Shigella is the leading cause of dysentery. There have been significant increases in the proportion of Shigella isolated that demonstrate resistance to nalidixic acid. While nalidixic acid is no longer considered as a therapeutic agent for shigellosis, the fluoroquinolone ciprofloxacin is the current recommendation of the World Health Organization. Resistance to nalidixic acid is a marker of reduced susceptibility to older generation fluoroquinolones, such as ciprofloxacin. We aimed to assess the efficacy of gatifloxacin versus ciprofloxacin in the treatment of uncomplicated shigellosis in children.The bacterial genus Shigella stool culture. We could not demonstrate superiority of gatifloxacin and observed similar clinical failure rate in both groups . The median (inter-quartile range) time from illness onset to cessation of all symptoms was 95 (66–126) hours for gatifloxacin recipients and 93 (68–120) hours for the ciprofloxacin recipients .We conducted a randomized, open-label, controlled trial with two parallel arms at two hospitals in southern Vietnam. The study was designed as a superiority trial and children with dysentery meeting the inclusion criteria were invited to participate. Participants received either gatifloxacin (10 mg/kg/day) in a single daily dose for 3 days or ciprofloxacin (30 mg/kg/day) in two divided doses for 3 days. The primary outcome measure was treatment failure; secondary outcome measures were time to the cessation of individual symptoms. Four hundred and ninety four patients were randomized to receive either gatifloxacin (n  =  249) or ciprofloxacin (n  =  245), of which 107 had a positive Shigellae are highly prevalent, ciprofloxacin and gatifloxacin are similarly effective for the treatment of acute shigellosis.We conclude that in Vietnam, where nalidixic acid resistant Controlled trials number ISRCTN55945881 Shigella is the most common cause of dysentery (diarrhea containing blood and/or mucus) and the disease is common in developing countries with limitations in sanitation. Children are most at risk of infection and frequently require hospitalization and antimicrobial therapy. The WHO currently recommends the fluoroquinolone, ciprofloxacin, for the treatment of childhood Shigella infections. In recent years there has been a sharp increase in the number of organisms that exhibit resistance to nalidixic acid , corresponding with reduced susceptibility to ciprofloxacin. We hypothesized that infections with Shigella strains that demonstrate resistance to nalidixic acid may prevent effective treatment with ciprofloxacin. We performed a randomized controlled trial to compare 3 day ciprofloxacin therapy with 3 days of gatifloxacin, a newer generation fluoroquinolone with greater activity than ciprofloxacin. We measured treatment failure and time to the cessation of individual disease symptoms in 249 children with dysentery treated with gatifloxacin and 245 treated with ciprofloxacin. We could identify no significant differences in treatment failure between the two groups or in time to the cessation of individual symptoms. We conclude that, in Vietnam, ciprofloxacin and gatifloxacin are similarly effective for the treatment of acute dysentery.The bacterial genus  Shigella. Humans are the only known reservoir of Shigella, which are transmitted from person to person by the fecal-oral route, the infectious dose is low Shigella are endemic in Vietnam Dysentery is an infection of the gastrointestinal tract characterized by diarrhea containing blood and/or mucous, abdominal cramping and tenesmus. The major cause of dysentery is the bacterial genus S. flexneri to S. sonnei which has been concurrent with a dramatic shift in antimicrobial resistance patterns Shigella strains we now isolate demonstrate resistance to nalidixic acid gyrA), the topoisomerase gene (parC) and multiple plasmid mediated quinolone resistance (PMQR) determinants can elevate the minimum inhibitory concentration (MIC) to ciprofloxacin, and may hinder effective treatment Shigella strains that have been isolated from patients with dysentery have already been reported as being resistant to ciprofloxacin, with an MIC > 0.25 µg/mL Antimicrobials are routinely administered to Shigellosis patients and correspond with clinical improvement in vitroShigellagyrA) with respect to ciprofloxacin, means that this agent is less prone to the inhibition induced by the common resistance associated mutations Gatifloxacin is a fourth generation fluoroquinolone. It has a broad spectrum of activity, with potent activity against many gram-positive and gram-negative organisms Shigella predominate.To date there very few published trials studying the efficacy of fluoroquinolones in the treatment of shigellosis in children Controlled trials number ISRCTN55945881.This study was conducted according to the principles expressed in the Declaration of Helsinki. This work was approved by the institutional ethical review boards of the Hospital for Tropical Diseases, Ho Chi Minh City, Huu Nghi Hospital, and The Oxford Tropical Research Ethics Committee (OXTREC) (number 010–06 (2006)), United Kingdom. The parent or guardian of all enrollees was required to provide written informed consent prior to entrance into the study.An open label randomized comparison of gatifloxacin  for 3 days versus ciprofloxacin  for 3 days for the treatment of uncomplicated bacillary dysentery in children. This trial was design to demonstrate the superiority of gatifloxacin over ciprofloxacin.nd, 2006 to March 13th, 2009. The study included children under the age of 15 years with a history of passing bloody or mucoid stools, with or without abdominal pain, tenesmus or fever (defined as a temperature >37.8°C) for less than 72 hours prior to admission. Exclusion criteria were any signs of a severe infection, including shock, jaundice, extensive gastrointestinal bleeding, a previous history of hypersensitivity to either of the trial drugs, known previous treatment with any (fluoro) quinolone during the current bout of disease prior to hospital admission, or a coexisting infection requiring antimicrobial therapy. Additionally, all children that had a trophozoite or Entamoeba histolytica present in their stool on microscopic examination were excluded from enrolment.The study physicians enrolled patients who were admitted to Pediatric Ward B, The Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam or the Department of Infectious Diseases, Huu Nghi Hospital, Cao Lanh, Dong Thap, Vietnam from June 22Each patient recruited into the study was randomized to receive one of two regimens, treatment with either gatifloxacin  10 mg/kg/day in a single daily dose for 3 days or treatment with ciprofloxacin  30 mg/kg/d in two divided doses for 3 days. Other treatments, including fluid  and antipyretics (paracetamol) were given to enrollees in both groups according to the treating clinicians' discretion. Seizures were treated with diazepam  0.25 mg/kg intravenously. No additional anti-diarrheal drugs, including smectite, loperamide or probiotics were permitted or used.On admission (study day 0), a detailed history of the present illness was documented on a standard report form which recorded the duration of illness prior to admission to hospital (days), the presence of fever (defined as a prolonged temperature > 37.8°C), abdominal discomfort, vomiting, bloody or mucoid diarrhea (defined as ≥3 loose stools with obvious blood or mucus), estimated number of episodes of diarrhea before attending hospital, convulsions believed to be related to fever and/or infection and the administration of any known pre-treatment with antimicrobials and or other treatment. Baseline data including age (in months), sex, location of residence and weight (kg) were also collected.A physical examination was performed on admission and daily thereafter until discharge. Particular note was taken of any bone or joint symptoms. The axillary temperature, pulse rate, respiratory rate, blood pressure, and frequency and character of stools were recorded every six hours. A full blood cell count was performed on all patients and stools were examined by microscopy (HPF (× 400)) to identify parasites, and to count white blood cells and red blood cells; the cell counts were scored on scale from zero to three, scale 0  =  0 cells/HPF, scale 1  =  1 to 10 cells/HPF, scale 2  =  11 to 20 cells/HPF, scale 3  =  21 to 30 cells/HPF and scale 4  =  >40 cells/HPF. A blood sample was taken on Day 0 (on enrolment) and on day 3 (at the same time at the blood sample on Day 0) and glucose test was performed on those in the gatifloxacin group to assess any potential dysglycemia (hypoglycemia or hyperglycemia) in this portion of the study population over the duration of the therapy. Time from initial investigation in hospital to the cessation of bloody/mucoid and watery diarrhea (in hours) was recorded. Duration of hospital stay was recorded in days post admission; patients were only discharged when all clinical symptoms had resolved completely.Enrolled patients were additionally required to attend a follow up visit, which was scheduled at seven days after discharge. During the follow up visit, the parents or guardians of the enrolled were questioned about their general health after discharge. Data regarding shigellosis-related symptoms were recorded in standard report form and a stool sample was collected for microbiological culture.Salmonella or Shigella (non-lactose fermenting) were sub-cultured on to nutrient agar and were identified using a ‘short set’ of sugar fermentation reactions ). After incubation for 18–24 h at 37°C, the test media were read for characteristic Shigella reactions and API 20E test strips of biochemical reactions  were used to confirm the identity of Shigella spp. Serologic identification was performed by slide agglutination with polyvalent somatic (O) antigen grouping sera, followed by testing with available monovalent antisera for specific serotype identification as per the manufacturers recommendations . Antimicrobial susceptibility testing of all Shigella isolates against nalidixic acid (NAL), ciprofloxacin (CIP) and gatifloxacin (GAT) was performed by disk diffusion following standardized Clinical and Laboratory Standards Institute methods E. coli ATCC 25922 and an in house fully sensitive E. coli control. Isolates were stored on Protect beads  at −70°C.Patients stool samples were cultured overnight in selenite F broth  and onto MacConkey and XLD agar (Oxoid) at 37°C. Colonies suggestive of The pre-defined primary endpoint of this study was the composite endpoint of in-hospital treatment failure defined as the occurrence of any clinical or microbiological treatment failure (or both). A clinical treatment failure was defined as fever (≥ 37.8°C), or the persistence of any signs or symptoms of the disease. These symptoms were defined as vomiting, abdominal pain or tenesmus with or without ≥3 loose stools with our without blood, mucus or blood and mucus after 120 hours of start of either treatment. Clinical treatment failures were subsequently treated with ceftriaxone at 50 mg/kg/day intravenously in single doses for 3 days at the discretion of the treating physician. A microbiological treatment failure was defined as a positive stool culture for the original infecting pathogen after the antimicrobial course was complete (day 3 of treatment or later).The secondary endpoints were defined to describe the time from study enrolment (i.e. from the first dose of study treatment) until resolution of specific symptoms. As Shigellosis can be self-limiting, the time to cessation of all symptoms was additionally calculated from the time of disease onset, i.e. accounting for the duration of disease prior to hospital admission. The secondary endpoints were fever clearance time (FCT), i.e. time until the temperature was for the first time ≤37.8°C and subsequently remained ≤37.8°C for at least 48 hours; bloody diarrhea clearance time (BDCT), i.e. time until the first non-bloody stool recorded; diarrhea clearance time (DCT), i.e. time until the first non-diarrheal stool was recorded; and total duration of illness, i.e. the time till cessation of all symptoms. The follow-up visit was scheduled to occur 7 days after hospital discharge and information at this time point was not deemed to be as quantifiable as