The concurrent implementation of targeted (tPITC) and blanket provider-initiated testing and counselling (bPITC) is recommended by the World Health Organization (WHO) for HIV case-finding in generalized HIV epidemics. This study assessed the effectiveness of this intervention compared to symptom-based diagnostic HIV testing (DHT) in terms of HIV testing uptake, case detection and antiretroviral therapy (ART) enrollment among children and adolescents in Cameroon, where estimated HIV prevalence is relatively low at 3.7%.In three hospitals where DHT was the standard practice before, tPITC and bPITC were implemented by inviting HIV-positive parents in care at the ART clinics to have their biological children (6 weeks-19 years) tested for HIV (tPITC). Concurrently, at the outpatient departments, similarly-age children/adolescents were systematically offered HIV testing via accompanying parents/guardians. The mean monthly number of children tested for HIV, identified HIV-positive and ART-enrolled were used to compare the outcomes of different HIV testing strategies before and after the intervention.In comparing DHT to bPITC, there was a significant increase in the mean monthly number of children/adolescents tested for HIV , but with no significant increase in the mean monthly number of children/adolescents: testing HIV-positive  and ART- enrolled . In comparing DHT to tPITC, there was no significant difference in the mean monthly number of children/adolescents: tested for HIV ; tested HIV-positive , and ART-enrolled . When comparing DHT versus bPITC+tPITC, there was a significant increase in the mean monthly number of children/adolescents: tested for HIV , testing HIV-positive , and ART-enrolled .These findings suggest that concurrent implementation of bPITC+tPITC was more effective compared to DHT in terms of HIV testing uptake, case detection and ART enrolment. However, considering that DHT and bPITC had comparable outcomes with regards to case detection and ART enrolment, bPITC+tPITC may not be efficient. Thus, this finding does not support concurrent bPITC+tPITC implementation as recommended by WHO. Rather, continued DHT+tPITC could effectively and efficiently accelerate HIV case detection and ART coverage among children and adolescents in Cameroon and similar low-prevalence context. Over the past decade, remarkable progress has been made in HIV care and treatment for people living with HIV (PLHIV). However, children and adolescents have not had proportionate benefits from life-saving antiretroviral therapy (ART). In 2017, global ART coverage for children less than 15 years old was 52%, compared to 59% in adults [Cameroon is a WCAR country with an estimated relatively low HIV prevalence of 3.7% and 470 000 PLHIV, including 40 000 children and 31 000 adolescents [Though multiple factors account for current gaps in pediatric and adolescent ART coverage, poorly-implemented and/or ineffective case-finding strategies are major barriers to ART roll-out in this population ,4,5. To The WHO recommends that in the context of a generalized HIV epidemic, both bPITC and tPITC should be implemented to enhance HIV case-finding and prompt treatment among infants, children and adolescents , 7, 8, 9Previous studies have reported on outcome of singular bPITC ,15,16 orThis was a quasi-experimental pre-and post-intervention study comparing the effectiveness of concurrent implementation of bPITC and tPITC with the symptom-based diagnostic HIV testing (DHT) in terms of HIV testing uptake, case detection and ART initiation at three healthcare facilities in Cameroon. Prior to study implementation (pre-intervention period), tPITC was not implemented at the ART clinics of the study hospitals and DHT was the prevailing HIV testing clinical practice implemented at the outpatient departments (OPDs) of these hospitals. In the post-intervention (post-intervention period), tPITC and bPITC were introduced and concurrently implemented in these health facilities (tPITC at the ART clinics and bPITC at the OPDs).The study was implemented for a period of 6 months from July through December 2015 at Limbe Regional Hospital (LRH) and from June through November 2016 for Ndop and Abong-Mbang District Hospitals. These periods constituted the post-intervention period of the study. The pre-intervention period corresponded to 6 months prior to study initiation at each facility. Hence, the pre-intervention period was from January through June 2015 for Limbe and from December 2015 through May 2016 for the other two sites.For both the pre and post-intervention periods, eligible participants were children and adolescents aged 6 weeks-19 years with unknown HIV status. In the pre-intervention period, the study population were children/adolescents presenting at the outpatient department (OPD) at the three hospitals with clinical manifestations of HIV/AIDS. In the post-intervention period, the study population comprised two sub-groups of children/adolescents: 1) biological children/adolescents of HIV-positive parents enrolled in HIV care at ART clinics of the study hospitals and 2) all children/adolescents who were seen for any medical reason at the OPDs of those hospitals.This study