Ankle sprains are common within the general population and can result in prolonged disablement. Limited talocrural dorsiflexion range of motion (DF ROM) is a common consequence of ankle sprain. Limited talocrural DF ROM may contribute to persistent symptoms, disability, and an elevated risk for re-injury. As a result, many health care practitioners use hands-on passive procedures with the intention of improving talocrural joint DF ROM in individuals following ankle sprains. Dosage of passive hands-on procedures involves a continuum of treatment speeds. Recent evidence suggests both slow- and fast-speed treatments may be effective to address disablement following ankle sprains. However, these interventions have yet to be longitudinally compared against a placebo study condition.We developed a randomized, placebo-controlled clinical trial designed to test the hypotheses that hands-on treatment procedures administered to individuals following ankle sprains during the post-acute injury period can improve short-, intermediate-, and long-term disablement, as well as reduce the risk for re-injury.This study is designed to measure the clinical effects of hands-on passive stretching treatment procedures directed to the talocrural joint that vary in treatment speed during the post-acute injury period, compared to hands-on placebo control intervention.http://www.clinicaltrials.gov identifier NCT00888498. Ankle sprains are the most common injury to the ankle joint, accounting for up to 2 million injuries per year . Annual Lateral ankle and midfoot injuries account for 80-85% of all sprains ,18. The Although the prognosis for functional recovery following ankle sprain typically includes a rapid reduction in disablement within the first 2 weeks after injury , recent One reason for continued pain and elevated risk for re-injury may be limited ankle joint mobility. Several studies have identified limited talocrural joint dorsiflexion range of motion (DF ROM) as an important predisposing factor to ankle sprains -29. SignMany clinicians use hands-on passive stretching techniques to improve limited joint mobility, such as ankle DF ROM. Hands-on passive stretching techniques, including mobilization and manipulation, vary on a dosage continuum involving the speed of iatrogenic force application. Mobilization typically involves a slow and sustained application of iatrogenic force, while manipulation is characterized by a rapid application of iatrogenic force. Despite the intuitive appeal of applying mobilization and manipulation to promote parallel improvements in talocrural DF ROM and functioning in individuals following ankle sprains, this idea has been the focus of relatively few prospective studies . Pellow Although initial results are promising, various methodological issues in existing studies challenge our collective understanding of the effectiveness of mobilization and manipulation on clinical outcomes in individuals with ankle sprains. The effect attributable to placebo manual stimulation and speed of iatrogenic force application during hands-on treatment remains unclear. Also, prior studies have not conducted longitudinal assessments over sufficient durations to adequately evaluate the effectiveness of mobilization/manipulation to reduce the risk for re-injury. Thus, the purpose of this paper is to describe the methodology of a randomized, placebo-controlled clinical trial to evaluate the effect of mobilization, manipulation, and hands-on placebo treatment of the talocrural joint on short-, intermediate-, and long-term clinical outcomes in individual with post-acute ankle sprains.http://www.clinicaltrials.gov (NCT00888498).Patients with post-acute ankle sprains will be recruited to participate in this study from multiple clinical centers across the United States. The Institutional Review Boards of the University of the Pacific  and Des Moines University  approved this study protocol. This study protocol is registered with th metatarsal, and navicular [Inclusion criteria for this study are age 16-60 years, onset of ankle sprain at least 2 weeks prior to enrollment, and Foot and Ankle Ability Measure Activities of Daily Living (FAAM ADL) subscale score less than or equal to 67 points . Exclusion criteria involve current assisted ambulation ; inability to bear weight through the affected extremity immediately after injury with tenderness to palpation of the medial and lateral malleolar zones, styloid process of the 5avicular ; positivavicular -39; voluavicular ; previouA total of 189 subjects will be recruited (n = 63 per group). A group size of 52 subjects will provide 80% statistical power to detect an 8-point (9.5%) difference in FAAM ADL subscale score based on Martin and colleagues' data, with ad2,1 = .87-.89). Minimum clinically important change scores have been identified for the ADL subscale (8 points) and Sports subscale (9 points) with respect to patient global rating of change.The FAAM is a self-report questionnaire consisting of a 21-item ADL subscale and 8-item Sports subscale, in addition to a global rating of self-perceived foot function from 0-100% . This inThe anterior drawer test is a manual assessment of the integrity of the anterior talofibular ligament (ATFL) . It is pThe inversion stress test is intended to elicit symptoms or excessive mobility due to calcaneofibular ligament rupture . It is p2,1=.99) and inter-tester reliability  [Water displacement volumetry will be used to assess for the presence of clinically significant ankle edema, which is operationally defined as ≤10% difference in left and right limb volume in this study. In this test, the subject will first place their uninvolved foot in a 32.5 × 12.5 × 22.5 cm clear acrylic box containing a known volume of water. As the subject's foot enters the box, water will flow from a spout in a box into a graduated cylinder. Measurement of displaced water will be completed and then the displaced water will be discarded. The graduated cylinder will be dried thoroughly and replaced beneath the box spout. The subject will then place their involved foot into the box, and the volume of displaced water will be measured. This volume represents the difference in volumes between involved and uninvolved sides. The residual volume of water displaced by the involved side will then be divided by the volume of water displaced by the uninvolved side. Water displacement volumetry demonstrates strong intra-tester reliability (ICC.93-.97) ,47. The .93-.97) .After pre-participation screening is completed and informed consent is obtained, baseline measures will be collected on the same day.The 11-point NPRS will be used to structure 3 measurements of subjects' pain intensity, including the levels at best in the past 24 hours, at worst in the past 24 hours, and the current level of pain. The NPRS ranges from "No Pain" and "Worst Imaginable Pain." NPRS measurements are reliable and valid for use in clinical trials . A pain 2,1=.77 and .90, respectively) [The FABQ is a questionnaire intended to quantify the level of fear of pain during various activities in individuals with lower back pain . It consctively) . Each suctively) ,51,52. WThe LExSES is a 20-item questionnaire intended to measure a subjects' self-efficacy related to lower extremity function. It consists of 3 subscales of patient self-efficacy, including functional and self-regulatory abilities, and exercise performance self-efficacy. Preliminary data regarding clinimetric properties of the LExSES also will be collected during this study in order to conduct future validation analyses.The PANAS is an inventory aimed at assessing a patients' mood. It consists of two checklists, each containing 10 items . PatientThe GROC is a single item 15-point scale intended to measure a subject's general perception regarding response to treatment . ResponsHip flexion with knee flexed, internal rotation, external rotation; knee extension; subtalar inversion and eversion; and ankle plantarflexion and dorsiflexion passive ROM will be measured with a standard goniometer by the evaluating therapist using previously described techniques that demonstrate adequate validity and reliability -58. An iMMT of the gluteus medius, gluteus maximus, quadriceps, tibialis posterior, tibialis anterior, peroneus longus/brevis (group), and gastocnemius will be completed according to established procedures and grading scheme . Pain an2,1 = .67-.97), and demonstrates discriminative validity between non-disabled individuals and patients with chronic ankle instability [The SBET is a clinical test of dynamic balance -65. Subjtability ,66.After completing pre-participation screening and baseline measures by a standardized licensed physical therapist , each subject will receive both an identification number and a unique random number indicating treatment group assignment. Numbers indicating group assignments will be concealed in a privacy envelope. A second licensed physical therapist blinded to the baseline examination (treating therapist) will open the proper randomization envelope that corresponds to the patient's unique identification number. The treating therapist will record the subject's group assignment on a standardized form. It will be impossible to blind the subject and treating therapist to treatment assignment. However, the evaluating therapist will remain blind to the subject's treatment assignment. Patients will be instructed to conceal their group assignment from the evaluating therapist.Subjects will be randomized into 3 groups after pre-participation screening is completed, informed consent is obtained, and baseline measures are recorded Figure . The firAll subjects will attend 5 treatment sessions as part of this study, including 2 sessions during the first week and 1 session per week for the next 3 consecutive weeks. All subjects will be scheduled for the first treatment session within 3 days of the baseline examination. In all treatment groups, the first 2 sessions will begin with delivery of the ankle manual therapy technique followed by the range of motion exercise described above. The final 3 sessions will involve instruction in a standardized strengthening program. The treating therapist will document daily treatment on a standardized form, as well as their subjective impression of the subject's improvement at 4 weeks after enrolment. Subjects will be requested to document home program compliance on a standardized log, and advised to refrain from new activities during the study. Clinicians and subjects will be free to pursue their treatments of choice after the 4-week measurements are obtained.The FAAM, NPRS, FABQ, PANAS, LExSES, and a side effect questionnaire will be administered at 1 week following enrolment. The demographic questionnaire, FAAM, NPRS, FABQ, PANAS, and LExSES will be administered at 4 weeks following enrolment, and mailed to subjects to complete at 6 months, 1 year, and 2 years following enrolment.The primary dependent variable for this study is FAAM score at 1 week, 4 weeks, 6 months, 1 year, and 2 years. Secondary dependent variables include NPRS, modified FABQ, PANAS, LExSES, and GROC scores at 1 week, 4 weeks, 6 months, 1 year, and 2 years. The independent variable is the manual therapy