outcomes during hospitalization and, therefore, was not included in the primary outcome but the proportion of patients with failure at the follow-up visit  was reported as a secondary endpoint.Shigella positive stool culture, gatifloxacin reduces the proportion of patients failing treatment from 25% to 5%. To detect such a reduction with 80% power at the two-sided 5% significance level, each group required 58 culture confirmed enrollees. We estimated the rate of Shigella positive stool culture to be approximately 33% of all children with bloody of mucoid diarrhea and the dropout rate to be approximately 5% and thus aimed to enroll a total of 366 cases with acute dysenteric syndrome. However, when 366 cases had been enrolled, only 80 culture positive patients with Shigella were identified (culture rate 22%), and the study was extended to enroll 134 more cases . When 500 patients had been enrolled, 107 cases were stool culture positive for Shigella. Because of time and budget limitations, recruitment was terminated at 500. Of note, the original sample size calculation was based on a conservative sample size formula; a more precise power estimate based on simulation revealed that the power to detect the target effect with the recruited number of Shigella patients was 81%.This trial was designed as a superiority trial of gatifloxacin versus ciprofloxacin with the hypothesis that in patients with Patients were randomly allocated to one of two treatments. An administrator otherwise not involved in the trial performed randomization in blocks of 10. The random allocations were placed in sealed opaque envelopes, which were opened once the patient was enrolled into the trial after meeting the inclusion and exclusion criteria. Consecutive patients who presented to the clinic and were eligible to be enrolled were randomized and enrolled in the same sequence as they presented. Blinding was not carried out in this trial due to different frequencies of administration and other logistical reasons.2-tests  and 95% confidence intervals for absolute risk differences were calculated according to the method of Agresti and Caffo The proportion of patients reaching the primary endpoint of overall treatment failure and its components, respectively, were compared between the two arms using χWe analyzed the secondary time-to-event endpoints using survival methods and comparisons were based on Cox regression models with treatment as the sole covariate. We also summarized the proportion of patients with failure at the follow-up visit as for the primary endpoint. Only patients who attended the follow-up visit were included, i.e. we did not perform any imputation of missing data.Shigella spp. stool culture positive patient. In addition, the primary endpoint was analyzed in the subgroups defined by the following grouping criteria: culture positive vs. negative, Shigella pathogen vs. Salmonella pathogen and Nalidixic acid sensitive Shigella vs. Nalidixic acid resistant Shigella. Heterogeneity of the treatment effect was tested with a likelihood ratio test based on a logistic regression model that included an interaction between treatment effect and the sub-grouping criteria. P-values for two-sided tests and 95% confidence intervals are reported throughout. All analyses were performed with the statistical software R version 2.9.1 The main analysis population included all patients who received at least one dose of the intervention analyzed according to the randomized treatment group (intention-to-treat) and analyses were repeated in the per-protocol population, which included only nd, 2006 and March 13th, 2009 551 pediatric patients hospitalized with acute dysentery were assessed for enrolment in this RCT. The flow chart of the trial is presented in Between June 22The baseline characteristics of the intention to treat patients (ITT) are shown in Shigella spp. respectively. Sixty seven point three percent (n  =  72) of the Shigella isolated were resistant to nalidixic acid (MIC ≥16 µg/ml), additionally, the same proportion (n  =  72) of Shigella isolates were S. sonnei, 33 were S. flexneri and 2 were S. boydii.There were more patients with a bacterial pathogen positive stool culture in the gatifloxacin group  than in the ciprofloxacin group , of which 61 and 46 were p  =  0.72). The majority of patients that failed therapy had clinical failure, which was principally associated with persistent diarrhea for longer than 120 hours after initiating treatment. There were four patients with prolonged fever and nine with microbiological failures in the ciprofloxacin group and six microbiological failures in the gatifloxacin group. There were no significant difference in secondary endpoints related to time to resolution of symptoms (Results for the primary and secondary endpoints in the ITT population are shown in symptoms .Shigella spp. stool culture positive patients), the risk of treatment failure was as 4/61 (6.6%) for gatifloxacin and 5/46 (10.9%) for ciprofloxacin (p  =  0.49). Three out of sixty one (4.9%) and 2/46 (4.3%) in the gatifloxacin group and the ciprofloxacin group, respectively, had persistent diarrhea for longer than 120 hours post treatment. In the per-protocol analysis, the time to resolution of symptoms was also similar in the gatifloxacin and ciprofloxacin groups, respectively: time from study enrolment to fever clearance  or bloody diarrhea clearance  and total illness duration . The risk of overall treatment failure in selected subgroups is displayed in In the per-protocol analysis  still had persistent diarrhea  patients attending follow up which still demonstrated evidence of disease had a diarrhea . There wp  =  0.18; 2 tailed t-test). There were limited number of non-severe events, these included, one patient in the gatifloxacin arm with night sweats and 18 children vomiting after taking the medication (12 in ciprofloxacin group and 6 in the gatifloxacin group). In the case of vomiting the treatment drug were re-administered one hour after the vomiting episode. There was no death or severe clinical complications during the course of the trial. The clinical status of two children (one in each group) after three days of the study treatments warranted the use of intravenous ceftriaxone.There is a concern about the use of gatifloxacin, as it has been associated with dysglycemia (hypoglycemia and hyperglycemia) in elderly adults (both diabetic and non-diabetic) Shigella infections, although the overall strength of data on antimicrobial therapy for shigellosis is weak and requires further consideration Shigella patients is reducing fecal carriage of the organisms after infection, thus reducing transmission to close contacts, such as household members or children attending the same day-care setting Shigellosis remains a common infection in low and medium human index countries and in countries undergoing industrialization with areas of inadequate sanitation S. dysenteriae type 1 infections Shigella positive stool culture) were treated by either current WHO recommendations, or three days of one daily dose of oral gatifloxacin. Our study could not demonstrate the superiority of gatifloxacin. Rather, it showed a similar efficacy of both drugs in the treatment of childhood dysentery, including those with a stool culture confirmed Shigella infection. However, gatifloxacin has a longer half-life than ciprofloxacin and the once-a-day administration may be considered a little more convenient than twice-a-day regime of ciprofloxacin. In total, 67.3% of Shigella strains isolated were nalidixic acid resistant, but both antimicrobials appeared to clear Shigella from stools equally effectively .A three day course of ciprofloxacin is the treatment currently recommended by the WHO for shigellosis, including Our work has some caveats, firstly, blinding was not performed due to financial limitations and differing regimens, thus there was the potential of introducing investigator bias, yet, this was minimal due as result of the randomization process. Secondly, the primary endpoint was a composite endpoint of both clinical symptoms and microbiological failure, which was deemed more appropriate due to the nature of the infection. Furthermore, it was not possible to identify an infecting agent in the majority of cases, and we know from our currently unpublished work that more than one etiological agent may cause the infection. Therefore, whilst cessation of symptoms is the most relevant clinical end point (for the treating clinician and the patient) for shigellosis, it may be difficult to assess accurately and consistently. We cannot rule out that the persistence of symptoms may be caused by an additional infecting pathogen. Finally, it would be difficult to conduct such a trial in the community in this setting, etiological diagnostics for diarrheal disease are not routinely performed in this location and we are uncertain of the burden of shigellosis in the community. Our study may represent the most severe end of the disease spectrum for shigellosis, yet it is these individuals that may require the most apposite antimicrobial therapy.Shigella serotype isolated. The most commonly isolated Shigella species here was S. sonnei, whilst S. dysenteriae was the most common isolated in the aforementioned 2002 study. S. dysenteriae causes a considerably more severe syndrome than S. sonnei, which is largely associated with the secretion of shiga toxin S. flexneri was the dominant serogroup and the failure rate with the fluoroquinolone, ofloxacin, was comparable to our current data, at 10% S. sonnei is gradually becoming a more benign infection, an opinion that is shared by others Shigella in Vietnam over the last ten years, it may not yet be substantial enough to hinder the bactericidal effect of ciprofloxacin in vivo. A similar effect of both antimicrobial agents, despite gatifloxacin having greater in vivo activity supports the theory of a less severe infection, which may not, in all cases, require an antimicrobial for the cessation of symptoms. Alternatively, Shigella may respond in atypical manner to gatifloxacin, which respect to other Gram-negative organisms, and mutations in the gyrA and parC gene may have a greater effect on reducing the potency of the antimicrobial agent.Our data show similar overall risks of treatment failure in the two treatment groups (11% in the ciprofloxacin group versus 12% in gatifloxacin group). The overall risk of treatment failure rate of 8.4% in culture confirmed shigellosis cases is considerably lower than the 31% to 35% reported in the treatment of dysentery in a 2002 study Shigella are clearly becoming increasingly limited. Gatifloxacin is a highly efficacious antimicrobial for the treatment of many gastrointestinal infections in the young and otherwise healthy patients and should be available for such indications in locations  where these diseases are endemic. However, in view of the potential risk of dysglycemia, it may be prudent to not treat patients over 50 years of age or with additional co-morbidities with such infections with gatifloxacin.The use of fluoroquinolones in children has been contraindicated for many years because of the fear of arthropathy, however there is limited evidence to support this theory. A two year of follow-up of children treated with a short course ciprofloxacin or ofloxacin for typhoid fever in Vietnam did not find any adverse effects on growth and there was no evidence or arthropathy Shigella with reduced susceptibility to older fluoroquinolones (ciprofloxacin and ofloxacin) remain limited and require further investigation. We conclude that in locations where nalidixic acid resistant Shigellae are highly prevalent, ciprofloxacin and gatifloxacin are similarly effective for the treatment of acute shigellosis.Our data demonstrate that despite a substantial increase in the number of organisms demonstrating resistance to nalidixic acid in the preceding years, ciprofloxacin remains an effective therapy for acute bacterial dysentery. Furthermore, we demonstrate that gatifloxacin is similarly effective as ciprofloxacin in the cessation of symptoms of shigellosis. Our current knowledge of the mechanisms and the global distribution of Checklist S1CONSORT Checklist(DOC)Click here for additional data file.Protocol S1Trial Protocol(PDF)Click here for additional data file.


