In recent years, several landmark trials have transformed acute ischemic stroke care. The most dramatic results from the field of acute endovascular intervention demonstrate unequivocal benefit for a select group of patients with moderate to severe deficits presenting within 7 hours from onset and with occlusions of proximal arteries in the anterior circulation. In addition, technological advances and workflow efficiencies have facilitated more rapid delivery of acute stroke interventions. This review provides an overview of recent advances in the management of acute ischemic stroke. In 2008, the ECASS-3 trial extended the window for r-tPA eligibility from 3 to 4.5 hours after symptom onset, with additional exclusion criteria5, which increased r-tPA utilization by as much as 20% in some centers6. In 2015, the introduction of advanced endovascular treatment approaches further expanded this treatment window in select patients to up to 7 hours from symptom onset. Rapid assessment of suspected stroke patients to determine eligibility for these treatments, therefore, remains a critical step. Systems and processes to efficiently identify suspected stroke patients as early as possible and rapidly deliver acute reperfusion therapy are now commonplace. Further technological advances using telestroke and mobile stroke units in the prehospital setting have increased r-tPA utilization and reduced delays to treatment. This review will discuss the most recent developments in acute stroke treatment and improved systems for their delivery in current practice.Until recently, recombinant tissue plasminogen activator (r-tPA) was the only acute ischemic stroke treatment. However, only 3–9% of patients with ischemic stroke actually receive r-tPA7. Therefore, swift reperfusion preserves tissue in the penumbra while reducing the size of the final infarct core, thereby limiting the volume of damaged tissue and reducing disability from stroke.The most effective treatment for acute ischemic stroke is timely reperfusion of the causative vessel occlusion via r-tPA and/or mechanical thrombectomy. Reperfusion improves outcomes by reducing the volume of brain tissue injury. Therefore, a small core infarction (irreversibly lost brain tissue) with a large penumbra (viable but ischemic tissue) is the ideal target for acute reperfusion therapy. As time from initial stroke increases, the penumbra is quickly replaced by infarcted tissue12. Overall, there was over twofold increased odds of good outcome (independent of activities of daily living) with endovascular therapy compared to standard medical management with no increase in harm such as major intracranial bleeding. Because of these studies, the American Heart Association/American Stroke Association (AHA/ASA) released an update in 2015  or middle cerebral artery (MCA) occlusions, moderate to severe stroke severity, and presenting within 12 hours of symptom onsetin 2015  to their14. In sum, these new trials validated long-held hypotheses that reperfusion is effective in patients with acute ischemic stroke due to large artery occlusion if provided early, when the majority of brain tissue is ischemic  but not infarcted .Compared to prior failed trials, these studies had notable differences and advantages. First, the trials emphasized workflow efficiency with targets for door to groin puncture and reperfusion that were far more aggressive than in previous trials and therefore achieved times from symptom onset to reperfusion in less than 4 hours for many patients. Second, the use of stent-retrievers, superior to first-generation devices used in earlier trials, achieved greater rates of near-complete or complete reperfusion. Third, each trial included at minimum a vessel imaging screening test, typically computerized tomographic angiography (CTA), for the detection of large artery occlusion, avoiding the scenario encountered in prior trials wherein the target lesion was absent in a substantial number of patients enrolled, biasing the study towards a null result12. The EXTEND-IA trial enrolled patients with CTA to confirm a proximal anterior circulation occlusion and CT perfusion imaging to confirm a small infarct core prior to randomization9. The ESCAPE trial also used CTA scans to confirm a proximal anterior circulation occlusion but measured infarct burden using ASPECTS (Alberta Stroke Program Early CT score), a 10-point scoring system which evaluates 10 pre-determined areas of the brain supplied by the MCA. A point is deducted for hypodensities seen in each area on a standard CT scan, which included scores from 0 (imaging evidence of complete infarction of the MCA territory) to 10 (no imaging evidence of early infarction). Patients with small infarct burden (defined as an ASPECTS >5) were enrolled. Multi-phase CTA was used to assess collateral circulation. Patients who had good collateral circulation  were enrolled11. SWIFT-PRIME utilized either MR angiography or CTA to identify proximal anterior circulation occlusion and the ASPECTS score to identify infarct core but included perfusion imaging in nearly 80% of patients enrolled using RAPID software15 to automate the interpretation of penumbra and infarct core volumes10. A meta-analysis of the major interventional trials showed that the benefit decreased every hour as time from stroke onset to time of arterial puncture for endovascular therapy, eventually becoming non-beneficial at 7.3 hours after stroke onset16.It is still unclear which imaging method is most appropriate in the acute evaluation of stroke patients for endovascular therapy. Two trials, MR-CLEAN and REVASCAT, utilized CTA and did not include any perfusion imaging prior to randomizationCurrently, an initial CT scan without evidence of a large infarction by ASPECTS along with evidence of a proximal anterior circulation occlusion on CTA is the simplest approach to select patients for endovascular intervention, provided the procedure is initiated within 7 hours of stroke onset.Though these trials ushered forth a new, exciting era for stroke intervention, further research is needed to evaluate whether more patients, such as those with basilar, vertebral, or posterior cerebral artery occlusions, may benefit from mechanical thrombectomy. In addition, treatment of occlusions beyond the first bifurcation of the MCA is uncertain, pending further study. Further research on optimal imaging selection, as will be discussed below, may be helpful in identifying patients who may benefit from intervention in delayed time windows.17, excluding many patients from acute stroke reperfusion therapy. As a result, there is great interest in identifying a physiologic “tissue clock” rather than a chronological one (i.e. from last known well). Specific patient populations such as those who experience stroke symptoms upon awakening and mild stroke patients may benefit from reperfusion beyond the currently approved chronological timeline.Only 25% of patients arrive at a hospital within 3.5 hours, and less than 65% arrive within 8 hours of symptom onset19. As a result, these wake-up stroke (WUS) patients are excluded from r-tPA treatment and often mechanical thrombectomy as well.About 15–25% of all ischemic strokes occur during sleep, without the patient knowing the exact time of symptom onset, often making the last known normal time greater than 6 hours before time of presentation21. Other studies found that MR diffusion-weighted imaging (DWI) sequences identify acute ischemic changes within minutes of symptom onset while fluid attenuated inversion recovery (FLAIR) sequences identify changes 3–6 hours after symptom onset22. Thus, a DWI-positive and FLAIR-negative MRI would suggest an acute ischemic stroke under 3 hours of symptom onset. The MR-WITNESS trial was a single-arm feasibility study which used the DWI/FLAIR selection criteria to administer r-tPA to 80 patients who woke up with stroke symptoms and presented to healthcare within 4.5 hours of waking up23. Only one patient had a symptomatic hemorrhage, and the group had functional outcomes similar to those of the patients in the ECASS-3 trial, suggesting that this technique may be a safe and effective way of selecting more patients for r-tPA treatment. Currently, the WAKE-UP and EXTEND trials are underway to further investigate this approach in a larger cohort of patients with WUS24. The DEFUSE III trial is a phase III trial investigating mechanical thrombectomy in patients with an ICA or proximal MCA occlusion and presenting between 6 and 16 hours from last known normal time, many of whom are WUS patients, using penumbra-core mismatch on perfusion imaging to identify stroke patients with salvageable tissue who could benefit from intervention25.The DEFUSE studies found early reperfusion was associated with improved clinical outcomes if there was a perfusion/diffusion mismatch (larger area of decreased perfusion than infarcted tissue) on MRI26. Since then, there is increasing concern that Asians in America may be at increased risk of intracranial hemorrhage after treatment of acute ischemic stroke with r-tPA27. The recently published ENCHANTED trial investigated low-dose r-tPA (0.6 mg/kg versus 0.9 mg/kg) for patients with acute ischemic stroke and showed that there was a reduction in mortality and symptomatic intracerebral hemorrhage with a lower dosage when compared to the standard-dosage r-tPA, but this benefit was offset by an increased rate of disability at 90 days in the low-dose group. While the study failed to meet its primary endpoint, a secondary ordinal analysis of severity of disability based on the modified Rankin scale did show non-inferiority28. While the lower dosage seems safer and may be suitable for particular high-risk populations, further research is needed to demonstrate efficacy.In the last few years, the Japanese drug safety authority approved r-tPA at a dosage of 0.6 mg/kg, a dose lower than the standard 0.9 mg/kg used for acute stroke treatment based on an uncontrolled open-label study done in 200629. The number of patients needed to treat to achieve an outcome of functional independence increases from 3.5 patients in the first 90 minutes to 7 patients between 91 and 180 minutes and to 14 patients between 181 and 270 minutes30. This is likely explained by the decreasing volume of viable brain tissue (e.g. penumbra) as time from symptom onset increases. Unfortunately, up to 69% of acute stroke patients are unable to get r-tPA secondary to delay in patient arrival31, spurring initiatives to deliver stroke care as quickly as possible. Several proven options include expediting hospital arrival to intervention times, telestroke, and mobile stroke units.Patients who received r-tPA within 90 minutes of symptom onset had better functional outcomes more than those who were treated at 181 to 270 minutes from onset32. Because of this success, Target: Stroke Phase II is underway with an even more aggressive goal of administering r-tPA to at least 75% of patients within 60 minutes of arrival and at least 50% of patients within 45 minutes of arrival.Target: Stroke is a quality initiative introduced by the AHA/ASA in 2010 which disseminated best practice strategies to achieve faster DTN times for r-tPA delivery at participating hospitals across the United States (US), with the goal of administering r-tPA in less than 60 minutes from hospital arrival in at least 50% of eligible patients. The best practices include 11 care strategies to achieve faster DTN: emergency medical services pre-notification to hospitals about stroke patients, hospital-specific stroke protocols, a rapid stroke identification and notification system, a single-call stroke activation system, direct to CT protocol, rapid transportation to imaging, rapid interpretation of imaging, rapid protocols for laboratory testing, pre-mixing of r-tPA in patients with high likelihood of stroke, a team-based approach, and a prompt feedback system. Implementation