intervention condition. All other outcome measures will be assessed as potential covariates of treatment success, which is defined as the achievement of minimum clinically important change score on the FAAM for this study.Descriptive statistics will be calculated for the data set, including frequencies, means, and standard deviations. Between and within-group comparisons will be made for outcome measurements at 4 weeks, 6 months, 1 year, and 2 years post-enrolment. Analysis of variance with appropriate post-hoc pairwise comparisons will be used to assess between-groups differences for continuous data. Statistical significance of between-group differences in categorical data will be assessed with chi square analysis. Pearson correlations and multivariate linear regression analyses will be performed to determine statistical significance of associations with treatment success and failure. An intention-to-treat analysis will be performed for subjects who drop out of the study after enrolment but prior to completion of all study procedures. Statistical significance of inferential statistical tests will be accepted at α≤.05.This study protocol describes a randomized, placebo-controlled clinical trial that measures the short-, intermediate-, and long-term effects of talocrural joint mobilization, manipulation, and placebo treatment for individuals with post-acute ankle sprains. Hands-on treatments that improve ankle DF ROM are hypothesized to cause related improvement in disability and mitigation of re-injury risks. We believe the study designed in this paper addresses methodological deficiencies in the manual therapy literature to date that interfere with our optimal understanding of best practices related to mobilization/manipulation in individuals with post-acute ankle sprains. Specifically, inclusion of a hands-on placebo control should allow for differentiation of generalized clinical benefit from manual stimulation and clinician attention versus iatrogenic force application. In addition, the length of follow-up measurements should allow for adequate estimation of the potential longitudinal effects of mobilization/manipulation during the post-acute injury period on re-injury rate. The methodological characteristics of this study should help generate high quality data that will further our collective understanding of best practices in manual therapy.2,1: Intraclass correlation coefficient - formula 2,1; LExSES: Lower Extremity Self Efficacy Scale; MMT: manual muscle test; NPRS: numeric pain rating scale; PANAS: Positive and Negative Affect Scale; RCT: randomized clinical trial; RICE: rest, ice, compression, and elevation; ROM: range of motionADL: activities of daily living; ATFL: anterior talofibular ligament; DF: dorsiflexion; FAAM: Foot and Ankle Ability Measure; FABQ: Fear Avoidance Beliefs Questionnaire; GROC: Global rating of change; ICCThe authors declare that they have no competing interests.TED, KK, and BEF contributed to the design of this study protocol. TED provided research funding. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1472-6882/10/59/prepub


A number of investigations indicated that higher levels of PCBs in mammary tissues or sera correlated to breast cancer risk, and PCBs might be implicated in advancing breast cancer progression.Polychlorinated biphenyls (PCBs) are a family of structurally related chlorinated aromatic hydrocarbons. Numerous studies have documented a wide spectrum of biological effects of PCBs on human health, such as immunotoxicity, neurotoxocity, estrogenic or antiestrogenic activity, and carcinogensis. The role of PCBs as etiologic agents for breast cancer has been intensively explored in a variety of in vitro. In the in vivo study, PCBs significantly advance disease progression, leading to enhanced capability of metastatic breast cancer cells to metastasize to bone, lung and liver. Additionally, PCBs robustly induce the production of intracellular reactive oxygen species (ROS) in breast cancer cells; ROS mechanistically elevate ROCK activity.In the current study, we for the first time report that PCBs greatly promote the ROCK activity and therefore increase cell motility for both non-metastatic and metastatic human breast cancer cells PCBs enhance the metastatic propensity of breast cancer cells by activating the ROCK signaling, which is dependent on ROS induced by PCBs. Inhibition of ROCK may stand for a unique way to restrain metastases in breast cancer upon PCB exposure. Polychlorinated biphenyls (PCBs) are chlorinated aromatic hydrocarbons with 209 congeners. They are highly stable and lipophilic chemicals widely distributed in the environment. Although the production and massive use of PCBs have been banned in the 1970 s, they persist in the environment, biomagnify through food chains and consequently accumulate in fat tissues in humans e.g. bone and lung) which accounts for 90% of deaths of breast cancer patients. Once breast cancer cells metastasize and form tumors in distant organs, the disease is incurable with available therapeutics Breast cancer is the most commonly diagnosed cancer and the second leading cause of cancer-related deaths among women. The real threat to lives of breast cancer patients is not the primary tumor in the breast, but secondary tumors in other organs , are major mediators of Rho activity to delineate the associations between the PCB exposure and breast cancer risk and progression, we assess the effects of PCBs on the tumorigenic and metastatic features of breast cancer cells. Overall, we describe a novel role of PCBs in enhancing metastatic properties of breast cancer cells by activating the ROCK signaling.In this study, +) MCF-7 cells and estrogen receptor-negative (ER-) MDA-MB-231 cells in order to discriminate the ER-dependent and -independent effects. There was a rather mild effect of the PCB mix on cell growth and survival at low concentrations (<60 nM) for both ER+ MCF-7 and ER- MDA-MB-231 cells (data not shown); however, PCBs exerted significant cytotoxicity on these cells and induce cell death at high concentrations (>60 nM). As shown in The concerns with respect to likely carcinogenic influence on mammary tissues with exposure to PCBs derived from the estrogenic activity of these compounds, which have the ability to mimic or interfere with the action of endogenous hormones + MCF-7 and ER- MDA-MN-231 (p-dioxin (TCDD) which has the ability to bind to and activate the ligand-activated transcription factor, the aryl hydrocarbon receptor (AhR). These non-dioxin-like PCBs therefore have no ability to bind to the AhR and activate its downstream signaling The previous studies indicated that PCBs were correlated with more aggressive breast cancers, and might promote tumor progression A-MN-231 , P<0.001A-MN-231 , P<0.001A-MN-231 . In addiin vivo using a mouse model of breast cancer metastasis (in vitro observation on cell proliferation (data not shown). However, PCBs greatly enhanced the capability of MDA-MB-231 cells to metastasize to lung, liver and bone. 2 out of 4 mice developed lung metastasis, and 1 out of 4 mice developed liver metastasis among the PCB-treated mice. In contrast, no mice in the vehicle control group developed either lung or liver metastasis , a strong ROS-inducer Although the ability of PCBs in provoking tumor initiation and development has been observed, the mechanism remains to be elucidated. Numerous possible mechanisms have been explored, such as the estrogenic activity, effects on vitamin A metabolism and intercellular communication, and induction of oxidative stress (ROS) PCBs are widespread and persistent environmental pollutants that impose potential hazards on human health. The possible correlation between environmental PCB exposure and breast cancer risk exists biologically plausible, and mounting evidence indicates that PCB exposure contributes to the aggressiveness and metastases of breast cancer. The findings from the current study suggest that PCBs potently augment the ROCK signaling to advance breast cancer metastases, and the activation of ROCK by PCBs is dependent on ROS, but independent of the ER signaling and the AhR signaling . InhibitThe PCB congener mix  was purchased from Sigma. Stock solutions of these compounds were diluted in 100% ethanol and added to the culture medium immediately before use. Equal volume of PBS corresponding to different concentrations of the PCB mix was diluted in 100% ethanol as the vehicle control.Human Breast cancer cell lines, MCF-7 and MDA-MB-231 were stored and cultured as described previously 3, the mouse was sacrificed. The primary tumors were removed and cut into small pieces in a cube shape with a scissor. 0.02 g of tumor tissues were implanted underneath MFPs of 8 wk old mice. 2 weeks later when primary tumors reached ∼75 mm3, one group of mice received one dose of intraperitoneal (i.p.) injection of the PCB mix diluted in ethanol .Control mice received ethanol-diluted PBS.All mouse care and experimentation were approved by the Committee of Animal Care at the RCEES, Chinese Academy of Sciences. Immunodeficient (NOD/SCID) mice were maintained under aseptic sterile conditions. Surgeries were performed under sterile conditions and mice received antibiotics (trimethoprim sulfa) in the drinking water for 2 weeks following all surgical procedures. Experimental set-up was similar to the methods described in our previous publication 2, mouse hind limbs, lungs, livers, kidneys and other tissues were removed for separate imaging, and detection of metastases.Bioluminescent imaging was performed 4 wks post the injection, with both primary tumors and metastases examined using the Xenogen 2000 and the IVIS software. Mice were administrated i.p. injections of luciferin , and after 10 minutes, anesthetized  for imaging of primary tumors. Following euthanization using COProtein extracts were prepared from cells, and 20 µg of each was used for separation by 4–12% SDS-PAGE and processed for Western blot analyses as described previously Apoptosis analysis was analyzed using FITC-conjugated Annexin V and PI as described previously 2. After two cold PBS washes, 1×106 cells were lysed with M-PER Mammalian Protein Extraction Reagent (Pierce). ROCK kinase activity was determined by the Rho-kinase Assay kit  according to the manufacturer's protocol. The kinase activity in the vehicle control was defined as 1.Breast cancer cells were treated with PCBs in medium with 1% FBS for 24 hrs at 37°C and 5% CO4/insert) in 1% serum medium with or without PCBs and allowed to migrate for 24 hrs with 10% serum medium in the bottom as chemoattractant. Cells on the filter-side of the upper chamber were cleaned with cotton swabs and the filters were stained with 1×DAPI solution after cold methanol fix. Cell nuclei on the filters were visualized under a fluorescent microscope.After breast cancer cells were serum-starved for 24 hrs, cell motility was assessed by the transwell (Corning) migration assay following the standard protocol. Cells were plated on the upper chamber (1×10Two-tailed Student's t-test was used to analyze the statistical significance of experimental data. All results are presented as mean±SEM, and a P-value of <0.05 determined statistical significance.


