aberrations occur or their impact on the malignant development remains unclear and needs to be subject to further studies. Nevertheless, BMS can still be used to exclude germline presence of genetic aberrations found in the AML clone.Interestingly, genetic aberrations of BMS have previously been reported.10 As the bone marrow contains a heterogeneous cell population, later studies aimed to define subpopulations of BMS. Gronthos et al.11 presented the use of cell surface marker STRO-1Bright VCAM-1+ to sort out a homogenous stroma population. However, our primary aim was to expand non-leukemic stroma cells and not a particular population of stroma cells. Now, we and others12 have shown that after few passages of BMS culture, non-adherent haematopoietic cells disappears either by washing away or by undergoing apoptosis resulting in a growth of a non-malignant and non-hematopoietic cell population.The primary finding of growing bone marrow cells based on their ability to attach to plastic surfaces was described by Friedenstein and Castro-Malaspina.In conclusion, our findings show that large amounts of non-hematopoietic cells defined as stroma cells can be derived from culturing adherent cells from mononuclear cells in the diagnostic bone marrow sample of AML patients. Furthermore, we show that these BMS cells can be used to exclude germline presence of mutations found in AML cells and thus define somatic mutations in AML patients. We suggest this can be a useful approach to obtain AML DNA as well as the control germline DNA from the same sample without additional sampling in the research setting as well as in clinical routine.


Impulsivity and substance use disorder (SUD) are strongly interconnected, with persons scoring high on impulsivity being more vulnerable to develop substance abuse, facing more challenges for successful treatment, and being more prone to engage in criminal behavior. Studies have shown that impulsivity and craving for substances are strongly correlated. Neurofeedback is an effective treatment to reduce impulsive behavior. This study intends to determine to what extent a neurofeedback-intervention that is aimed at reducing impulsivity can also reduce levels of craving in forensic patients with SUD and comorbid Axis I and/or II diagnoses.The main objective of this study is to investigate to what extent a reduction in impulsivity by a sensorimotor rhythm (SMR)-neurofeedback intervention will lead to a reduction in craving in a population of forensic psychiatric patients with a diagnosis of SUD.Participants will be male SUD patients with various comorbidities residing in an inpatient forensic treatment facility approached through treatment supervisors for participation. Participants have tested positive for drug use in the past 24 months. The study consists of 2 parts: a randomized controlled trial (RCT) and a n-of-1 clinical series. In the RCT, 50 patients will be randomly assigned to an intervention (n=25) or a control (n=25) condition. Patients in the intervention group will receive 20 SMR neurofeedback sessions aimed at reducing impulsivity; participants in the control group receive treatment-as-usual (TAU). Additionally, 4 in depth n-of-1 clinical trials will be conducted where effects of an SMR neurofeedback intervention will be compared to effects of sham neurofeedback.Results of this study are expected by the end of 2017.This protocol describes the design of a study testing the effects of an impulsivity-based neurofeedback protocol among forensic patients with SUD and various comorbidities. We expect a significant reduction in impulsive behavior, level of craving, and actual drug-use for participants receiving the SMR neurofeedback protocol. The n-of-1 approach might help to explain effects possibly found in the RCT study since it allows for a more direct focus on treatment effects by following participants more closely and thereby being able to directly attribute behavioral and neurophysiological change to the SMR neurofeedback protocol employed.Dutch National Trial Register NTR5386; http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=5386 (Archived by WebCite at http://www.webcitation.org/6nXLQuoLl) Impulsivity has been defined as a dysfunctional trait, leading to a tendency for an individual to display behavior that is performed with little or inadequate forethought  and mighSeveral studies have demonstrated that substance use disorder (SUD) is strongly associated with elevated impulsivity scores on various measures . In SUD,The concept of impulsivity has been of particular interest in studies involving criminal offenders, as these individuals often suffer from major mental disorders and are therefore more likely to be involved in criminal acts than persons without major mental disorders . In crimElectroencephalographic (EEG) spectral analysis is a frequently used method to compare healthy controls with prolonged drug users by focusing on differences in the (relative) strength of naturally occurring rhythms in the EEG  . In SUD,Although the relationship between impulsivity and symptoms of SUD such as craving and actual drug use has been established, to date there is no evidence about the effects of an impulsivity-based neurofeedback