of these strategies resulted in a reduction of r-tPA administration times from a mean of 74 minutes to 59 minutes and reduced in-hospital mortality and long-term mortality33. Three features of protocol – pre-notification by ambulances, direct-to-CT imaging, and pre-mixing r-tPA – were introduced in Melbourne, Australia, with similar results34.Internationally, a few DTN process improvement efforts have been even more stunning. An expedited protocol developed in Helsinki, Finland, in a single-provider area has demonstrated the most efficient DTN times in the world. Their ambulances have a direct line to a stroke neurologist, enabling the on-call neurologist to obtain a history and r-tPA consent over the phone as well as ready the stroke team at the hospital for prompt CT scanning and r-tPA administration before the patient arrives. The patient arrives and is taken from the ambulance to the CT scanner directly, during which time the neurologist performs a quick neurologic examination. After the CT scan excludes hemorrhage, r-tPA can be given immediately, often in the CT scanner, resulting in DTN times averaging 20 minutes35. In these instances, other solutions will be necessary.There are some limitations to applying the Helsinki protocol in the US. First, rather than one hospital in a region, most urban areas have multiple stroke centers. Close contact with ambulance systems and pre-notification of receiving hospitals may still help expedite r-tPA delivery but would require coordination across multiple hospital systems in a region. Second, the lack of universal health records in the US increases delays to treatment owing to time spent in eligibility determination. For example, use of anticoagulants and recent surgical history are relevant for r-tPA eligibility determination and require verification by patient or caregiver interview or medical record review. Third, a substantial portion of the US still does not reside within close proximity to designated stroke centers36. Studies have shown that telemedical consultation with a stroke neurologist remotely can reduce DTN times substantially at small hospitals37. While the DTN times are higher than the Helsinki protocol, transport to the nearest hospital is faster than to the "hub" hospital, potentially resulting in similar onset-to-treatment times38.Telestroke permits remote audio-visual connection between a stroke center (the "hub") and multiple community hospitals (the "spokes"). Patients who arrive at non-stroke center hospitals, often smaller rural hospitals, may particularly benefit from telestroke, as these hospitals do not have access to an on-site stroke expert with experience in delivering r-tPA efficiently and safely39, and this has not changed over the last decade40. The largest, and most important, window for reducing delays to treatment is therefore prior to hospital arrival. Programs have been developed to bring neurologists and r-tPA administration to the field in the form of a mobile stroke ambulance41. These ambulances are equipped with a mobile CT scanner and point-of-care laboratory testing42. In some programs, a vascular neurologist travels in the rig for in-field interview and examination before administration of r-tPA43. Other programs have installed telemedicine equipment for remote interview and examination by a neurologist with the aid of emergency medical technicians in the ambulance44.While DTN times are the focus of quality improvement at the hospital, reducing time from symptom onset to treatment makes the most impact on functional outcomes. Half of patients arrive at a hospital after 2 hours from symptom onsetP<0.001). Among patients who received r-tPA, the pre-hospital thrombolysis arm had a remarkably lower median onset-to-intervention time 45. In a comparative analysis of symptom onset to r-tPA treatment times, pre-hospital thrombolysis with a mobile stroke unit provides the best times, even when compared to the Helsinki protocol and telestroke programs46. However, this comes at a very large financial cost , which may be an obstacle for implementation within many healthcare systems47.The prospective PHANTOM-S study compared conventional care to pre-hospital thrombolysis with r-tPA with an in-field emergency-trained vascular neurologist. Significantly more patients received r-tPA in the pre-hospital thrombolysis arm of the study versus conventional care (31% versus 4.9%,With the technological advances in acute stroke care, many more patients with the most severe strokes can receive treatments that can reduce death and disability from the disease. Endovascular intervention with mechanical thrombectomy has been shown to improve functional outcomes in select patients with severe stroke and large artery occlusion in the anterior cerebral circulation. Administration of r-tPA has been shown to be effective up to 4.5 hours from symptom onset. New protocols have been developed to potentially expand r-tPA treatment to patients with WUS, approximately 15–25% of all ischemic strokes and mild stroke, and up to 75% of all ischemic strokes. Advances in technology have also led to models of care to deliver r-tPA in a speedy and efficient manner, whether through pre-hospital triage via telephone, r-tPA administration via telemedicine, or actually administering r-tPA in the ambulance. These innovations have revolutionized acute ischemic stroke care from a disease with no treatments to one with multiple proven options.


We provide evidence that clofazimine induces apoptosis in PDAC cells with an EC50 in the μM range via its specific inhibitory action on the potassium channel Kv1.3. Intraperitoneal injection of clofazimine resulted in its accumulation in the pancreas of mice 8 hours after administration. Using an orthotopic PDAC xenotransplantation model in SCID beige mouse, we show that clofazimine significantly and strongly reduced the primary tumor weight. Thus, our work identifies clofazimine as a promising therapeutic agent against PDAC and further highlights ion channels as possible oncological targets.Pancreatic ductal adenocarcinoma (PDAC) represents the most common form of pancreatic cancer with rising incidence in developing countries. Unfortunately, the overall 5-year survival rate is still less than 5%. The most frequent oncogenic mutations in PDAC are loss-of function mutations in p53 and gain-of-function mutations in KRAS. Here we show that clofazimine (Lamprene), a drug already used in the clinic for autoimmune diseases and leprosy, is able to efficiently kill  Pancreatic ductal adenocarcinoma (PDAC) is one of the most aggressive types of tumors, being the fourth leading cause of cancer mortality. In general, patients are diagnosed at a rather late stage of disease and their life expectancy is at most five years after diagnosis. In most cases, the only valid therapeutic approach is the radical surgical resection of the tumor, which however is feasible only in 20% of the cases, and recurrence of cancer lesions often occurs. Some other patients (30-40%) show unresectable locally advanced pancreatic cancer (LAPC) with a median survival of one year . For theFor about 20 years, the only therapeutic option considered valid for the treatment of PDAC has been 5-fluorouracil (5-FU). Although the most widely used chemotherapy drug is gemcitabine, administered alone or in combination with other chemotherapeutics such as 5-FU, capecitabine, platinum analogues and taxane , currentin vivo studies in preclinical models  in DMSO and sterile water for injection . For the therapy, it was administered in a dose of 5μg/g (10 nmol/g) intraperitoneally. The control group was treated with a solution containing DMSO and physiological saline buffer. All animals were examined daily for general signs of distress and complications. Thirty days after cell inoculation, the animals were sacrificed and tumor weight was determined after blood removal. Thereafter, the tumors were cut into two equal parts, which were directly either frozen in liquid nitrogen or formalin-fixed and later paraffin-embedded (FFPE). The mice were carefully inspected for any macroscopic metastases in liver, spleen, and mesenterium. Furthermore, several organs were embedded in paraffin for histological staining and analysis.The orthotopic injection was performed as previously described . Human mPrimary tumor samples from paraffin-embedded tissue were cut into 3μm sections and mounted onto slides. The specimen were tested for pan-cytokeratin , Ki-67  and CD31 . The immunohistochemistry (IHC) was carried out according the following procedure: de-paraffinization with xylene, rehydration in descending concentrations of ethanol, followed by heat-induced epitope retrieval with sodium citrate buffer (pH 6.0). Washing steps were performed at room temperature with tris-buffered saline (TBS); to avoid non-specific binding of the antibody to the tissues, all specimen were incubated with POD  for fifteen minutes. The primary diluted antibodies  were applied and the samples were kept in a humidified chamber for one hour. For detection, the tissues were incubated with HPR-conjugate anti-rabbit/mouse (Dako) and Mouse-PO anti-rat for thirty minutes; subsequently, the substrate chromogen-DAB (Dako) was added and the staining developed for five minutes. Finally, the samples were counterstained with Hematoxylin (Dako) and dehydrated with ascending concentrations of ethanol and rinsed in xylene. To test the proliferation activity of the tumors in both control and clofazimine-treated samples, the Ki-67 nuclear staining was evaluated by an experienced pathologist who performed the Ki-67 % scoring. Briefly, for each tumor sample the areas with a positive staining (hot spot) were selected. In the selected field, the cells showing nuclei with weak intensity of the staining were regarded as Ki-67 positive cells and counted at 40X magnification. Finally, the Ki-67 % scoring was determined as number of positive cells compared to the total number of nuclei in the corresponding area. Slides were scanned with Scn400 Image Viewer software . Tumors samples were screened at 10X magnification. The areas with a higher positive staining for CD31- as vascular hot spots- were further examined at 20X magnification to observe the vascular structures.Clofazimine (10 nmol/g) was injected i.p. into control mice. 24 hours after last injection the animals were sacrificed and blood and various tissues were collected. Up to 100 mg of each tissue were weighted precisely, PBS (1 vol) was added, and the tissue sample was cut into small pieces and homogenized with an electric pestle. 100 μM 5-methoxypsoralen (5-MOP) in acetone (0.1 vol) was added as internal reference and clofazimine was then extracted adding 4.35 M acetic acid (0.1 vol) and acetone (10 vol). Each sample was vortexed (2 min), sonicated (2 min), and centrifuged ; the supernatant was collected, concentrated using a Univapo 150H (Uniequip) vacuum concentrator, and finally analyzed via HPLC-UV according to established protocols previously used for other drugs . Blood s


