Ecological momentary assessment (EMA) may elicit physical activity (PA) estimates that are less prone to bias than traditional self-report measures while providing context.The objective of this study was to examine the convergent validity of EMA-assessed PA compared with accelerometry.The participants self-reported their PA using International Physical Activity Questionnaire (IPAQ) and Behavioral Risk Factor Surveillance System (BRFSS) and wore an accelerometer while completing daily EMAs (delivered through the mobile phone) for 7 days. Weekly summary estimates included sedentary time and moderate-, vigorous-, and moderate-to vigorous-intensity physical activity (MVPA). Spearman coefficients and Lin’s concordance correlation coefficients (LCC) examined the linear association and agreement for EMA and the questionnaires as compared with accelerometry.P<.05) for sedentary time (EMA: ρ=.16), moderate-intensity PA , and MVPA . Only EMA estimates of PA were statistically significant compared with accelerometer for agreement.Participants were aged 43.3 (SD 13.1) years, 51.7% (123/238) were African American, 74.8% (178/238) were overweight or obese, and 63.0% (150/238) were low income. The linear associations of EMA and traditional self-reports with accelerometer estimates were statistically significant (The mobile EMA showed better correlation and agreement to accelerometer estimates than traditional self-report methods. These findings suggest that mobile EMA may be a practical alternative to accelerometers to assess PA in free-living settings. Using self-report measures to assess physical activity (PA) can result in over-reporting of PA volume by respondents -3. PossiA less commonly utilized approach to PA assessment, the ecological momentary assessment (EMA), may overcome many of the limitations of traditional self-report measures while providing contextual information on PA. The EMA is an approach to measurement that allows individuals to repeatedly report on their experiences in real time, in real-world settings, over time, and across contexts  . This unEMA techniques may also help to bridge the gap between self-report and objective assessment of PA by addressing many of the major limitations of both options . Research has demonstrated that EMA is a feasible tool for monitoring health behaviors among at-risk groups of adolescents and adults ,12. PrevTherefore, the primary objective of this study was to assess the correlation and agreement between daily diary EMAs of PA and accelerometer-derived estimates of PA among a group of free-living adults. The secondary purpose was to compare the agreement between EMA and accelerometer estimates of PA with traditional self-reported PA questionnaire estimates and accelerometer estimates. It was hypothesized that EMA estimates of PA and sedentary behavior would have acceptable convergent validity measurement properties and that EMA would display better agreement with accelerometer estimates than traditional self-reported PA from questionnaires.This study is a secondary data analysis of the Pathways between Socioeconomic Status and Behavioral Cancer Risk Factors Study (PATHS). The PATHS was a 7-day prospective observational study designed to characterize proximal predictors of health behavior using mobile phone–based EMA. A subset of the PATHS participants also received a mobile phone–based sedentary behavior intervention  . A raciaThe participants completed questionnaires on laptops or tablet computers, including items on demographic and socioeconomic factors such as age, race and ethnicity, educational attainment, employment status, and income. Household income was classified as low if it was reported to fall between less than or equal to 100% of the 2012 Federal Poverty Threshold and 199% of Federal Poverty Threshold.Weight and height were measured by study staff, and body mass index (BMI) was calculated using the standard formula (kg/m²).Self-reported PA and sedentary behavior were measured using three instruments with varying periods of assessment: EMA, “past 24 hours”; 7 items from the 2007 Behavioral Risk Factor Surveillance System (BRFSS), “usual week”; and ten items from the 2011 International Physical Activity Questionnaire (IPAQ), “past 7 days.”For the EMA, participants were provided with a LG Optimus T Smartphone with the Android 2.2 operating system, on which they were prompted to complete daily diary assessments of health behavior (including PA) over a 7-day observation period. The EMA program was developed by and accessed through the e-Health Technology resource provided by the Duncan Family Institute at the MD Anderson Cancer. Participants completed daily diary assessments once daily, 30 min after their self-reported usual wake time.First, participants were asked to select the time spent over the past 24 hours in moderate-intensity PAs via 8 response options that ranged from 0 to ≥70 min, in increments of 10 min. Participants were provided with examples of moderate-intensity PAs  to aid with recall. Next, participants were asked to report the time spent per day in vigorous-intensity PAs. Again, examples of vigorous-intensity PAs  and 8 response options were provided to facilitate recall. Summary estimates were expressed as the mean value within response categories for moderate- and vigorous-intensity PA separately. For example, if the participant reported 20 to 29 min of moderate-intensity PA over the previous 24 hours, 24.5 min was used. These values were summed across all days of observation and expressed as time spent per week in moderate-, vigorous-, and moderate- to vigorous-intensity PA (MVPA).As part of a larger survey administered to participants during the initial visit , 7 items from the 2007 BRFSS PA questionnaire were utilized to assess usual leisure-time PA; these items were adapted for self-administration. Participants were asked to report the duration (minutes per day) and frequency (times per week) of PA within broad intensity categories . The summary estimate reflecting moderate- to vigorous-intensity leisure-time PA was computed as the product of the reported duration and frequency (minutes per week) summed across intensity categories. The PA questions from BRFSS have previously been shown to be reliable and valid .Ten items from the 2011 IPAQ were also included in the initial survey to assess occupational- and transportation-related PA in the past week . For occThe IPAQ was scored to calculate a comparable summary estimate  to the other PA measures. First, the total number of hours per week of each of the questions was calculated by taking the product of the reported number of days per week and the total time (hours) spent per day engaging in each of the activity intensities. Then, the total number of hours per week was multiplied by 60 to determine the total number of minutes per week of each of the questions. Finally, the sum of the total number of minutes per week for each of the PA intensity was calculated; walking for work and transport and bicycling for transport were considered moderate-intensity PAs . LogicalSelf-reported sedentary behavior, separate from what was queried in the IPAQ, was assessed with 8-items that inquire about the time, in hours per day, spent watching television and using the computer during the week and on the weekends .Device-based PA was assessed using the ActiGraph GT3X accelerometer (ActiGraph). The ActiGraph is a small (3.8 x 3.7 x 1.8 cm) triaxial piezoelectric accelerometer that is typically worn at the waist. Data outputs from the ActiGraph accelerometer are activity counts, which quantify the amplitude and frequency of detected accelerations. Activity counts are summed over a researcher-specified time interval . In this study, a 60-second epoch was reported. The sum of the activity counts in a given epoch is related to activity intensity and can be categorized on the basis of validated activity count cut points . Technicz-transformation) self-reported and device-based estimates were assessed using Lin’s concordance correlation (LCC) coefficients with 95% CIs. Generally, LCCs are considered poor if they are less than .90 [First, descriptive univariate analyses were conducted on measured parameters, and all continuous estimates were assessed for normality using histograms and Shapiro-Wilk tests. Continuous estimates were reported as means with standard deviations (SD) and medians with 25th and 75th percentiles, depending on normality; frequencies and percentages were reported for categorical variables. Next, the linear associations between and within self-reported  and device-based estimates were computed using Spearman rank-order correlation coefficients. Significance of the Spearman correlation coefficient was tested using Holm’s sequential Bonferroni adjustment. Then, the agreement between the inverse hyperbolic tangent transformed  and the mean (SD) duration of time (minutes per week) spent in each of the activity intensities as measured by self-report and accelerometer are shown in r=.77, P<.001) whereas all other self-report measures presented acceptable associations  with each other. When compared with accelerometer-determined sedentary time, only the corresponding EMA estimate was significantly correlated . Because of complete case analysis for missing data, the sample sizes for tests of correlations may differ (see P>.05) from those who adhered to the protocols, based on age, race, BMI, employment status, and income.Regarding self-reported time spent sedentary, the BRFSS and IPAQ sedentary estimates were shown to be highly correlated . Although all the traditional self-report estimates were significantly correlated to the accelerometer estimate , the EMA estimate performed the best with a correlation coefficient of .29 (P<.01).With regard to the moderate-intensity PA summary estimates, participants over-reported the time spent in moderate-intensity PA when measured using BRFSS and IPAQ. Among the traditional self-report estimates only, the instruments displayed acceptable correlations (P<.01). When compared with accelerometer-derived vigorous-intensity PA, none of the traditional self-report or EMA measures were significantly correlated .For the estimates reflecting vigorous-intensity PA, all of the traditional self-report and EMA measures overestimated the amount of time spent in vigorous-intensity activity when compared with accelerometer-derived estimates. Within the traditional self-report and EMA measures, correlations were low (.18-.29) but significant . When compared with accelerometer-derived estimates of MVPA, the EMA estimate displayed an acceptable correlation  whereas the correlations with traditional self-report measures were low but significant .Finally, for MVPA, participants over-reported the amount of time spent in MVPA when compared with accelerometer estimates. The traditional self-report and EMA measures presented acceptable correlations within each other . The BRFSS and IPAQ estimates of vigorous-intensity PA had poor and statistically nonsignificant agreement to accelerometer estimates . EMA had poor agreement but a CI not containing a null result  and a significant level of precision . None of the self-reports of vigorous-intensity activity had an accuracy estimate considered acceptable (BCF<0.90). Among the MVPA estimates, traditional self-report measures did not significantly agree with the accelerometer estimates, but there was agreement with EMA . For MVPA, EMA was the only estimate to produce significant levels of precision  and an acceptable level of accuracy (BCF=0.90).Agreement between the traditional self-report and EMA measures and device-based PA and sedentary behavior measures are shown in Finally, Lin concordance correlation plots  and BlanThe results of this study indicated that EMA performed better than other forms of PA self-report measures when compared against accelerometry. The BRFSS and IPAQ measures indicated over-reporting of an average of 464.4 and 902.3 min per week of MVPA, respectively, compared with EMA over-reporting MVPA by an average of 70.7 min per week. Similarly, EMA performed better than the other self-report measures in the areas of correlation (moderate-intensity PA and MVPA) and agreement . Additionally, the strong participant compliance to the EMA (93%) protocol further supports the feasibility of EMA as a method to assess PA and sedentary behaviors. This finding, considering the diverse sample in this analysis, underscores the ease-of-use of mobile phones in assessing PA and other health-related behaviors.These findings align with other studies that have found EMA to be a valid tool to estimate PA when compared with an objective assessment device. Dunton et al (2005) concluded that among adolescents, heart rates and accelerometer counts were significantly greater during EMA diary-reported PA than during non-PAs . SimilarPrevious work in the measurement and evaluation of PA has primarily used correlation coefficients to assess reliability and validity. In this study, with the use of an accelerometer as a comparison measure, the calculated Spearman correlation coefficients support the convergent validity of EMA. The Spearman statistic presented for moderate-intensity PA, for example, is evidence that the EMA estimate of time spent engaging in moderate-intensity PA has a linear relationship, in direction and magnitude, with the accelerometer-derived estimate of time spent engaging in moderate-intensity PA. However, a drawback to this approach is that when only plotting the linear relationship between two estimates, the test is unable to detect departures from the plotted line that would indicate poor reproducibility or shifts in the data. For a more complete explanation on the drawbacks on the use of correlation coefficients to evaluate reproducibility and validity, see Lin (1989) . Lin proThis study compared estimates of PA derived from accelerometry with various self-report measures . These are estimates of total PA, whereas each of the self-report tools measures various different domains of PA. There are four proposed domains of PA that make up an individual’s total PA: 1) leisure-time PA, (2) transit-related PA, (3) occupation-related PA, and (4) household/domestic-related PA . Each of leisure-This study has strengths and limitations. The population sample primarily included non-white and low-income urban-dwelling adults. This is a subgroup that is less frequently included in validation studies; however, much of the focus in PA research is directed at this subgroup for their disparate prevalence of many of the illnesses related to physical inactivity. Participants were enrolled as a convenience sample, and they may have inherent volunteer bias. Additionally, the PA assessment devices (self-report surveys and device-based) capture different aspects of PA  while attempting to compare one against the other as a means to validate. Finally, the time when PA was assessed differed across instruments . Previous reviews have found that self-report questionnaires asking about the previous week showed slightly higher correlation than those asking about a usual week . AdditioIn conclusion, direct “real-time” assessment of PA can remove many of the inherent biases found in self-reporting of PA that can result in overestimation. However, device-based PA assessment can require expensive equipment and lacks contextual information on the PA. The EMA is a proposed self-report measure of PA that may minimize bias by reducing recall time while also providing context. This study suggests that mobile EMA is a practical tool for assessing PA behavior. Overall, mobile EMA performed better than the other more traditional forms of self-report of PA assessment, indicating its potential ability to overcome bias. Future research should focus on a larger, more representative sample and longer EMA protocols to determine if the compliance to the protocols remains after a certain period of time.