was part of the “Active Search for Pediatric HIV/AIDS” (ASPA), a larger study aimed at comparing the acceptability, feasibility and effectiveness of tPITC versus bPITC in Cameroon . This laBefore this study, there was no systematic HIV testing for children through their parents (routine index-case testing or tPITC) in care in the three hospitals and no data on this strategy were available at these sites. Likewise, children/adolescents visiting the outpatient departments (OPDs) for consultations were not systematically offer HIV testing. Thus, before the study, there was no implementation of tPITC at the ART clinics nor bPITC at OPDs of the three health facilities. Instead, outpatient HIV testing for children/adolescents at the OPDs was essentially symptom-based and for diagnosis-of-illness purposes. Care providers offered HIV testing to children/adolescents presenting with signs and symptoms suggestive of HIV infection. Thus, the prevailing standard clinical practice for HIV testing during the pre-intervention period was limited only to the diagnostic HIV testing (DHT) .Prior to implementation and data collection, the study provided the following inputs to the study sites: staff training on tPITC and bPITC implementation, provision of HIV testing kits (to eliminate stock-outs during the study), standardized data collection and monitoring tools , and additional human resources to support study implementation . SpecifiWe implemented tPITC at ART clinics by counseling HIV-positive parents in care to have their biological children of unknown HIV status tested for HIV. At the ART clinics, current patients visiting the clinic for drug refills or new patients referred for enrollment in HIV care were approached and counselled by a trained counsellor for enrolment in the study. Consenting eligible parents were invited to enroll their biological children in the study for HIV testing, either in the hospital or at home/community. At the OPDs (bPITC site), all parents/guardians accompanying child(ren) for consultation were also approached and counselled by a trained counsellor for enrolment in the study. Consenting eligible parents were invited to enroll child(ren) in the study for HIV testing. At both ART clinics and OPDs, children/adolescents of consenting parents were study-enrolled, tested for HIV and positive cases initiated on ART as described below.For children below 18 months of age, blood specimen was collected using dried blot spot (DBS) kits and shipped to the reference laboratories for HIV testing by PCR techniques. The reference laboratories were the Cameroon Baptist Convention Reference Laboratory in Mutengue (South West Region) for samples from the Limbe Regional Hospital, the Chantal Biya Foundation Reference Laboratory in Yaoundé (Centre Region) for samples from Abong-Mbang District Hospital and the Bamenda Regional Hospital Reference Laboratory (North West) for samples from Ndop District Hospital. For children 18 months and older, they were tested either in the hospital or in the community at the convenience of the parents. In any either case, HIV testing was done using two rapid tests (RT) for HIV antibody namely Alere Determine HIV-1/2  for RT1 and Oraquick  for RT2. The HIV antibody rapid tests were conducted following the national HIV testing algorithm as described in the Cameroon’s national guideline on HIV prevention and management : for chiWe had no contact with participants for this retrospective phase of the study. Rather, we collected retrospectively routine data on DHT implementation from OPDs, laboratory and ART clinic standardized registers. Trained data clerks used a structured form see  to extraData on tPITC and bPITC implementation and respective outcomes were collected prospectively. For that purpose, trained data clerks used structured forms  was measured using the arithmetic monthly mean of the following variables: 1) number of children/adolescents tested for HIV (HIV testing uptake), 2) number of children/adolescents testing HIV-positive (HIV case detection) and 3) number of HIV-positive children/adolescents enrolled on ART (ART enrollment). Data were entered into a Microsoft Excel sheet and analyzed using STATA 2013 . We calculated the arithmetic means of the aforementioned variables. The number of values for each variable was 6, representing the number of months of implementation of the testing interventions. When applicable, we reported the values of these means as monthly outcomes for the pre-and post-intervention periods. Using Student’s t-test at 5% significant level, we compared these means before and after the intervention to assess for differences.For the retrospective study, inform consent from participants was not required as we had no direct contact neither with patients nor with their medical records. More so, we did not collect personal identifiers information for patients, but rather numerical data from hospital registers. For the post-intervention period, participation in the (larger) study was voluntary for both parents and children. Only parents who consented were enrolled and assent was requested from adolescents above 11 years of age. Consent from parents was obtained via signed