Cardiac resynchronization therapy(CRT) has been recommended as a standard treatment for patients with advanced heart failure. However, some studies have reported different clinical and echocardiographic outcomes between male and female patients who received CRT. This Meta-analysis is to determine whether gender difference has any significant impact on clinical and echocardiographic outcomes in patients with heart failure after CRT.PubMed, Embase, and the Cochrane library database were searched. A total of 149,259 patients in 11 studies were identified. Our analysis demonstrated that women showed lower all-cause mortality than men after CRT . No significant difference was observed in the increment of New York Heart Association (NYHA) functional class, 6-minitue walk distance (6-MWD) , and quality of life (QoL) . With respect to the echocardiographic parameters, women exhibited statistically significant improvement in left ventricular ejection fraction (LVEF) , and decrement of left ventricular end diastolic diameter (LVEDD)  as compared with men. No significant difference was observed in left ventricular end diastolic volume (LVEDV)  and left ventricular end systolic volume (LVESV)  between men and women.Women seem to obtain greater benefits from CRT both in clinical and echocardiographic outcomes compared with men. But as this gender superiority could be observed only during long-term follow-up periods, further studies are needed to elucidate exact reasons for this phenomenon. Cardiac resynchronization therapy (CRT) has been recommended as a beneficial treatment modality for advanced heart failure patients with New York Heart Association (NYHA) functional class II-IV, left ventricular ejection fraction (LVEF)≦35% and QRS duration≧120 ms by ACC/ESC heart failure guidelines –10. AlthThis meta-analysis was developed and reported according to the preferred reporting items for systemic reviews and meta-analysis statement checklist . PubMed,Studies were considered eligible if they 1) performed a comparison of male and female gender in response to CRT , but not including implantable cardioverter defibrillator (ICD) alone); and 2) reported at least one relevant endpoint. These endpoints included clinical outcomes, including all-cause mortality, NYHA class, 6 minute walk distance (6-WMD), quality of life (QoL), and echocardiographic outcomes including left ventricular ejection fraction (LVEF), left ventricular end diastolic diameter (LVEDD), left ventricular end diastolic volume(LVEDV), and left ventricular end systolic volume (LVESV); The exclusion criteria were: 1) studies associated with the patients receiving ICD alone; 2) Abstracts, or studies with incomplete data; and 3) studies without the targeted endpoints.The outcomes of this pooled analysis included clinical and echocardiographic outcomes. The clinical outcomes included one primary endpoint—all-cause mortality, and three secondary endpoints, including QoL measured by Minnesota Living with Heart Failure Questionnaire, NYHA class, and 6-WMD, and the echocardiographic outcomes included LVEF, LVEDD, LVEDV, and LVESV.Three reviewers  independently screened titles and abstracts of all records. A standard data extraction form was made before extraction. From each article, the following information was derived: the first author, year of publication, nationality of the first author, follow-up duration, patients of study, baseline characteristics, and clinical or echocardiographic outcomes. The Newcastle-Ottawa Scale(NOS) was used to evaluate the quality of each study . QualityI2 statistic. Fixed effects models were performed unless there was evidence of heterogeneity (I2≥ 50%), where random effects model was used. Sensitivity analyses was performed to detect whether any single study was primarily responsible for the final results. A P value less than 0.05 was considered statistically significant.In this study, data was analyzed using the statistical software Stata . For all the outcomes, continuous data were analyzed by standard mean difference (SMD), and dichotomous data were pooled as Mantel-Haenszel odds ratio (OR). Percentage data  and rank data  were considered as continuous data and calculated in SMD. All the results were reported with 95%CI. Statistical heterogeneity was assessed by Chi- square test and reported by Fig 1. Our initial search yielded 953 citations from Pubmed, Embase, and the Cochrane Library. After several steps of screening, 11 observational studies assessing the gender difference in response to CRT met the inclusion criteria and were included into this meta-analysis [The results of literature search were presented in analysis ,16–22. T A total of 149,259 patients enrolled into this analysis. The proportion of female patients who underwent CRT was significantly smaller than that of male patients (26% versus 74%). The mean age of the women ranged from 58±14 to 74±11years, and men from 58±12 to 72±11years. Male patients tended to have more ischemic cardiomyopathy (ICM) compared with female patients when receiving CRT in many studies [The general characteristics of the included studies are listed in  studies –20,22. H studies ,18,21,22 studies , and 8 i studies –22.I2 = 67.4%) . The follow-up duration ranged from 6 months to 3.7 years. In terms of the follow-up period, women not only showed a significant short-term (< a year) reduction in all-cause mortality  but a long-term (≥a year) reduction in all-cause mortality . Sensitivity analysis was performed to identify the heterogeneity among the studies. Significant heterogeneity was noticed in one study [I2 = 3.5%).Seven studies involving 147,537participants reported the clinical outcomes of all-cause mortality. The pooled data showed that female patients benefited more from CRT than male patients  . Further analysis revealed that although women were similar to men in the increment of NYHA class in the short-term follow-up after receiving CRT , more significant exercise capacity was acquired in female patients compared with counterparts during the long-term follow-up period .Data from 8 observations involving 3189 participants indicated that in general, there was no significant difference in response to CRT between men and women on the increment of NYHA functional class  . A more detailed analysis was also performed stratified by a long and a short-term follow-up, but no significant difference was observed in both genders , and 0.01 , respectively).Pooled data from 4 observational studies involving 1496 participants demonstrated that both genders could benefit from CRT device implantation in terms of 6-MWD  . Further analysis according to the follow-up duration did not show any appreciable difference between men and women. The SMD for the long-term follow-up between both genders were -0.10 , and the short term was -0.10 .Change in QoL was reported in 4 of the 11 studies involving 1339 participants. Overall, no significant difference was found in the improvement with CRT in scores on the Minnesota Living with Heart Failure Questionnaire between male and female patients  . However, high heterogeneity was observed between studies. Sensitivity analysis of this Meta-analysis showed that one study with apparent clinical heterogeneity was identified [P<0.0001). After removal of the study, female acquired more LV reverse remodeling in LVEF compared with male patients . Three studies reported the short-term follow-up outcome of LVEF and found no significant difference between the two genders . Three studies evaluated the long-term outcome of LVEF and found that CRT offered more favorable outcomes in women compared with those in men .Data from 7 observations involving 2639 participants indicated that there was no significant difference in post-CRT LVEF improvement between male and female patients  .Three of 11 studies assessed LVEDD changes in 1186 patients who received CRT. Pooled analysis demonstrated a significant difference between men and women during the follow-up period ranging from 6 months to 3.7 years. LVEDD was reduced more significantly in female patients than that in male patients who received CRT  .Two studies involving 751 participants compared short-term LVEDV change between men and women. No significant disparity was observed between men and women who received CRT  .Data from three studies (1258 participants) indicated that female patients gained no more benefit from CRT compared with male patients  and QoL ,24. HoweWhy is this contradictory situation present in the utilization of CRT? Many investigators have tried to identify the underlying mechanisms. Firstly, women tend to have diastolic heart failure with preserved LVEF but worse NYHA class. According to the ESC /ACC guidelines, CRT could be considered only in heart failure patients with reduced LV function . However, few female patients could meet the criteria compared with men ,2,31,32.Up to now, the reasons for the gender difference in response to CRT still remain unclear, however, potential explanations have been presented. Firstly, there are many differences existing between male and female patients with heart failure. It was found  that womThis study also demonstrates that although women obtained great benefits from CRT in the primary endpoint of all-cause mortality, no significant difference was observed between men and women in the secondary clinical endpoints including NYHA function class, 6-MWD and QoL. The potential reason might be that gender difference has less impact on the secondary clinical outcomes than that on the primary endpoint. Hence, longer follow-up observations are required to see whether women could also benefit more from CRT in terms of the secondary clinical endpoints in the long run.Data from our analysis indicate that female patients tended to acquire more increment of LVEF from CRT compared with the counterpart male gender after removal one study with obvious heterogeneity in clinical characteristics. Schuchert et al  reportedP = 0.0004) and men usually toward to death because of sudden cardiac death . This provides a potential explanation that women might derive benefit from CRT while men probably obtain more survival in use of ICD. However, the benefit of this device therapy can only be achieved by a long time of utilization, and the sex-specific difference can only be detected by a long time observation.Some scientists have tried to find the mechanism underlying the superiority of female gender in response to CRT in the long run. Rho et al  found thTo better identify the difference between men and women in response to CRT, future investigators should focus on long time outcomes of patients treated with CRT; future health policy decision makers and guideline setters should well recognize the gender difference in CRT performance, address the importance of the role of female gender, and individualize the guideline recommendations for men and women with heart failure; future physicians should understand the superiority of female gender in response to CRT, raise the referral rate of women patient, and prompt the utilization of CRT in this special population group.First of all, to better evaluate the gender difference in response to CRT, we only included studies associated with patients undergoing CRT alone or CRT-D, and excluded studies related to patients treated with ICD, which may have excluded many studies assessing sex-specific difference in device therapy. Secondly, we only included the all-cause mortality as the primary endpoint without recruiting other endpoints such as cardiac death, sudden cardiac death and hospitalization because of limited data. Thirdly, of the 11 studies included in this Meta-analysis, no study evaluated all the clinical and echocardiographic outcomes, only two studies evaluated the LVEDV changes and three studies focused on LVEDD and LVESV changes after CRT. So the gender difference in these echocardiographic indexes might not be well established. Finally, owing to limited studies enrolled into each analysis (no more than 10), publication bias test was not performed, and therefore a potential publication bias may exist.In summary, women may obtain more beneficial effects from CRT than men with respect to the clinical and echocardiographic outcomes. However, the superiority of female gender in response to CRT may not be evident during short-term follow-ups, and therefore future long-term follow-up observations are required to verify gender difference in clinical and echocardiographic outcomes and find out the exact mechanism underlying this gender difference.S1 Appendix(TIF)Click here for additional data file.S2 Appendix(TIF)Click here for additional data file.S3 Appendix(DOCX)Click here for additional data file.S4 Appendix(DOCX)Click here for additional data file.S5 Appendix(DOCX)Click here for additional data file.