N = 5759) from major food stores in Slovenia. The average and sales-weighted sodium content, as well as the share in total sodium sales (STSS) were calculated for different food category levels, particularly focusing on processed meat and derivatives , bread , cheese , and ready-to-eat meals . Reduced sale-weighted sodium content was observed in cheese (57%), a neutral trend was observed in processed meat and derivatives (99%) and bread (100%), and an increase in sodium content was found in ready meals (112%). Similar trends were observed for average sodium levels, but the difference was significant only in the case of ready meals. No statistically significant changes were observed for the matched products, although about one-third of the matched products had been reformulated by lowering the sodium level by more than 3.8%. Additional efforts are needed to ensure salt reduction in processed foods in Slovenia. Such efforts should combine closer collaboration with the food industry, additional consumer education, and setting specific sodium content targets (limits) for key food categories.A voluntary gradual reduction in the salt content of processed foods was proposed Slovenia in 2010. Our objective was to determine the sodium content of prepacked foods in 2015 and to compare these results with data from 2011. Labelled sodium content and 12-month sales data were collected for prepacked foods ( Excess dietary sodium intake is a well-recognised modifiable risk factor of high systolic blood pressure and a major cause of chronic non-communicable diseases ,2. DailyAlthough average sodium excretion in 24 h urine is recognised as the gold-standard marker for measuring salt intake in the population , this meThe sodium content of processed foods varies between different food categories. From a public health perspective, reformulation should be especially stimulated in food categories that present the largest contribution to sodium intake either due to their very high sodium content or their high consumption level by the population. Apart from plain salt (used as a condiment), the most important food sources of sodium include processed meat, bread and bakery products, cheese, as well as ready-to-eat prepared meals ,17,18,19In Slovenia, the dietary salt intake is around 12 g daily , which iThe objective of this present study is to investigate sodium levels in prepacked foods in the Slovenian food supply in 2015 and to compare these results with the data available for 2011. We aim to particularly focus on processed meat and derivatives, plain bread, cheese, as well as ready-to-eat meals. The assessment relied on both the average sodium content of available prepacked foods and the sales-weighted average sodium content.Cross-sectional data on the nutritional composition of prepacked foods in the Slovenian food supply were collected during January–February 2015 in five shops  of three major grocery chains with the largest nationwide shop networks . Sampling was done in Ljubljana, Slovenia. In agreement with the retailers, all prepacked products with a unique European/International Article Number (EAN) barcode were systematically photographed and recorded in an online Composition and Labelling Information System (CLAS) database . The datThe comparison was performed with previously reported cross-sectional data for 2011 , which wThe average sodium content of available prepacked foods  and average sodium content of sold prepacked foods  were calculated for selected food (sub)categories for 2011 and 2015, according to the previously reported protocol . SCA valShare in total sodium sales (STSS) was calculated using the data for 2015. Using the data related to the content of food per packaging, we calculated the amount (kg/L) of each product sold per year. In the next stage, the total sodium content of products sold within a specific food category (kg) was calculated using labelled sodium levels and 12-month sales data. STSS was calculated as the ratio between the total sodium in all sold foods in the (sub)category and the total sodium in all sold foods in the sample.t-test or Mann-Whitney U test (for non-parametric variables) was used. For statistical comparison of the matched products in processed meat and derivatives, plain bread, cheese, and ready-to-eat meals between the years of 2011 and 2015, a paired t-test was used. p < 0.05 was considered to be statistically significant.The data were processed and evaluated using the computer programs Microsoft SQL Server Management Studio V13.0, Microsoft Analysis Services Client Tools 13.0, Microsoft Data Access Components (MDAC) 10.0, Microsoft Excel 2013 , the program tool CLAS V1.0 , and the XLStat statistical software package V19.01 . For SCA, the 95% confidence intervals (95% CI) were calculated. SCS was given as an exact value and, therefore, no confidence intervals are presented. Given that the samples consisted of all available foods in the food supply in the selected stores, a comparison between years was performed directly by calculating the SCA (2015/2011) and SCS (2015/2011) ratios. For statistical evaluation of differences in the average sodium content of available prepacked foods, a SCA and SCS was calculated using the CLAS database with representative data on the availability of prepacked foods on the Slovenian market and 12-month, country-wide sales data for each product included in the database (see p = 0.013) and 155% (p = 0.002), respectively). We noted a considerable increase in the proportion of products with labelled sodium content from 2011 to 2015 . Due to a lack of sodium content data, a considerable proportion of 2011 sample was not included into analyses, and this limited the comparison of both samples in food categories with the lowest penetration of nutrition declaration (meat spreads (Percentage of products with labelled sodium content (% LSC): 4%); canned fish and seafood (12%); cakes, muffins, and pastry (12%); cheese (13%); processed meat and derivatives (15%); cream (19%); pasta sauces (21%); plain bread (30%); noodles (31%); and ready meals (34%)).The comparison of the determined average sodium levels in prepacked foods in the Slovenian food supply in 2015 was further assessed according to the data collected in 2011 . The betp = 0.08, 0.22, 0.25, and 0.76 for processed meat and derivatives; cheese; plain bread; and ready-to-eat meals, respectively), although about one-third of the matched products had been reformulated by lowering the sodium level by more than 3.8% .Considering the national Action Plan to Reduce Salt , which hUsing a combination of 12-month food sales data provided by food retailers covering most of the national market along with a comprehensive food composition database compiled using food labelling data, we showed that processed meat and derivatives (STSS: 13.1%), canned vegetables (9.1%), and plain bread (8.1%) were major sources of salt in prepacked foods in the Slovenian food supply in 2015 due to their high sodium levels and high level of consumption by the population.p = 0.13) and there were also no important changes in the sales-weighted sodium content (SCS 2015/2011 ratio: 99%). Reduced sale-weighted sodium content was observed in cheese, butter and margarine, biscuits, as well as meat spreads   . Differep = 0.12). Furthermore, the sales-weighted sodium content in plain bread was the same as that in 2011 (SCS: 492 mg/100 g). For comparison, about 10% lower sales-weighted sodium levels in bread was reported in the UK study [Bread is considered a major source of sodium intake in the Slovenian population . This waUK study . ConsideUK study .p < 0.05 for both). Given that such “convenience” foods are gaining in importance for a large number of consumers [Increased sodium content was observed in cakes, muffins, and pastry; ready-to-eat meals; mayonnaise/dressings; and pasta sauces , which altogether contributed about 7% of the total sodium sales (STSS). Similar trends were observed with the SCA ratios where there was a statistically significant increase in sodium content of ready-to-eat meals and pasta sauces (SCA 2015/2011: 106% and 155% with onsumers , greateronsumers ,6,29; hoonsumers  with theonsumers . Surprisonsumers ,33. WateIn line with observations made in 2011 , sales-wThe first monitoring of sodium content in foods in the Slovenian food supply was performed just after the national Action Plan to Reduce Salt in 2011 was launched . A limitThe results of this study indicate that activities forming the national Action Plan to Reduce Salt had a limited effect on sodium levels in major prepacked food categories that are considered as major dietary sources of sodium. In this respect, extra efforts are needed to ensure further progress, which should entail even closer collaboration with the food industry and additional consumer education. Specific target sodium content values should be set for key food categories, rather than the expected annual lowering of sodium content in foods, as contained in the existing Action Plan. Further studies are needed to verify the efficacy of salt-reduction programmes, which should include both measuring the dietary intake of sodium and changes in sodium levels in foods in the future food supply.