Metformin is, if not contraindicated and if tolerated, usually preferred over other antidiabetic drugs for the first line treatment of type-2 diabetes. The particular decision on which antidiabetic agent to use is based on variables such as efficacy, cost, potential side effects, effects on weight, comorbidities, hypoglycemia, risk, and patient preferences. However, there is no guidance how to consider these in the selection of antidiabetic drug treatment. In this work, we aimed to summarize available evidence and tried to give pragmatic treatment recommendations from a clinical practice perspective.There are clear contraindications for some drugs in those with impaired renal and liver function and precautions in those with heart failure for the use of metformin (NYHA III-IV) and glitazones. On the other hand, GLP-1 analogs, DPP-4 inhibitors and acarbose are generally less critical and can be used in the majority of patients. We identified the following gaps with respect to the selection of antidiabetic drug treatment in patients with co-morbid disease conditions: 1) Guidelines fail to give advice on the use of specific antidiabetic drugs in patients with co-morbidity. 2) The literature is deficient in studies documenting antidiabetic drug use in patients with severely impaired renal function, diabetic retinopathy, cerebrovascular disease and systolic heart failure. 3) Further there are no specific data on patients with multiple of these co-morbid disease conditions. We postulate that differential use of antidiabetic drugs in patients with co-morbid disease constellations will help to reduce treatment related complications and might improve prognosis. There is appropriate guidance for the pharmacotherapy of patients with type-2 diabetes. In general metformin is, if not contraindicated and if tolerated, considered the first line antidiabetic agent . If non-A recent position statement of the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD) on a patient-centred approach in the management of patients with type-2 diabetes ,4. BecauThis overview was consolidated over the course of a total of two board meetings in which the authors discussed the data on antidiabetic pharmacotherapy in patients with co-morbid disease conditions. On this basis a tabular overview for pragmatic decision making from a clinical practice perspective was developed Figure .In 2010 the prevalence of obesity among adult patients with type 2 diabetes in US was 56.9%, according to the Centres for Disease Control and Prevention. This is not only important on a quantitative basis but also because obesity in patients with diabetes is associated with poor control of blood glucose, making obese patients with diabetes a high risk population for micro- and macrovascular events.United Kingdom Prospective Diabetes Study (UKPDS) in which even weight loss was observed for metformin users [It appears that metformin is the principal choice for obese patients with type-2 diabetes because it is neutral with respect to weight. This has been shown in the in users . On the in users -9, althoin users . Dipeptiin users ,12. Lirain users . The newin users  or to a in users .Insulin and insulin analogues seem to induce weight gain as a recent meta-analysis showed that insulin and glitazones were associated to weight gain when added to a combination therapy of metformin and SU . A 6-yeaMetformin appears to be the primary choice for obese patients with type-2 diabetes Figure . For metDeveloping Education on Microalbuminuria for Awareness of Renal and Cardiovascular Risk in Diabetes (DEMAND) survey [Diabetic nephropathy is characterized by albuminuria and abnormal glomerular function and is a major cause of renal failure. The prevalence of microalbuminuria (MAU) among those with type-2 diabetes was 39% in the ) survey .A Diabetes Outcomes Prevention Trial (ADOPT) trial, in which 4,351 recently diagnosed, drug-naïve patients with type-2 diabetes were treated and followed for up to 5 years with rosiglitazone, metformin, or glyburide [In patients with MAU it has been shown that an intensified glucose lowering treatment is superior to standard of care in reducing levels of MAU . Howeverlyburide . While tlyburide .The most relevant study related to MAU is probably the Steno-2 study, which showed that intensive therapy -consisting on tight glucose regulation, lifestyle modification, and the use of the renin-angiotensin system blockers, aspirin, and lipid-lowering agents- had sustained beneficial effects with respect to vascular complications, renal disease, and on total and cardiovascular death in type 2 diabetes patients with persistent MAU .No firm recommendations can be derived based on the available literature Figure . The onlDiabetes is the leading cause of kidney failure, accounting for 44% of all new cases of kidney failure in 2008 in the United States . The cle2 and to stop treatment at a serum creatinine of 1.7 mg/dl or a GFR of below 30 ml/min per 1.73 m2. The uncertainty is mirrored in clinical practice when metformin is prescribed despite full knowledge of the relevant cut-offs. Nevertheless, there is no evidence from prospective comparative or observational studies that metformin confers an increased risk of lactic acidosis. This was shown in a meta-analysis from 347 comparative trials and cohort studies [A number of antidiabetic drugs are contraindicated in patients when glomerular filtration rate (GFR) falls below variable thresholds, such as 25 ml/min for acarbose, 30 ml/min for exenatide and SU, 50 ml/min for DPP-4 inhibitors and 60 ml/min for metformin and liraglutide. There are scant data on the actual efficacy and safety of diabetes medications depending on patients’ renal function. Furthermore, contraindications do not necessarily match with available evidence. This is exemplified with metformin : The lab studies .Insulin is generally considered to be safe in patients with a reduced kidney function. When there is a reduction of renal function, its half-life is prolonged because of lower levels of degradation . This haAvailable pharmacokinetic and clinical studies suggest that DPP-4 inhibitors may be safe in patients with renal impairment. Because of their variable degree of renal clearance (except for linagliptin), they may however need dose adjustment. Additionally, DPP-4 inhibitors have a decreased risk of hypoglycemia .As outlined above, glitazones may have a protective effect to either prevent or slow the progression of diabetic kidney disease. This drug class may therefore be preferred over other drugs for the treatment of patients with diabetes. It further undergoes hepatic metabolism and has been demonstrated to be effective without an increased risk of hypoglycemia in patients with chronic kidney disease . HoweverImpairment of renal function is an important co-morbidity to be considered when selecting antidiabetic drugs Figure . When taDiabetic retinopathy is the most frequent vascular complication and the most feared by patients. The prevalence ranges in newly diagnosed patients ranges from 0 to 30% . DiabetiOptimal glycaemic control is crucial for preventing the progression of retinopathy. Furthermore, an early achievement of good glycaemic control in the course of diabetes has been shown to delay progression of diabetic retinopathy independent of glucose control . The useAction to Control Cardiovascular Risk in Diabetes (ACCORD) eye substudy did not demonstrate a conclusive link between TZD use and DME [Among the antidiabetic drugs insulin has been shown to directly influence retinal blood flow, vascular tone and angiogenesis . For gli and DME .No conclusive recommendations can be derived based on the available literature Figure . All ageCoronary artery disease (CAD) is the most common cause of morbidity and mortality in patients with type-2 diabetes. In 2004, heart disease was noted on 68% of diabetes-related death certificates among people aged 65 years or older in the United States .It has been postulated that metformin might promote CAD  and is kA meta-analysis of 35 trials including 8,478 patients examined the effect of insulin on mortality in the hyperglycemic critically ill patient, mostly after myocardial infarction . It demoAcarbose is the most extensively studied alpha-glucosidase inhibitor. In STOP-NIDDM subjects with prediabetes and early diabetes were included and suggested that acarbose was associated with a 49% risk reduction in cardiovascular events .SU, on the other hand, have been reported to reduce myocardial blood flow, increase infarct size, and to increase early mortality after direct angioplasty for acute myocardial infarction. These untoward effects have been reported more so for the first-generation SU such as tolbutamide  than forIn patients with cardiovascular disease, SU or glinides should rather be avoided and other treatment options preferred instead Figure . BecauseIn 2004, stroke was noted on 16% of diabetes-related death certificates among people aged 65 years or older in the United States and the risk for stroke is 2 to 4 times higher among people with diabetes . When co1) In a Danish follow-up study of 4,817 patients hospitalized with ischemic stroke between 2003 and 2006  the prea2) Antidiabetic drugs during acute stroke are based on the association of hyperglycemia with poor outcome after acute ischemic stroke. The 2007 American Heart / American Stroke Association guidelines suggest treating at lower glucose levels based on expert opinion . One of 3) We found no data to prefer any antidiabetic drug over another in patients with anamnestic stroke.Recommendations for those with cerebrovascular disease in general match those with cardiovascular disease Figure . While SPatients with type-2 diabetes are at high risk for developing systolic heart failure. In a population based cohort  of patients with recent-onset type-2 diabetes the incidence was 6% over 5.2 years . PharmacData available for acarbose in patients with heart failure are limited. In a meta-analysis of seven randomized, controlled studies with a minimum treatment duration of 52 weeks in type-2 diabetic patients and no heart failure at baseline incident heart failure was rare (about1%) and there was a trend towards a reduced incidence of heart failure with acarbose (HR 0.55 (95%CI 0.21-1.45) . InsulinIt appears that glitazones and, in NYHA III-IV heart failure, metformin should not be used in patients with heart failure Figure . Other dLiver dysfunction, particularly non-alcoholic fatty liver disease (NAFLD), and type 2 diabetes frequently coexist. Indeed, 49–62% of type 2 diabetes patients have NAFLD . NAFLD mTreatment of type 2 diabetes in patients with liver dysfunction is complex as many OADs may be contraindicated because the risk of hypoglycemia may be magnified, and therefore doses may also need to be adjusted. There are only a few reported cases of hepatotoxic side effects for metformin , but theInsulin therapy is probably the safest and most effective therapy in patients with liver dysfunction, with the limitation that increased risk of hypoglycemia in such patients requires extra care with insulin dosage. Regarding SU and glinides, the existence of increased risk of hypoclycemia due to reduced hepatic gluconeogenesis should also be considered. Indeed, glinides are contraindicated in the setting of liver dysfunction because they are mostly cleared through the liver, and SU are contraindicated in advanced liver failure.Data regarding the use of DPP-4 inhibitors in patients with liver disease are currently lacking.Patients with moderate liver dysfunction can take sitagliptin or exenatide ,68. VildType 2 diabetes patients with liver dysfunction are at increased risk of cirrhosis, liver failure and hepatocellular carcinoma. Identification and tight control of metabolic risk factors remains the mainstay of treatment. Although based on the available literature no conclusive recommendations can be derived, given that OADs are contraindicated in patients with advanced liver disease, insulin treatment remains the available option for glycemic control.Hypoglycemia is the principal reason that blood glucose targets are not achieved in many patients and has been