protocol and its effectiveness on impulsivity and on symptoms of SUD. This study aims to examine the treatability of impulsivity with an SMR-neurofeedback intervention in a population of forensic psychiatric patients with SUD and comorbid Axis I and/or II disorders. It also aims to investigate whether a reduction of impulsivity through an SMR-based neurofeedback protocol will also result in a reduction of SUD symptoms such as craving and actual drug use.The study will combine a randomized controlled trial (RCT) design with an n-of-1 clinical trial. The RCT allows for investigating to what extent an SMR-neurofeedback protocol can reduce craving and actual drug use by augmenting levels of impulsivity for forensic psychiatric patients at a group level. However, RCTs have several disadvantages. First, they focus on between-group differences, making it difficult to determine the exact working mechanisms of neurofeedback at the single patient level. Despite the fact that the number of studies employing neurofeedback has increased over the past 2 decades, to date the underlying working mechanisms of neurofeedback remain unclear. Success of treatment is usually determined by a reduction in subjective complaints or based on other behavioral measures, independent of patients’ responses to neurofeedback on a neurophysiological level . Second, most RCTs focus on participants with single, well-defined disorders or diagnoses, making it difficult to apply previous findings to patients who have a more complex psychopathology as is usually the case in forensic patients. Third, finding a reduction in subjective complaints could partially be explained by the interaction with the person giving the treatment, as this occurs with almost all frequently given types of therapy in the psychological field . To rulePrimary outcome variables are the degree of impulsivity as measured with the Dutch version of the BIS-11 ; inhibitPrimary objective: To what extent does a reduction in impulsivity by using SMR-neurofeedback result in a reduction of core symptoms of SUD such as craving and actual drug use in a population of forensic psychiatric patients with a diagnosis of SUD?Secondary objectives:1. To what extent can an SMR-based neurofeedback intervention reduce levels of impulsivity as measured by BIS-11 and a cued go/no-go task in a population of forensic psychiatric patients with a diagnosis of SUD?2. To what extent can an SMR-based neurofeedback intervention reduce levels of craving as measured by self-report questionnaire DAQ-SF (short form) in a population of forensic psychiatric patients with a diagnosis of SUD?3. To what extent can an SMR-based neurofeedback intervention reduce actual drug use as measured with urine, saliva, or breathalyzer analysis in a population of forensic psychiatric patients diagnosed with SUD?This study will be conducted according to the principles of the Declaration of Helsinki  and in accordance with the Medical Research Involving Human Subjects Act. It has been approved by the medical ethical council of Brabant, the Netherlands (study number NL46390.008.13).This study takes place in Forensic Psychiatric Centre (FPC) Dr S van Mesdag, a maximum security inpatient forensic treatment facility in Groningen, the Netherlands. Patients in this treatment facility are male criminal offenders with at least one Axis I or II diagnosis and considered to be at risk for criminal recidivism if not treated properly. About 70% of all patients treated in this facility have a comorbid diagnosis of SUD .A randomized controlled trial with N=50, where 25 participants are randomly assigned to treatment as usual (TAU) combined with 20 SMR-based neurofeedback sessions and 25 participants are randomly assigned to TAU only, without neurofeedback intervention. The 2 groups are compared pretreatment (T0) and posttreatment (T1) on variables linked to the research questions. Both groups will receive pre- and posttreatment measurements with an interval between T0 and T1 of approximately 10 weeks in which participants in the intervention group will receive 20 neurofeedback treatment sessions and participants in the control condition will follow TAU.The design of this part of the study is a 2×2 design with the condition (neurofeedback vs TAU) as a between-subjects factor and time as a within-subjects factor (pre- and postintervention).1B1A2B2design (single time series) will be conducted, of which 2 single case studies will apply an actual SMR-neurofeedback protocol and 2 single case studies will apply a sham neurofeedback training. The clinical trial will be single-blinded, indicating that participants do not know which part of the training they will receive. Participants are selected from the control group of the previously described RCT protocol who have already completed pre- (T0) and posttreatment (T1) measurements. Inclusion in the n-of-1 trial will be selective: participants with the highest scores on outcome measures on T1 of the RCT will be approached first as it is believed that these patients have the highest need for treatment. However, allocation to treatment  will be random.To zoom in on specific treatment effects, 4 single case studies with an A1: no treatment, lasting 3 weeks) is followed