The reliability of items on dietary habits, body figure, skin tone and sun exposure in early life periods (age 6–12 and 13–18) was moderate-to-almost perfect, and most other items had fair-to-substantial reliability in all life periods . Differences in reliability by strata of the 5 subgroups were only observed in a few items. This study is the first to report the reliability of an NPC questionnaire, and make the questionnaire available online. Overall, our questionnaire had acceptable reliability, suggesting that previous NPC study results on the same risk factors would have similar reliability.We evaluated the reliability of early life nasopharyngeal carcinoma (NPC) aetiology factors in the questionnaire of an NPC case-control study in Hong Kong during 2014–2017. 140 subjects aged 18+ completed the same computer-assisted questionnaire twice, separated by at least 2 weeks. The questionnaire included most known NPC aetiology factors and the present analysis focused on early life exposure. Test-retest reliability of all the 285 questionnaire items was assessed in all subjects and in 5 subgroups defined by cases/controls, sex, time between 1 EBV infection is ubiquitous worldwide while NPC remains a rare cancer in most parts of the world2. Genetic predisposition is clearly associated with NPC, but the decline in risks for NPC observed in subsequent generations of Chinese migrants6 strongly suggests that the role of environmental exposure is crucial. The most commonly used method to measure environmental exposure is through self-reports in questionnaires and interviews.The aetiology of nasopharyngeal carcinoma (NPC) remains largely unclear. Multiple factors are implicated, including Epstein-Barr virus (EBV) infection, genetic susceptibility and environmental factors7, highlighting the importance of early life exposure. Indeed, previous case-control studies observed that salted fish consumption during childhood seems more strongly related to NPC risk than adulthood exposure14. To understand the role of early life exposure, the ideal would be a population-based birth cohort study with repeated measures of the exposure, and follow-up of the subjects in a few decades for NPC outcomes. Given that cohort studies are not feasible, retrospective case-control studies with high-quality data on early life exposure remain essential for research on NPC and other rare cancers. Nevertheless, information on early childhood exposure collected by interview and questionnaire relying on adult recall is subject to recall errors (random and systematic). Studies of reliability can inform researchers about such errors. The reliability of a survey instrument is most commonly assessed using the test-retest method, comparing responses given in the second survey with those in the first15. However, the reliability of questionnaires used in case-control studies were rarely reported. No evidence of test-retest reliability of NPC questionnaires was found. Such evidence is especially important on early life exposure, which would have greater error than adulthood exposure.NPC incidence in Southern China increases with age, and decreases after the peak at age 40–59We evaluated the reliability of early life NPC aetiology factors in the questionnaire of an NPC case-control study in Hong Kong.Seventy subjects in Queen Mary Hospital , and 70 in Queen Elizabeth Hospital  were included   reliability coefficients were observed for the number and sex of siblings and offspring, cancer history, family history of cancer and NPC, smoking and quitting status. Although some FFQ items at age 19–30 and 10 years ago showed poor (0–0.2) coefficients, most factors in the questionnaire had fair-to-substantial reliability coefficients  reliability of sun exposure in earlier periods was found in our analysis, suggesting that the data are still useful but with limitations.This test-retest study is the first to report the reliability of a computer-assisted, self-administered questionnaire in an NPC case-control study. We found moderate-to-almost perfect 0.4–1.0) reliability of the data on most NPC aetiology factors in early life periods  reliability coefficients were found in most FFQ items at age 6–12 and 13–18, and higher reliability coefficients were observed for frequency than portion size, which are consistent with previous test-retest reliability studies on FFQ15.Despite decades of research to find the causal factors of NPC, few studies have reported their reliability of the exposure dataThe test-retest reliability of a questionnaire is essential for assessing the validity of epidemiological studies but seldom reported. Such results are particularly important when exposure data are largely based on recall, as in almost all case-control and many cohort studies, especially for rare cancers such as NPC. Evidence of test-retest reliability of NPC questionnaires has been very limited. We took NPC as an example to reaffirm that assessing the recall errors is fundamental while using epidemiological data, and informing the reliability of a questionnaire is important, especially on early life exposure. We also share our questionnaires online for future references (Supplementary questionnaires).st and 2nd questionnaire (2–29/≥30 weeks), education (secondary or less/postsecondary) or age (25–44/45–59/60+ years) at the first questionnaire was unlikely to be large because most of the reliability coefficients were similar.Our present study included 140 subjects within an NPC case-control study in Hong Kong, showing all the coefficients of each questionnaire items for all subjects and for five subgroups, making it the largest and most comprehensive test-retest reliability analysis on NPC case-control studies in the literature. A computer-assisted questionnaire was used to minimise errors from the interviewer, especially subjective bias. We allowed sufficient time (at least 2 weeks after the first questionnaire: average of 30.5 [standard deviation = 18.8] weeks) between interviews to prevent subjects from simply recalling their responses in the first interview. Moreover, differential recall by cases/controls, sex, time between 125. However, we have found that the respondents had similar basic characteristics as all subjects, suggesting that any non-response bias should be small. Secondly, patients were recruited from two of the five hospitals only, but substantial differences in reliability in subjects from different hospitals were unlikely. However, caution is needed for applying the results to other settings. Because only those who agreed to be re-interviewed were included for assessing test-retest reliability, our results might not be applicable to non-respondents. Thirdly, although our present study is the largest test-retest reliability analysis on NPC case-control studies, small numbers in some rare exposure were observed, including vitamin A supplements (no subject reported ever use), and vitamin D supplements (only 1 reported ever use) and alcohol intake (only 1 reported drinking beer using the one-pint glass). Increasing sample size and revising the questions on rare exposure are recommended. Fourthly, because the short-version (any changes) of FFQ was used at age 19–30, and 10 years ago, the present analysis included only the FFQ at age 6–12 and 13–19. This made it difficult to compare results on FFQ among different life periods. We also found poor reliability coefficients for FFQ items at age 19–30, and 10 years ago. Researchers are recommended to include all periods of exposure on FFQ with the standard version15 in future NPC studies.A limitation of our reliability study was the relatively low response rate (62.8%), which might affect the representativeness of our findings. Such problem is common in test-retest reliability studiesThis study has shown that the questionnaire data of most NPC aetiology factors of an NPC case-control study in Hong Kong have acceptable reliability. Test-retest reliability study for case-control studies of early life exposure in NPC and other rare cancers is warranted, and the results should be taken into account during data analysis. We recommend that reliability test results should be included for publication of main results from case-control studies, particularly for rare cancers, and the questionnaires should be made available for future references.16. Briefly, eligible subjects for the main study were Chinese aged 18+ in 5 major regional hospitals  during 2014–2017 without the following conditions: chronic kidney failure, liver cirrhosis, serious heart disease, autoimmune diseases, pregnancy, thyroid disorder, previous thyroid/parathyroid removal surgery, dementia, frailty and cognitive impairment. Cases were incident NPC patients diagnosed with histological and/or radiological evidence in the past 2 months in the Department of Clinical Oncology in the hospitals. Controls were new patients or referrals of a new health complaint in the past 12 months in specialist outpatient clinics, or new inpatients admitted in the past 3 months in the same hospitals who were frequency-matched by age (5-year age groups) and sex to the cases. The controls were selected from patients who attended the clinics or admitted to the hospitals with a wide range of medical diseases unrelated to NPC. Those who had been screened positive for NPC related symptoms such as recent facial nerve palsy, tinnitus, unilateral hearing loss, and epistaxis were excluded. With reference to some questionnaires in previous NPC case-control studies and permission from corresponding authors, we designed a computer-assisted, self-administered questionnaire with 285 questions. A life-course milestone approach was used to collect information on socio-demographics, family cancer history, diet17, sun exposure, smoking18 and drinking history, occupational, household and others factors.This test-retest reliability study was a supplementary part of a case-control study in Hong Kong, the main study, on the life-course determinants of NPCw) and intra-class correlation coefficients (ICCs) for categorical, ordinal and continuous variables, respectively. Reliability coefficients were interpreted according to guidelines from Landis and Koch 19. All analyses were conducted using R 3.3.1.For the test-retest reliability study, eligible subjects were those who verbally agreed to join at least 2 weeks after completing the first questionnaire, and were invited to be interviewed again during January to December 2016 in two hospitals (QMH and QEH) contributing the largest number of subjects. The present analysis included 140 subjects with a response rate of 62.8% , (4) education (secondary or less/postsecondary) and (5) age (25–44/45–59/60+ years) at the first questionnaire. The differences between/among coefficients were (1) defined by a difference between/among coefficients of >0.30, and 2) tested by Fisher Z transformation (p < 0.01) with Bonferroni correction to adjust for multiple testing.The present analysis focused on dietary patterns in early life periods, including late childhood (age 6–12) and adolescence (13–18), and on body figure and sunlight exposure in two adulthood periods . All items in the questionnaire are shown in Supplementary Table All participants gave written, informed consent before participation. The Institutional Review Board of the University of Hong Kong/Hospital Authority Hong Kong West Cluster (UW 11–192) and the Research Ethics Committee of the Hospital Authority Kowloon Central/Kowloon East (KC/KE-13-0115/ER-2) approved the study protocol, and all methods were carried out in accordance with relevant guidelines and regulations.Supplementary materials 1 (figures and tables)Supplementary materials 2 (questionnaires)