Most patients with chronic obstructive pulmonary disease (COPD) receive inhaled long-acting bronchodilators and inhaled corticosteroids. Conventional meta-analyses established that these drugs reduce COPD exacerbations when separately compared with placebo. However, there are relatively few head-to-head comparisons and conventional meta-analyses focus on single comparisons rather than on a simultaneous analysis of competing drug regimens that would allow rank ordering of their effectiveness. Therefore we assessed, using a network meta-analytic technique, the relative effectiveness of the common inhaled drug regimes used to reduce exacerbations in patients with COPD.We conducted a systematic review and searched existing systematic reviews and electronic databases for randomized trials of ≥ 4 weeks' duration that assessed the effectiveness of inhaled drug regimes on exacerbations in patients with stable COPD. We extracted participants and intervention characteristics from included trials and assessed their methodological quality. For each treatment group we registered the proportion of patients with ≥ 1 exacerbation during follow-up. We used treatment-arm based logistic regression analysis to estimate the absolute and relative effects of inhaled drug treatments while preserving randomization within trials.1 was ≤ 40% predicted, long-acting anticholinergics, inhaled corticosteroids, and combination treatment reduced exacerbations significantly compared with long-acting beta-agonists alone, but not if FEV1 was > 40% predicted. This effect modification was significant for inhaled corticosteroids (P = 0.02 for interaction) and combination treatment (P = 0.01) but not for long-acting anticholinergics (P = 0.46). A limitation of this analysis is its exclusive focus on exacerbations and lack of FEV1 data for individual patients.We identified 35 trials enrolling 26,786 patients with COPD of whom 27% had ≥ 1 exacerbation. All regimes reduced exacerbations statistically significantly compared with placebo  for long-acting anticholinergics to 0.78 (95% CI 0.70 to 0.86) for inhaled corticosteroids). Compared with long-acting bronchodilators alone, combined treatment was not more effective . If FEV1 ≤ 40%.We found no evidence that one single inhaled drug regimen is more effective than another in reducing exacerbations. Inhaled corticosteroids when added to long-acting beta-agonists reduce exacerbations only in patients with COPD with FEV Chronic obstructive pulmonary disease (COPD) has become a leading cause of death worldwide and its management requires an enormous amount of human and financial resources ,2. ReducOpinions differ about whether a long-acting bronchodilator alone is sufficient or if an inhaled corticosteroid provides additional benefits at least for some patients ,9,10. AnSince such a trial is very unlikely to become available, a network meta-analysis or individual patient data meta-analysis can be very informative . Such poth 2007) and the Health Technology Assessment database (last search November on 20th 2007) for randomized trials included in existing systematic reviews .We searched the Cochrane Database of Systematic Reviews , the Database of Abstracts of Reviews of Effects  on exacerbations with or without placebo control. We included all trials where the proportion of patients with at least one exacerbation during follow-up was reported. We did not include trials where only the mean number of exacerbations per patient year was reported because meta-analysis of such data is prone to bias without individual patient data .We retrieved all full reports of potentially eligible trials. Two reviewers  independently assessed them and determined their inclusion or exclusion. If the two reviewers disagreed even after discussion, a third reviewer (epidemiologist with MD and PhD degree) arbitrated. Out of 56 trials identified initially, we excluded 20 , one reviewer extracted the number of patients with at least one exacerbation during follow-up and the number of patients with no exacerbation during follow-up . A second and, in case of disagreement, third reviewer, checked the data extraction for correctness. We also recorded whether the studies' definition of exacerbation was event based  or symptom based  and recFor each trial, two reviewers independently evaluated the quality of reporting for important components of internal validity , we created as many data entries with respective coding for treatment and exacerbation (yes/no) as there were patients in the respective cell. For example, in the study of Brusasco et al  there we1), or the definition of exacerbation influenced the (relative) treatment effects. We performed separate analyses for trials with a treatment duration of ≤ and > 6 months and≤and > 12 months, for trials with event- or symptom-based exacerbations, and for trials including patients with a mean post-bronchodilator FEV1 of ≤ and > 40% and 50% predicted (where available). We did not select 35% predicted as cut-off because there was only one trial [1. To assess effect modification formally, we tested for interaction by introducing product terms between predictor variables and treatments into the logistic regression analysis. With a random coefficient model, we investigated the presence of any additional variation of the treatment effects due to differences across trials [We performed a logistic regression arm-level analysis with the presence of exacerbation as dependent and the different treatment options as independent variables. We started with placebo treatment as the reference group followed by identical analyses where long-acting beta-agonists, long-acting anticholinergics and inhaled corticosteroids, respectively, served as reference group to which the other treatments were compared. To preserve randomization within each trial, we included a dummy variable for each of the studies. This dummy variable also adjusted for differences in risk profiles and study setup between trials. Second, we conducted stratified analyses to assess whether treatment duration or follow-up, respectively, disease severity . A total of 26 trials (74%) with 23,245 patients used an event-based definition for exacerbations, and nine trials (26%) with 3541 patients had a symptom-based definition. 7201 patients (27%) suffered from at least one exacerbation. A total of 8312 patients received placebo , 6357 received long-acting beta-agonists , 4764 received a long-acting anticholinergic , 3492 an inhaled corticosteroid , and 3861 patients combination treatment .Table The median number of adequately reported aspects of study quality was 4 out of 6  for long-acting anticholinergics to 0.78 (95% CI 0.70 to 0.86) for inhaled corticosteroids Figure . Compari1 ≤ 40% , long-acting anticholinergics , inhaled corticosteroids , and combination treatment  reduced exacerbations significantly compared with long-acting beta-agonists alone , there were no differences between treatments. Thus, the difference between point estimates in patients with FEV1 ≤ or > 40% was small for long-acting anticholinergics (0.09) but larger for inhaled corticosteroids (0.35) and combination treatment (0.26). This effect modification was confirmed when we tested for effect modification formally . Effects of long-acting anticholinergics and combination treatment did not differ significantly . There was no effect modification when stratified for FEV1 ≤ or > 50%. In the other stratified analyses (stratified for treatment duration of ≤ and > 6 months and ≤ and > 12 months as well as for definition of exacerbation), we did not observe any influence of treatment duration or the definition of exacerbations on (relative) treatment effects.When we analyzed patients with FEV-6 to 10-9).The random coefficient model showed very similar point estimates and 95% CIs. Compared with the simpler logistic regression model, there was very small extra variability arising from differences of treatment effects across trials  [According to the recently published BOLD study, the prevalence of COPD with GOLD stage II to IV in populations over 40 years of age is around 10%, and approximately 80% of these patients have an FEVtage II) . For thetage II) ,59, our 1 (below 40% predicted), long-acting anticholinergics appear to be the most attractive choice. They are as effective as combination treatment in reducing exacerbations but offer advantages in terms of costs and adverse effects [1 [In contrast, in patients with low FEV effects . The onl effects . The INSfects [1 .Exacerbation is not the only outcome that should inform the decision for or against adding inhaled corticosteroids to long-acting bronchodilators. Other outcomes should be considered as well. A recent systematic review found no risk reduction in terms of mortality if an inhaled steroid was added to a long-acting bronchodilator . Health-Unlike previous meta-analyses based on comparisons of inhaled drugs with placebo or, in some instances, with another inhaled drug -6,11,12,There are other approaches for indirect comparisons -18. An eA limitation of our study is that we focused on exacerbations and did not consider additional outcomes such as health-related quality of life or mortality. When we planned the current analyses the body of evidence on mortality was too small to provide precise effect estimates, even if pooled. The TORCH trial  publisheA limitation of any approach to pool data on exacerbations is that (relative) treatment effects can only be estimated adequately based on the proportion of patients with at least one exacerbation. Analysis of exacerbation rates expressed as mean exacerbation rates per person-year would offer a more comprehensive use of the data and would be less dependent on the length of follow-up. However, such data cannot be pooled adequately without having access to adequate and fully reported analyses that took within- and between-patient variability in exacerbations into account. But as Suissa points out, most trials are not analyzed and reported adequately. IdeallyA common problem of systematic reviews in COPD is poor reporting of clinical and spirometric characteristics of patients enrolled in included trials. It is sometimes difficult to judge whether all patients had COPD, or if some patients had other lung disease such as asthma. Also, there is often no separate reporting for moderate and severe exacerbations, although it would be informative to estimate the effects of inhaled steroids stratified for the severity of exacerbations. COPD is a heterogeneous disease and it is important that future studies provide more information about their patients, including clinical characteristics, lung function data and also information on co-treatments.1, combination treatment and long-acting anticholinergics should be favored because they reduce the risk for exacerbations more than single treatment with a long-acting beta-agonist. Our analyses, together with the existing meta-analyses that considered additional outcomes, inform patients and physicians to balance the benefits and downsides of different inhaled drug treatments for COPD.The results of our study may support physicians in selecting inhaled drug treatments for patients with COPD. In general, long-acting beta-agonists or anticholinergics appear to be the treatment of choice to reduce exacerbation rates. Adding an inhaled corticosteroid does not provide additional protection from exacerbations. In patients with low FEVNone of the authors has any competing interests related to the content of this paper. Dr. Kleijnen received restricted research grants from Pfizer Ltd.All authors had full access to all of the data in the study. MAP takes responsibility for the integrity of the data and accuracy of the data analysis. MAP, LMB, JK, and AGK undertook Study concept and design. MAP, LMB and AGK were responsible for data acquisition. MAP, LMB, JK, GtR and AGK performed Analysis and interpretation of data. MAP, LMB and AGK drafted the manuscript. JK and GtR undertook critical revision of the manuscript for important intellectual content. MAP, LMB, GtR and AGK performed the statistical analysis. JK and AGK supervised the study. All authors have read and approved the final manuscript.The pre-publication history for this paper can be accessed here:Appendix 1. Existing systematic reviews used for identification of articles.Click here for fileAppendix 2. Excluded studies.Click here for fileAppendix 3. Quality assessment.Click here for fileAppendix 4. Approach to create new data set with n data entries where n is the total number of included patients.Click here for file