reported to occur at 10 to 70 per 100 patient years . While aIn patients with a history of (severe) hypoglycemia drugs such as SU, glinides and insulin should be avoided and less stringent blood glucose targets pursued Figure . On the Diabetes is associated with increased hospital admission and length of hospital stay  and therCurrent guidelines for inhospital patients with diabetes recommend that the glucose concentration target value should be maintained in the 140 to 180 mg/dL range as long as these values can be achieved safely . Lower tInsulin is considered the standard of inpatient glucose management . NeverthIn view of the many restrictions on the use of oral antidiabetic drugs, temporary insulin treatment remains the most practical means of glycemic control for many hospitalized patients with type 2 diabetes. Glucose-lowering strategies must be chosen individually for each patient, with consideration of the relevant comorbidities and special conditions.The majority of patients have to be considered “elderly” when an age above 65 years is used as a threshold. “The elderly” however is a heterogeneous group with varying physiologic profiles, functional capabilities, and life expectancy. While some are actually “young”, many suffer from multiple co-morbidities for which specific considerations have been summarized above .The risk of hypoglycemia is increased in elderly patients due to impaired renal and hepatic function, drug interaction and malnutrition  and a loSubstantial gastrointestinal side effects may limit the use of alpha-glucosidase inhibitors particularly in older patients. There is limited information on the use of DPP-4 inhibitors in the elderly. DPP-4 inhibitors may, however need their dose adjusted (see section on nephropathy). There are not sufficient data on exenatide use in the elderly. It may be beneficial in elderly patients with reduced mobility who could benefit from weight loss, whereas it is less optimal for frail, normal weight adults. However, trials in the elderly have not been performed in larger cohorts.A recent study investigated the efficacy and safety of adding once-daily insulin glargine to patients’ current OAD treatment and compared this to a strategy of increasing OAD doses in the elderly with poor glycemic control . During Age is not a co-morbid disease condition per se but usually a constellation that increases the likelihood of co-morbid diseases such as those outlined above. Therefore most of the treatment recommendations for the elderly have to rely on other co-morbidities Figure . PreferrRandomized, controlled trials often employ narrow inclusion criteria, enrolling patients at a low risk for complications, a low degree of co-morbidity and to avoid the enrollment of patients with adverse effects or poor adherence. We identified the following gaps with respect to the selection of antidiabetic drug treatment in patients with co-morbid disease conditions: 1) Guidelines fail to advice on the use of specific antidiabetic drugs in patients with co-morbidity. 2) The literature is deficient in studies documenting antidiabetic drug use in patients with severely impaired renal function, diabetic retinopathy, cerebrovascular disease and systolic heart failure. 3) Further there are no specific data on patients with multiple of these co-morbid disease conditions.Basis for the preparation of this article were two Advisory Board Meetings. For the participation at these board meetings members received financial compensation by Sanofi Aventis Deutschland GmbH. The authors were free in the selection of content and the decision to publish the results. They take full responsibility for the content of this article. Diethelm Tschöpe and Peter Bramlage serve as guarantors. DT, MH, JJM, AKG, MH, PB and PMSD received consultancy fees, attended advisory boards and have held lectures for a number of pharmaceutical companies producing antidiabetic drugs including sanofi-aventis.The present manuscript has been developed over the course of a total of two board meetings in which all authors gathered and discussed the data on antidiabetic pharmacotherapy in patients with co-morbid disease conditions. PB assembled the manuscript and screened the literature for further supporting evidence. All authors revised the article for important intellectual content. All authors read and approved the final manuscript.


The pharmacological chaperones therapy is a promising approach to cure genetic diseases. It relies on substrate competitors used at sub-inhibitory concentration which can be administered orally, reach difficult tissues and have low cost. Clinical trials are currently carried out for Fabry disease, a lysosomal storage disorder caused by inherited genetic mutations of alpha-galactosidase. Regrettably, not all genotypes respond to these drugs.We collected the experimental data available in literature on the enzymatic activity of ninety-six missense mutants of lysosomal alpha-galactosidase measured in the presence of pharmacological chaperones. We associated with each mutation seven features derived from the analysis of 3D-structure of the enzyme, two features associated with their thermo-dynamic stability and four features derived from sequence alone. Structural and thermodynamic analysis explains why some mutants of human lysosomal alpha-galactosidase cannot be rescued by pharmacological chaperones: approximately forty per cent of the non responsive cases examined can be correctly associated with a negative prognostic feature. They include mutations occurring in the active site pocket, mutations preventing disulphide bridge formation and severely destabilising mutations. Despite this finding, prediction of mutations responsive to pharmacological chaperones cannot be achieved with high accuracy relying on combinations of structure- and thermodynamic-derived features even with the aid of classical and state of the art statistical learning methods.We developed a procedure to predict responsive mutations with an accuracy as high as 87%: the method scores the mutations by using a suitable position-specific substitution matrix. Our approach is of general applicability since it does not require the knowledge of 3D-structure but relies only on the sequence.Responsiveness to pharmacological chaperones depends on the structural/functional features of the disease-associated protein, whose complex interplay is best reflected on sequence conservation by evolutionary pressure. We propose a predictive method which can be applied to screen novel mutations of alpha galactosidase. The same approach can be extended on a genomic scale to find candidates for therapy with pharmacological chaperones among proteins with unknown tertiary structures. Pharmacological chaperone (PC) therapy has been recently proposed as a promising strategy for the treatment of some genetic diseases. PC therapy exploits small molecules which can be administered orally, reach difficult tissues such as the brain and have low cost. The new approach relies on an unexpected finding: some molecules that at high dosage inhibit specific proteins, can, at low dosage, restore their activities in cells. They act as life jackets or chaperones for proteins that, although retaining the essential residues needed for activity, become unstable upon mutation and are degraded. These proteins are able to fulfill their duty if they are given the chance to survive long enough and get to the site where they are needed.et al in 1999 . Different mutations of the gene encoding AGAL result in a wide phenotypic spectrum, with respect to age at onset, rate of disease progression, severity of clinical manifestations. Mutations with low or absent residual AGAL activity are generally observed in the classic infantile form of the disease. Patients with the late onset form of FD retain some AGAL activity and are asymptomatic until adult age when they develop cardiac and kidney problems. Nonetheless, as pointed out by Schaefer tients " . Since ttients " .et al [FD offers an interesting case for studying the potentiality of PC because, since the pioneering work by Fan et al , responset al -15. A reGLA mutations associated with FD is galactosidase activity less than 50% of the normal mean value in plasma [To try to correlate the properties of AGAL mutants to their responsiveness to PC, we needed a set of mutations as large as possible. DGJ has been tested on a large proportion of AGAL mutants and we collected data from three different papers which reported the enzymatic activity for each mutation in the presence and absence of DGJ and the activity of the wild-type protein -15. We gn plasma .Clinically important mutations can affect either the function or the structure of a protein: assessment of responsiveness to PC may depend critically on the correct classification of mutations. The first step in our analysis was the identification of the active site. For this purpose we detected pockets on the surface of AGAL, pdb code 3GXT, with the program CASTP ,18. AmonThe pocket with the highest proportion of conserved amino acids includes four groups of amino acids: a) D92, D93, C142, D170, R227, D231  with an r-value 0.23 and a p-value 0.2 10Similarly we sorted mutations by increasing MUPRO score and divided them into 4 bins: non responding mutations are more abundant in the bins associated with low MUPRO scores Figure  panel B We built box plots for the results obtained with the two programs: differences between respondent and non respondent mutations are more evident comparing the first quartile for SDM Figure  panel C de facto standard classification algorithms. We compared the results obtained with MATLAB-Arsenal classifiers to those obtained with the ZeroR classifier. ZeroR classifier simply predicts the majority class in the training data. For example, if most of the training data are non respondent, ZeroR will predict all inputs as non respondent. Running ZeroR is necessary for determining a baseline performance as a benchmark for other learning schemes.Analysis of AGAL structure reveals that three groups of mutations, those affecting the active site, those affecting disulphide bridges and those severely scored by SDM (< -3) are unlikely to be respondent to PC. However, a mutation which does not belong to any of these groups, can be either responsive or non responsive. In order to improve the usefulness of the model in patient therapy, we would like to predict responsiveness to DGJ for any AGAL mutation after having seen a number of training examples and this is, in statistical sense, a typical supervised classification task. Mutants have been labelled as respondent (23) or not respondent (73) and seven independent features derived from the analysis of 3D-structure of the enzyme and two features associated with their thermo-dynamic stability have been assigned to each of them as described before. Our goal is to find a mathematical function that given a set of features returns the correct class of the mutation. We tested all classification methods available in MATLAB-Arsenal developed by Rong Yan , which rWe found that although many structural derived features, distance from active site, side chain accessibility, SDM scores, disruption of disulphide bonds, correlate with percentage recovered activity  is better than the baseline (24% accuracy), but much lower than that obtainable with MUPRO scores (81% accuracy). We decided to take into account the position where mutations occur in the protein using position specific substitution matrices (PSSM). PSSMs are built with PSI-BLAST , a progr-3; r-value 0.44 and p-value <0.1 10-3; r-value 0.32 and p-value 0.2 10-3. The scores obtained with PSSMs were used as inputs for DecisionStump to test their ability to predict responsive mutations. The PSSM built aligning close homologs  led to the best results: its performance (87% accuracy) is better than that obtained with the scores of MUPRO and, in particular, recall is much higher (49% versus 30%) which means that less false negatives are predicted (Table We run PSI_BLAST independently on the three sets and obtained different PSSM. The scores obtained with the PSSM built with close homologs of AGAL as