Caenorhabditiselegans to humans has enabled relatively rapid implementation of findings in model systems to the clinic. The convergence of the capacity for genomic screening being implemented in the prevailing precision medicine initiative and the capabilities of microRNA to address these changes holds significant promise. However, prostate, ovarian and breast cancers are heterogeneous and face issues of evolving therapeutic resistance. The transforming growth factor-beta (TGFβ) signaling axis plays an important role in the progression of these cancers by regulating microRNAs. Reciprocally, microRNAs regulate TGFβ actions during cancer progression. One must consider the expression of miRNA in the tumor microenvironment a source of biomarkers of disease progression and a viable target for therapeutic targeting. The differential expression pattern of microRNAs in health and disease, therapeutic response and resistance has resulted in its application as robust biomarkers. With two microRNA mimetics in ongoing restorative clinical trials, the paradigm for future clinical studies rests on the current observational trials to validate microRNA markers of disease progression. Some of today’s biomarkers can be translated to the next generation of microRNA-based therapies.The high degree of conservation in microRNA from  Caenorhabditis elegans, the noncoding RNAs, let-7 and lin-4 induced mRNA degradation , inhibin, activin, nodal, endoglin, lefty and BMP ligands . InteresSmall molecule and neutralizing antibody-based antagonism of the TGF-β signaling axis is being pursued for multiple cancers. However, with the pleotropic roles of TGF-β it was not surprising that targeting the TGF-β ligands or receptors was associated with some unwanted side effects . Smad2 aCNN1  and ACTA2 (α-smooth muscle actin)  is a multi-step process that regulates changes in cell morphology during embryogenesis, tissue development and tumor development . One of in vivo . Interesin vivo . Howeverin vivo  . As a target of miR-21, Smad7 translation is inhibited leading to an increase in cells with the CAF phenotype. However, when miR-21 is blocked or Smad7 was overexpressed, TGF-β1-induced CAF formation was inhibited. The CAF and tumor epithelia of many cancer types rely on TGF-β signaling to mediate communication and increase tumor growth and potentiate therapy resistance   (P = 0.047) and miR-145 (P = 0.011) compared to lower risk scores  were identified as associated with poor overall survival  can develop malignancies. Although the epithelial tumors are the most common, the contribution of CAF in this disease is evident by shear bulk and prevalent cross-talk. The fibrotic scarring and development of fibroblast populations closely related to the epithelial tumor cells seem to correlate with miR functions. It has been difficult to stratify serous ovarian cancer. The pathologic similarities of this common ovarian cancer type do not reveal the level of chemoresistance of these tumors. However, a set of ECM and ECM remodeling proteins . Interestingly, miR-34a downregulation is frequently regulated by promoter methylation in cancer cells. These counter acting epigenetic regulations impact the expression of endogenous oncogenes  as well as exogenous immune infiltration  have been used in the clinic, but none have reached phase III yet. However, there are only two current trials using miRs in interventional trials. In these phase I studies, miR mimetics have been used to restore miR-34 (MRX34) and miR-16 (TargomiRs) activity. Some of the roles of miR-34 have already been discussed, as one of its targets is Smad4. As previously described, miR-16 inhibits TGF-β-induced EMT by silencing p-FAK and p-Akt expression, disrupting NF-κB and Slug transcriptional activity  as well as newer antagonists to the androgen signaling axis. Yet, metastatic prostate cancer has no cure as resistance to androgen antagonists are inevitable, and taxane therapy was approved by the FDA for providing an increase in three months of overall survival  explores the possibility of dosing enzalutamide therapy (androgen receptor antagonist) based on reduction in a panel of select miRs to assess treatment response . A phase II trial conducted by University of Erlangen-Nürnberg Medical School  explores the feasibility and toxicity of focal brachytherapy in 50 patients with low-risk prostate cancer . The secondary outcome of this study is to correlate miR-375 and miR-141 to visible efficacy of the radiation therapy. This secondary endpoint is supported by a number of previous clinical studies including, one where miR-21, miR-141 and miR-221 was detected in the plasma of a prostate cancer cohort of 51 patients  had higher expression compared to 20 healthy controls  or other such agent. MXR34 tries to address the two primary obstacles in gene therapy, tissue-specific delivery and cellular uptake.The first-in-man miR-based therapeutic trial, MXR34 (Nbib1829971), delivered in a liposomal nanoparticles was in part based on the important work by Liu and coworkers showing that systematic delivery of miR-34a reduced prostate tumor and metastasis in mice   can only detect late stage disease with little predictive value as to therapy response or relapse. Unfortunately, since three-fourths of the patients present with advanced disease, surgical cytoreduction and platinum/taxane-based chemotherapy are among the first lines of intervention. Benson and coworkers first reported that the concentration of circulating miRs is altered after administration of carboplatin and decitabine chemotherapy regime in platinum resistant recurrent ovarian cancer patients, in a phase II clinical trial of 18 subjects . It is being tested for safety in late stage pleural mesothelioma and non-small cell lung cancer subjects. TargomiRs are EGF receptor-targeted antibody conjugated to minicells containing a miR-16 mimic. The mimic is a double-stranded RNA molecule in a bacteria-based nanoparticle (minicell). As previously mentioned, miR-16 is implicated as a tumor suppressor for many cancers. However, there are compelling preclinical reports in which the ovarian cancer models were treated with cisplatin alone or in combination with miR-15a and miR-16 mimetics  results account for the poor prognosis, often treated with a cytotoxic chemotherapy or/and targeted therapy (with exception of HER2 antagonists). As with prostate cancer, hormone responsive breast cancer can evolve to a hormone-nonresponsive disease in heterogeneous tumors. As with other cancers discussed, there is a lack of reliable biomarkers for patient selection and therapeutic efficacy where miRs can play an important role. Heneghan and coworkers demonstrated that among the elevated breast cancer-associated miRs present in circulation, miR-195 can help distinguish from other malignancies  and from non-malignant subjects . Accordingly, a miR-34a mimetic was given with chemotherapeutic 5-flurouracil (5-FU) to reveal a more efficient anti-tumor effect than either single agent treatment . These studies support the promise of miR-34a (MXR34) as a potential therapeutic agent for breast and other cancer patients.With MXR34 being tested and the breadth of supporting literature for its application, many patients including those with breast cancer may benefit following pharmacokinetics/maximum tolerated dose (PK/MTD) are established in the phase I trial. In a recent report, anti-tumorigenic effect of miR-34a administration in triple negative breast cancer models inhibited proliferation, invasion and metastasis  and National Cancer Institute at the National Institutes of Health (grant number R01CA108646).


Medical evaluation pre-operatively is an important component of risk stratification and potential risk optimization. However, the effect of timing prior to surgical intervention is not well-understood. We hypothesized that total hip arthroplasty (THA) patients seen in pre-operative evaluation closer to the date of surgery would experience better perioperative outcomes.We retrospectively reviewed 167 elective THA patients to study the relationship between the number of days between pre-operative evaluation  and surgical intervention. Patients’ demographics, length of stay (LOS), ICU admission frequency, and rate of major complications were recorded.When pre-operative evaluation carried out 4 days or less before the procedure date, there was a significant reduction in LOS . When pre-operative evaluation carried out 11 days or less prior to the procedure date, there was a four-fold decrease in rate of intensive care admission (p=0.04). Furthermore, the major complication rate also significantly reduced (p<0.05). However, when pre-operative evaluation took place 30 days or less before the procedure date compared to more than 30 days prior, there were no significant changes in the outcomes.From this study, pre-operative medical evaluation closer to the procedure date was correlated with improved selected peri-operative outcomes. However, further study on larger patient groups must be done to confirm this finding. More study is needed to define the effect on rare events like infection, and to analyze the subsets of THA patients with modifiable risk factors that may be time-dependent and need further time to optimization. The volume of total joint arthroplasty procedures is increasing within the United States, as both the supply and demand have steadily climbed -3. In paThere are a number of studies within the literature that have examined best practices of pre-operative evaluations for a variety of medical procedures, but very few have examined when to conduct these examinations pre-operatively -14. In fThis study aims to determine whether the timing of pre-operative evaluations for patients undergoing THA affects perioperative health outcomes. More specifically, this study examines the relationship between the timing of pre-operative evaluations and three quality measures: length of stay (LOS) in hospital, need for higher acuity of care in-hospital (ICU admission frequency), and the frequency of major complications post-operatively.This study included 175 patients who underwent either a THA or revision THA procedure from November 21, 2011 to June 11, 2012. The data set was obtained directly from the institutional data requisition department under a Strategic Decision Support (SDS) facility. Complete data was available for 167 patients, which comprised the final cohort. The patients were divided into two study cohorts: Total Cohort and a Total Hip Arthroplasty (THA) Cohort. The Total Cohort included patients who underwent either THA and revision THA procedures, while the THA Cohort included only patients who underwent a THA.The data sets were then analyzed to determine total numbers, frequencies, means and standard deviations for key clinical values. Univariate and stepwise forward logistic regression analyses were utilized in order to determine the statistical relationships between days pre-op and our chosen measures of quality: LOS, ICU admission frequency, and major complication frequency. The variable “Days pre-op” refers to how many days prior to the date of surgery the pre-operative evaluation occurred. Major complications included: myocardial infarction, pulmonary embolism, acute renal failure, cerebral vascular accident, hypotension, circulatory failure, and respiratory failure. ASA classification was used as a general surrogate for patients’ health. A two-tailed Fisher’s t-test was used in order to detect statistical significance, while a p-value of < 0.05 was deemed statistically significant. The time intervals