Few diabetes HRQOL instruments are available in Chinese language. We tested psychometric properties of a Diabetes Quality of Life (DQOL) in Chinese language for diabetes patients in Taiwan and estimated its minimally important differences (MIDs).Data were collected from 337 patients treated in diabetes clinics of a Taiwan teaching hospital. Pearson's correlations among domain scores of the DQOL , the D-39S  and the RAND-12  and mental health composite (MHC)) were estimated to determine convergent/discriminant validity. Known-groups validity was examined using 2-hour postprandial plasma glucose (2 h PPG), hemoglobin A1c (HbA1c)) and presence of complications . We used a combined anchor- and distribution-based approach to establish MIDs.The DQOL scores were more strongly correlated with the physical domains of the D-39S (diabetes control and energy and mobility) and RAND-12 PHC than psychological domains of the D-39S  and RAND-12 MHC. The DQOL showed satisfactory discriminative ability for the known groups of 2 h PPG and HbA1c (effect size (ES) ≥ 0.2) and retinopathy, neuropathy, and diabetic foot complications (ES ≥ 0.3), but less satisfactory for the known groups of cardiovascular and cerebrovascular complications. MIDs for the DQOL domains were 3–5 points for satisfaction, 4–5 points for impact, 6–8 points for worry, and 3–4 points for overall HRQOL.We validated a DQOL in Chinese language for diabetes patients in Taiwan and provided MIDs to facilitate the measure of diabetes HRQOL. Diabetes mellitus (DM) is associated with long-term damage of multiple organ systems and increased age-adjusted mortality rates. Conventional assessment for diabetic patients relies on clinical measures, e.g., glycemic control and diabetes complications. However, the use of clinical measures alone for diabetes management is limited because clinical measures can not fully capture patient's health outcomes, especially psychological impact . Health-Several instruments are available for assessing diabetes HRQOL, including generic and diabetes-specific instruments. Generic instruments measure HRQOL domains which are universally important across diseases, while diabetes-specific instruments measure specific impacts of diabetes on functioning and well-being. Specific instruments may be more sensitive to patients' score changes over time ,3.There is a great need to develop and validate diabetes HRQOL instruments for Chinese populations, which comprise the largest group of people with diabetes . AlthougIn testing the usefulness of diabetes HRQOL instruments, the selection of psychometric methods and clinical variables can influence the success of instrument validation . HemogloAn issue limiting the use of diabetes HRQOL measures is that little guidance is available to interpret HRQOL scores, especially clinical meaning in score difference among treatment groups or score change within individuals over times ,17. ConvTwo methods are commonly used to determine MID: distribution-based and anchor-based approaches ,19. DistTo date, there is no consensus on the best approach to evaluate MID ,19. StudThe main purpose of this study was to validate and interpret a Taiwanese version of the DQOL . We evalData were collected from the Taiwan Diabetes Health Survey, an initiative to systematically develop HRQOL instruments for diabetes patients. In the second-year of the project, we focused on the DQOL and assessed its psychometric properties. Face-to-face interviews were conducted by two trained research associates for type-1 and type-2 diabetes patients who utilized outpatient services in the Tainan Hospital – a Taiwan's Department of Health (DOH) affiliated teaching hospital – between 07/2006–10/2006. In total, data from 337 diabetes patients were collected for the statistical analysis. This study was approved by the Institutional Review Board of the Tainan Hospital and received informed consent from each patient.Data on laboratory measure, clinical diagnosis and HRQOL assessment were collected at the same time from individual patients and tested using the same methods for all patients. Laboratory indicators include fasting plasma glucose (FPG), 2-hour postprandial plasma glucose (2 h PPG), and HbA1c. Diabetes complications were abstracted from medical records, including retinopathy , neuropathy (none vs. present), diabetic foot disorders , cardiovascular complications , and cerebrovascular complications .The DQOL was originally developed to assess HRQOL for type-1 diabetes  and has The extant Chinese version developed for Chinese people in Canada can not be directly applied to our study population because different spoken dialects and syntax  are used by Chinese people in Canada and Taiwan. The extant DQOL in Chinese language was developed based on the dialect of Cantonese , where p version  and compThis Taiwanese version includes the same items as those in a Chinese version developed in Canada . CompareAll items are scored on a five-point Likert scale, ranging from 1 (very satisfied) to 5 (very dissatisfied) in satisfaction domain, and from 1 (never) to 5  in impact and worry domains. Domain scores were calculated by summing responses of all items in the corresponding domains, and lineally transforming them to a 1–100 scale with higher scores representing poorer HRQOL. A summary score  is further derived by summing three domain scores and lineally transforming to a 1–100 scale.We collected other HRQOL measures to validate the DQOL, including the D-39S and the RAND-12. The D-39S is a short-form (23 items) of the D-39, which is a diabetes-specific HRQOL instrument designed for patients with type-1 and type-2 diabetes . The D-3The RAND-12, a generic HRQOL instrument, is a short-form of the RAND-36 . The RANPsychometric properties of the DQOL were examined using internal consistency (reliability), convergent/discriminant validity, and known-groups validity.Internal consistency of each domain was estimated using Cronbach's alpha coefficient. An alpha of ≥ 0.7 is considered to be acceptable for the purpose of group comparisons . ConvergKnown-groups validity of the DQOL was examined by the extent to which the DQOL can discriminate between clinically well-defined patient groups, including laboratory diagnosis and diabetic complication groups. Laboratory diagnosis known groups are for those patients whose values of laboratory measures were below vs. above the accepted cut-off points: 110 mg/dL for FPG, 140 mg/dL for 2 h PPG, and 7.0% for HbA1c . DiabeteWe also compared scores of the DQOL domains by treatment regimens, including 1) lifestyle modification alone or lifestyle modification plus oral agent (L/LO) and 2) lifestyle modification plus insulin or lifestyle modification plus oral agent and insulin (LI/LOI). We hypothesized that patients who were treated with L/LO regimen would demonstrate better HRQOL compared to patients who were treated with LI/LOI regimen.We used a cross-sectional method to determine MID which compares HRQOL scores in patients who were classified by level of health-relevant criteria ,19. BecaThree-single items measuring patient's self-reported diabetes severity, general health status, and global quality of life were considered as anchors. Items of diabetes severity and global quality of life were rated by a seven categories, with scores ranging from 1 to 7 (from most severe/very dissatisfied to least severe/very satisfied). The item of general health status was rated by a five categories, with score ranging from 1 to 5 . We estimated differences in average HRQOL scores across adjacent categories of a specific anchor ,23,33. WFor a distribution-based approach, we estimated a standard error of measurement (SEM) which accounts for reliability of the DQOL and standard deviation of patients under the investigation. SEM was estimated by a standard deviation of the DQOL scores multiplied by a square root of one minus internal consistency of the DQOL scores. Based on evidence supported by Wyrwich and colleagues, we adopted a one-SEM criterion to reflect MID ,36. We fIn this study, all of the analyses were performed using the STATA 9.02 .Table Internal consistency was ≥ 0.7 for all domains of the DQOL .Table Table For the diabetes complication known groups, after adjusting for age, gender, education background, and diabetes duration, the impact, worry, and overall HRQOL domains of the DQOL demonstrated better discrimination than the satisfaction domain. This is especially evident for the known groups of retinopathy, neuropathy, and diabetic foot complications. Taking neuropathy as an example, the effect sizes in score differences of the impact, worry, and overall HRQOL domains were 0.44, 0.46, and 0.45, respectively, which were larger than the satisfaction domain (0.24). The discriminative ability of the DQOL and the D-39S by the known groups of retinopathy, neuropathy, and diabetic foot complications was compromised. Compared to the RAND-12, both diabetes-specific HRQOL instruments showed slightly better discrimination by laboratory indicators. By contrast, compared to the RAND-12 the discriminative ability of the DQOL and the D-39S was compromised by cardiovascular complication known groups, but less satisfied by cerebrovascular complication known groups.Figure Table Combining the findings from anchor- and distribution-based approaches, the range of MIDs were 3–5 points for the satisfaction domain, 4–5 