well as those obtained with far homologs and close orthologs correlate with the percentage of recovered activity upon treatment with DGJ (+DGJ/wild × 100) respectively with r-value 0.44 and p-value <0.1 10The approach we used to predict responsiveness to PC is similar to that used by some programs to predict disease-associated mutations: results obtained with PolyPhen , which aWhen developing a classifier, the numbers of responding mutations erroneously predicted as non responding (FN) as well as non responding mutations erroneously predicted as responding (FP) should be kept at a minimum. Therefore precision (TP/TP+FP) and recall (TP/TP+FN) are very useful to assess the performance of different methods. It is not surprising that precision and recall are lower than accuracy (TP+TN/TP+TN+FP+FN) in any case reported in Table Results obtained with sequence information alone do not improve if structure derived information are added as features for the classifiers in MATLAB-Arsenal  sites that are critical for the function of enzymes in mammals or in metazoa might have varied in evolutionary distant species and many compensative mutations might have arisen2) the inclusion of proteins in the twilight zone necessarily raise the possibility of introducing false homologs.3) The inclusion paralogs can hinder functional important sites.Our analysis proves that the choice of homologs for the construction of the PSSM is critical: paralogs can be included, but too distant homologs must be excluded.Our method can be applied to predict PC responsiveness of novel and as yet untested mutations of alpha galactosidase. This is feasible and useful because a very high number of natural missense mutations have been found for AGAL, a middle sized protein of 429 aa: 146 are listed in Uniprot/Swissprot , 256 in in vitro for responsiveness to DGJ is encountered, clinicians can direct Fabry patients towards the therapy more likely to ameliorate their phenotype: a high PSSM score should suggest a beneficial effect of DGJ whereas a low PSSM score should suggest caution and direct towards enzymatic replacement [When a AGAL mutation not already tested lacement ,37. DeciAlthough PC therapy will not substitute other therapies for FD such as enzymatic replacement ,37, our Our approach to find candidates for PC therapy is not limited to alpha galactosidase, but can be extended on a genomic scale among proteins with unknown tertiary structures. Moreover due to the low cost associated with an in silico screening it meets regulators which look for ways to make it easier and cheaper for drug companies to develop treatments for rare diseases.A list of AGAL mutations was created and to each one a label, 1 for responsive and 0 for non responsive ones, was added. Original data of enzymatic activity in the presence or in the absence of DGJ were taken from three different papers -15. The The reference wild type activity, measured in the absence of DGJ was obtained for each mutation from the appropriate paper.Mutants are responsive if in the presence of DGJ recover at least 50%, of normal activity and non responsive in the other case.We identified three sets of sequences: the first includes 163 homologs of AGAL with e-value < e-3 and identity ranging from 98% to 20% from GenBank CDS Translations, PDB, SwissProt, PIR, PRF; the second includes 13 homologs with e-value <e-50 and identity ranging from 95% to 30% from Uniprot/Swissprot; the third includes 15 orthologs with evalue e < e-150 and identity ranging from form 98%to 64% from translated GenBank, EMBL, DDBJ.BLASTPGP (BLASTP2.2.18) in PSI-BLAST mode was used on each set flagging on the output of a checkpoint file (PSSM matrix) and selecting one of the following scoring matrices: Blosum80, Blosum62, Blosum45, Pam70 or Pam30.Fifteen different PSSM were obtained and exploited in a second round of BLASTPGP to calculate net scores for AGAL mutants (mutant score PSSM(i)-Agal_wild score PSSM(i)) .With any set of homologous proteins the best results Table  were obtThe percentage of identical amino acids was also assessed aligning AGAL with 13 homologs with e-value <e-50 and identity ranging from 95% to 30% from Uniprot/Swissprot. At each position in the alignment we count the number of sequences sharing the same amino acid of AGAL and we divided by the total number of sequences in the alignment. Results in percentage are included in additional files et al [We detected active site residues with a procedure of general applicability inspired by the paper published by Dundas et al .We detected cavities in AGAL structure, 3GXT, with the program CASTP ,18 and wAll the residues lining that pocket, irrespective of their conservation, were considered to potentially belong to the active site.MUPRO1.1  was kindModels of all AGAL mutants are constructed using as template 3GXT  with theThe asymmetric unit in 3GXT  contain SDM ,26 uses The programs SDM and ANDANTE were kindly provided by T. Blundell and collaborators.Residue accessibility was calculated using PSA v2.0  which uses the rolling probe algorithm . For theThe numbers of responsive or non responsive mutations with accessible side chain was divided by the total number of mutations with accessible side chain and multiplied by 100. In a similar way it was calculated the percentage of responding and non responding mutations with non accessible side chain.The program PSA was kindly provided by T. Blundell and collaborators.We assigned each residue in the wild type AGAL structure 3GTX to alpha helices, beta sheets or other with the program SEGNO .We tested all classification methods available in MATLAB-Arsenal developed by Rong Yan The accurWhen analysing structural features, mutations occurring on different chains had to be taken into account and therefore DecisionStump used 96 × 2 input data, when analysing sequence derived features, i.e. MUPRO, Blosum 62, PSSMs scores or PolyPhen PSIC score differences, DecisionStump used 96 input data.All statistical analyses were carried out with MATLAB.To calculate the correlations and p values shown in additional files To analyse the data shown in Figure To evaluate the influence of solvent accessibility on PC responsiveness and to assess the statistical significance of the differences observed and differences expected by chance, we took a random sample of 30% in both exposed and non exposed population and counted the number of responding and non responding mutations. We repeated the randomization 100 times and calculated the differences between the percentage of responsive mutations in exposed and non exposed sites and the differences between the percentage of non responsive mutations in exposed and non exposed sites.To test the hypothesis that distribution of Mupro and SDM scores among responsive and non responsive mutations is different from what could be expected by chance , close homologs  or close orthologs . On each set of sequences PSI-BLAST was run selecting different scoring matrices, Blosum 45, Blosum62, Blosum80, Pam30, Pam70.Click here for file


Objective: New diagnostic criteria for mild cognitive impairment (MCI) due to Alzheimer's disease (AD) have been developed using biomarkers aiming to establish whether the clinical syndrome is likely due to underlying AD. We investigated the utility of magnetic resonance imaging (MRI) and cerebrospinal fluid (CSF) biomarkers in predicting progression from amnesic MCI to dementia, testing the hypotheses that (1) markers of amyloid and neurodegeneration provide distinct and complementary prognostic information over different time intervals, and that (2) evidence of neurodegeneration in amyloid-negative MCI individuals would be useful prognostically.Methods: Data were obtained from the ADNI-1 (Alzheimer's Disease Neuroimaging Initiative Phase 1) database on all individuals with a baseline diagnosis of MCI, baseline MRI and CSF data, and at least one follow-up visit. MRI data were processed using a published set of a priori regions of interest to derive a measure known as the ``AD signature,'' as well as hippocampal volume. The CSF biomarkers amyloid-β, total tau, and phospho tau were also examined. We performed logistic regression analyses to identify the best baseline biomarker predictors of progression to dementia over 1 or 3 years, and Cox regression models to test the utility of these markers for predicting time-to-dementia.Results: For prediction of dementia in MCI, the AD signature cortical thickness biomarker performed better than hippocampal volume. Although CSF tau measures were better than CSF amyloid-β at predicting dementia within 1 year, the AD signature was better than all CSF measures at prediction over this relatively short-term interval. CSF amyloid-β was superior to tau and AD signature at predicting dementia over 3 years. When CSF amyloid-β was dichotomized using previously published cutoff values and treated as a categorical variable, a multivariate stepwise Cox regression model indicated that both the AD signature MRI marker and the categorical CSF amyloid-β marker were useful in predicting time-to-event diagnosis of AD dementia.Conclusion: In amnesic MCI, short-term (1 year) prognosis of progression to dementia relates strongly to baseline markers of neurodegeneration, with the AD signature MRI biomarker of cortical thickness performing the best among MRI and CSF markers studied here. Longer-term (3 year) prognosis in these individuals was better predicted by a marker indicative of brain amyloid. Prediction of time-to-event in a survival model was predicted by the combination of these biomarkers. These results provide further support for emerging models of the temporal relationship of pathophysiologic events in AD and demonstrate the utility of these biomarkers at the prodromal stage of the illness. When insidious in onset and gradually progressive, mild cognitive impairment (MCI) is a clinical syndrome commonly arising as a result of neurodegenerative pathology . In liviIn persons with MCI, what are the best MRI-derived biomarkers of neurodegeneration with regard to prediction of progression to dementia? One very commonly used measure is hippocampal volume, which has consistently been shown to predict dementia in MCI . We havein vivo methods  rapid progression  from MCI to AD dementia is better predicted by markers of neurodegeneration rather than the presence of amyloid; (2) longer-term progression from MCI to dementia  is best predicted by the presence of abnormal levels of brain amyloid. This prediction follows from the notion that cerebral amyloidosis may be a relatively earlier development in AD pathophysiology compared to evidence of neurodegeneration measured using  methods . Further methods . As suchFinally, the focus of a number of studies of biomarker prediction of AD dementia in amnestic MCI has been on the 50–75% of subjects with evidence of cerebral amyloidosis. What about the other individuals, especially those who may show evidence suggestive of neurodegeneration ? Are MRIHere we undertook a set of analyses of the Alzheimer’s Disease Neuroimaging Initiative (ADNI) dataset to investigate these questions, focusing on the utility of MRI and CSF biomarkers for prognosis in MCI.1. The ADNI was launched in 2003 by the National Institute on Aging (NIA), the National Institute of Biomedical Imaging and Bioengineering (NIBIB), the Food and Drug Administration (FDA), private pharmaceutical companies, and non-profit organizations, as a $60 million, 5-year public–private partnership. The primary goal of ADNI has been to test whether serial MRI, PET, other biological markers, and clinical and neuropsychological assessment can be combined to measure the progression of MCI and early AD. Determination of sensitive and specific markers of very early AD progression is intended to aid researchers and clinicians to develop new treatments and monitor their effectiveness, as well as lessen the time and cost of clinical trials.Data used in the preparation of this article were obtained from the ADNI databasewww.adni-info.org.The Principal Investigator of this initiative is Michael W. Weiner, MD, VA Medical Center and University of California – San Francisco. ADNI is the result of