were chosen based on the time points at which a pre-surgical clearance may occur pre-operatively. Time intervals of 5-days, 10-days, and 30-days were analyzed, while statistically significant differences in the quality of care mean values were presented. In addition, a power analysis shows that a minimum cohort number of 17 was required for sufficient statistical power—assuming a power of 80% and a statistically significant p-value of < 0.05 for the LOS variable. All comparison cohorts contained more than n=52 samples each, meeting the statistical power threshold. The study examined differences in clinical factors varying days of pre-operative medical evaluation.1. The mean clinical values, along with their standard deviations and p-values are presented in Table 2. The two cohort populations did not differ statistically for any of these clinical values.Data was analyzed for the respective patient groups: Total Cohort (n=167) and THA Cohort (n=144). The demographic and clinical data of these study cohorts are listed in Table 3. More specifically, patients who obtained their pre-operative evaluation 4 or less days prior to surgery had a 0.58 day (p=0.03) reduction in the LOS in the Total Cohort, and a 0.53 day reduction (p=0.04) in the LOS in the THA Cohort. Additionally, patients who obtained their pre-operative evaluation 6 or less days prior to surgery had a 0.45 day (p=0.02) reduction in the LOS in the Total Cohort, and a 0.41 day reduction (p=0.04) in LOS in the THA Cohort.There was a correlation between fewer days pre-operative medical evaluation and lower average LOS. These findings are presented in Table 4, the study found that fewer pre-op days directly correlated with lower ICU admission frequency. This was found to be true for patients who obtained their pre-operative evaluation 4 or fewer days prior to surgery, compared to 5 days or more prior to surgery, as well as 10 days or fewer prior to surgery, compared to 11 days or more prior to surgery in both the study cohorts. Additionally, within the Total Cohort, it was found that patients obtaining their pre-operative evaluation 11 days or less prior to their procedure date had a lower ICU admission frequency compared to those obtaining their pre-operative evaluation 12 days or more prior to their procedure .Evident in Table 5, fewer pre-op days was correlated with lower major complication frequency. Specifically, patients who obtained their pre-operative evaluation 11 or less days prior to surgery had a lower major complication frequency compared to those who obtained their pre-operative evaluations 12 or more days before surgery in the Total Cohort , and in the THA Cohort .As outlined in Table 6). This was found in both the Total Cohort as well as the THA Cohort.There were no statistically significant differences in age, ASA class, or BMI between the patient populations undergoing pre-operative evaluations 4 days or fewer compared to 5 days or more prior to surgery (Table 7).The patient population undergoing pre-operative evaluation 11 days or less prior to surgery had, on average, a lower ASA class than those undergoing pre-operative evaluations 12 days or more prior to surgery in the Total Cohort . However, this difference was not significant in the THA Cohort . Neither age nor BMI were significantly different in either cohort or population  may be too small to draw broad conclusions, although the sample sizes and comparison groups met the threshold for statistical power analysis. Second, the time intervals chosen for subgroup analysis may experience selection bias, as they were chosen based on when pre-surgical clearance might occur pre-operatively. Time intervals of 5-days, 10-days, and 30-days were analyzed, while statistically significant differences in the quality of care mean values were presented. Additionally, the study data was gathered from one institution, and thus may not be generalizable to other institutions. As a retrospective study of correlations, no causal relationship can be concluded. Thus, although the study found that shorter times between pre-operative evaluations and procedures correlated with improved perioperative outcomes, the study may not conclude that these improved outcomes were due to the timing of pre-operative evaluations alone. Further, although the results discussed within the study exhibited statistical significance, the differences observed in the LOS, ICU admission frequency, and major complication frequency may hold less clinical significance in a practice setting than statistical significance. In addition, new issues found 4 days prior to surgery may be difficult or even impossible to address fully in a clinical setting. These differences in outcomes may be due to a variety of factors, such as differences in the health of the compared populations, differences in treatment, and many other confounding factors , 34. CerIn conclusion, as the THA procedure volume continues to grow, it becomes more important to identify potential processes that may improve surgical outcomes. A vital aspect of any medical procedure is the reduction of risk through pre-operative evaluations. This study sought to examine whether or not the timing of pre-operative evaluations may contribute to perioperative outcomes, a novel topic absent from the present literature. While this study finds that pre-operative evaluations closer to the procedure date are correlated with improved outcomes, additional studies must be performed in order to validate this conclusion.


To the Editor: Cholera—a severe, waterborne, virulent entericinfection caused by toxigenic strains of Vibriocholera—frequently causes epidemics in developing countries and sporadiccases or local outbreaks in developed countries. The geographic features of Russia andintensive globalization have established favorable conditions for travel-associatedcholera from regions to which it is endemic. During 2005–2012, six such casesoccurred in Russia; these cases were related to travel from India. Three of the caseswere registered in 2010, three months before the cholera outbreak in Haiti, one of themost extensive outbreaks in recent history , even though she had no distinct symptoms ofcholera. The source of infection for the woman and child was unclear but was assumed tobe related to eating fruit rinsed in tap water while in the city of Vrindavan inIndia.Isolate RND6878 was isolated on July 7, 2012 from a 28-year-old male Russian citizen. Theinfection was most likely caused by the patient drinking fountain water and coming intocontact with river water while living in Srinagar, India. Isolate RND19191 originatedfrom a 25-year-old female flight attendant operating a Moscow–Delhi–Moscowflight. Her infection was suspected to have occurred in Delhi during June 26–28,2010, from ingestion of contaminated fruit. Isolate RND19187 was obtained on June 9,2010, from a 29-year-old woman with severe cholera. Microbiological testing alsoconfirmed the presence of V. cholerae genomesshowed that all the isolates from the travel-associated cases clustered with choleracases that occurred in 2010. The isolates from the 29-year-old woman and her daughter(RND19187 and RND19188) accurately clustered with isolates from the Nepal-3 clade , Vibrio seventh pandemic islands, and SXT-ICE (ctxB7 variant of the ctxB gene and five 7-mertandem repeats (TTTTGAT). Finally, isolate RND6878 and the Haiti/Nepal-4 clade formed awell-supported monophyletic group with an estimated most recent common ancestor date of2009 (95% CI 2008–2010) .Maximum-likelihood phylogenetic analysis based on high-quality orthologoussingle-nucleotide polymorphisms (hqSNPs) among 75 -3 clade . Isolate-3 clade . RND1919 SXT-ICE . Notably08–2010) . InaddiV. cholerae strains similar to those from Nepal can be detected incountries other than Nepal and Haiti  from 3 months before the first cholera casesoccurred in Haiti showed higher genetic similarity to the Haiti strain than Nepalisolate VC-25. This finding should be interpreted with caution because this study waslimited to the analysis of only 1 isolate, with no epidemiologic context to link theisolate to the Haiti or Nepal outbreaks. Thus, India could not be validated as a primarysource of Haiti strains, and the existence of a direct transmission route from India toHaiti that does not involve Nepal could not be substantiated. It is generally acceptedon the basis of epidemiologic data and molecular phylogenetics that the Haiti strain wasintroduced from Nepal (Vibrio cholerae O1 El Tor, Russia.Methods used for the comparative analysis of genomes in this study oftravel-associated Vibrio cholerae O1 El Tor genomes used in thisstudy.List of Vibrio pathogenic islands 1 and 2,Vibrio seventh pandemic islands I and II, andintegrative and conjugative element genomic islands to the 2010EL-1786genome based on open reading frame similarity.Comparison of


Low levels of nonandrogenic anabolic hormones have been linked with frailty, but evidence is conflicting and prospective data are largely lacking.To determine associations between nonandrogenic anabolic hormones and prospective changes in frailty status.A 4.3-year prospective observational study of community-dwelling men participating in the European Male Ageing Study.Men (n = 3369) aged 40 to 79 years from eight European centers.Frailty status was determined using frailty phenotype  and frailty index .Regression models assessed relationships between baseline levels of insulinlike growth factor 1 (IGF-1), its binding protein 3 (IGFBP-3), dehydroepiandrosterone sulfate (DHEA-S), 25-hydroxyvitamin D (25OHD), and parathyroid hormone (PTH), with changes in frailty status (worsening or improving frailty).The risk of worsening FP and FI decreased with 1 standard deviation higher IGF-1, IGFBP-3, and 25OHD in models adjusted for age, body mass index, center, and baseline frailty . Relationships between IGF-1 and FI were attenuated after adjusting for IGFBP-3. Higher DHEA-S was associated with a lower risk of worsening FP only in men >70 years old . PTH was unrelated to change in frailty status.These longitudinal data confirm the associations between nonandrogenic anabolic hormones and the changes in frailty status. Interventional studies are needed to establish causality and determine therapeutic implications. We studied the endocrine risk factors for frailty and found significant longitudinal relationships between higher IGF-1, IGFBP-3, and vitamin D and lower risk of worsening frailty in aging men. Frailty describes a state of increased vulnerability to stressors and reduced homeostatic reserve in the elderly that is associated with adverse outcomes such as loss of mobility, functional disabilities, dependency, and death , 2. WithThe pathophysiology of frailty has been linked with dysfunctions in multiple physiological systems but the mechanisms remain poorly understood. Decline in muscle mass and function is thought to be central to the development of frailty, and because anabolic hormones are one of the key factors responsible for muscle growth and repair, endocrine dysregulation has been suggested as a potential etiological factor for frailty. This is further supported by clinical sequelae of various endocrinopathies that share common features with those of frailty in both men and women.Several studies have investigated associations of anabolic hormones with muscle function and physical performance but relatively few have focused on frailty –7. TheseIn this study, we hypothesized that nonandrogenic anabolic hormone levels would be related to changes in frailty status. Using the population-based European Male Ageing Study (EMAS), we sought to determine prospective