by a treatment period , which is followed by a period where treatment is withdrawn (A2: lasting 3 weeks). During all periods, outcome measures DAQ-SF and BIS-11 will be assessed 2 times per week. At the end of the A2period, statistical analyses are applied to test for significant improvements in study end points. In cases of significant improvement during treatment, a second period of neurofeedback, B2, will be applied. This way, if neurofeedback does not prove to be effective within B1, participants will not be burdened with the requirement of completing more sessions. It is expected that patients who have not shown any significant improvement during neurofeedback sessions in B1will not show any further improvements when undergoing more sessions. After completion of the study, patients and treatment supervisors will be debriefed about whether the neurofeedback intervention was real or sham.For a detailed description of this design of n-of-1 studies, see Rizvi and Nock . BasicalTo test for transient effects of the neurofeedback intervention, a follow-up measurement of resting state EEG, BIS-11, DAQ-SF, and cued go/no-go task will be performed 12 months after completing the posttreatment measures for both participants in the intervention group of the RCT and for participants in the n-of-1 clinical trial.f) of 0.80 yielded a recommended sample size of 21 participants each in the control and intervention conditions. Given the special research population we aim to select 25 participants for each condition.A power analysis calculation for the RCT using G*Power 3 (Department of Psychology) based on a 1-tailed alpha value of .05, a power value of 0.80, and an effect size  according to the SM-IV-TR ) and curParticipants are allowed to continue using prescription medication  but are required to inform researchers of any medication they are currently using or any change in medication during treatment with neurofeedback.Recruitment will start with the selection of patients for the RCT part of the study. Participants are approached through treatment supervisors for participation. Treatment supervisors are informed about the general inclusion criteria for this study. Out of all participants that meet the requirements, a random sample of 50 will be drawn and randomly assigned to 1 of the 2 conditions (intervention and control). Prior to participation in the trial all participants are asked to provide written consent. If at this point a participant chooses not to participate in the trial, this will be coded as a nonresponse. Missing numbers of participants will be complemented by randomized allocation of other suitable participants who are willing to participate in order to guarantee the sample size. Once all patients for the RCT have been recruited, recruitment for the n-of-1 clinical trial will begin. All participants will receive a financial reward after completing pre- and posttreatment measurements.Participants will undergo a 21-channel EEG measurement with Nexus-32 hardware and Biotrace+ software (Mind Media BV). The EEG will be collected from 19 standard 10/20 positions  and the For participants in the neurofeedback group, a 1-minute baseline recording over 3 conditions will be conducted before start of the first neurofeedback session and after the last session. EEG signal will be recorded from electrode position Cz against a right ear mastoid reference across the conditions (1) eyes open, (2) eyes closed, and (3) cognitive task . These measurements will be used to determine neurofeedback threshold values and to assess change in mean magnitude of frequency bands before and after neurofeedback training.The Dutch version of the BIS-11 (eleventh edition)  is a selThe cued go/no-go task is a continuous performance test measuring impulse control by the ability to inhibit prepotent responses . ParticiThe DAQ-SF  is a selAll questions of the original questionnaire are designed to measure craving purely for alcohol; however, within the treatment facility alcohol use is less common than other drug use (such as marijuana and/or cocaine). Therefore, questions from the questionnaire have been altered so they can fit any type of drug dependency. An example of this is “My desire to drink seems overpowering” which has been altered to “My desire to use drugs seems overpowering.”The Instrument for Forensic Treatment Evaluation (IFTE) is an observational treatment evaluation instrument consisting of 22 items measuring 3 factors: Problematic behavior, protective behavior, and resocialization skills. It is scored on a 17-point Likert scale with 5 anchor points: none, rarely, sometimes, often, and always . The IFTDrug testing is performed on a regular basis, usually once every 2 weeks. Whenever staff suspects illegal use of substances within 2 moments of drug testing, spontaneous and unexpected drug testing can be performed. Number of drug tests will be counted, as will be positive (meaning drug use in the period of time since last drug test) and negative (meaning no drug use since last testing) outcome scores. Drug testing is done in the form of urine, saliva, or breathalyzer  analysis.Covariates are sociodemographic characteristics; specific psychopathology; duration of forensic treatment; actual