points for the impact domain, 6–8 points for the worry domain, and 3–4 points for the overall HRQOL.Although the DQOL has been widely used in many studies -27, rigoOur findings indicate that scores of the DQOL were moderately correlated with the D-39S  and the RAND-12. Magnitudes in the correlations of all DQOL domains with the physical relevant domains of the D-39S (diabetes control and energy/mobility) were slightly larger than with other domains of the D-39S . Additionally, magnitudes in the correlations of all DQOL domains with the RAND-12 PHC were slightly larger than with MHC. A DQOL validation study by Yildirim and colleagues reported that domains scores of the DQOL were more strongly correlated with the physical domains  of the 15D (a generic HRQOL measure) than with the psychological domains  . AnotherFor known-groups validity, we found that, compared to the RAND-12 both diabetes-specific HRQOL instruments demonstrated slightly better discrimination by known groups of 2 h PPG and HbA1c. Additionally, compared to the RAND-12 both diabetes HRQOL instruments (DQOL and D-39S) discriminated better between the known groups of retinopathy, neuropathy, and diabetic foot complications than the known groups of cardiovascular and cerebrovascular complications. This finding may be in part due to the fact that the indicators of 2 h PPG, HbA1c, retinopathy, neuropathy, and diabetic foot complications are closely associated with diabetes treatment and diabetes control, and their impact might be directly captured by the domains included in both diabetes-specific instruments. In contrast to retinopathy, neuropathy, and diabetic foot complications, the impact of cardiovascular and cerebrovascular complications  on daily functioning is more significant and might not be directly attributed to glycemic control, which could be better captured by the RAND-12. This finding suggests that it might be an ideal approach to use diabetes-specific HRQOL instruments combined with generic HRQOL instruments to fully measure HRQOL burden for diabetes patients ,39,40.Our study extends conventional methods used to validate diabetes HRQOL instruments. Previous studies have often used HbA1c as a glycemic control indicator to validate HRQOL instruments. However, evidence is mixed regarding the association between HbA1c and HRQOL -43. Our A previous DQOL study suggests that patients with diabetes complications tended to report more impaired DQOL scores compared to their counterparts . In thisOur study suggests that patients who received more intensive treatment  was associated with the more impaired HRQOL in all domains compared to patients who received less intensive treatment . These comparisons were independent of the influence of age, gender, education, and diabetes duration. Johnson et al reported that, using the SF-12 patients on oral medication plus insulin had significantly lower physical and mental health than patients on oral medication, followed by lifestyle modification alone . SimilarTo facilitate interpretation of the DQOL scores, we estimated the minimally important difference (MID). MID has been defined as the smallest difference in a HRQOL measure that is perceived by patients as being clinically meaningful ,47. ImpoBecause neither anchor-based nor distribution-based approaches are superior to one another, we estimated MIDs based on several anchors and combined these estimates with a distribution-based estimate  -23. We fThere are a number of limitations to this study. First, the generalizability of our results may be limited because our samples were collected from a single center in Taiwan. Second, although the DQOL was designed for measuring patients with type-1 and type-2 diabetes, only 4 patients in our sample had type-1 diabetes. Therefore, the psychometric properties of DQOL are based largely on type-2 diabetes. Further studies are needed to replicate our finding in patients with type-1 diabetes. Third, we estimated MIDs using a cross-sectional rather than a longitudinal design. We calculated differences in average HRQOL scores across adjacent categories of an anchor for MID estimations ,23,33. HThere is a great need to develop and validate diabetes HRQOL instruments for Chinese populations. In this study, we validated a Taiwanese version of the DQOL in Chinese language for diabetes patients in Taiwan. We used different psychometric methods together with different laboratory indicators and diabetes complications to validate the DQOL. In addition to providing a useful questionnaire, we also used a combined anchor-based and distribution-based method to interpret the DQOL scores. Further evaluation and improvement are indicated, especially to estimate responsiveness.The authors declare that they have no competing interests.IH, JL, and CH conceived the study and its design. MW and CH collected the data in Taiwan. IH, JH, and WL analyzed the data. IH, JL, and CH interpreted the data. IH drafted the manuscript. IH, JL, AW, MW, WL, and CH revised critically for important intellectual content.


P=0.02) and DFS . This individual patient-based meta-analysis demonstrated that oral UFT significantly improves both OS and DFS in patients with curatively resected rectal cancer.Uracil–Tegafur (UFT), an oral fluorinated pyrimidine chemotherapeutic agent, has been used for adjuvant chemotherapy in curatively resected colorectal cancer patients. Past trials and meta-analyses indicate that it is somewhat effective in extending survival of patients with rectal cancer. The objective of this study was to perform a reappraisal of randomised clinical trials conducted in this field. We designed an individual patient-based meta-analysis of relevant clinical trials to examine the benefit of UFT for curatively resected rectal cancer in terms of overall survival (OS), disease-free survival (DFS), and local relapse-free survival (LRFS). We analysed individual patient data of five adjuvant therapy randomised clinical trials for rectal cancer, which met the predetermined inclusion criteria. These five trials had a combined total of 2091 patients, UFT as adjuvant chemotherapy compared to surgery-alone, 5-year follow-up, intention-to-treat-based analytic strategy, and similar endpoints (OS and DFS). In a pooled analysis, UFT had significant advantage over surgery-alone in terms of both OS , 0.70–0.97;  Colorectal cancer accounts for 10–15% of all cancers and is the second leading cause of cancer deaths in developed countries . SurgicaRecently, in the field of Stage III colon cancer treatment, adjuvant chemotherapy by 5-fluorouracil (5-FU)/levamisole was proved to be superior to surgery-alone therapy, and then various 5-FU/leucovorin (LV) regimens were confirmed to be effective from the results of numerous large-scale randomised trials and from the pooled analysis of clinical trials . A meta-analysis of three old trials (Uracil–tegafur (UFT) is one of the O-FPs. In colon cancer, the majority of recurrences occurred in the liver, whereas in rectal cancer many recurrences occurred in the lung and locally in addition to the liver. Treatment effect may thus differ between colon cancer and rectal cancer. As the previous meta-analysis, two trials of UFT in patients with rectal cancer have been reported. The present study focused on rectal cancer, which lacked a clear-cut survival benefit in our previous meta-analysis. Unlike oral fluoropyrimidines such as carmofur and capecitabine, the formulation of UFT includes a dihydropyrimidine dehydrogenase inhibitor , designeHere, we present an individual patient data meta-analysis of five centrally randomised trials recently performed in Japan to compare rectal cancer patients treated with UFT, with the surgery-alone control group. This meta-analysis includes data from more than 2000 patients and therefore provides a more reliable assessment of the effect of UFT on the survival, disease-free survival (DFS), and local relapse-free survival (LRFS) of the patients with rectal cancer than is available from any of the individual studies.Trials that randomly assigned patients to either long-term (12 months) administration of UFT or surgery-alone treatment after curative resection of rectal cancer were eligible for meta-analysis. The randomisation technique used in these trials was the centralised randomisation that precluded the possibility of prior knowledge of the treatment to be allocated.−2) at 1 week and once monthly for 6 months. In the JFMC15-1 and 15-2 trials, patients who were randomly assigned to the experimental group additionally received an induction course of intravenous 5-FU (250 mg daily−1) during 7 postoperative days  7-1 , sex , and age (three groups of increasing age). Tests for interaction were applied to detect departures from the homogeneity of treatment effects. Multivariate analyses were performed with the use of the Cox proportional hazards regression model for DFS, LRFS, and survival to assess the robustness of the observed effects to adjustments for important covariates and the magnitude of interaction between treatment effect and covariate  with no significant heterogeneity between the treatment effects in different trials . UFT showed significant effect on survival of curatively resected rectal cancers with a 5-year survival benefit of approximately 5%.Survival hazard ratios for all the trials are presented in A=0.60, Dukes' B=0.79, Dukes' C=0.86) but heterogeneity tests did not show any significant difference . There was no statistically significant difference in sex  or age .P<0.0001) with a 5-year DFS benefit of 9.7%, but demonstrating some heterogeneity among the treatment effects in different trials . Additionally, random effect model assuming the variation between trials was applied. The results of the random effect model still revealed highly significant differences owing to the relatively high effect in TAC–CR and NSAS-CC trials.Disease-free survival hazard ratios are presented in P=0.0026), and demonstrating some heterogeneity among the treatment effects in different trials . UFT also showed significant effect on LRFS of curatively resected rectal cancers.The overall hazard ratio was 0.68  plus oral LV  as well as DFS , and LRFS . As can seen by comparing the data in This meta-analysis found a statistically significant benefit of UFT with regard to overall survival (OS) (hazard ratio=0.82; Most of the Japanese rectal cancer patients did not receive pre- or postoperative radiotherapy in any of the trials. Although radiotherapy has been considered one of the standard adjuvant treatments in the Western countries, significant survival benefit has not been shown with reproducibility . The ostAlso, there is still a debate whether adjuvant chemotherapy for early stage rectal cancer is feasible . In termRegardless of the disease stage and patient background characteristics, there is a need for further trials involving UFT and new agents that are effective in advanced disease, such as irinotecan, oxaliplatin, and monoclonal antibodies.