associations between a number of nonandrogenic anabolic hormones and changes in frailty status.The subjects were participants in the EMAS, the details of which have been described previously . BrieflyParticipants were recontacted after a minimum of 4 years ; the methods of data collection at follow-up were the same as in the baseline study. During the follow-up period, 193 (6%) men died and 440 (13%) were lost to follow-up.The longitudinal analysis was restricted to men with complete frailty data at baseline and follow-up. We excluded participants with self-reported adrenal or pituitary disease or the use of medications affecting the somatotrophic axis , parathyroid hormone (PTH)/25OHD levels , or DHEA-S levels (DHEA-S supplements).am) venous blood sample was used for all hormone measurements as previously described .A fasting morning  and frailty index (FI).Supplemental Table 1 for details). Individuals with three or more criteria were classed as frail, those with one or two criteria as prefrail, and those with none as robust. The EMAS FP has been internally validated by showing that it predicts adverse health outcomes, including falls and death  known to accumulate with age and associated with adverse health outcomes. The deficit variables were derived from the Medical Outcomes Study 36-item short form survey and Beck Depression Inventory questionnaires, physical performance and cognitive tests, and self-reported comorbidities  were coded as 0.5. Continuous variables were dichotomized based on the distribution of participants’ scores; cut-points were set at the worst performing 10th centile. Individuals with >20% missing data were excluded.The EMAS FI comprises 39 health deficits  or n (%), and statistical significance of between-group differences was assessed using analysis of variance.Change in frailty was defined using transitions in frailty states between baseline and follow-up. The transitions considered were: worsening frailty  and improving frailty .z score [(raw score – mean)/SD] to allow comparison of results between endocrine predictors with different units of measurement. We adjusted all models for baseline frailty to account for the heterogeneity of baseline frailty status. Models were then further adjusted for variables significantly correlated with the hormonal predictors, such as age and body mass index (BMI), and center. In further analyses, the effects of additional adjustments for other potential confounders, such as smoking, alcohol use, education, physical activity, diabetes and cardiovascular disease (CVD), and other hormones were also explored. Additionally, all analyses in which PTH and 25OHD were the main predictor variables were adjusted for 25OHD and PTH levels, respectively. The results were displayed as odds ratios (OR) with 95% confidence intervals (CIs) for change in frailty status associated with a 1 SD difference in baseline hormone level.Logistic regression models determined relationships between an individual predictor (hormone at baseline) and outcome (transition in frailty state). Each potential endocrine predictor was considered as an untransformed value standardized as a z scores. The results were presented as percentage change (95% CI) in FI associated with a 1 SD difference in baseline hormone level .In view of the right skewing of the FI variable, relationships between baseline hormone level and FI at follow-up were assessed using a negative binomial regression. The FI variable was converted to a 0- to 39-count scale where “0” represented no deficits and “39” represented the maximum number of deficits. Analyses were serially adjusted for baseline FI (model 1), age (model 2), center (model 3), and BMI (model 4). As earlier, endocrine predictors were standardized as To assess for potential effect of age on the relationships between hormones and frailty, we performed an exploratory analysis introducing an interaction term (baseline hormone × age category) to the fully adjusted model. The “age category” represented four age bands: 40 to 49, 50 to 59, 60 to 69, and 70 to 79 years.All analyses were performed using Stata 13 SE software .Supplemental Fig. 1). Compared with the main analytical sample, men lost to follow-up (n = 435) were older and had a higher prevalence of smoking, depression, diabetes, and frailty at baseline . This was the case also for the men who died (n = 188), with addition of a higher systolic blood pressure, creatinine, and waist-to-hip ratio in this group when compared with the analytical sample.Of the 3369 men who participated in EMAS, 2444 men remained in the FI analysis and 2114 in the FP analysis after excluding those with known pituitary or adrenal disease (n = 29), relevant medication use (n = 47), missing FI (n = 556) or FP (n = 226) data, and failure to show up for follow-up assessment (n = 623) .Of 1589 men who were robust at baseline, 390 became prefrail and 20 became frail at follow-up. Among 505 men who were prefrail at baseline, 49 progressed to frailty. Therefore, in total, 459 men presented with worsening frailty at follow-up .One hundred ninety-two men who were prefrail and two who were frail at baseline became robust at follow-up. Additionally, 12 men who were frail at baseline transitioned to the prefrail state at follow-up. Therefore, in total, an improvement in frailty status was observed in 206 men , were less active physically, had lower BMI, and had a higher prevalence of diabetes and CVD . Their bMen whose frailty status improved were younger (59 vs 64 years) and had higher diastolic blood pressure and a lower prevalence of CVD when compared with men who remained prefrail or frail throughout the study period . BaselinSupplemental Table 5). Similarly, IGFBP-3 was no longer an independent predictor of FI and FP after adjustment for IGF-1.Higher baseline levels of IGF-1 and IGFBP-3 were associated with a lower likelihood of worsening frailty status as assessed by FP and FI in baseline frailty–adjusted models with and without additional adjustment for age, BMI, and center .Higher baseline levels of IGFBP-3 were associated with a greater probability of improving frailty phenotype in only the model adjusted for baseline frailty status . This reP = 0.021], but this relationship was not observed in younger men . The association in older men remained significant after further adjustment for depression score and diabetes. There were no significant age-related interactions in the relationships between other hormones and change in FP or FI (not shown).In a secondary analysis, there was evidence of age-related differences in the relationships between DHEA-S and worsening FP. In men aged >70 years, higher baseline DHEA-S levels were associated with a lower risk of worsening FP [OR, 0.57 , Our study has shown robust longitudinal multivariable-adjusted relationships between higher baseline levels of IGF-1, IGFBP-3, and vitamin D and lower 4-year risks of worsening frailty status in middle-aged and older community-dwelling European men. In models adjusted for baseline frailty status, higher levels of DHEA-S were associated with lower risk of worsening frailty status but statistical significance was lost on age adjustment. We also showed that baseline PTH was unrelated to changes in frailty status in any model. Importantly, the associations between hormone levels and frailty showed consistency regardless of whether frailty was assessed by FP or FI. These data highlight potential mechanisms of frailty and identify possible modifiable targets for intervention.et al. . Therefore, overadjustment bias cannot fully explain the discrepant results. It seems likely that sample size, the restricted and older age range (>70 years), and the quartile modeling strategy adopted by Yeap et al. (4) may have limited the statistical power to show significant relationships. Our study adds important data by assessing frailty through clinical objective assessments (not simply questionnaires) based on validated methods, in a larger cohort, over a wider age range and in a younger group capturing earlier frailty transitions and having a lower risk of “healthy survivor” bias.Our findings contrast with the results from the longitudinal study of Yeap et al.  of 1484 Similarly, our results contrast with those from a study of 1271 men and women >65 years of age who were participants in the Longitudinal Aging Study Amsterdam . In thatOur results are biologically plausible in light of previous research, highlighting the central role of IGF-1 in mediating muscle growth and repair across the lifespan . DespiteOur group  and otheSeveral smaller studies have assessed the prospective relationship between vitamin D and incident frailty/reduced physical performance and have generated differing results, some positive , 32 and The largest of these prior studies involved 1267 community-dwelling men in which baseline vitamin D level did not predict incident frailty defined by the Fried FP criteria . The anaThere are several potential mechanisms through which low vitamin D levels could contribute to frailty. Low vitamin D levels have been linked to altered muscle protein synthesis, decreased muscle strength, sarcopenia, worsening physical performance, and falls . These eOur prospective data are also supported by results of clinical trials and meta-analyses that indicate beneficial effects of vitamin D supplementation on muscle function, especially in older individuals with vitamin D deficiency . HoweverThis hormone has potential mechanistic links to frailty because it has been implicated in the development of neuromuscular dysfunction and has effects on muscle protein turnover and energy metabolism . The diret al.  have previously reported relationships between DHEA-S levels and incident frailty , 11. BotSeveral potential pathways could link low DHEA-S with frailty. DHEA-S may have an anabolic effect on skeletal muscles, which has been suggested to be age-dependent and vary across lifespan  and, morOur study has several important strengths, which include (1) use of a well-defined, longitudinal, community-based multicenter cohort, (2) a large sample size with adequate power to provide conclusive results, (3) use of standardized methods to assess hormone levels, and (4) use of two well-validated frailty models providing internally consistent results. We acknowledge some limitations, including the response rate for participation at baseline, which was 41%. Although this is comparable to other large epidemiological studies, the prevalence of frailty at baseline might have been overestimated or underestimated through selection. Additionally, 435 men were lost to follow-up and therefore the true incidence of frailty has probably been underestimated. Because this would tend to bias the results toward the null, the reported strength of our associations is likely to be conservative. Finally, our analysis is based on the results of single hormone measurements that do not capture pulsatile hormone variation and could attenuate regression coefficients to the null through regression dilution bias.We showed significant longitudinal age-adjusted relationships between higher levels of IGF-1, IGFBP-3, and vitamin D and lower risks of worsening frailty in men. In unadjusted analyses, we also showed that higher levels of DHEA-S were associated with lower risk of worsening frailty. These robust findings from a large well-characterized community-based cohort enhance our understanding of the etiology of frailty and suggest potential for therapeutic interventions that could shape new treatment strategies and public health policies aimed at increasing health span, independence, and well-being in older age.