Medical rehabilitation involving behavioral training can produce highly successful outcomes, but those successes are obtained at the cost of long periods of often tedious training, reducing compliance. By contrast, arcade-style video games can be entertaining and highly motivating. We examine here the impact of video game play on contiguous perceptual training. We alternated several periods of auditory pure-tone frequency discrimination (FD) with the popular spatial visual-motor game Tetris played in silence. Tetris play alone did not produce any auditory or cognitive benefits. However, when alternated with FD training it enhanced learning of FD and auditory working memory. The learning-enhancing effects of Tetris play cannot be explained simply by the visual-spatial training involved, as the effects were gone when Tetris play was replaced with another visual-spatial task using Tetris-like stimuli but not incorporated into a game environment. The results indicate that game play enhances learning and transfer of the contiguous auditory experiences, pointing to a promising approach for increasing the efficiency and applicability of rehabilitative training. Rehabilitative training has long been used to improve perceptual and cognitive performance in normal  as well In our previous report , after aFigure 1). We trained FD with a roved standard frequency , a task that we have previously shown to produce learning over multiple sessions  were recruited from the University of Nottingham campus and neighboring communities. All participants had normal hearing (<=20 dB HL on tone audiogram between 0.5 and 4 kHz) and gave informed written consent. The research protocol was approved by the Nottingham University Hospitals Research Ethics Committee.Figure 1A), similar to the training paradigm that has been previously shown to produce learning on FD-rove  for 900 trials (∼35 min), Tetris  played for ∼35 min  or with visual mental rotation . The Control group (n = 16) did not receive any training, but had the same number of days between pre- and post-test sessions as the training groups. Seventy-one participants returned for the retention test.In Pre-, Post- and Retention tests participants performed probe tasks of tone FD, with roving and fixed standards. Auditory working memory for frequency was also tested (see below for task description). Task order was randomized across participants but fixed within individuals. In each training session, the training groups practiced FD with a roving standard , each trial consisted of three sequentially presented tones, two of which were identical (standards) and the third had a higher frequency (the target). The target tone’s temporal position was randomized across trials. Participants were instructed to indicate the position of the target by pressing a button. Feedback was provided visually after each trial. All tones were 100 ms long, including 10-ms rise-fall ramps, presented at 75 dB SPL with an interstimulus interval (ISI) of 300 ms. In the fixed-standard task (FD-fixed), the standard frequency was always 1 kHz. In the roving-standard task (FD-rove), the standard frequency varied randomly from trial to trial between 0.9 and 1.1 kHz in 50 Hz steps.For FD tasks (p > 0.16).For FD testing and training, the frequency difference between the target and standard  was adaptively varied in blocks of 50 trials. In each block, ΔF started at 50%, and was divided by 2 after every correct response until the direction of change switched from decreasing to increasing. Thereafter, the adaptive rule switched to 3-down 1-up, where ΔF was divided by 1.41 after three consecutive correct responses or multiplied by the same factor after one incorrect response, to estimate FD threshold at 79% correct point on the psychometric function . The rovFigure 1B, bottom row) consisted of 43 sequential 100-ms tones with an ISI of 2,400 ms. Participants were instructed to press a button if the current tone matched the tone 3 positions back (a target). Twelve of the last 40 tones, randomly selected for each sequence, were targets. No responses were required for non-targets. At the end of each sequence, performance feedback (percent correct) was visually provided. All tones were presented at 60 dB SPL. Each sequence contained eight frequencies drawn between 1,080 and 4,022 Hz and separated by at least one equivalent rectangular bandwidth  was calculated from hit and false-alarm rates for each sequence. Average d’ of the two sequences was used for session performance.Figure 1C) was modified after The visual mental rotation task  or a fixed  standard frequency. During training, FD-rove threshold improved (decreased) significantly for all three FD-rove training groups . The training results indicate that silent Tetris play intermixed with auditory training enhanced FD learning. This training could not be accounted for by the visual-spatial training involved in game play.Before training, there was no group difference in FD performance with either a roving . Further, the FD + Tetris group improved FD-rove more than the FD only group  must therefore have resulted from an interaction between game play and auditory training. All groups improved on the untrained FD-fixed task , indicating that learning on the FD-fixed task saturated by end of the pretest. As the two FD tasks were similar in procedure and test environment, it is unlikely that procedural learning should continue with FD-rove but not with FD-fixed. Thus, the additional learning induced by FD training with a roving standard, compared with untrained controls, should be indicative of perceptual learning.Between the pre- and posttest, performance on the trained, FD-rove task changed differently among the five groups . Before training, there was no group difference in Tone 3-back performance . The five groups changed differently from the pretest to the posttest . Neither did the FD only group  or the FD + Rotation group . The FD + Tetris group, however, improved significantly more than the Control group  returned 2–4 weeks after the posttest for a ‘retention’ test. There was no significant difference between the posttest and retention test for the trained FD-rove task  with the target training (auditory discrimination), unlike the aforementioned task-irrelevant learning, which occurs only to the subliminal background stimuli that are synchronous with the presumably reward-producing target . As propThis study was carried out in accordance with the recommendations of the Nottingham University Hospitals Research Ethics Committee with written informed consent from all subjects.Y-XZ and SA conceived and designed the study. Y-XZ performed the experiments, Y-XZ and D-LT analyzed the data, and prepared the manuscript with contributions from SA and DM.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. The reviewer SA and handling Editor declared their shared affiliation, and the handling Editor states that the process nevertheless met the standards of a fair and objective review.