Extreme obesity affects nearly 8% of Canadians, and is debilitating, costly and ultimately lethal. Bariatric surgery is currently the most effective treatment available; is associated with reductions in morbidity/mortality, improvements in quality of life; and appears cost-effective. However, current demand for surgery in Canada outstrips capacity by at least 1000-fold, causing exponential increases in already protracted, multi-year wait-times. The objectives and hypotheses of this study were as follows: 1. To serially assess the clinical, economic and humanistic outcomes in patients wait-listed for bariatric care over a 2-year period. We hypothesize deterioration in these outcomes over time; 2. To determine the clinical effectiveness and changes in quality of life associated with modern bariatric procedures compared with medically treated and wait-listed controls over 2 years. We hypothesize that surgery will markedly reduce weight, decrease the need for unplanned medical care, and increase quality of life; 3. To conduct a 3-year (1 year retrospective and 2 year prospective) economic assessment of bariatric surgery compared to medical and wait-listed controls from the societal, public payor, and health-care payor perspectives. We hypothesize that lower indirect, out of pocket and productivity costs will offset increased direct health-care costs resulting in lower total costs for bariatric surgery.Population-based prospective cohort study of 500 consecutive, consenting adults, including 150 surgically treated patients, 200 medically treated patients and 150 wait-listed patients. Subjects will be enrolled from the Edmonton Weight Wise Regional Obesity Program , with prospective bi-annual follow-up for 2 years. Mixed methods data collection, linking primary data to provincial administrative databases will be employed. Major outcomes include generic, obesity-specific and preference-based quality of life assessment, patient satisfaction, patient utilities, anthropometric indices, cardiovascular risk factors, health care utilization and direct and indirect costs.The results will identify the spectrum of potential risks associated with protracted wait times for bariatric care and will quantify the economic, humanistic and clinical impact of surgery from the Canadian perspective. Such information is urgently needed by health-service providers and policy makers to better allocate use of finite resources. Furthermore, our findings should be widely-applicable to other publically-funded jurisdictions providing similar care to the extremely obese.Clinicaltrials.gov NCT00850356 Extreme obesity, defined herein as patients with moderate or severe obesity, is the fastest growing obesity subgroup affecting nearly 8% of Canadians  or severely [> 40 kg/m2] obese), we estimate that over 125 000 adult patients within our region's catchment area has a BMI ≥ 35 kg/m2 [Weight Wise includes a central, region-wide single-point-of-access referral system; community education and weight management sessions; and adult and pediatric bariatric specialty clinics. Adult specialty services are offered to patients with BMI levels of ≥ 35 kg/m35 kg/m2 . Communi2 and a major medical comorbidity  or BMI levels ≥ 40 kg/m2 are considered potential candidates for surgery. Absolute contraindications to surgery include pregnancy, uncontrolled psychiatric disease, active substance abuse or smoking (patients are required to quit prior to surgery), an active eating disorder (anorexia or bulimia), and high-risk for surgery medical status (e.g. severe coronary artery disease). Because of limited data documenting the benefits of surgery in patients younger than 18 years of age and evidence for possible harm in patients over 60,[Within the adult specialty clinic, patients receive approximately 24-36 weeks of intensive lifestyle counselling , delivered by a multidisciplinary staff  according to current recommendations . Patient over 60, procedur1. Male or female patients in the Weight Wise Regional Obesity Program2. 18-60 years old2 and a major medical comorbidity or BMI levels ≥ 40 kg/m23. BMI levels ≥ 35 kg/m4. Able to provide informed consent1. Pregnant or nursing2. Currently participating in an obesity-related clinical trial or in whom protein-sparing low calorie diet is planned.3. Contraindication to bariatric surgery and/or weight loss4. Unable or unwilling to complete questionnaires or expected to experience difficulty with attendance of visits or completion of study data5. Any other medical, social or geographic condition which, in the opinion of the investigators, would not allow safe completion of the study protocolRoux-en-Y gastric bypass, gastric banding and sleeve gastrectomy are all performed. Surgical techniques have been previously detailed ,48,49. GFollow-up visits will be scheduled every 6 months for two years and will be performed in-person or by telephone if necessary. The final two year follow-up visit will be performed in-person.After informed consent is obtained, baseline data collection for consenting patients will include the following: age, sex, race, marital status, employment status, household income quintile , general medical history and obesity-related comorbidities, smoking status , detailed current and past medications, weight, BMI, waist circumference, blood pressure, fasting lipids, fasting glucose, HbA1c, and liver enzymes.Body weight will be measured using a validated, calibrated scale to the nearest 0.1 kilogram after the patient has emptied his/her bladder. Subjects will wear light indoor clothing with empty pockets and no shoes. Height will be measured using a wall-mounted stadiometre. A single reading taken using an automated blood pressure monitor and using an appropriately sized blood pressure cuff will be recorded with the subject seated in a chair and after five minutes of rest.Repeat assessment of blood pressure, body weight, and cardiovascular risk factors  will be performed at 2 years.Additional outcomes to be collected every 6 months will include:Household income and employment status1. Quality of life and utility measurement: Health related quality of life will be measured using validated, widely-used instruments. Generic and preference-based quality of life will be assessed using the Short Form-12 (SF-12[2. 12 (SF-12) and the12 (SF-12) respect12 ,[4. e (WLIQ), is a preEdmonton Obesity Staging Score (EOSS):[5. e (EOSS): EOSS is Economic Data  administrative data sources will be performed according to previously described methods [a.  methods ,56. BecaPatient-Reported: Second, in order to comprehensively capture all economic consequences and enable a societal perspective, each patient enrolled in the study will provide additional information retrospectively for the year prior to enrolment and prospectively for two years after enrolment on a bi-annual basis. Resource use will be identified through investigator and clinical experience as well as examination of comprehensive costs lists, and published literature  using appropriately calibrated and constructed linear regression models and/or analysis of variance. Because these are self-reported data collected on a semi-annual basis, we will use a "last-value carried forward" approach to handle missing data as our primary analytic strategy.The sample size of 150 subjects provides ample power to detect 2-year change scores and explore potential independent correlates of change. For example, for a 2-year change in SF-12 domains such as physical function, with baseline score of 31.6, SD 9, a clinicOutcomes are similar to those listed above. Two-year mean changes in continuous variables will be compared between the surgical arm and medical or wait-listed controls using unpaired t-tests for continuous outcomes and chi-squared tests for dichotomous ones. Multivariable predictors of the 2-year change in a given outcome will be identified using appropriately constructed and calibrated covariate-adjusted linear regression models for continuous outcomes or logistic regression models for dichotomous ones. Patients who cross over to another study arm  will be censored at the point of cross over and a last-observation-carried-forward approach to missing data will be used for the primary analysis.As an example, we calculated the sample size required to examine changes in body weight. Conservatively assuming a 2-year weight loss of 33% for surgical patients with a standard deviation of 17%,,27 a 25%First, descriptive statistics will be used to assess cumulative and incremental costs (by perspective and cost category) in each year using the arithmetic mean and 95% confidence interval for normally distributed variables and median with interquartile ranges for skewed variables. Within and between-group comparisons will be performed. Distributions of cost are often skewed and will be normalized, if necessary, by using log-transformations. Unadjusted analyses of costs will be performed using ANOVA; if cost cannot be normalized then nonparametric  tests will be used. If log-transformation of costs is necessary, Duan's smearing estimator will be used to calculate appropriate error estimates after the data are re-transformed from the logarithmic scale .Second, covariate controlled sequential multiple linear regression models will be constructed to determine the independent association of surgery  on each incremental cost outcome. Cumulative costs over time will be calculated using standardized methods,,65and coThird, the net economic impact of increasing bariatric surgery rates from a societal, public payor, and health care payor perspective will be assessed using a mathematical model developed by our team. The costs determined above will be input, and the net economic impact of increasing rates of bariatric surgery from current rates (0.1% of eligible patients) to 0.5% (estimated current rates in US), 5% and 10% of all eligible patients will be calculated.Using previous estimates, we have Using anonymised and de-identified study identification numbers, we will link our study sample with provincial administrative databases so as to facilitate extended follow-up of health care utilization, clinical events, and costs. We have undertaken several previous studies linking clinical registry and cohort data with these high quality databases, and have previously reported greater than 96% linkage success with follow-up extending 5 years and beyond ,67.APPLES has been approved by the Health Research Ethics Board of the University of Alberta.In summary, APPLES is a prospective observational study that aims to address current knowledge gaps by examining the impact of wait times for bariatric care in a surgery eligible population and by generating prospective, population-based Canadian bariatric clinical, economic and humanistic outcome data. Protracted, multi-year wait times are a major concern within Canada's publicly funded health care system . TherefoAn additional advantage of the APPLES study design is that, because subjects are enrolled from a regional program, the study will examine outcomes and costs on a population-wide basis rather than from a more selected source such as a single clinic or group of clinics. Thus, we feel that the results should both inform health care delivery in the Canadian context as well as be generalizable to