efforts of many co-investigators from a broad range of academic institutions and private corporations, and subjects have been recruited from over 50 sites across the U.S. and Canada. The initial goal of ADNI was to recruit 800 subjects but ADNI has been followed by ADNI-GO and ADNI-2. To date these three protocols have recruited over 1500 adults, ages 55–90, to participate in the research, consisting of cognitively normal older individuals, people with early or late MCI, and people with early AD. The follow-up duration of each group is specified in the protocols for ADNI-1, ADNI-2, and ADNI-GO. Subjects originally recruited for ADNI-1 and ADNI-GO had the option to be followed in ADNI-2. For up-to-date information, see n = 154). Detailed diagnostic, inclusion, and exclusion criteria are described on the ADNI website2.For the current analysis, we selected individuals with a baseline diagnosis of MCI who had baseline MRI and CSF data available, and at least 1 year of clinical follow-up  previously determined to be associated with AD, the “cortical signature” of AD , and phosphorylated tau (p-tau). For the primary analyses, we used the raw values as continuous measures; however, t-tau and p-tau were log-transformed to better approximate normality in distribution. For analyses in which we classified subjects as having CSF amyloid-β values consistent with those of autopsy-proven AD, we used a cutoff value of levels less than 192 . IndividHere we used outcomes at 1 or 3 years. The primary outcome measures used in the present analysis were conversion to a diagnosis of AD dementia at 1 or at 3 years.post hoc pairwise comparisons where relevant; a = 0.05. Since effect sizes were expected to be subtle and strong a priori hypotheses were being tested, no multiple comparisons correction procedures were performed. In addition, the impact of biomarkers on clinical outcome was analyzed using separate logistic regression models for each of the two intervals of follow-up, constructed using the dichotomous conversion to dementia outcome measure as the dependent variable. Cox regression models were constructed to investigate the relationship of baseline biomarkers to the likelihood of progression to AD dementia using a more fine-grained time-to-event outcome rather than the two follow-up intervals employed in the other analyses. A multivariate Cox regression model was then constructed including independent variables that reached a trend-level effect (p < 0.1) in the univariate analyses . Covariates of age, education, and gender were generally not significant in the models and had minimal impact on the findings. Statistical analyses were performed using IBM SPSS 21.0.Tests of group differences were performed using Chi-square analysis (for frequencies) or Analysis of Variance (for continuous measures) with Table 1 for additional details.Of the 156 MCI participants with baseline MRI and CSF data who were followed for 1 year, 31 (20%) were diagnosed with probable AD dementia. Of the 111 who had 3-year outcome data, 48 (43%) were diagnosed with probable AD dementia. In the subset of MCI participants with baseline CSF evidence of cerebral amyloidosis, 26 of 116 (22%) were diagnosed with probable AD dementia at 1 year and 45 of 83 (54%) at 3 years. In contrast, in the subgroup of MCI participants with normal baseline CSF amyloid-β levels, only 5 of 40 (13%) converted to AD dementia at 1 year and 3 of 27 (11%) at 3 years. See p < 0.0001). In addition, baseline CSF p-tau levels were predictive of AD dementia, with each 1 SD increase in CSF p-tau levels being associated with a 1.7-fold increase in the likelihood of AD dementia . None of the other biomarkers demonstrated effects or trend-level effects. In the stepwise multivariate logistic regression model, the AD signature MRI marker entered but CSF p-tau did not, indicating that CSF p-tau did not explain additional variance in outcome beyond that explained by the AD signature MRI marker.We first sought to determine which of the baseline biomarkers would be useful in prediction of the likelihood of a diagnosis of probable AD dementia in the entire sample of MCI subjects. For the 1-year outcome interval, baseline cortical thickness measured with the AD signature MRI biomarker index was strongly associated with the likelihood of probable AD: a logistic regression model predicting a 1-year AD outcome indicated a nearly threefold increase in the likelihood of AD dementia for each 1 SD thinner cortex , p = 0.003). A slightly weaker effect was observed for the AD signature index . Significant effects were also observed for CSF p-tau  and CSF t-tau  while hippocampal volume displayed a strong trend . In the stepwise multivariate model, CSF amyloid-β entered but the other two did not.In contrast, 3-year conversion was best predicted by baseline CSF amyloid-β levels, with each 1 SD of reduction indicating a 1.9-fold increase in 3-year likelihood of AD dementia . The mean values for CSF amyloid-β are lower in both groups of converters than in stable MCI , but there is no difference based on year of conversion (p > 0.3). Alternatively, values for AD signature cortical thickness are lower for both groups of converters than the stable group , but also for the 1-year converters compared to the 3-year converters .p = 0.005). None of the other biomarkers were predictive in these univariate models. For 3-year prediction, a significant effect for the AD signature MRI biomarker  and a trend for hippocampal volume  were observed.We next investigated the utility of biomarkers for prediction of a diagnosis of AD dementia in subgroups of MCI subjects divided on the basis of baseline CSF amyloid-β levels. In the subgroup of MCI subjects with abnormally low baseline CSF amyloid-β levels , 1-year conversion to AD dementia was predicted by the AD signature MRI biomarker , with hippocampal volume showing utility as well  but not entering the multivariate model. None of the CSF markers demonstrated predictive value. For 3-year prediction, none of the markers were useful although power was extremely low due to the small number of individuals who were diagnosed with AD dementia.In the subgroup of MCI subjects with normal CSF amyloid-β levels, indicating the likely absence of cerebral amyloidosis, 1-year conversion to AD dementia was best predicted by the AD signature MRI biomarker . In multivariate analysis, a stepwise forward conditional model demonstrated that the AD signature MRI biomarker was the best and only predictor when each independent variable was entered as a continuous variable. However, when CSF amyloid-β was dichotomized using previously published cutoff values . This result is illustrated in Figure 3 in which the AD signature was also dichotomized to maximize sensitivity and specificity between amyloid-negative controls and amyloid-positive mild AD patients from the ADNI cohort.Finally, we performed a survival analysis to investigate the utility of these biomarkers for predicting the time to a diagnosis of AD dementia. Univariate Cox proportional hazards regression models indicated that each of the biomarkers was a predictor of time to diagnosis of AD dementia over the 3-year follow-up period  with all CSF biomarkers relative to the raw AD signature, suggesting that this adjustment for “brain age” improves the specificity of this MRI biomarker for AD-related neurodegeneration.Finally, to begin to assess the specificity of the refined AD signature index measure we analyzed the relationships between CSF biomarkers and the raw AD signature measure (in millimeters) and the adjusted AD signature index measure ; it may also be valuable in some trial designs to use a marker of neurodegeneration to identify patients in whom progression to dementia is likely within a relatively short time interval, such as 1 year. Such a stratified design for inclusion might be valuable in that most such participants would be likely to decline substantially during a reasonable follow-up interval, thereby maximizing power to detect a beneficial effect of the intervention. Of course, it is also possible that in these more “aggressive” cases of prodromal AD a drug might be less efficacious than in more indolent forms of the disease, but that remains an open question.These considerations are also becoming of greater relevance in clinical practice, particularly in light of recent FDA approval of the amyloid PET ligand florbetapir. Further, with the development of the above-described guidelines for incorporation of biomarkers into the assessment of MCI patients, it is likely that clinicians will be bringing these measures into their clinical practice for prognostication of MCI. The current work emphasizes that these tests may provide somewhat different information, which may have important implications for their value depending on the question that is being addressed. For example, MRI may be more valuable when interested in determining the likelihood of decline in the near future, which could influence life decisions that need to be made within that timeframe whereas the presence of amyloid may more definitively reflect the likelihood of progression, but have less value in predicting the timing.Figure 2). This indicates that once AD-related neurodegenerative cortical atrophy is prominent enough in MCI patients, further cognitive decline and loss of functional independence is imminent. Such a finding demonstrates the greater degree by which markers of neurodegeneration, particularly structural MRI measures, track disease state during symptomatic stages of disease.It seems intuitive, based on current models of biomarkers of AD pathophysiology , that thThe differences described here in temporal prediction and, ultimately, the complementary nature of biomarkers of cerebral amyloidosis with neurodegeneration are quite consistent with a number of recent studies in the literature exploring this issue. For example, A variety of MRI measures have been proposed as potential biomarkers of neurodegeneration in early AD, both with regard to the identification of presumed atrophy consistent with AD and with regard to monitoring changes over time that indicate progression of neurodegeneration. Hippocampal volume is the most widely employed and discussed measure of this type, and while clearly informative, it is increasingly appearing to be less sensitive and specific than other measures such as regional cortical thickness. We have previously shown using receiver operating characteristic analyses that the AD signature measure is superior to hippocampal volume in discriminating individuals with prodromal AD who progress to dementia within 3 years from those who do not . Here weIt is also important to note that we compared CSF molecular biomarkers on an individual basis, as opposed to the combination of these markers. However, it appears that a combination of these measures may further enhance prediction . In partIn the present study, we employed a novel approach to the calculation of our AD signature measure. In the past, we have generally not adjusted for age-related cortical atrophy, but in some analyses have simply corrected statistically for a participant’s chronological age. We recently reported on the cortical signature of normal aging (the “Aging signature”), describing a set of association and sensorimotor regions that undergo the most prominent loss of thickness in cognitively normal elderly adults compared to young adults . In the Finally, our analysis indicated that the MRI-derived AD signature biomarker was useful for predicting progression to dementia within 1 year in MCI participants with baseline CSF amyloid-β levels not low enough to meet typical cutoffs indicating cerebral amyloidosis. Even though the percentage of individuals who progressed to dementia in this subgroup was low (13%), the MRI marker was still useful for prediction in this short time interval. To interpret this finding, we have considered several possibilities. First, it is possible that these individuals have a non-Alzheimer pathology that is associated with atrophy in some of the same structures affected by AD. Although this consideration certainly seems reasonable when the structural MRI measure is of the hippocampus, since pathologies such as hippocampal sclerosis could be playing a role, it seems harder to reconcile with an MRI biomarker measuring a spatially distributed pattern of atrophy. We are currently examining the use of the AD signature marker in differential diagnosis of other neurodegenerative diseases, including frontotemporal dementias and Lewy body dementia; findings from this work will provide important data on the specificity of this marker in other neurodegenerative diseases. It is also possible that these individuals actually have underlying AD pathology but are “below the threshold” of amyloid pathology to meet current CSF cutoffs. This group could also be akin to previously reported cognitively normal and MCI individuals with evidence of AD-like neurodegeneration and negative amyloid status, which has been labeled suspected non-Alzheimer pathology sNAP; . While dLimitations of the present study include the relatively short follow-up period and the small number of individuals who were amyloid-negative at baseline with adequate longitudinal follow-up data. Furthermore, a more broadly representative sample of individuals with MCI might be helpful to better determine whether these findings are generalizable to clinical practice. Nevertheless, we believe the results of the present analysis provide valuable insights about the use of biomarkers in an MCI sample likely to be similar to that considered for clinical trials of putative AD interventions.