To examine the differences of associated characteristics and prescription drug use between co-occurring unipolar and bipolar disorders in patients with eating disorders (EDs).Patients with EDs and major depressive episode (MDE) were recruited from psychiatric outpatient clinics. They were interviewed and completed self-administered measures assessing eating and general psychopathology. The prescribed drugs at the index outpatient visit were recorded. Clinical characteristics and prescription drugs of groups with major depressive disorder (ED-MDD), MDE with lifetime mania (ED-BP I), and MDE with lifetime hypomania (ED-BP II) were compared. Continuous variables between groups were compared using generalized linear regression with adjustments of age, gender, and ED subtype for pair-wise comparisons. Multivariate logistic regression with adjustments of age, gender, and ED subtype was employed to estimate adjusted odds ratios with 95% confidence intervals between groups.Two hundred and twenty-seven patients with EDs had a current MDE. Among them, 17.2% and 24.2% experienced associated manic and hypomanic episodes, respectively. Bipolar I and II patients displayed significantly poorer weight regulation, more severe impulsivity and emotional lability, and higher rates of co-occurring alcohol use disorders than ED-MDD patients. ED-BP I patients were found to have the lowest IQ, poorest working memory, and the most severe depression, suicidality and functional impairment among all patients. Patients with ED-BP II shared affect and behavioral dysregulations with ED-BP I, but had less severe degrees of cognitive and functional impairments than ED-BP I. Patients with ED-BP I were significantly less likely than those in the ED-MDD and ED-BP II groups to be on antidepressant monotherapy, but a great rate (27%) of ED-BP I individuals taking antidepressant monotherapy had potential risk of mood switch during the course of treatment.Our study identified discriminative features of bipolar I and II disorders from MDD among a group of depressed ED patients. We suggest that the associated mania, hypomania, and mood lability are predictors of clinical severity and should be identified from ED patients presented with depressive features. Accurate diagnosis of bipolar disorders may have implications for pharmacotherapy in patients with EDs.The online version of this article (doi:10.1186/s12888-017-1243-0) contains supplementary material, which is available to authorized users. The relationship between affective disorders and eating disorders (EDs) has been well documented , but mucIndividuals were classified as having lifetime bipolar I disorder if they had ever had a manic episode, defined as a period of seven days or longer with elevated mood, and three other mania symptoms, or with irritable mood plus four other mania symptoms, with the mood disturbance resulting in marked impairment, or hospitalization. Individuals were classified as having lifetime bipolar II disorder if they had had both major depressive episodes (MDEs) and a hypomanic episode, defined by a period of four days or longer with symptom criteria similar to mania, and with an unequivocal change in function, but without a manic episode . In a feBipolar II disorder is defined as a milder form of bipolar disorder with regard to hypomanic symptom intensity . HoweverThe evidence of efficacy of drug treatments for EDs has been mostly weak or moderate . FluoxetBased on the above reviews, we hypothesized that depressed ED patients with comorbid bipolar I and bipolar II disorders had differential features from patients with comorbid MDD and those with comorbid bipolar I and II disorders were under-treated with drugs other than antidepressants. This study aimed to examine the associated features between co-occurring bipolar and unipolar disorders in depressed ED patients. We stratify bipolar disorders into bipolar I and bipolar II considering they may have different associated features from unipolar depression. Moreover, we examined the differences of prescription drugs between the three groups of depressed ED patients in clinical practice.n = 288) who were enrolled upon their first visit to the general psychiatric clinics at a teaching hospital via a two-phase method between August 2010 and July 2014 [Participants were selected from a group of ED patients . The minimum frequency and duration of binge-eating/purging was once per week for three months for BN and BED . ParticiThe MINI is a short, diagnostic interview for the DSM-IV and ICD-10 psychiatric disorders . It is dThe 87-item Structured Interview for Anorexic and Bulimic Disorders, Expert-Assessment (SIAB-EX) covers a wide range of symptoms frequently seen in EDs — body image disturbances, bulimic symptoms, social integration problems, problems associated with sexuality, depression, compulsion, and anxiety . Each itIn this study, we used the short form of Wechsler Adult Intelligence Scale—Third Edition (WAIS–III) to assess the intelligence quotient in the groups. It comprises four subtests  and has been demonstrated to exceed other subtest combinations with respect to validity, content representation, and time saving . This shThis self-reported measure includes the Symptom Scale (30 items) and the Severity Scale (6 items). The Chinese BITE has good internal consistency  and test-retest reliability  for the two scales .The BSQ was initially developed as a 34-item questionnaire for assessing feelings about body shape, and the behavioral and emotional consequences of such feelings. The BSQ-8 used in this study, which has 8 items derived from the Chinese BSQ-34  has goodThis study adopted an 18-item short form (ALS-18) that was established by selecting items from the original 54-item ALS using exploratory factor analysis with eigenvalues greater than 1 . The oriThe BDI is a 21-item measure examining depressive symptom severity over the last week. Each question has at least four response options of differing intensities. A value ranging 0–3 is assigned to each answer and the total score determines depression severity. The Chinese version of the BDI has shown good reliability and construct validity . and shoThis is a 30-item self-report questionnaire measuring trait impulsivity . The Chip < .05 was considered significant. All statistical analyses were performed using SAS, version 9.4 .Clinical and demographic characteristics of groups with MDD (ED-MDD), MDE with lifetime hypomanic episodes (ED-BP II), and MDE with lifetime manic episodes (ED-BP I) were compared. Descriptive statistics were computed to determine means and standard deviations of all continuous variables and frequency distributions for categorical variables. The differences of demographic data between groups were compared using ANOVA and Chi-square tests for continuous variables and categorical variables, respectively. With apparent differences in the distribution of gender and ED subtypes in different comorbid groups, multivariate analyses were therefore applied. Continuous variables between groups were compared using generalized linear regression with adjustments of age, gender, and ED subtype for pair-wise comparisons. Multivariate logistic regression with adjustments of age, gender, and ED subtype was employed to estimate adjusted odds ratios (AORs) with 95% confidence intervals (CIs) between groups. Since there were four subtypes in ED patients, three dummy variables were involved in the regression model. All tests were two-tailed, and Among the ED patients, 227 were diagnosed to have a current MDE. Patients who had current MDE had a later age of onset of ED compared to those who did not have (20.1 ± 6.3 vs. 18.1 ± 4.3). There were no differences of age, gender, and educational levels between the two groups. Table Information concerning clinical correlates of the ED with different affective disorders adjusting with sex, age, and ED subtypes is presented in Tables p = .017) and ED-BP II  groups to be on antidepressant monotherapy, a great rate of ED-BP I individuals taking antidepressant monotherapy (27%) was exposed to the risk of mood switch during the course of treatment. The second most commonly prescribed pharmacotherapy was atypical antipsychotic monotherapy (20.7%), followed by combination therapy of antidepressants and atypical antipsychotics (15.9%). Patients with ED-BP I disorder were more likely to be taking atypical antipsychotics than those with ED-BP II disorder, and were also more likely to be taking mood stabilizers and less likely to be taking antidepressants than those with ED-MDD. No differences presented in other comparisons between groups.Antidepressants were the most frequently prescribed medication (63.0%), either as monotherapy 44.9%) or concomitantly with other drugs, for ED patients with a current MDE (Table 4.9% or cUsing structured interviews and self-administered questionnaires, we found that lifetime hypomania and mania were prevalent in ED patients with a current MDE, with bipolar I disorder being diagnosed in 17.2% and bipolar II in 24.2% of patients. There were varying associated psychopathology across groups with different comorbidities. ED-BP I and ED-BP II patients tended to have a greater body weight and increased suicidality, greater affect lability, impulsiveness, and a higher rate of alcohol use disorder than ED-MDD patients. Patients with ED-BP I reported the most severe binge-eating, depression, affect lability, impaired intelligence and working memory, and lifetime functional impairments. Although patients with ED-BP I had statistically significantly severe degrees of impulsiveness and higher co-occurrence rates of panic disorder and alcohol use disorder than patients with ED-MDD, they did not differ from patients with ED-BP II in these dimensions. Twenty-seven percent of ED-BP I patients were treated with antidepressant monotherapy that left this subgroup of patients unprotected from future mood switch and increased likelihood of chronicity of illness.This study successfully illustrated heterogeneity among ED patients with a current MDE. Anxiety, impulsivity, suicide attempts, and alcohol/drug use disorders are prevailing comorbidities observed in ED patients , 52–54. It is interesting to notice that heterogeneity also existed between patients with ED-BP I and ED-BP II when compared to those with ED-MDD. Patients with ED-BP II appeared to share affect and behavioral dysregulations with ED-BP I, but did not have as severe degrees of cognitive and functional impairments as ED-BP I. This finding added more evidence to support earlier concerns that failure to recognize the history or co-existence of hypomania symptoms in patients with MDE might result in no or correspondingly inadequate treatment as discussed as follows.Although the benefits of antidepressant monotherapy remain unclear in the treatment of bipolar depression , it is tSeveral open series studies  or doublThis study did have a few methodological limitations. The first was the small sample size. Consequently, all types of EDs were grouped together. Different ED subtypes may have different risks of association with psychiatric morbidities that would have influences on our current findings. Second, participants were selected in a tertiary center in a non-Western country, and thus, the sample may not be representative of the population with EDs elsewhere. Third, the medication use reported in this study was per psychiatrists’ prescriptions from their initial encounters with patients. We did not follow up any changes in prescription at subsequent visits, or check patients’ compliance in taking these medications. Finally, this is a cross-sectional design, and diagnosis of lifetime hypomania/mania was per patients’ self-reports. Recall bias may exist. In spite of these limitations, to our knowledge, this is a pioneering work, examining the influence of bipolar disorders on ED patients during MDEs. It has important implications for pharmacotherapy in the management of ED.Our study identified discriminative features of bipolar I and II disorders from MDD among a group of depressed ED patients. It is critical to recognize the presence of mood lability, a history of hypomanic/manic episodes, and other features associated with bipolar disorders, to evaluate if individuals with major depression may have hidden bipolarity. The co-occurrence of bipolar disorders in ED patients may provide clues indicating disease severity and the likelihood of presentation of impulsiveness, suicidality, psychiatric comorbidities, and even cognitive and functional impairments. The use of antidepressants in patients with EDs should be considered carefully if they have co-existent dysregulated mood and behavioral symptoms.