other single-payor systems with universal health care coverage. Notably, lengthy wait times for surgery are not isolated to Canada and are present in publicly funded health care systems across the world .APPLES will also provide a comprehensive assessment of the costs related to bariatric care and will examine contemporary procedures, including sleeve gastrectomy. Data will be collected from both administrative and patient sources within a health care delivery model that includes universal access and comprehensive capture of hospital and outpatient encounters. These high quality costing data will include an assessment of costs commonly viewed as 'indirect' in nature. Although the time frame for data collection is limited to 2 years, these data will also be useful to inform economic models and will thus enable assessment of cost-effectiveness over a longer time frame. This will be particularly useful in more accurately assessing the overall cost-effectiveness of bariatric surgery in Canada. For example, a finding of unequivocal cost savings or neutrality from a public payor perspective would indicate that bariatric surgery is "dominant"  over medical management, and expansion should be a priority.As of May 2010, 95% of baseline enrolment within APPLES has been completed. Recruitment of all 500 patients is expected by June 2010, with two-year follow-up extending to June 2012. Final results for the APPLES analysis are anticipated by late 2012 or early 2013.DB has received honoraria for advisory boards, teaching and research from Ethicon Endo-Surgery Inc., a Johnson and Johnson company. All other authors had no competing interests to declare at the time of submission of this manuscript.RP drafted the initial study concept and all authors contributed to the study design. RP wrote the initial draft of the protocol and all authors provided input into revisions and approved the final draft.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1472-6963/10/284/prepubAPPLES Case Report Forms. baseline and follow-up data collection forms for the APPLES studyClick here for file


High-density electroencephalography (hd-EEG) combined with transcranial magnetic stimulation (TMS) provides a direct and non-invasive measure of cortical excitability and connectivity in humans and may be employed to track over time pathological alterations, plastic changes and therapy-induced modifications in cortical circuits. However, the diagnostic/monitoring applications of this technique would be limited to the extent that TMS-evoked potentials are either stereotypical (non-sensitive) or random (non-repeatable) responses. Here, we used controlled changes in the stimulation parameters  and repeated longitudinal measurements (same day and one week apart) to evaluate the sensitivity and repeatability of TMS/hd-EEG potentials.In 10 volunteers, we performed 92 single-subject comparisons to evaluate the similarities/differences between pairs of TMS-evoked potentials recorded in the same/different stimulation conditions. For each pairwise comparison, we used non-parametric statistics to calculate a Divergence Index (DI), i.e., the percentage of samples that differed significantly, considering all scalp locations and the entire post-stimulus period. A receiver operating characteristic analysis showed that it was possible to find an optimal DI threshold of 1.67%, yielding 96.7% overall accuracy of TMS/hd-EEG in detecting whether a change in the perturbation parameters occurred or not.These results demonstrate that the EEG responses to TMS essentially reflect deterministic properties of the stimulated neuronal circuits as opposed to stereotypical responses or uncontrolled variability. To the extent that TMS-evoked potentials are sensitive to changes and repeatable over time, they may be employed to detect longitudinal changes in the state of cortical circuits. Several studies have suggested that the combination of high-density electroencephalography (hd-EEG) and transcranial magnetic stimulation (TMS) sensitivity) and should not change if stimulation parameters are kept constant (100% repeatability).A first step to evaluate the potential of TMS/hd-EEG as a diagnostic and monitoring tool involves defining the sensitivity and repeatability of this technique. In other words, before employing TMS/hd-EEG at the patient's bedside, one would like to assess to what extent TMS-evoked potentials reflect particular electrophysiological properties of the stimulated cortical circuits rather than a stereotypical brain's reaction, or uncontrollable variability. Indeed, TMS-evoked potentials would have limited diagnostic/monitoring application if they were found not to change when different neuronal subsets are stimulated, or if they were found to vary randomly when stimulation parameters are kept constant. Ideally, TMS-evoked potentials, recorded across different sessions in a healthy brain, should always change significantly if stimulation parameters are varied , or keeping stimulation parameters constant over time (no-change comparison - NC). For each comparison, we applied non-parametric statistics to compute a Divergence Index (DI), i.e. the percentage of spatial-temporal samples that differed significantly between two sessions of TMS-evoked potentials. At this point, considering each DI as a threshold, we performed receiver operating characteristic (ROC) analysis and we computed the true positive rate (the fraction of C comparisons with DI > threshold) and the true negative rate (the fraction of NC comparisons with a DI < threshold).ROC analysis showed that the overall accuracy of TMS/hd-EEG in disclosing changes in the stimulation parameters was 96.7%, with 95% sensitivity and 100% specificity (i.e. repeatability) at a DI threshold of 1.67%. These results demonstrate that TMS-evoked potentials are sensitive  and repeatable (non-random) responses and that they reflect, deterministically, particular properties of the stimulated set of cortical neurons. To the extent that TMS-evoked potentials are sensitive and repeatable for changes in the stimulation parameters, they may also be accurate in detecting longitudinal changes in the state of cortical circuits.Ten right handed healthy volunteers  were enrolled into the study after a neurological screening to exclude potential adverse effects of TMS. Subjects with medical history of seizures, convulsions, loss of consciousness and traumatic brain injury, carriers of intracranial metallic objects and/or of cardiac pace-makers were excluded from the study. The entire experimental procedure was approved by the Local Ethical Committee of the Hospital “L. Sacco” and each volunteer gave written informed consent to participation.3 spatial resolution (1T Philips scanner). Three TMS targets were identified on individual MRIs in the left occipital lobe (Brodmann's area - BA19), the left parietal lobe (BA7) and the left frontal lobe (BA6). Precision and reproducibility of stimulation were achieved by using a Navigated Brain Stimulation (NBS) system , that employs a 3D infrared Tracking Position Sensor Unit to map the positions of TMS coil and subject's head within the reference space of individual structural MRI. In addition, the NBS system computes on-line the distribution and intensity (V/m) of the intracranial induced electric field using a locally best-fitting spherical model of the subjects' head and brain and taking into account the exact shape, 3D position and orientation of the TMS coil. Stimulation intensity, expressed as a percentage of the maximal output of the stimulator, was kept between 40–75% for all subjects, corresponding to an electric field between 110–120 V/m on the cortical surface. In each area, the TMS hot spot  was always kept on the convexity of the gyrus, about 1 cm lateral to the midline. These medial stimulation sites were selected because they are easily accessible and far from major head or facial muscles whose unwanted activation may affect EEG recordings. The reproducibility of the stimulation coordinates across sessions was guaranteed by a virtual aiming device that indicated in real-time any deviation from the desired target greater than 3 mm. The TMS stimulator consisted of a Focal Bipulse 8-Coil  driven by a Mobile Stimulator Unit . The coil was always placed tangentially to the scalp, in order to optimize transmission of the magnetic field to the cortical surface. TMS pulses were delivered at an inter-stimulus interval randomly jittered between 700–900 ms .Structural magnetic resonance images (MRI) were recorded from all subjects at 1 mmContinuous hd-EEG was recorded using a 60-channel TMS-compatible amplifier . This equipment ensured artefact-free EEG recordings starting from 8 ms after the TMS pulse The experimental protocol consisted of two main arms, aimed at evaluating the sensitivity and the repeatability, respectively, of TMS-evoked potentials. In order to test for sensitivity, different, randomly ordered, TMS sessions were performed in the same day (day1) varying only one stimulation parameter at a time . TMS-evoked potentials were considered sensitive to the extent that they changed when stimulation parameters were changed. In order to evaluate repeatability, a subset of TMS sessions was repeated later in the same day (day1) as well as one week afterward (day8), without changing any stimulation parameter. TMS-evoked potentials were considered repeatable to the extent that they did not change over time when stimulation parameters were kept constant. In order to quantify sensitivity, single-subject pairwise comparisons were performed between TMS-evoked potentials obtained with different stimulation parameters. We called these comparisons “change comparisons” (C). To quantify repeatability, we performed single-subject pairwise comparisons between TMS-evoked potentials with identical stimulation parameters. We called these comparisons “no change comparisons” (NC). As described below, each pairwise comparison involved applying a non-parametric test based on random permutations between the single-trial TMS-evoked potentials of the two sessions.Pairwise comparisons were carried out between TMS-evoked responses to perturbation of BA6, BA7, and BA19 for each subject separately. Using the NBS, stimulation intensity  was always adjusted in each subject and in each area in order to compensate for local differences in scalp-to-cortex distance and to generate a comparable electric field between 110–120 V/m. The NBS was also used to keep the angle of stimulation parallel to the cortex midline (0° angle). In this case, the total number of pairwise comparisons was 22 instead of 30, because in 4 out of 10 subjects cortical responses to perturbation of one area (BA6 in 3 subjects and BA19 in 1 subject) were corrupted by artefacts and therefore excluded from the analysis.Single-subject pairwise comparisons were carried out between TMS-evoked responses obtained at I% and I%+10%. Using the NBS, the stimulation target, as well as the angle of the induced currents were kept unvaried. A total of 20 comparisons were performed, involving BA6 in 4 subjects, BA7 in 7 subjects, and BA19 in 9 subjects.Pairwise comparisons were carried out between TMS-evoked responses obtained with a stimulation angle of 0° and responses obtained after clockwise rotating