drug use during the past 24 months (or as long as patients reside in the treatment facility); medication use; clinical risk assessment score  ; actual All participants already receive TAU at the moment of inclusion. They will continue to do so during the course of this trial. Type of TAU is dependent on disorder and behavior but can range from cognitive behavioral therapy, psychotherapy, and psychomotor therapy to relapse prevention treatment and can be either individual treatment or in-group treatment. Treatment can also be supplemented by medication for psychotic symptoms or depressive symptoms, for example. In some rare cases, aversion or craving reducing medication is prescribed.Participants in the intervention condition of the RCT will receive 20 neurofeedback sessions, each lasting approximately 40 minutes. EEG magnitude is measured across delta (0.5-3.5 Hz), theta (3.5-7.5 Hz), alpha (7.5-12 Hz), beta (12-20 Hz), SMR (12-15 Hz), high beta (20-32 Hz), and gamma 32-49 Hz) frequency bands. To reduce inattention and impulsivity, a conventional neurofeedback protocol will be used that consists of suppressing theta magnitude and enhancing SMR magnitude  Hz frequ. The aimFor the n-of-1 design of the trial, 2 participants will receive the SMR-neurofeedback intervention and 2 participants will receive sham neurofeedback.Real and sham neurofeedback procedures will be similar  except that for the sham neurofeedback training group, participants are instructed to enhance an irrelevant frequency band that is randomly chosen from higher beta bands . Therefore, no specific frequency band is systematically modulated and thus should not result in desired treatment outcomes. Participants will still be given positive feedback and be able to influence the video games in order to minimize possible irritation of participants.Neurofeedback will be applied as implemented within the BrainMarker software engine .Participants will be shown simple video games implemented in the software that will provide feedback about their brain activity. During the video games, they are instructed to be attentive to the feedback (no movement/movement of objects) in the video game and to find the most successful strategy to reach the goal of the game. Example of such video games are a car moving on a road, where participants are instructed to keep the car in the right lane of the road, or a basketball court where participants are instructed to try to throw the ball in the basket. The video game–based neurofeedback rounds will last 1 minute at a time, with a short break between rounds. Also, movie-based neurofeedback will be applied. During movie-based neurofeedback participants will watch a digital video disk of their own choice and be instructed to keep the monitor as free as possible from black curtains appearing on both sides of the monitor and keep the volume of the movie at an audible level. Movie-based training will last 90 seconds at a time with a short break when necessary. Participants will receive both game- and movie-based neurofeedback in each session.Thresholds will be set manually in a way that if a participant maintains the reinforced frequency band above a threshold for 80% of time, positive feedback will be received. To determine threshold values, mean magnitude of the baseline measurement across the 3 conditions described above will be used to roughly assess threshold values for the neurofeedback training. For each training session, mean magnitude values will be calculated for all frequencies.All statistical analysis will be conducted using SPSS version 19 (IBM Corp). Summarizing descriptive statistics and frequency tables will be provided.Resting state EEG data will be analyzed using custom-made Matlab R2012b scripts . A repeaRepeated measurement with time (pre- [T0] and postintervention [T1]) as the within-subject factor and group (control vs intervention) as the between-subject factor will be conducted for the DAQ-SF, BIS-11, IFTE, and IFTE-SR. If main or interaction effects are observed, post hoc test will be used to determine which levels of the factors are explaining the observed effects. A repeated measures analysis of covariance will be conducted to examine differences in actual drug use as dependent variables to test for a moderating effect of impulsivity on craving and actual drug use.First, a time-plot will be inspected using the autocorrelation coefficient  . After iResults of all measurements will be expected by the end of 2017 and will be published in corresponding articles.This study aims to evaluate the efficacy of an SMR-based neurofeedback treatment on reducing impulsivity in a population of inpatient forensic patients. Possible effects of a reduction in impulsivity on substance abuse will be assessed as well. We expect a significant reduction in impulsive behavior, level of craving, and actual drug use for participants receiving the SMR-neurofeedback protocol. The n-of-1 approach might help to explain effects possibly found in the RCT study since it allows for a more direct focus on treatment effects by following participants closely and thereby being able to directly attribute behavioral and neurophysiological change to the SMR-neurofeedback protocol employed. The