Lower urinary tract symptoms—in particular, storage disorders  as well as bladder underactivity—are major health-related problems that increase with age. Yet lower urinary tract symptoms remain under-diagnosed and poorly managed, and incontinence has been cited as the major reason for institutionalization in elderly populations and is one of the most common conditions in primary care practice. Although lifestyle and behavior therapy has been used as a useful treatment regimen for urge incontinence, medications (often used as adjunct) can provide additional benefit. This review will include current therapies used for treatment of urinary incontinence. UI is 1.5 times more common in women than men, affecting approximately 45% and 77% of adult males and females, respectively, in the US, the UK, and Sweden4. Both severity and frequency of UI significantly increase mortality among men and women5. An industry report recently predicted a 2.9% global market growth rate of pharmacological treatments for OAB from 2017 to 2022 and projected a total cost of USD $4.19 billion by the year 20206. Despite its widespread prevalence and socioeconomic burden, incontinence therapy remains limited and often accompanied by significant adverse effects (AEs), low efficacy, and high discontinuation rates8. In addition, there is surprisingly little information regarding biomarkers that can identify age-induced bladder dysfunction or patient response to treatment. There is a growing and pervasive need for pharmacologic therapies that are efficacious, safe, and tolerable. Efforts in the past three years have identified potential new targets in addition to combination therapies or adding a non-pharmacological intervention or both. This article will highlight advances within the last three years regarding current pharmacological treatments for both urge UI (UUI) and stress UI (SUI).Urinary incontinence (UI), alone or as an overactive bladder (OAB) symptom, is a growing global health-care problem that increases in prevalence with age9 whereas the most prevalent subtype is SUI10. The pathophysiology underlying UUI is complex and based on altered physiological mechanisms controlling bladder storage and emptying. Causal factors have been focused on myogenic, neurogenic, and (more recently) sensory dysfunction  inhibitors, are available and may have fewer unwanted AEs but have not been shown to be any more effective in improving storage lower urinary tract symptoms. Several advances are being made to reduce anti-cholinergic side effects primarily by creating receptor-selective agents, altering formulation or administration (or both), thus minimizing AEs caused by systemic antagonism of cholinergic receptors.Anti-muscarinic (anti-cholinergic) drugs remain the most widely used treatment option for UUI and often are used in primary care in combination with behavioral and lifestyle changes, which can include pelvic floor muscle training exercises or reduction of caffeine intake or both. An unfavorable balance between efficacy and tolerability of anti-muscarinic agents, despite their widespread use, exists and has raised questions regarding the overall benefits derived from use of these agents. Furthermore, caution regarding use of anti-muscarinics is recommended in frail elderly patients because of an increased risk of cognitive impairment11. Oxybutynin is the most widely available anti-muscarinic in the US, where it is also available in oral ER and transdermal formulations13.Currently licensed anti-muscarinics indicated for incontinence include orally prescribed oxybutynin, tolterodine, and trospium available as immediate release (IR) and extended release (ER) formulations. In addition, US Food and Drug Administration (FDA)-approved anti-muscarinics include fesoterodine, darifenacin, and solifenacin as oral IR formulations. Propiverine is an oral anti-muscarinic approved in Asia and recently in Canada and is awaiting FDA approval for the US15. A phase 3 study assessed the efficacy and safety of once-daily applied oxybutynin transdermal gel 3% (OTG3%) (84 or 56 mg) or placebo in 624 adult patients with OAB-UUI. At 12 weeks, OTG3% 84 mg reduced the weekly number of incontinence episodes (urge and mixed) compared with placebo . The study concluded that OTG3% 84 mg/day was well tolerated and effective in this adult population16. Lastly, a large meta-analysis in women with OAB found that long-acting oxybutynin formulations , compared with IR, were more effective, had a lower incidence of AEs, and were better tolerated17.Transdermal formulations of oxybutynin and tolterodine were introduced in 2007 to avoid/minimize systemic AEs associated with oral treatments. A comparison study in 2017 involving 1,530 patients (more than 20 years old) with OAB assessed efficacy and toxicity at 12 weeks between the oxybutynin patch and oral propiverine (20 mg). The authors reported non-inferiority in terms of reducing the number of incontinence episodes . While a greater incidence of AEs was reported with oxybutynin patch versus propiverine group (74.8% versus 64.9%), the incidence of dry mouth or constipation was reduced more than 50% compared with propiverine. The predominant AE associated with the patch, which affected 40.2% of patients, was dermatitis and was reportedly mild in the majority of cases; 26.7% of the affected group  continued treatment with topical steroidal treatment18 as well as mood disorders, including depression19. These findings support earlier reports of associated depression with short-term anti-muscarinic treatment20. The new knowledge of incident dementia and mood disorders warrants careful consideration by clinicians and patients when considering treatment options for incontinence, particularly in elderly patients and those with neurobiological disease such as multiple sclerosis and Alzheimer’s disease. In the past three years, clinicians have created FORTA (Fit fOR The Aged), a clinical tool to help aid decision making regarding appropriateness of pharmacotherapies in elderly patients often being treated for multiple conditions21.Little evidence is available to support the long-term use of anti-muscarinics. Besides the typical systemic effects which can include dry mouth, constipation, and blurry vision, increasing new evidence indicates that cumulative anti-muscarinic use is associated with an increase in incident dementia22. Oxybutynin IR and ER  are the only currently FDA-approved anti-muscarinics for treatment of OAB symptoms in children. Newer anti-muscarinics have not yet been approved but are prescribed off-label in treatment-resistant children. In these cases, tolterodine and solifenacin have shown comparable efficacy with fewer side effects22. Propiverine  (0.4–0.8mg/kg per day in two doses) is approved for children in other countries, including Japan23. Trials in children have reported efficacy in reducing incontinence with an acceptable tolerability using propiverine open-label25 and trospium26. Oxybutynin transdermal patches may offer a viable alternative to oral oxybutynin, reducing AEs and difficulty of dosing, in children with OAB symptoms, including incontinence27. Solifenacin seems a promising drug option for children and adolescents with incontinence as part of OAB and non-neurogenic detrusor overactivity and those refractory to other anti-muscarinics (oxybutynin and tolterodine treatment). Nadeauet al. have reported efficacy using solifenacin in children as part of a dual anti-muscarinic therapy approach28. In addition, a phase 3 placebo-controlled trial concluded a clinically relevant improvement in mean voided volume in children at 12 weeks following once-daily treatment with solifenacin oral suspension29. This study was one of the first to report long-term use of solifenacin in 119 children/adolescents compared with placebo, reporting improvement in incontinence by 3 weeks (change from baseline) which was maintained for the study period (52 weeks)30. Further studies are needed to establish efficacy, safety, and tolerability compared with placebo and other anti-muscarinics.Anti-muscarinics are the main pharmacological treatment for children (<12 years) when non-pharmacological or neuromodulation or both are not effective, usually in severe cases32. This drug is associated with improved bladder compliance, increased bladder capacity, reduced urinary frequency, and reduced incontinence32. Recent evidence has suggested that mirabegron may relax the smooth muscle via a dual mechanism of action which includes activation of β3-AR in addition to blockade α1-AR34. It is acknowledged that long-term toxicity and efficacy, compared with those of standard treatment, remain to be established.Mirabegron, a β3-adrenoceptor (AR) agonist, is a first-in-its-class drug approved for the treatment of OAB with symptoms of UUI, urgency, and urinary frequency36. A recentpost hoc analysis of three phase III randomized control trials (RCTs) in women with OAB-incontinence concluded a significant improvement in the number of incontinence episodes with mirabegron versus placebo and established a greater treatment effect with increasing severity of incontinence37. These results raise the possibility that mirabegron is more effective in severe forms of OAB-incontinence and thus may provide a preferred treatment option for these patients. Available evidence would suggest that it offers an effective alternative to anti-muscarinic therapy38.In phase II and III clinical trials, mirabegron was found to be efficacious in reducing OAB symptoms as well as reducing the number of incontinence episodes. Improvement was found to be maintained throughout treatment (up to 12 months) and appeared to be well tolerated in patients, including those at least 65 years old39. Further head-to-head comparisons between mirabegron and anti-muscarinic drugs are necessary to compare efficacy and safety. Notably, mirabegron appears effective in adult patients who are refractory to or unsuitable for anti-muscarinic therapy35. This finding is further supported by a recent phase III, multicenter, open-label RCT in Japan, where the authors reported long-term (52 weeks) efficacy and safety of mirabegron in patients with OAB. The majority of patients remained on 50 mg treatment with concomitant improvement in all domains of quality of life (QOL) scores40.A large meta-analysis of 44 RCTs of 27,309 patients concluded that mirabegron (50 mg) has similar efficacy to most anti-muscarinic drugs but with fewer incidences of AEs, particularly dry mouth, which is the most frequently reported anti-muscarinic AE and reason for discontinuation among patients42. Blaiset al. (2016) reported improvement in continence and QOL in children/adolescents with refractory OAB and unsatisfactory management of symptoms with anti-muscarinic therapy41. The second trial reported mirabegron to be beneficial as an add-on therapy along with anti-muscarinic therapy, again in children with refractory OAB. The addition of mirabegron to the treatment schedule was well tolerated