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Soft tissue sarcomas are heterogeneous tumors that are difficult to treat. Up to 50 percent of patients develop metastatic disease and require systemic chemotherapy. Ifosfamide and doxorubicin are the two most active agents.2/24-hour continuous infusion) for a total of 12 cycles. At that time a computed tomography scan showed long-term partial response with excellent treatment tolerability.A 33-year-old Caucasian woman presented to our facility with a metastatic myxoid liposarcoma. Our patient was initially treated with surgery and radiation therapy, but experienced three recurrences during a six-year period, the first and the last occurring while our patient was pregnant. The first recurrence, which occurred two years after diagnosis and was localized in the left cervical and right axillary region, was treated with surgery followed by chemotherapy. Molecular analysis of this tumor showed a t + translocation resulting in a FUS-DDIT3 or EWSR1-DDIT3 fusion. Three years later our patient experienced a second recurrence in the left supraclavicular fossa, upper thoracic and anterior mediastinum, which was treated with surgery alone. Eight months later, during the second pregnancy, our patient experienced a third recurrence as a large cervical mass that was treated, upon pregnancy, with trabectedin (1.5mg/mThis case report illustrates the potential therapeutic activity of trabectedin in patients with myxoid liposarcoma. Soft tissue sarcomas (STS) are heterogeneous tumors that are difficult to treat. Up to 50 percent of patients develop metastatic disease and require systemic chemotherapy. Ifosfamide and doxorubicin are the two most active agents (response rates: 10 to 25 percent) . ML is aHere, we present the case of a patient with metastatic LPS who achieved a prolonged partial response (PR) with trabectedin.A 33-year-old Caucasian woman was diagnosed in 2006 with a localized myxoid LPS of the right thigh that was treated with compartmental resection of the right quadriceps, with histopathological results showing a 10.7cm low-grade ML , with infiltration of margins that required extension surgery up to the periosteum, without the presence of residual tumor in the margins. Subsequently, she received adjuvant treatment with external radiotherapy to a dose of 70Gy. Two years later, while pregnant, she noted a mass in her left cervical and right axillary region, which proved to be a metastatic low-grade LPS  and after four cycles a significant clinical improvement in her dyspnea and pain was noted. A magnetic resonance imaging (MRI) scan showed a 50 percent reduction in the left supraclavicular mass, improvement in the chest lesion and resolution of the pleural effusion. This was considered stable disease by RECIST  criteria and a PR according to the criteria of Choi et al.[Our patient was given trabectedin  and the natural history of the disease in the individual patient. Standard chemotherapy is based on anthracyclines as first-line treatment ,6.Only a few cases of recurrent LPS have been reported during pregnancy to date, and no solid evidence of an increased incidence or a worse outcome has been demonstrated. Trabectedin has shown activity in patients with STS with a response rate of eight percent and a 47 percent one-year survival. In a phase II study focused on patients with leiomyosarcomas and LPS, the agent demonstrated a 14-month median survival that is superior to the expected 12 months seen with historical controls [This case report highlights the activity of trabectedin on myxoid LPS with  + translocation resulting in a FUS-DDIT3 or EWSR1-DDIT3 fusion after failure of local and post-operative chemotherapy.Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.The authors declare that they have no competing interests.All authors made substantial contributions to all of the following: (1) the acquisition of data; (2) drafting of the article and (3) final approval of the version to be submitted. All authors read and approved the final manuscript.


In Reply to Dahl: The emergence and spread of multidrug-resistant Salmonellaenterica serovar Typhimurium DT104 (MDR DT104) contributed to an international increase in antimicrobial drug resistance in S. Typhimurium in the late 1990s , which corresponds to a relative mortality rate of 4.18  2.18 to 8.02) compared with a matched sample of the general population. Of 1,432 patients infected with pansusceptible strains, 43 patients died . In other words, the mortality rate in patients infected with strains resistant to ACSSuT (Nx susceptible) was 1.6 times higher than in patients with pansusceptible strains . These estimates were not adjusted for coexisting conditions as were the estimates in the paper  resistant , our recent estimates suggest that the death rate is approximately 60% higher in patients infected with such strains. This view is corroborated by recent studies from the United States, which suggest that S. Typhimurium R-type ACSSuT is associated with an increased risk for blood stream infection (Salmonella is associated with an increased risk for admission to hospital (We agree with Dahl that particular problems are associated with quinolone resistance in zoonotic salmonellae and that fluoroquinolones may have reduced efficacy to treat patients infected with


India has the second largest diabetic population (61 million) and tobacco users (275 million) in the world. Data on smoking cessation among diabetic patients are limited in low and middle income countries. The objective of the study was to document the effectiveness of diabetic specific smoking cessation counseling by a non-doctor health professional in addition to a cessation advice to quit, delivered by doctors.In our parallel-group randomized controlled trial, we selected 224 adult diabetes patients aged 18 years or older who smoked in the last month, from two diabetes clinics in South India. Using a computer generated random sequence with block size four; the patients were randomized equally into intervention-1 and intervention-2 groups. Patients in both groups were asked and advised to quit smoking by a doctor and distributed diabetes specific education materials. The intervention-2 group received an additional diabetes specific 30 minutes counseling session using the 5As , and 5 Rs  from a non-doctor health professional. Follow up data were available for 87.5% of patients at six months. The Quit Tobacco International Project is supported by a grant from the Fogarty International Centre of the US National Institutes of Health (RO1TW005969-01).bidis smoked per day > 50% of baseline use) at six months.The primary outcomes were quit rate (seven day smoking abstinence) and harm reduction : 4.1-17.1] for intervention-2 group compared to intervention-1 group. Even among high level smokers the odds of quitting was similar. The odds of harm reduction was 1.9 (CI: 0.8-4.1) for intervention-2 group compared to intervention-1 group.The value addition of culturally sensitive diabetic specific cessation counseling sessions delivered by non-doctor health professional was an impressive and efficacious way of preventing smoking related diabetic complications.Clinical Trial Registry of India (CTRI/2012/01/002327) India has the second largest population 1210 million)  after Ch million Kerala, the Indian state most advanced in epidemiological transition  and the All of the 2490 male diabetic patients (aged 18 years and above) who attended two referral diabetes clinics located in peri-urban areas of two south Indian cities located in Kerala state were screened for smoking through the use of a brief instrument provided to patients at the clinic registration counter from December 2008 to April 2011. Among them 14.6% n=363) were current smokers. Being a pilot study we decided to include all the patients who satisfied the inclusion criteria during the recruitment period. Inclusion criteria for the study were: male diabetes patients aged 18 years or above, literate, native to the clinic catchment area, high probability that they would be treated at the clinic for the next six months and willingness to participate in the study. After excluding patients who did not meet inclusion criteria, or did not agree to participate in the study (n=139) a total of 224 male diabetes patients (mean age 53 years) who smoked in the previous month were selected for the study. Female patients were excluded since the smoking rate among females in Kerala was zero percent [63 were cThe procedure followed was minimally invasive. A screening instrument was kept at the hospital reception where all the patients had to register after entering the hospital. Smokers were identified by the counselor from this screening tool which inquired the patient’s smoking status. Patients attending the clinic routinely go to the lab for a blood glucose examination and then have a waiting period before lab results are ready and they can be seen by the doctor. During this time, the counselor met patients who had indicated a history of smoking on the screening instrument. After being informed about the study details written consent from the patients was obtained. From those who gave consent, the counselor collected baseline information using a pre tested structured interview schedule. Details about basic demographic information, smoking history, current smoking patterns and presence of any other chronic diseases  were collected.Subsequently the counselor randomized the patients equally into two groups; intervention–1 and intervention–2 groups, with block size four. Sequentially, every four patients enrolled were randomized into the two intervention groups using a computer generated random sequence to achieve a block size of four, to facilitate interim analysis. Their medical records were then flagged with different colored stickers by the counselor in order to identify group assignment. After the interview, the patient consulted the doctor. The doctor gave the patient a standard diabetes specific tobacco cessation message. The doctor also showed the patient visual images of common diabetes complications exacerbated by smoking. At the end of consultation the doctor instructed the patient to meet with the counselor. The counselor provided educational materials on tobacco and diabetes developed by the QTI on the harm of tobacco for diabetes patients that built on formative research and followed a question answer format for all the patients  and gaveIntervention–2 group patients received three diabetic specific tobacco counseling sessions  lasting about 30 minutes in each session following the 5 ‘A’s  and 5 ‘R’s  . In thisAll patients were given smoking