study aims to extend previous findings on the efficacy of neurofeedback treatment in reducing impulsivity, not only by linking possible findings regarding a reduction of impulsivity to substance abuse symptoms but also by examining effects in a forensic psychiatric population with various comorbid disorders.Studies about the efficacy of neurofeedback in a psychiatric forensic setting, in which the population is characterized by various comorbidities and various kinds of medication, are lacking. In our study, exclusion criteria are kept to a minimum to include as many participants with SUD as possible and to be able to generalize effects of an SMR-neurofeedback treatment over different types of comorbidities.Although RCTs with a treatment and a sham treatment arm are considered the gold standard in research, conducting large trials is often times difficult in forensic settings; treatment motivation might be low for the type of patients in the treatment facility because they are placed under compulsory inpatient custody and are not seeking treatment due to inner motivation for change. In RCTs, number of participants usually has to be quite high to reach the desired effect size . ParticiBy employing an n-of-1 approach combined with an RCT, this study might help shed light on the underlying mechanisms of neurofeedback because an n-of-1 approach allows closer monitoring of treatment effects and provides valuable insight into an individual’s treatment progress that might otherwise be lost in a between-group design .If effective, neurofeedback could be a noninvasive treatment option for the reduction of impulsivity, which may lead to a reduction in feelings of drug craving and in actual drug use. Both impulsivity and drug-seeking behavior are known to hamper treatment progress and are strongly linked to criminal behavior . By reduThere are several important issues to consider that might influence the results. First of all, participants are not selected based on their level of impulsivity. Even though the most commonly observed disorders in the treatment facility are schizophrenia and personality disorder and both types of disorders are associated with increased impulsive behavior, not all suitable participants might show elevated levels of impulsivity. Studies have shown that although there is evidence that heightened impulsivity can be found across different types of substance use disorders, there is still substantial heterogeneity on impulsivity levels within these groups . A recenAlso, participants will be included who have tested positive for drug use in the past 24 months. This implies that there will also be participants whose substance use disorder is in early remission. Although substance abuse–related symptoms such as craving are known to persist even after drug use is terminated, this period of time might be too long for these participants to report any craving at the moment of the administered questionnaire.


Asymptomatic malaria parasitaemia has been documented in donor blood in West Africa. However, donated blood is not routinely screened for malaria parasites (MPs). The present study therefore aimed to document the frequency of blood transfusion-induced donor-recipient malaria parasitaemia patterns, in children receiving blood transfusion in a tertiary health-centre. A cross-sectional, observational study involving 140 children receiving blood transfusion was carried out. Blood donor units and patients' blood samples were obtained, for the determination of malaria parasites (MPs). Giemsa staining technique was used to determine the presence of malaria parasitaemia. Malaria parasites were detected in 7% of donor blood and in 8.3% of the recipients' pretransfusion blood. The incidence of posttransfusion MPs was 3%, but none of these were consistent with blood transfusion-induced malaria, as no child with posttransfusion parasitaemia was transfused with parasitized donor blood. Majority of the blood transfusions (89.4%) had no MPs in either donors or recipients, while 6.8% had MPs in both donors and recipients, with the remaining 3.8% showing MPs in recipients alone. In conclusion, the incidence of posttransfusion malaria parasitaemia appears low under the prevailing circumstances. The transmission of malaria through blood transfusion was one of the first recorded transfusion-transmissible infections , and theAccording to a World Health Organization (WHO) report, only four transfusion-transmitted infections are tested for in Africa, namely, human immune-deficiency virus (HIV), hepatitis B virus (HBV), hepatitis C virus (HCV), and syphilis , malariaThe cost of screening blood routinely for MPs is enormous , and a pMany studies have documented the prevalence of MPs among blood donors and therefore their potential to cause BTM. However, few studies have demonstrated the actual incidence of BTM in blood recipients, especially among children. And fewer studies have described the proportion of transfusions that are free of BTM from a malaria endemic area.In view of the above facts, there is a need to carry out an observational study on blood transfusion-induced malaria in a malaria endemic area, to document the patterns of MPs between donors and recipients of blood