Flow cytometry data from the 24 transplanted participants in the high-dose immunosuppression and autologous stem cell transplantation for poor prognosis multiple sclerosis (HALT-MS) trial are presented to illustrate immune reconstitution out to 36 months in patients with aggressive RRMS treated with AHSCT and to highlight experimental challenges inherent in identifying biomarkers for relapse and long-term remission through 60 months follow-up. AHSCT induced changes in numbers of CD4 T cells and in the composition of CD4 and CD8 T cells that persisted through 36 months in participants who maintained disease remission through 60 months. However, changes in T cell phenotypes studied were unable to clearly discriminate durable remission from disease reactivation after AHSCT, possibly due to the small sample size, limited phenotypes evaluated in this real-time assay, and other limitations of the HALT-MS study population. Strategies and future opportunities for identifying biomarkers of clinical outcome to AHSCT in autoimmunity are also discussed.Autoimmunity represents a broad category of diseases that involve a variety of organ targets and distinct autoantigens. For patients with autoimmune diseases who fail to respond to approved disease-modifying treatments, autologous hematopoietic stem cell transplantation (AHSCT) after high-dose immunosuppressive therapy provides an alternative strategy. Although more than 100 studies have been published on AHSCT efficacy in autoimmunity, the mechanisms that confer long-term disease remission as opposed to continued deterioration or disease reactivation remain to be determined. In a phase II clinical trial, high-dose immunosuppressive therapy combined with autologous CD34 Autologous hematopoietic stem cell transplantation (AHSCT) therapy utilizes immunoablation and immune reconstitution from hematopoietic progenitors. For more than two decades, AHSCT has been studied as a therapeutic approach for severe autoimmunity, including multiple sclerosis (MS), systemic sclerosis (SSc), systemic lupus erythematosus (SLE), Crohn’s disease, type 1 diabetes (T1D), and rheumatoid arthritis (RA) . Mechanide novo autoreactive population, possibly reflecting a genetic predisposition to disease. In this perspective, we present data from the high-dose immunosuppression and autologous stem cell transplantation for poor prognosis multiple sclerosis (HALT-MS) trial to illustrate past and present approaches to address this question and discuss experimental challenges and strategies for identifying the biomarkers of clinical response to AHSCT in autoimmunity.Although more than 100 studies have been published, the mechanisms that confer long-term disease remission with AHSCT in autoimmunity, as opposed to limited short-term benefit and early disease recurrence, are not well understood. Restoration of regulatory immune networks may contribute to durable treatment; however, functional assessments of the reconstituted immune system compared to pretherapy profiles are needed to understand how AHSCT limits or controls autoreactive lymphocytes during and after repopulation. Currently, it is unclear whether relapse after AHSCT is driven by residual autoreactive memory cells that escaped depletion and are resistant to regulatory mechanisms in the renewed immune system or to re-emergence of a High-dose immunosuppression and autologous stem cell transplantation for poor prognosis MS was a phase II clinical trial conducted by the ITN that investigated the efficacy of AHSCT in treatment-resistant patients with relapsing-remitting multiple sclerosis (RRMS) . Twenty-n = 15–17) with individual lines for the seven participants who experienced disease reactivation at different times through 60 months follow-up to help illustrate the obstacles these variances impose on our biomarker efforts. We hypothesized that favorable changes in the balance of pro-inflammatory and regulatory/naive/hyporesponsive T cell phenotypes in reconstituted peripheral blood would be associated with long-term remission after AHSCT. Paired statistical comparisons pretherapy to posttherapy were restricted to the long-term remission group because of the sample size and heterogeneity of the group that experienced disease reactivation during the 60 months post-AHSCT follow-up.Here, we present flow cytometry data from HALT-MS to demonstrate the characteristics of immune reconstitution in RRMS patients through 36 months post-AHSCT and to highlight potential confounders that interfere with identification of biomarkers for relapse and long-term remission. Of the 24 transplanted participants in HALT-MS, 3 experienced clinical relapse, 2 showed disease progression by increased Expanded Disability Status Scale, and 2 had increased MRI through 60 months follow-up. Results are displayed as mean values for the long-term remission group  increased after their initial decline and remained significantly elevated at 36 months post-AHSCT, indicative of thymic renewal  and CD8 (CD28−CD57+ or PD-1+) T cells. However, T cell phenotypes that clearly discriminate disease reactivation from long-term remission post-AHSCT have not been identified in the immunophenotyping studies presented here or previously published for HALT-MS  has been reported in AHSCT trials in MS, SSc, SLE, and T1D   . Some ofSince the primary objective of AHSCT is to achieve durable remission of autoimmunity without immunosuppressive agents, a long-term follow-up period is required for the assessment of clinical and scientific goals. This provides researchers the opportunity to monitor the dynamic process of immune reconstitution for biomarker discovery. It also magnifies potential variances between biomarker studies as standardized schedules for specimen collection post-AHSCT were lacking. Guidelines for immune monitoring and biostorage of AHSCT-treated autoimmune patient specimens have been published to provide a consistent framework for future biomarker research . SpecimeSerial samples of whole blood, peripheral blood mononuclear cells (PBMCs), plasma, serum, saliva, and urine specimens can be readily obtained in sufficient volumes for biomarker studies of AHSCT in autoimmunity. In contrast, sequential sampling of disease-relevant tissues may not be possible or may be limited due to ethical constraints and the practicalities of trial conduct. Preanalytical variations can be introduced by sample types, timing, technique, and collection devise; handling and storage conditions, including stabilizing agents, temperature, duration, and freeze–thaw cycles; and documentation of specimen data . Since fMechanistic studies of AHSCT in autoimmunity have focused on disease-specific autoimmune parameters in the context of general immune reconstitution using immunophenotyping and transcriptional analyses. Despite rapidly evolving technologies and variation between cohorts, this global approach has revealed similar patterns of immune reconstitution and qualitative changes in PBMC in different autoimmune diseases , 18–20. de novo and if they are even relevant to disease. Reliable ex vivo assays for phenotyping and sorting disease-relevant central nervous system (CNS) antigen-reactive T cells for molecular assays pretherapy to posttherapy are highly desirable because they could determine whether functional differences of reconstituted T cells are associated with clinical response. However, validated assays for MS clinical trials that do not require in vitro manipulation are still in development, in part because CNS antigen-reactive T cells are rare in blood of MS patients, and disease-relevant CNS antigens need to be clarified. This approach could be used in other diseases where the autoantigen is known, and ex vivo tetramer reagents are available, such as in T1D  of response to AHSCT may be disease specific and require different assays. The prevailing view is that both B cells and T cells are important in SSc, SLE, and MS, whereas the role of B cells in T1D is not clear . Previous in T1D .de novo, and there was expansion of pre-existing CD8 clones through 12 months post-AHSCT  to better understand how AHSCT shapes adaptive immunity in the reconstituted immune system. CSF is the compartment in closest proximity to the CNS parenchyma that might reflect immune pathology in MS. The impact of AHSCT on TCR repertoire diversity was investigated during the HALT-MS trial, and distinct effects on circulating CD4 and CD8 T cells were identified. The majority of CD4 TCR clones arose st-AHSCT . Reconstst-AHSCT , 24, 25.Overwhelming amounts of mechanistic data can now easily be generated and integrated with relevant clinical data for hypothesis-based and unbiased biomarker discovery approaches. This presents a major challenge for determining the right data sets to include and the appropriate statistical models needed to address key scientific questions . DiffereBefore putative biomarkers that correlate with clinical response can help guide clinical practice, they must be validated and shown to be clinically meaningful. This is the biggest challenge for biomarker efforts because well-matched cohorts may not be available due to inconsistencies in trial designs and specimen collection  or in reHigh-dose immunosuppression and autologous stem cell transplantation for poor prognosis MS demonstrated that it is possible to achieve durable remission in patients with treatment-resistant RRMS using AHSCT therapy . We specThe success of the HALT-MS trial has provided the foundation for a clinical trial in the development by the National Institutes of Health and the ITN that will compare AHSCT with best available approved therapy in the treatment of RRMS. This trial presents a unique opportunity to follow-up on TCR repertoire and immunophenotyping studies from HALT-MS in a larger, controlled study. The primary mechanistic objective of the follow-up trial is to understand the mechanisms that distinguish AHSCT from the high-efficacy approved agents in the control arm. Quality specimens from peripheral blood and CSF will be interrogated using state-of-the-art technologies that become available and validated for analysis of primary end point outcomes to corroborate proposed and discover new, biomarkers of response to AHSCT compared to high-efficacy disease-modifying therapies. This knowledge will confirm the treatment rationale and help refine future protocols, so patients with aggressive RRMS can achieve durable remission in the absence of ongoing immunosuppression.In summary, HALT-MS uncovered a number of challenges for identifying biomarkers of clinical response to AHSCT, many of which can be avoided in future trials through thoughtful trial design, specimen collection, experimental planning, bioinformatics, and data sharing. To achieve this, the ITN brings together a multidisciplinary team of clinicians, regulatory officials, research scientists, and biostatisticians through partnerships between academia, government, industry, and other research consortia. Data sharing is available through ITN TrialShare,Clinical data from the HALT-MS participants have been reported previously  and are By using a stain-lyse method, peripheral blood cells shipped ambient overnight to the ITN Flow Cytometry Core at RPCI were stained with 5-color monoclonal antibody panels using anti-human CD3-PECy7, CD4-PERCP, CD4-APC, CD8-PERCP, CD31-FITC, CD45RA-APC, CD45RO-PE, CD27-FITC, CD28-APC, CD57-FITC, CD56-PE, CD19-PECy7 . Blinded samples were acquired on a Canto A flow cytometer (BD Biosciences), then gated, and analyzed using FlowJo Software (Tree Star Inc.).t-test was used to compare changes from baseline at 36 months within the durable remission group. Analyses were performed in SAS 9.4 , and graphics were plotted in R Version 3.4.1 .Data sets for these analyses are accessible through ITN Trial Share, a public website managed by the Immune Tolerance Network . This study was carried out in accordance with the recommendations of NIAID with written informed consent from all subjects. All subjects gave written informed consent in accordance with the Declaration of Helsinki. The protocol was approved by the by the IRB at each of the clinical sites.The HALT-MS study  was sponsored by NIAID and conducted by the ITN (ITN033AI) (LT contributed to concept development and experimental design. NL collected data. NL and TL helped with data analysis and visualization. KH interpreted the data and wrote the manuscript. All authors made contributions to the final manuscript prior to submission.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.