cessation advice on each visit by the doctor for the next six months. Participants in intervention–2 group additionally received face to face counseling sessions on each visit for the next six months. Thus patients in the intervention group-2 received three counseling sessions: first at baseline, second at month one and third at month three of follow-up.The doctors and diabetes educators selected to counsel patients in the study sites were initially given training on the harm of tobacco for diabetes patients including: 1) a review of epidemiological data on smoking as a diabetes risk factor, 2) complications strongly associated with smoking among those afflicted with diabetics, and 3) the mechanisms through which smoking contributes to vascular constriction and obstructed blood flow. Educational materials developed by the QTI for diabetes patients that explain these facts in simple terms were provided to the counselor to give to patients. Doctors and the counselors were also trained in basic brief intervention cessations skills. Doctors were instructed to ask all patients about their smoking status and to strongly advise patients not to smoke using a standardized diabetes specific cessation message linking smoking to the complications of diabetes. Doctors were provided a visual aid illustrating how tobacco narrows the passage of blood in the vascular system and pictures illustrating diabetes complications at distal points of the vascular system such as eyes, feet, fingers, and penis. In sum, the doctors were instructed to actively deliver two of the Five As, Ask and Advise, using illness specific visual aids. The counselors were given additional training in tobacco cessation counseling and instructed to actively conduct all of the five ‘A’s with patients in intervention group–2 each time they attended the clinic and 5 ‘R’s when necessary. The counselors were instructed to document the details of cessation offered to at least 15 patients using five ‘A’s and five ‘R’s. An examination was conducted by one of the authors (MN) based on these 15 brief interventions to assess their cessation skills. A certificate titled “basic tobacco cessation competency” was issued on successful performance in the examination by the University of Arizona.bidis used in an average day. We reminded all the patients in both the groups by phone about the six month follow up in order to get maximum response. All the diabetic patients followed up at one, three and six months were seen by the doctor and were advised to quit smoking.Follow up interviews were conducted with all study participants in both groups at one month, three months and six months. All the follow-up interviews were conducted in person, although some of them were reminded by phone calls to come for the follow-up visit. Patients were asked about their smoking in the last seven days as well as questions related to the number of cigarettes/bidis smoked on an average day of use.The primary outcome measure was a seven day smoking abstinence (quit rate) measured by a question: “During the past seven days, did you smoke even a puff?” Other smoking outcomes gathered included patients’ reports on the number of cigarettes/Statistical comparisons of means and proportions were made using Student’s t-tests, Chi-square tests, Chi-square tests for trend or Fisher’s exact test. The relative risk was estimated by computing odds ratios (OR). Multivariable models using multiple logistic regression analyses were used to identify the correlates of quit rates. A complete case analysis and intention to treat analysis were done. In order to test our hypothesis that high level smokers are more addicted to smoking and less likely to quit smoking compared to their low level smoking counterparts, we did a stratified analysis of baseline level smoking and quit rate at six months. All the analyses were done using SPSS version 17.0 and statistical significance was set at two tailed p<0.05. The statistician was blinded to group assignment.We screened 2490 male diabetic patients. Among them 363 (14.6%) were current smokers. Of these 363 patients, after excluding patients who were not willing to participate in the study (n=31), who were not the natives to the clinic catchment area (n=89) and who could not come for follow ups for the next six months (n=19), a total of 224 patients were included in the final study.Average age of the study patients was 53 years (range 28–75). Under the age of 40 years there were 17 patients (7.6%), confirming previous findings of the early onset of diabetes in India . Median The mean age of initiation of smoking was 21 years . Around 44% of patients initiated smoking in their adolescent years (< 20 years). Twenty eight patients (12.5%) were diagnosed in the last two years prior to the study. Mean age of diagnosis of diabetes was 45.4 years . Thus on an average these patients smoked 24 years before the diagnosis of diabetes.In the first follow-up wave (month one) we were able to contact 173 (77.2%) patients, in the second follow-up (month three) 163 (72.8%) patients and in the third follow-up (month six) 196 (87.5%) patients.Smoking status of the patients at the six-month follow up based on complete case analysis is given in Table bidis used per day compared to baseline use), which was significantly higher in the intervention–2 group, was not found to be significant in the intention to treat analysis. The mean number of cigarettes/bidis smoked per day at month six was 4 (SD 8.2) in the intervention–2 group, significantly lower (p < 0.001) than that of 10 (SD 13.7) in the intervention–1 group in complete case analysis.Data from the six-month follow-up was available for 196 patients (87.5%). The odds for quitting was 10 times higher for intervention–2 group compared to intervention–1 group in the complete case analysis and close to nine times higher in the intention to treat analysis. Harm reduction  and the intervention–2 group (19.6%) was not statistically significant (p = 0.09). At three months follow up the quit rate remained at almost the same level in the intervention–1 group (10.7%), whereas in the intervention–2 group the quit rate increased to 28.6% and the difference was statistically significant ( p <0.001). At the six-month follow-up the quit rate further increased to 51.8% in the intervention group–2. Among those who came for all the three follow up visits in this group, statistically significant (p=0.007) positive trend in quit rate was seen with increase in the number of counseling sessions attended.Readiness to quit was assessed only for intervention group-2 as part of the intervention strategy. Out of the 112 patients in the intervention – 2 groups 77 reported that they were ready to quit at baseline. At six month follow-up, 40 patients (51.9%) out of these 77, quit smoking where as among the 35 patients who were not ready to quit at baseline, 18 (51.4%) quit smoking at six month follow-up.Quit Rate at six months by baseline level of smoking is given in Table The study found that both the doctor’s message alone and counseling lead many patients to quit or significantly reduce their smoking habit. This was true of both low level smokers at baseline and high level smokers. Quit rates in the intervention–1 group were 12.5% at month six compared to the baseline, indicating the importance of routine smoking cessation advice by doctors to all diabetes patients. Doctor’s cessation advice that is disease specific is responded to better by patients than general advise . Our finbidis smoked per day in Kerala compared to Indonesia, the highly educated population in Kerala, better implementation of the national tobacco control program and the repeated 30 minutes counseling sessions for quitting each time the patient visited the clinic. High quit rates of 50% at one year follow-up was reported by chronic obstructive pulmonary disease (COPD) patients in a recent study on smoking cessation buddies in COPD indicating that high quit rates are possible in chronic disease patients [The only prior study from a developing country on cessation among diabetes patients from Indonesia reported a quit rate of 30% in the group that received doctor’s advice and 37% in the group that received doctor’s advice and counseling. Although this difference in quit rate was not statistically significant, the quit rate of both groups’ was significantly higher at the six-month follow-up compared to the base line. The quit rate of 52% in our intervention–2 group was much higher than the 37% in Indonesia. This could be due to several factors, including the lower average number of cigarettes/patients .Generally, people including health professionals do not associate smoking with diabetes. Awareness of the association between smoking and cancer, cardiovascular diseases and respiratory diseases are generally higher . HoweverThis study found a dose response relationship between counseling and quit rate. The quit rate increased significantly from the one-month follow-up to the third month and again at the six-month follow-up. This demonstrates the significance of repeat counseling at frequent intervals for increasing quit rates and probably sustaining it. It is important to treat smoking as a chronic disease understanding the nature of addiction, possibility of relapse and the need for continuum of care . The docThe Indian Institute of Diabetes in Kerala, one of our study sites for this study, has taken note of the outcome of this study and is currently planning to incorporate smoking cessation counseling as a routine activity in their diabetic clinics and advise the State Government to follow this practice.Our study followed the patients only for six months, the outcomes were self reported and we did not conduct biochemical verification due to resource constraints. However, it has been reported by the Society for Research on Nicotine and Tobacco subcommittee on biochemical verification that for population based trials with low demand situation biochemical verification may not be necessary . The couAll doctors should routinely ask and advise diabetes patients to quit smoking, including calling attention to the complications that are more likely if they continue to smoke. We have demonstrated that a brief intervention by doctors is likely to result in a quit rate of about 10–13%. If this brief intervention is further supported by counseling sessions by a trained non-doctor health professional, the patients were able to reach a 52% quit rate at the six-month follow-up. Even among the high level smokers the quit rate at six months was 51%. And of those who did not quit, at least 25% engaged in harm reduction by reducing their former smoking levels to more than 50% of baseline. Counseling sessions using disease specific diabetes messages and culturally sensitive use of the five ‘A’s and five ‘R’s cessation protocol is an efficacious way of reducing smoking, an important risk factor that significantly increases the chances of life threatening, debilitating and costly diabetes complications.If this system of brief intervention by the doctors supported by a counseling session by a non-doctor health professional can be incorporated in the national health system, a substantial proportion of diabetes complications due to smoking can be prevented.The authors declare that they have no competing interests.The contribution of each of the authors is listed below: KRT: Conception, design, revision of the manuscript with critical contribution for intellectual content, and giving final approval of the version to be published, GKM: Conception, design, analysis and interpretation of data, and revision of the manuscript for intellectual content, MD: Conception, design, analysis and interpretation of data and drafting of the manuscript, GV: Conception, design, and revision of the manuscript with critical contribution for intellectual content, PSS: Analysis, interpretation of data, and contribution to critical revision of the manuscript for statistical accuracy, MN: Conception, design, analysis and interpretation of data, and revision of the manuscript for intellectual content. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2458/13/47/prepub