transfusions. This study attempts to determine the burden of transfusion malaria, in children admitted to Ahmadu Bello University Teaching Hospital (ABUTH), Shika-Zaria, Nigeria.The study was conducted at the paediatric medical and surgical wards of ABUTH, Shika-Zaria, a tertiary health facility for many northern states of Nigeria. The study was descriptive and cross-sectional, spanning from November 2011 to May 2012, which corresponds to the off-peak or low-malaria transmission season. Children aged 0–12 years that were admitted into the aforementioned wards of ABUTH, who required and subsequently received a blood transfusion during the study period, were enrolled. Patients who were to receive a second blood transfusion within 48 hours of a transfusion were excluded from the study. Approval was obtained from the Scientific and Ethical Committee of ABUTH before commencement of the study. Informed written consent was obtained from parent(s) or guardian(s) of each patient before enrollment into the study. Verbal assent was also obtained from children old enough to understand (seven years and older). Those who consented were recruited consecutively, until the desired quota sample size was obtained.Patients that fulfilled the inclusion criteria were recruited consecutively, until the required sample size was obtained. Quota sampling was employed in order to capture the different paediatric age groups requiring blood transfusion. Thus, 28 neonates [0 to 28 days], 28 infants [29 days to 11 months (mo)], 28 toddlers [1 yr to 2 yr 11 mo], 28 preschoolers [3 yr to 5 yr 11 mo], and 28 school-age children [6 yr to 12 yr 11 mo] were recruited.Finger prick blood samples were obtained in capillary tubes before and after blood transfusion for preparation of thin and thick blood films for the detection of MPs and parasite densities, using Giemsa staining technique . One milA positive result in the posttransfusion blood film of a recipient was termed posttransfusion malaria parasitaemia, and conversely absence of MPs in the posttransfusion film was termed no posttransfusion MPs. Where the donor had positive MPs, but recipient had a negative pretransfusion blood film, then a positive posttransfusion film would be suggestive of blood transfusion-induced MPs. On the other hand, positive donor MPs, with a negative pretransfusion and negative posttransfusion film, implied no blood transfusion-induced MPs. If, however, there was a negative result in the donor, but recipient had a positive result in the posttransfusion film, with or without a positive pretransfusion film, then it was termed posttransfusion malaria. Presence of positive results in all the three cohorts of specimens (donor and recipient pretransfusion and posttransfusion samples) was also termed posttransfusion MPs.p value of less than 0.05 was considered statistically significant in comparative analysis.Data obtained from the study were analyzed using the statistical software EPI-info 3.5.3. A Out of the 140 subjects recruited into the study, 132 completed their blood transfusions and had the posttransfusion blood film examined. There were 78 males and 54 females, with a ratio of 1.4 : 1. These comprised 26 neonates (mean age 7.9 ± 4.7 days); 27 infants (mean age 6.4 ± 3.0 months); 25 toddlers (mean age 22.1 ± 7.7 months); 27 preschoolers (mean age 51.6 ± 10.7 months); 27 school-aged subjects (mean age 8.4 ± 1.9 years).A total of 138 blood donor units were used for the study participants. Out of these blood donor units, nine units were infected with MPs, giving a malaria parasitaemia prevalence of 7% among blood donors. There were 11 positive MPs in the pretransfusion samples among the 132 subjects, giving a pretransfusion malaria parasitaemia prevalence of 8.3%. On the other hand, four out of the 132 recipients had positive MPs in their posttransfusion samples at the end of the study. This gave a posttransfusion malaria parasitaemia incidence of 3%.P. falciparum trophozoites were demonstrated in all samples that were positive for MPs. No mixed infections were detected.p value = 0.18). The four cases of posttransfusion malaria parasitaemia were recorded in one male neonate, two female preschoolers, and one male school-aged.The positivity rate was not significantly different in the donor blood compared to the recipients pre- and posttransfusion samples . Each of these accounted for 0.8% of the study.Interestingly, no scenario was encountered where a donor had MPs, and the recipient developed MPs in the posttransfusion sample. So, there was no case of blood transfusion MPs detected in the study.