written consent form. Likewise, assent for adolescents over the age of 11 was obtained through a signed written assent form. The ASPA study received ethical approval from the Cameroon National Ethics Committee (CNERSH), the Ludwig-Maximilians-Universität, Munich (Germany) and the Albert Einstein College of Medicine  . In addiA total of 5,891 and 4,643 children/adolescents were seen at the OPDs of the three hospitals during the pre-and post-intervention periods, respectively. The mean monthly number of children/adolescents tested for HIV for the three hospitals combined was 223.0 and 348.3 (p = 0.0073) with DHT and bPITC, respectively. The mean monthly number of HIV-positive children/adolescents identified was 10.5 and 9.6 (p = 0.7574) for DHT and bPITC, respectively. The mean monthly number of HIV-positive children/adolescents enrolled on ART was 7.3 and 6.3 (p = 0.5819) for DHT and bPITC, respectively .During the post-intervention period, we identified 2,829 children/adolescents eligible for HIV testing through index HIV-positive parents at ART clinics of the 3 hospitals. Of these 2,829 children/adolescents, 1,163 were tested for HIV, 64 found HIV positive and 35 enrolled on ART . The maiDuring the post-intervention period, a total 7,472 eligible children/adolescents were identified for HIV testing in the 3 hospitals including: 2,829 from ART clinics and 4,643 from OPDs. This represents a 27% increase compared to the 5,891 children/adolescents who consulted at the outpatient departments in the pre-intervention period. The mean monthly number of children/adolescents tested for HIV was 223.0 and 542.2 during the pre-and post-intervention periods, respectively. This difference was statistically significant (p<0.0001) and represented an increase of 143% in HIV testing uptake in the three hospitals combined .The mean monthly number of HIV-positive children/adolescents identified was 10.5 and 20.3 during the pre-and post-intervention period, respectively. This difference was statistically significant (p = 0.0256) and represented a 94% increase of HIV case-detection .The mean monthly number of HIV-positive children/adolescents enrolled on ART was 7.3 and 12.2 during the pre-and post-intervention periods, respectively (p = 0.0388), and representing a 66% increase in ART enrolment for the three hospitals combined .Our study provides previously limited data on the effectiveness of single and concurrent implementation of bPITC and tPITC vs. symptom-based diagnostic HIV testing (DHT) in terms of HIV testing, HIV case detection and ART enrolment among children and adolescents. Implementation of bPITC alone resulted in a 1.5-fold increase in HIV testing uptake compared to DHT. However, bPITC did not improve HIV case detection  nor ART enrolment . This could be explained by the fact that during the pre-intervention period, most children tested for HIV were symptomatic; thus, there was a high pre-test likelihood of HIV case-detection given the clinical status of children being tested. This finding does not support bPITC implementation as recommended by WHO. It also suggests that bPITC implementation may not be effective in relatively low HIV prevalence settings such as Cameroon and much of the rest of the WCAR. Previous studies , 21 haveDuring the post-intervention period, the concurrent implementation of tPITC and bPITC resulted in significant increases in HIV testing uptake , case detection  and ART enrolment . However, as indicated above, bPITC implementation had comparable case detection and ART enrolment with DHT. Similarly, tPITC had comparable outcomes to DHT in terms of HIV testing uptake, case detection and ART enrolment. Thus, the significant increase observed in HIV testing uptake, case detection and ART enrolment was attributable to the effect of both bPITC and tPITC. However, considering that bPITC had comparable outcomes to DHT with regards to case detection and ART enrolment, the concurrent implementation of bPITC+tPITC may not be efficient in low HIV prevalence settings.It’s noteworthy mentioning that in a previous article, we demonstrated the superiority of tPITC over bPITC in terms of case detection timeliness among children and adolescents . SimilarOur study found that compared to DHT, concurrent implementation of bPITC and tPITC was effective in increasing HIV testing uptake, case detection and ART enrolment among children 6 weeks to 19 years of age. However, compared to DHT, bPITC alone was effective in increasing HIV testing uptake, but did not demonstrate superiority with respect to case detection and ART enrolment. These findings do not support the concurrent implementation of bPITC and tPITC as recommended by WHO from 2010 to date , 8,9 andThe WHO declares that “efforts in the global research agenda on pediatric HIV must be focused on generating targeted evidence that improves HIV programme implementation through a better understanding of what works for infants and children” . Our stuOur study however has some limitations. We did not assess the effectiveness of bPITC  in other potentially high yield HIV case detection entry points such as TB clinics, malnutrition units and inpatient wards. Thus, our conclusions with