the angle by 45° and 90°. Intensity and site of stimulation were kept constant. Overall, 20 comparisons were evaluated, involving BA6 in 2 subjects, BA7 in 4 subject, and BA19 in 4 subjects (10 comparisons 0° vs. 45° and 10 comparisons 0° vs. 90°).For each subject, the first TMS session  was compared with an identical session repeated on day1, at the end of the experiment, without changing any stimulation parameter (10 comparisons). This procedure allowed to control for possible plasticity-related modifications induced by repeated TMS sessions.A subset of the TMS/hd-EEG sessions recorded on day1 (intensity I% and direction 0°) was compared with identical sessions accurately replicated on day8, namely stimulation of BA6 in 4 subjects, of BA7 in 7 subjects and of BA19 in 9 subjects. In these cases, we carefully controlled that not only the stimulation parameters, but also other environmental and subjective conditions  were exactly the same. To further reduce sources of measurement variability, electrodes digitization was used to ensure that the relative position between the EEG cap and subject's head did not differ across the two sessions.2/Hz Data analysis was carried out using MATLAB® . Visual inspection of single-trial recordings was performed by a trained experimenter after automatic rejection of trials with EOG >70 µV and/or with absolute power of EEG channel F8 in the fast beta range (>25 Hz) exceeding 0.9 µVWe implemented a non-parametric permutation-based statistical procedure to perform pairwise comparisons between TMS-evoked potentials, and to synthesize their degree of diversity in a single value (divergence index - DI), corrected for multiple hypothesis testing.P>0.05). The percentage of rejected trials was always less than 5%. At this point, we could test the null hypothesis that two sets of TMS-evoked potentials  are equivalent. If this is the case, “mixing” together, in any random combination, the single trials collected during the two TMS/hd-EEG sessions should always result in statistically equivalent TMS-evoked potentials. Otherwise, the null hypothesis can be rejected. Thus, for each comparison, 1000 “mixed” TMS-evoked potentials were obtained by randomly mixing and averaging 1000 times the single trials collected in two different sessions . Cortical meshes were automatically parcellated into subregions  using the masks provided by WFUPickAltas tool  of the single trials, contributing to the two TMS-evoked potentials to be compared, had the same distribution. In case of a negative result, the most deviated trials were removed and the test was repeated until the baseline distributions of the two groups of trials were statistically equivalent  forsessions ; iii) thinterest ; iv) twointerest . Finallyhttp://www.fil.ion.bpmf.ac.uk/spm) was used to warp individual MRIs to the Montreal Neurological Institute atlas and to compute cortical meshes (7204 vertices each). EEG sensors and individual meshes were co-registered by rigid rotations and translations of anatomical landmarks . Conductive head volume was modeled according to the 3-spheres BERG method http://neuroimage.usc.edu/brainstorm). Finally, inverse solution was computed on each single trial by applying the empirical Bayesian approach The Statistical Parametric Mapping software package . The optimal DI threshold was set in correspondence to the maximum of the Younden index The statistical analysis described above, yielded 92 DIs, resulting from 62 C comparisons  and from 30 NC comparisons . ROC analysis was applied to evaluate the overall ability of TMS-evoked potentials in disclosing well-controlled modifications of stimulation parameters against measurement variability/error. Briefly, each measured DI was set as threshold to decide whether a change occurred (> threshold), or not (< threshold). Thus, the true positive rate (sensitivity%) and the true negative rate  was computed for all 92 DI thresholds. Then, we plotted the ROC curve as sensitivity% vs 100-specificity% using a Matlab script  and 30 NC comparisons (10 same-day and 20 one-week-apart recordings with the same stimulation parameters).Results of a representative subject are reported in Generally, comparing the brain responses evoked by TMS pulses delivered over different stimulation sites revealed obvious differences in the space distribution and time course of voltages and currents  also shoVarying stimulation intensity  as compared to the one computed for late latencies (120–250 ms), although the relative differences among types of comparison were preserved across all time intervals (P<0.01).In order to understand whether the observed differences between TMS-evoked potentials were preserved over the entire post-stimulus period, rather than limited to a specific latency, we computed the DI over three subsequent post-stimulus intervals, namely 0–60 ms, 60–120 ms and 120–250 ms . For eacResults of ROC analysis showed that the optimal DI threshold according to the Younden index was 1.67% and yielded a 95.1% sensitivity and 100% specificity (repeatability), corresponding to an overall accuracy of 96.7%. The efficacy of DI in reliably quantifying the pairwise differences between TMS-evoked potentials was 99.1%, as measured by the area under the curve .How accurately TMS-evoked potentials can detect actual changes in cortical responsiveness? If the EEG response to TMS tends to be stereotypical, actual changes in cortical responsiveness may go undetected (low sensitivity). On the other hand, if TMS/hd-EEG measurements tend to be too variable and noisy, changes in cortical responsiveness may be overestimated (low repeatability).Defining sensitivity and repeatability concerns the interpretation of the responses to any kind of stimulation: however, this task is particularly relevant when interpreting the EEG responses triggered by TMS, a technique that activates the brain in a way that is non-ecological and that is difficult to control.Unlike sensory stimulation, TMS activates simultaneously a rather large cortical volume containing both inhibitory and excitatory fibers, possibly belonging to different functional subsystems. Thus, it is possible that different TMS perturbations may result in EEG responses that engage many different circuits and that are largely overlapping. In addition, TMS not only perturbs cortical neurons directly but may also activate the brain indirectly, due to the stimulation of scalp nerves and to the click sound associated with the coil's discharge over the subject's head. For this reason, it is also conceivable that differences in the brain's reaction may be partially obliterated by an invariant event-related potential triggered by unwanted somatosensory or/and acoustic stimulations. Altogether, these factors may significantly hamper the sensitivity of TMS-evoked potentials. On the other hand, due to the complexity of the technique, TMS-evoked potentials may also lack repeatability, by showing accidental changes related to stimulation and/or recording errors. Indeed, stimulating directly the cortical surface involves the control of several factors, since a large number of cortical locations can be arbitrarily selected and perturbed, each one with several stimulation parameters . Thus, a lack of precise control of these parameters across subsequent TMS/hd-EEG sessions, may result in large measurement errors and in an apparent modulation of cortical responsiveness. Similarly, other factors, such as EEG sensors positioning, coil temperature, calibration of amplifiers, etc., may, if not adequately controlled for, affect the repeatability of TMS-evoked potentials.In this work, we used controlled changes in the stimulation parameters  and repeated longitudinal measurements (same day and one week apart) in order to jointly evaluate the sensitivity and repeatability of TMS/hd-EEG. In order to synthetically quantify the extent to which pairs of TMS-evoked potentials, recorded in various conditions, differed in their overall spatial-temporal pattern, we employed non-parametric statistics to calculate a Divergence Index (DI). ROC analysis showed that an optimal DI threshold of 1.67%, yielded a 96.7% accuracy (95.1% sensitivity and 100% specificity) of TMS-evoked potentials in detecting whether a change in stimulation parameters occurred, or not. The finding that TMS-evoked potentials, rather than being stereotypical or noisy responses, reflect to a large extent deterministic properties of the stimulated cortical circuits has different implications, as discussed below.Integration and differentiation  within regions are fundamental organizing principles of thalamocortical networks In the present experiments, changing stimulation parameters almost invariably resulted in higher DIs compared to the no-change conditions . ImportaChanging the site of stimulation resulted in very different responses and in high DI values that were even higher when the responses triggered in areas located far away (area 19 vs. area 6) where compared  of TMS-evoked potentials in the ROC analysis. Previous work Certainly, in order to evaluate the fine grain of cortical differentiation with TMS/hd-EEG, one should design ad hoc experiments where stimulation parameters are varied in a systematic way . Meanwhile, it would be interesting to test whether the DI resulting from two different perturbations decreases in physiological  and pathological  conditions, where the capacity for integration and differentiation in thalamocortical circuits is thought to be altered TMS-evoked potentials recorded on the same day, with the same stimulation parameters  was slightly higher than mean DI between same-day sessions (0.28%). This minor discrepancy might be ascribed to different factors: i) small co-registration errors, that clearly reduce the reproducibility of navigation; ii) small errors in re-positioning the EEG cap; iii) unavoidable and unpredictable biological variability due to changes in brain excitability that likely takes place on the time-scale of several days. Nevertheless, this comparison clearly demonstrated that TMS-evoked potentials, besides being sensitive to changes, are also very stable over time. Thus, as suggested by the ROC curve in The DI values computed in the C conditions allowed detecting changes in the stimulation parameters with excellent accuracy: however their absolute values spread over a wide range . This diVarious classifiers, describing differences between evoked potentials, could have been used to build the ROC curve. In this work, we implemented the DI because it allows to quantify the differences between TMS-evoked potentials starting directly from the entire matrix of spatial-temporal data, without requiring a priori information, and to synthesize them into a single number. However, the ability of the DI in detecting modifications of TMS-evoked potentials due to physiological and/or pathological alterations in cortical circuits should be carefully evaluated. Indeed, the DI is rather conservative (it corrects for multiple comparisons in time) and explores the entire post-stimulus period, at all sensors. Thus, since several channels and latency ranges are often not involved by a TMS-evoked potential, one should generally expect low absolute DI values. In fact, we found that maximum DI values were around 20% . When te