μl–550/μl in the donor group, while it was relatively higher at 28/μl–5,080/μl in the pretransfusion group. On the other hand, the parasite density range was 74/μl–100/μl in the posttransfusion group. Among the cohorts with positive MPs in both donor and pretransfusion samples, the recipients had higher parasite densities before transfusion compared to their donors in three transfusions –(3) in As shown in μl and 100/μl, resp.) and relatively higher than the average posttransfusion parasitaemia (83/μl).The geometric mean parasite densities showed that the average parasitaemia in donors and pretransfusion recipients was similar  of donors had +, and the other 22.2% had densities of ++ each. No donor had +++ or ++++. In the pretransfusion group, nine (81.8%) had +, one (9.1%) had ++, and the remaining one (9.1%) had +++. All the posttransfusion MPs had densities of +.The study detected the presence of malaria parasites in donated blood units and the recipients of blood in their pretransfusion and posttransfusion samples. As demonstrated by microscopy, the prevalence of malaria parasitaemia in blood donor units of 7% obtained in this study is low, although not insignificant. This low prevalence may be accounted for by the study period which was in the dry season, with low transmission rates of malaria. The timing of the study from November to May, and the duration of seven months, did not cover the peak rainfall period of April to October. This timing could have influenced the prevalence of malaria in the population. Malaria transmission is favoured by the availability of stagnant surface waters that are abundant during the rainy season; these act as breeding sites for the vector mosquitoes of the infection. The studies from Abakaliki  and NnewAnother factor influencing the study's low donor parasitaemia could be the relatively small sample size of 132, although statistically it is adequate to demonstrate the desired parameter. However, a larger sample size would have increased the power or accuracy of the study, and the obtained prevalence rate might have been higher. This effect of sample size can be seen in the studies from Abakaliki  and NnewThe prevalence of MPs in blood donor units in the study of 7% is closer to the levels found by the workers in Jos  and ZariInterestingly, the prevalence of malaria parasitaemia in the pretransfusion samples was 8.3%, similar to the 7% prevalence level in the blood donor units. This similarity probably reflects the risks or chances of malaria infection in the general population, and statistically it may suggest that the donors do not pose additional risks to the recipients since their malaria experience is the same. However, this assertion may not be accurate in real life since there will always be a probability that a blood unit containing parasites may be transfused to a recipient hitherto negative for MPs. Again, this assumption of low potential risk will not hold true if the recipients were from a non-malaria endemic region, where the recipients' level of parasitaemia is likely to be naught.It is difficult to compare the level of MPs in pretransfusion patients of this study with other studies with a similar methodology to this study, since none declared the level of MPs in the pretransfusion samples of their patients. The study of Ali et al.  from SudThe prevalence of malaria parasitaemia in the posttransfusion samples of the study was 3%, which is quite lower than the donor or the pretransfusion levels. There was no readily discernible explanation, but possibility of confounders like the use of antimalarials cannot be ruled out. Based on microscopy technique, no case of blood transfusion malaria occurred in this study, despite the four cases of posttransfusion malaria seen. None of the 132 patients that completed the study fulfilled the criteria, since none of the participants had a negative pretransfusion sample and received a MPs-positive donor blood unit and then subsequently developed positive MPs after transfusion. When compared with the study by Ali et al.  where thThe finding of a zero incidence of blood transfusion-induced malaria is not strange. The study by Onankpa et al.  from Sokμl) which would otherwise convert some negative specimens to positive. Either way, it further shows that the potential risk and occurrence of blood transfusion MPs are very low under the prevailing circumstances. The study by Ali et al. [The predominant scenario of parasite distribution between donor-recipient pairs found in this study was that of negative MPs in donor and pretransfusion and posttransfusion samples (89.4%). Incidentally, all donor units that were positive for MPs in this study were also transfused to recipients with positive pretransfusion MPs, even though none of these had positive MPs after transfusion. While all the “permutations and combinations” of the donor and recipient parasitaemia were entirely based on chance occurrence, the patterns observed may also result from the inability of microscopy to detect very low levels of parasitaemia (<5/i et al.  also hadi et al.  has cleaThe average parasite densities obtained in the study were low in the donor blood units. These low levels of parasitaemia in the asymptomatic donors correspond to findings by Ali et al. , Ikeh anFrom this study, it can be concluded that malaria parasitaemia is as common in asymptomatic donors as in the recipients of blood transfusion, the incidence of posttransfusion malaria parasitaemia is low in our environment, and blood transfusion-induced malaria is much less common during the dry low-malaria transmission season. The majority of blood transfusions do not contain or transmit malaria parasites during the low-malaria transmission season. And in transfusions that harbor MPs, the density of parasites is lower in asymptomatic blood donors than in recipients of blood transfusions.