In patients with ST-segment elevation myocardial infarction (STEMI), successful primary percutaneous coronary intervention (PCI) was found to be useful in earlier restoration of TIMI flow 3. However, the incidence of left ventricular (LV) dilatation and remodelling after successful primary PCI is still high. We aimed to determine the independent predictors of LV remodelling after successful primary PCI for patients with first STEMI.We included 232 STEMI patients treated with primary PCI. Echocardiography was done on the day of PCI and after six months. LV remodelling was defined as ≥ 20% increase in the six-month left ventricular end-diastolic volume (LVEDV).In patients with remodelling, symptom-to-door and symptom-to-balloon times were significantly longer (p < 0.00001 for each), initial ejection fraction (EF) was significantly lower (p = 0.044), six-month LVEDV, left ventricular end-systolic volume (LVESV) and LVEDV increase were significantly higher, and EF was significantly lower (p < 0.00001 for each). Mean myocardial blush grade (MBG) was significantly lower in patients with remodelling (p < 0.00001). There was a significant positive correlation between LVEDV increase and both symptom-to-balloon time  and symptom-to-door time , and a significant negative correlation between LVEDV increase and MBG . Logistic regression showed that the independent predictors of LV remodelling were symptom-to-balloon time (p = 0.00068), symptom to door time (p = 0.0013) and MBG (p = 0.0057).Symptom-to-door time, symptom-to-balloon time and MBG were the only significant predictors of LV remodelling. ST-segment elevation myocardial infarction (STEMI) is one of the most important causes of death and disability around the world.2When compared with fibrinolytic therapy for STEMI patients, successful primary percutaneous coronary intervention (PCI) was found to be useful in earlier restoration of thrombolysis in myocardial infarction (TIMI) flow grade 3 flow in the infarctrelated artery, it limited the infarction size, and decreased heart failure and mortality rates.4Previous studies have searched for predictors of LV remodelling after primary PCI. Regional and global LV systolic dysfunction, severe LV diastolic abnormalities,This prospective study was done in the coronary care and cardiac catheterisation units of the Cardiology Department, Zagazig University. The study population consisted of 260 patients who were admitted with acute STEMI during the period between January 2012 and January 2015.The inclusion criteria were: confirmed acute STEMI, defined as the presence of typical chest pain that lasts for at least 20 minutes, and ST-segment elevation ≥ 0.1 mV in at least two contiguous leads;9Patients were excluded from our study in the presence of one or more of the following: previous history of coronary artery disease (CAD), myocardial infarction, or revascularisation; more than mild valvular stenosis or regurgitation; patients with left bundle branch block; and unsatisfactory echocardiographic images.We had a written informed consent from every patient. The study protocol was approved by the institutional review board of the Faculty of Medicine, Zagazig University A full history was taken and a complete clinical examination was done on every patient. The time of onset of chest pain (symptom time), the time of the patient’s arrival at the hospital (door time), and the time of first balloon inflation or stent deployment  were carefully recorded.Symptom-to-door time was defined as the interval between the appearance of symptoms and arrival at the hospital. Doorto- balloon time was defined as the interval between the arrival at hospital and the time of balloon inflation. Symptom-to-balloon time was defined as the interval between the onset of symptoms and the time of balloon inflation.10Complete standard 12-lead electrocardiography was carried out on each patient. Echocardiographic studies were performed on all patients using the GE VIVID E9 machine with 2.5-MHz transducers. The studies were performed by two operators unaware of each other’s measures and of the patients’ clinical and angiographic data. Views were taken while the patients were in the left lateral position.Left ventricular end-diastolic volume (LVEDV) and end-systolic volume (LVESV) were measured from the apical two-chamber and apical four-chamber views. Ejection fraction (EF) was calculated using the Simpson’s method.11 Echocardiography was done within 24 hours of admission, and was repeated after six months. LV remodelling was defined as ≥ 20% increase in the six-month LVEDV.5Primary PCI was performed on all patients within 12 hours of onset of symptoms by two expert interventionists; at least one met the criteria of individual operator level volume of the 2007 Clinical Competence Statement on Cardiac Interventional Procedures and its 2013 revision.TIMI flow and myocardial blush grade (MBG) were assessed by two expert angiographers unaware of each other’s results and of the patients’ other data. MBG was assessed according to the dye density score as follows: MBG 0 = no myocardial blush or contrast density, MBG 1 = minimal myocardial blush or contrast density, MBG 2 = moderate myocardial blush or contrast density but less than that obtained during angiography of a contralateral or ipsilateral non-infarctrelated coronary artery, MBG 3 = normal myocardial blush or contrast density, comparable with that obtained during angiography of a contralateral or ipsilateral non-infarctrelated coronary artery.13After discharge, all patients continued to receive medical treatment, including aspirin, clopidogrel, beta-blockers, statins, aldosterone antagonists and angiotensin converting enzyme inhibitors (ACEIs) or angiotensin receptors blockers (ARBs).8All data were analysed using the SPSS for windows package . Differences between the study groups were analysed using the χ2 and student’s t-tests. Correlations between different variables were investigated by Pearson correlation analysis. The logistic regression analysis was evaluated by the Hosmer–Lemes goodness-of-fit test. A p-value < 0.05 was regarded as being statistically significant.In order to assess the intra-observer variability, we repeated the measures offline for echocardiography and angiography in 30 patients within seven days of the first measure. The interand intra-observer variability were calculated by dividing the difference between the two sets of measurements by the mean of the two observations.Twenty-eight more patients were excluded from the initial study group . The remaining 232 patients  constituted the study group.LV remodelling was detected in 68 patients (29.3%). Patients were divided into two groups according to the presence or absence of LV remodelling.Regarding clinical and echocardiographic data, and as shown in Mean EF was significantly lower in patents with remodelling (p = 0.044). After six months, mean LVEDV, LVESV and percentage of LVEDV increase were significantly higher, and mean EF was significantly lower in patients with remodelling (p < 0.00001 for each). Mean symptom-to-door and symptomto- balloon times were significantly higher in patients with remodelling (p < 0.00001 for each).Regarding primary PCI data, and as shown in Logistic regression for the independent predictors of LV remodelling is shown in Inter- and intra-observer variability for different echocardiographic parameters ranged from 1.5 to 7.1%. For LVEDV, inter- and intra-observer variability were 5.2 ± 2.7 and 6.2 ± 3.4%, respectively. For MBG score, inter- and intraobserver variability were 2.3 ± 1.1 and 4.5 ± 2.4%, respectively.In our study, logistic regression analysis showed that the only significant independent predictors for the occurrence of LV remodelling were symptom-to-balloon time, symptom-to-door time and MBG.The great advantage of primary PCI over thrombolysis is the earlier and the more effective restoration of coronary flow. This in turn leads to fewer incidences of recurrent ischaemia, better LV function, and of course better clinical outcome of STEMI patients treated with primary PCI, compared to those treated with thrombolysis.However, even after successful restoration of blood flow in the infarct-related artery after STEMI, a considerable number of patients still suffer from LV dilatation and impairment in systolic function. Among 284 STEMI patients treated with primary PCI, Bolognese and colleagues recorded a 30% incidence of LV remodelling, defined as > 20% LVEDV increase.Primary PCI significantly improves blood flow in epicardial coronary arteries in STEMI patients. However, this improvement does not always include microvascular flow and myocardial perfusion. After restoration of blood flow in the occluded epicardial artery, some pathophysiological changes tend to occur and may contribute to the impairment in microcirculatory flow. These changes include infiltration of neutrophils, endothelial dysfunction, tissue oedema and microembolisation.14The relationship between microvascular dysfunction and LV function and outcome after primary PCI has been studied by many investigators. Poli and colleagues found that MBG score and ST-segment elevation recovery after successful primary PCI were associated with the degree of early and late recovery of LV function.15The ability of MBG score to predict survival rate was studied by Stone et al.Bolognese et al. found that microvascular dysfunction, as assessed by intracoronary myocardial contrast echo score index, was able to predict the occurrence of LV remodelling as well as unfavourable long-term outcome.18The value of time to primary PCI was studied by Soon and colleagues. They found that symptom-to-balloon not door-toballoon time was a significant independent predictor of shortand medium-term mortality rates and major adverse cardiac events.19Why do some STEMI patients, even after successfully performed primary PCI, have poor myocardial perfusion with MBG 0 or 1? In an attempt to answer this question, Prasad et al. studied the effect of prolonged ischaemia on MBG score after primary PCI. Their main finding was that delayed primary PCI was associated with greater injury to the microcirculation and impaired myocardial perfusion. They also found that patients presenting four hours after symptom onset had a higher incidence of MBG 0 and 1, compared to those presenting within two hours.20Several mechanisms may lead to impaired myocardial perfusion in patients with prolonged ischaemic time. These include endothelial dysfunction and damage, interstitial and cellular haemorrhage/oedema, formation of micro-thrombi within the micro-vessels, and an increase in thrombus organisation with time, which lessens its responsiveness to antiplatelet and anticoagulant therapies and increases the probability for distal macro- or micro-embolisation.22Earlier researchers found that many factors may influence the process of LV remodelling, such as patency of the infarctrelated artery,27In our study, which was a single-centre study, all our patients were treated in a similar way. This may explain why symptom-toballoon time, symptom-to-door time and MBG score were the only significant predictors for LV remodelling. Mean door-toballoon time was 46.1 ± 11.8 minutes in the whole study group and it did not differ significantly between the two groups. It also did not correlate with increase in LVEDV. The door-to-needle time was also fairly similar in the whole study group, probably since the study was conducted in a single centre with the same treatment strategy applied to all patients.The longer symptom-to-door time in the remodelling group made the symptom-to-balloon time significantly longer as well. This may have been caused by many factors, including lack of public awareness of the symptoms of STEMI and the importance of seeking medical help timeously, the small number of centres capable of performing primary PCI, the large distance between these centres and primary health centres, and the huge traffic problem in a developing country such as Egypt.Limitations of this study are that it was carried out in a single centre, and recording the time of onset of symptoms is totally subjective, which may make measuring of symptom-to-door time inaccurate.Our study showed that after successfully performed primary PCI for STEMI patients, symptom-to-door time, symptom-toballoon time and MBG were the only significant predictors of LV remodelling. Efforts must be made to reduce symptom-todoor time, including promoting health awareness of cardiac symptoms, educating primary healthcare providers, and improving the ambulance system.