and appeared to be safe42.Mirabegron is not currently licensed for use in children; however, it is prescribed open-label for various types of incontinence, including nocturnal enuresis and daytime incontinence. Safety and efficacy in children remain to be confirmed. Two open-label trials in Canada have shown mirabegron to be effective and safe in children (ages 5 to 17 years) with OAB-incontinence/enuresis43. In a follow-up study, SYMPHONY II, Abramset al. reported improvement in objective and subjective efficacy outcomes with combination mirabegron 25/50 mg and solifenacin 5/10 mg compared with placebo or solifenacin 5 mg alone44. Herschornet al. evaluated solifenacin 5 mg combined with mirabegron 25 or 50 mg and found superior efficacy in patients with OAB-UI45. The effect size (from baseline) in both treatment groups compared with placebo was superior to either therapy alone45. Only one phase IV trial, performed in Japan, confirmed that mirabegron was effective as an add-on therapy to anti-muscarinic treatment46. This study (MILAI) assessed mirabegron (25 or 50 mg) with solifenacin (2.5 or 5 mg) over 16 weeks in 223 patients (at least 20 years old) with OAB. The authors reported significant improvements in mean number of UI or UUI episodes per 24 hours, OAB symptom score, and QOL-related scores in all treatment groups.Combination therapy using an anti-cholinergic agent coupled with mirabegron has also been used. Several phase III trials in the past three years have assessed its efficacy and safety as add-on to anti-muscarinic treatment . The phase II randomized control SYMPHONY trial (2015) assessed combination mirabegron 25 or 50 mg and solifenacin 5 or 10 mg in women with OAB48. This also indicates a cautionary note whereby more extensive pre-clinical screening (including in human cells) for off-target effects may help to identify potential risks.Early studies demonstrated that cannabis had therapeutic benefit on urgency incontinence in patients with multiple sclerosis. Constitutively active fatty acid amide hydrolase (FAAH) is the enzyme that breaks down endogenous cannabinoids which are released ‘on demand’ and can target cannabinoid and vanilloid receptors all of which play a role in bladder dysfunction. Thus, targeting FAAH (inhibitors/inactivators) may have a number of therapeutic applications, including treatment of bladder dysfunction and incontinence. A number of animal studies have shown that inhibition of FAAH has benefit in normalizing a number of urodynamic parameters in experiment bladder disorders  with exercise50. Although data supporting long-term use are limited, α1-AR antagonists have been used to increase urethral tone to ensure continued closure during episodes of increased pressure. Alternative drugs such as β2-AR agonists have been used in Japan for SUI treatment23.SUI is the involuntary leakage of urine on exertion, sneezing, or coughing52. The route of administration appears to be very important as recently concluded by a Cochrane review. The authors reported worsening of UI with systemic estrogen versus an improvement in UI when estrogen was applied locally53. Conversely, the addition of vaginal estrogen to IR or ER tolterodine did not improve urinary symptoms more than tolterodine alone51. In addition, vaginal estrogen has been shown to normalize the microbiota and bladder function, making the case for preventive treatment55. Current guidelines suggest the use of estrogen as an adjunct therapy51.Studies report an increased risk of pelvic floor disorders after menopause and this may be linked to estrogen deficiency; thus, estrogen therapy may be beneficial in improving SUI in post-menopausal women. A meta-analysis of clinical trial data rated the evidence for efficacy of estrogen in reducing incontinence as low but well tolerated, much more so than alternative drugs for OAB/incontinence56. Despite reported efficacy in US and Canadian phase III trials58, licensing in the US and Canada failed because of concerns over incident suicidality. The FDA reported a doubling in suicide attempts in women receiving the drug for SUI compared with that in the general population . An independent analysis of the dataset used by the European Medicines Agency to license duloxetine was performed by a Canadian research group specifically assessing psychological disturbances. The authors concluded that the risks outweighed the benefits, thus raising concerns regarding the rationale for duloxetine use for treatment of SUI60. As of 2013, National Institute for Health and Care Excellence guidelines recommend duloxetine (Yentreve) as a second-line therapy in place of surgery for women with SUI, and counseling on expected AEs is advised61.Duloxetine is a dual serotonin and noradrenaline reuptake inhibitor currently approved in Canada, the US, and Europe for depression. In 2004, duloxetine, under the trade name Yentreve, was approved and licensed in Europe as an add-on therapy for SUIIn terms of pharmacologic treatment for UI, many drugs exhibit poor efficacy and increased incidence of AEs. Alternative approaches such as the herbal medicine drug AOBO-001 have been introduced for OAB-incontinence and frequency in adults, and a phase II clinical trial is under way to study efficacy in adults with urge incontinence. There is a need for development of new therapeutic approaches, especially in terms of SUI, which have limited options. However, given the recent examples of off-target effects, one should carefully consider increased patient vulnerability to toxicity and AEs due to change in organ function which presents more opportunity for drug-disease interactions.


In the chronic DSS colitis model SBA treatment significantly reduced clinical symptoms in a dose-dependent manner. The positive therapeutic effect of SBA was characterized by a decreased histopathological score indicating tissue healing. Moreover, the number of neutrophils as well as the expression of the neutrophil-recruiting chemokine CXCL-1/KC in the colon tissue was significantly reduced, whereas the recruitment of macrophages was induced. Also, the expression of inflammatory markers was significantly suppressed, while the expression of the anti-inflammatory cytokine interleukin-10 was induced in colon tissue following treatment with SBA. Phytopharmaceuticals are increasingly recognized as potential therapeutics in IBD. Thus, based on the results from this study, SBA can be considered as an alternative or supplementary option for IBD therapy.Inflammatory bowel diseases are multifactorial disorders of the gastrointestinal tract with rising incidence worldwide. Current standard therapies are only partially effective and often show severe adverse effects. Thus, novel, more efficient and well-tolerated therapeutic options are urgently needed. We have studied the therapeutic potential of a phytopharmaceutical combining sage and bitter apple (SBA) in the mouse model of chronic dextran sulfate sodium (DSS) colitis. SBA represents a traditional medicine against diarrhea and was shown to exhibit anti-inflammatory effects  IBD are multifactorial diseases with unknown etiology and increasing prevalence and incidence, particularly in countries with a western lifestyle4. Pharmacological and surgical interventions are the two main approaches in treatment of IBD. The most commonly used drugs for IBD treatment are aminosalicylates, glucocorticoids, and immunomodulators which are used to reduce or inhibit the chronic inflammatory response. However, these drugs show limited efficiency with respect to long-term remission and are associated with severe side effects5. Antibodies inhibiting tumor necrosis factor (TNF)-α, such as infliximab or adalimumab, have shown clinical efficacy but caused serious side effects and are relatively expensive7. Furthermore, 20–40% of patients do not respond to anti-TNF treatment (primary failure) and up to 50% lose their effective therapeutic response within 1 to 2 years (secondary failure)10. Surgery is needed for 20–30% of patients who are non-responders and develop complications such as perforation, refractory rectal bleeding or toxic megacolon. Even after resection, patients suffer from postoperative complications11. Therefore, there is an urgent need for new therapeutic options that are well-tolerated and improve clinical symptoms as well as initiate tissue healing.Inflammatory bowel diseases (IBD), such as Crohn’s disease (CD) and ulcerative colitis (UC), are chronic-relapsing inflammatory disorders of the gastrointestinal tract. Due to chronic inflammation with ensuing disintegration of the gut epithelium and the underlying tissue, patients present with symptoms such as abdominal pain, diarrhea, bloody stool and weight loss15. Sage  is an oil-producing subshrub that has long been cultured for culinary use. Furthermore, sage is known for its therapeutic effects, including anti-microbial, anti-viral, anti-inflammatory, and pain-relieving properties that are due to the antioxidant as well as anti-inflammatory activity of different flavonoids21. In contrast, the desert plant bitter apple (Citrullus colocynthis (L.) SCHRAD.) containing curcubitacins has been used for centuries as a therapeutic purgative, but has also shown anti-diarrheal effects in combination with other substances23. Furthermore, anti-microbial, anti-fungal, anti-inflammatory, and analgesic effects have been described in context with the medical use of bitter apple25.In recent years, the use of phytopharmaceuticals has come into focus as supplementary therapy or in combination therapies with classical IBD therapeutics. Several phytosubstances have already been tested in different IBD models and revealed promising therapeutic effectset al., submitted]. In this model, the standard-of-care (SoC) therapeutics 6-thioguanine (6-TG) and cyclosporine A (CsA) reduced both clinical and histopathological symptoms, qualifying this model for testing potentially new IBD therapeutics. In the current study, we investigated the therapeutic effect of a traditional phytopharmaceutical extract based on sage and bitter apple (SBA) in the chronic DSS colitis model with respect to reduction of clinical symptoms and histopathology as well as its impact on immune cell infiltration into the colon tissue.Various animal models are available to study pathogenesis of IBD or to prove potentially new therapeutic approaches. The acute dextran sulfate sodium (DSS)-induced colitis model is the most commonly used mouse model in IBD research. However, its major caveats are the lack of a chronic adaptive immune response as well as severe body weight loss of the animals. Therefore, our group has developed a refined mouse model of chronic DSS-induced colitis that reflects clinical symptoms of IBD without risky weight loss usually observed in DSS colitis models . Since DSS induces the strongest pathology in the distal part of the colon28, this study focused on the analysis of colon tissue from the distal part only. It could be demonstrated that SBA was effective as stand-alone therapy in this chronic IBD model and, for some endpoints, revealed similar therapeutic efficacy as the SoC treatment control 6-TG. Not only did oral administration of SBA ameliorate clinical symptoms, such as stool consistency and colonic hemorrhage, it also significantly reduced histopathology as well as the underlying intestinal inflammation. Although previous studies have demonstrated antioxidant activities of sage in different experimental setups29, to our knowledge this is the first report to demonstrate that a sage-containing extract was effective in ameliorating experimental colitis through a consistent regulation of immune cell infiltration and cytokine expression in the colon tissue.Phytochemicals have recently come into focus as potential therapies for the treatment of IBD30. This question should be addressed by staining for subtype-specific markers or cytokines in subsequent studies using this model. Own previous in-vitro studies, investigating the effect of SBA on the human monocytic cell line THP-1, revealed significantly enhanced secretion of lipopolysaccharide(LPS)-induced IL-6 and more moderately of LPS-induced IL-10 in a dose-dependent fashion, which is in line with the IL-10 result from the present study. However, SBA had different effects on the expression of pro-inflammatory cytokines in THP-1 cells in vitro. The LPS-induced secretion of TNF-α was found to be suppressed, whereas IL-1β was found to be induced implying no clear polarization into the inflammatory M1 or the regulatory M2 macrophage subtype .To analyze the inflammatory response in the colon as well as its regulation by SBA in more detail, colon tissue sections were stained for different immune cell markers and inflammatory mediators, i.e. F4/80 (macrophages), CD3 (T cells), CD4 (Th cells), MPO, COX-2, and IgA. As a first line of defense against potentially harmful microorganisms, e.g. gut bacteria which have entered the subepithelial space of the intestinal tissue, cells of the innate immune system are immediately recruited to contain the infection and sample antigens to trigger the adaptive immune response. Cell types of the innate immune system that are most prominent in the chronic DSS model include macrophages and neutrophilic granulocytes (neutrophils) which are characterized by expression of the cell surface marker F4/80 or the intracellularly expressed or secreted enzyme myeloperoxidase (MPO), respectively. As demonstrated by immunofluorescence staining of F4/80, 6-TG significantly reduced the number of infiltrating macrophages in the colon tissue. In contrast, SBA-treated mice showed a higher number of macrophages infiltrating colon lesions in DSS colitis compared to control animals. Those macrophages which were directly or indirectly recruited by SBA might belong to the regulatory (M2b) or wound-healing macrophage subtype (M2c), supporting anti-inflammatory activity and tissue repair, respectively31. MPO can be detected in the colon tissue as cell-bound and secreted molecule and together with DAPI staining identifies MPO-producing cells. In addition, MPO can be found in the colon crypts and the gut lumen, particularly in DSS-treated animals. Administration of 6-TG as well as SBA  significantly reduced MPO expression in diseased animals. CXCL1/KC is produced by macrophages, neutrophils or epithelial cells and has neutrophil-chemoattractant activity33. Thus, in addition to MPO expression, the up-regulation of the chemokine CXCL1/KC represents a further endpoint demonstrating neutrophil infiltration. Consistent with the results obtained for MPO staining, analysis of CXCL1/KC in colon homogenate revealed significant reduction of this neutrophil-attractant chemokine after treatment with either 6-TG or SBA.MPO is mainly produced by neutrophils and exerts anti-microbial activity by catalyzing the production of hypochlorous acid during the neutrophil’s respiratory burst34. In the chronic colitis model applied in the present study, treatment with 6-TG or with the lowest dose of SBA caused significant reduction of the number of CD3+ T cells in colon tissue. Likewise, 6-TG reduced the number of CD4+ Th cells in the colon, while SBA showed ambiguous effects depending on the applied dose. The highest applied dose of SBA significantly reduced the number of CD4+ Th cells similar to 6-TG. However, the lowest SBA dose even increased the infiltration of Th cells in colon tissue. The reason for these divergent dose-dependent SBA effects remains unclear but let assume different effects of low- and high-dose SBA on the regulation of Th cell differentiation and/or recruitment.Dysregulation of T cell homeostasis is considered a major factor in the pathogenesis of IBD. Chronic activation of inflammatory T cells, i.e. Th1, Th2 and Th17 cells, and impaired regulation by Treg cells promote a continuous inflammatory response in the colon36. In our refined chronic DSS colitis model, IgA expression is increased after DSS uptake and can be detected as both cell-bound and secreted IgA in colon tissue. In the present study, SBA administration efficiently reduced IgA expression in the colon, in which the lowest SBA dose was even exceeding the therapeutic effect of the positive control 6-TG. It can thus be speculated that SBA either directly or indirectly regulates the recruitment and/or activation of IgA-producing plasma cells in the mucosal tissue.IgA is produced by plasma cells residing in the lamina propria and contributes crucially to barrier function of the gut endothelium as well as homeostasis of the mucosal immune system37. In chronic DSS colitis, goblet cells are frequently destroyed or functionally impaired and consequently the mucus barrier is significantly disturbed. In the current study, SBA treatment was capable of restoring goblet cell number, indicating a tissue-healing capacity of the phytochemical. Interestingly, colonic mucus production in SBA-treated mice was even increased compared to 6-TG treated animals possibly indicating a functional overreaction of restored goblet cells as a response to the tissue injury induced by DSS treatment. Thus, therapeutic efficacy of SBA was inferior to 6-TG with respect to goblet cell function.Another important barrier mechanism of the gut epithelium is the production of mucus by goblet cells. The mucus barrier can be subdivided into an outer layer that can be penetrated by commensal bacteria and an inner layer that is normally impermeable to the gut microbiotaThe integrity of the epithelial barrier is primarily mediated by tight junction (TJ) proteins, such as CLDN1, CLDN4, ZO-1 and OCLN. To further analyze the effect of SBA on the integrity of the epithelial barrier, colon tissue sections were analyzed for the aforementioned TJ proteins. Except for OCLN, SBA treatment significantly increased TJ protein expression in colon tissue, with the strongest effect being observed for CLDN1. Together with the reduced histopathological score and the induction of goblet cell regeneration, these results indicate that therapy with SBA has a strong capacity to induce healing processes within the epithelial barrier.26. For example, anti-inflammatory effects are known for different substances contained in sage, such as flavonoids41. Consistent with this idea, in our study SBA treatment significantly reduced the expression of IL-1β, one of the key cytokines in the induction of inflammatory responses, as well as COX-2 and MPO in colon tissue of DSS-treated animals. Furthermore, SBA induced expression of the anti-inflammatory cytokine IL-10, which is frequently dysregulated in both CD and UC42, possibly resulting in suppression of pro-inflammatory cytokines and chemokines as well as inhibition of T cell activation.Two main categories have been proposed for the therapeutic effect of phytochemicals in IBD models, i.e. their antioxidant functions as well as their capacity to inhibit pro-inflammatory cytokines and enzymes, such as TNF-α, IL-1β, IL-6, IFN-γ, iNOS, COX-2, and MPOIn summary, we propose that SBA represents an effective therapeutic agent for the treatment of tissue inflammation in the chronic DSS colitis model by down-regulating different stages of the inflammatory process. In addition, SBA initiates healing of the epithelial layer and regeneration of the crypt structure. Further investigation of SBA and other phytochemicals could reveal a new class of therapeutics for IBD with little side effects to be applied as stand-alone therapy or in combination therapies with SoC treatments.ad libitum. Animals were acclimatised to the environmental conditions for 14 days before starting of treatment. All experimental procedures were approved by the State Animal Care and Use Committee  and were carried out in accordance with the European Communities Council Directive (86/609/EEC) for the Care and Use of Laboratory Animals. For organ collection, all animals were sacrificed using carbon dioxide. All efforts were made to minimize suffering of the animals.Female BALB/c mice  were purchased from Janvier . Mice were housed as five animals per cage in a temperature- and light/dark cycle-controlled environment . They had free access to pelleted standard rodent chow and water et al., submitted]. In brief, administration of 2% DSS  in autoclaved drinking water for 7 days, followed by 1% DSS for 10 days and 2% DSS for another 12 days. DSS solutions were changed every 3 to 4 days. Animals were inspected daily for overall physical and behavioural appearance, and body weight loss as well as scores for stool consistency and blood in stool were assessed. The clinical score was calculated as the average of the scores for body weight loss, stool consistency, and blood in stool. The stool-consistency-blood score was calculated as the average of the scores for stool consistency and blood in stool.Chronic DSS colitis was induced as described recently . For each treatment group, two sections per animal were analysed.For immunofluorescent analysis, rehydrated tissue sections were subjected to heat-induced antigen retrieval in citrate buffer (pH 6) or Tris-EDTA buffer (pH 9), or proteolytic-induced antigen retrieval using proteinase K in Tris-EDTA-CaClTM protease inhibitor cocktail, EDTA-free ). A colon homogenate was prepared using an Ultra-Turrax® . The homogenate was centrifuged at 21,000 × g, 10 min, 4 °C and the supernatant was transferred into a new tube. Samples were stored at −80 °C until analysis. For detection of CXCL1/KC, IL-1β, and IL-10 by ELISA, the DuoSet® ELISA Mouse CXCL1/KC , Mouse IL-1β ELISA Ready-SET-Go!® and Mouse IL-10 ELISA Ready-SET-Go!®  were used according to the manufacturer’s instructions. Supernatants were used undiluted. The concentration was quantified by measuring the optical density (OD) at 450 nm using a conventional microplate reader .A piece of the colon was transferred into a 1.5 ml-Eppendorf tube containing 1 ml of ice-cold homogenate buffer (PBS + 10% FBS (Biochrom) + cOmpleteAll data generated or analysed during this study are included in this published article.