regards to the outcomes of bPITC are limited to a single-entry point, which is the outpatient department (OPD). This limitation may be addressed by further studies. In the interim, the utility of bPITC  in these potentially high yield service delivery points should be continued as per WHO recommendations. We had limited control over the quality of the retrospective data collected in the pre-intervention period. Thus, our results may have been affected by validity threats inherent to retrospective studies . AdditioThat notwithstanding, our study could have been affected by the seasonality bias resulting from the natural fluctuation in the number of children visiting the hospitals over time. However, our results show that fewer children were seen at the OPDs during the post-intervention period . Thus, tGlobally, children and adolescents living with HIV are at risk of significant morbidity and mortality if left undiagnosed and untreated. Ironically, WCAR’s low HIV-prevalence countries are lagging behind high-HIV prevalence Eastern/southern African countries in ART coverage for children and adolescents. Poor ART coverage for these sub-populations will not appreciably improve without increased case-detection. However, it is clear that differentiated approaches need to be tailored to the context, including HIV prevalence and pre-test likelihood of HIV infection. These tailored approaches are needed not only to increase yield, but also for efficient use of already-limited and scarce resources.For both effectiveness and efficiency reasons, we recommend continued symptom-based HIV testing combined with scale-up of tPITC approaches for Cameroon and potentially other low HIV prevalence countries such as in West and Central Africa Region. For higher HIV prevalence countries such as in Eastern/southern Africa Region, we recommend further studies to ascertain the comparative effectiveness of DHT vs bPITC as well as the concurrent implementation of bPITC and tPITC. This evidence is needed to guide the tailoring testing and treatment approaches consistent with settings and subpopulations characteristics. Thus, ensuring that the agenda to End AIDs by 2030 will leave no children behind regardless of where they live.S1 Text(DOCX)Click here for additional data file.S2 Text(DOCX)Click here for additional data file.S1 Table(DOCX)Click here for additional data file.S1 Dataset(XLSX)Click here for additional data file.


Objective: Although various short forms of Zarit Burden Interview (ZBI) have been developed, there is a lack of standard psychometric testing and comparison among them. The study aims to examine the psychometric properties of ten short versions of the most frequently used ZBI among a sample of schizophrenia caregivers and to find the one with the best performance.Methods: Cross-sectional door-to-door survey of ZBI-22 and a series of validated instrument data from 327 family caregivers of schizophrenia patients in a Chinese rural community were conducted from October 2015 to January 2016. Reliability was assessed using McDonald's omega coefficient (ω). Validity including concurrent validity, known group's validity, and criterion validity were assessed by Spearman correlations and Mann-Whitney U tests. Overall discrimination ability was evaluated using the area under the receiver operating characteristic curve (AUC).Results: Reliability was generally good for all short forms (ω = 0.69–0.84), except for the Gort ZBI-4 (ω = 0.58), which is acceptable considering its small item numbers. Concurrent validity was good across all various ZBI forms with significant negative correlations with patient's function , as well as significant positive correlations with caregiver's depression , and anxiety symptoms . Known groups' validity  showed inconsistent results among various short forms. Criterion validity was generally good for all short forms with significant positive correlations with Family Burden Interview Schedule , except for the Higginson ZBI-1. Discriminative ability was also good for all short forms (AUC range: 0.85–0.99), with various cutpoints proposed. Among all ten short forms, the Ballesteros ZBI-12 and the Gort ZBI-7 outperformed others with almost equally good performance in comprehensive psychometric testing.Conclusions: This study provides support for the reliability, validity, and discriminative ability of the ten various short forms of ZBI for use among schizophrenia family caregivers, with the Ballesteros ZBI-12 and the Gort ZBI-7 endorsed as the best ones. The Zarit Burden Interview (ZBI) is one of the oldest and most commonly used instruments for assessing caregiving burden at an international level , and thus used non-parametric testing in the following validity testing.Secondly, validity of the scales was tested and compared for the following three tests: concurrent validity, known group's validity and criterion validity. We first tested the normal distribution of FBIS score, GAF score, and GAD score using sktest and found none of them fit normal distribution , as well as significant positive correlations with caregiver's depression (PHQ-9 score), and anxiety symptoms (GAD-7 score)  was also computed to assess how much the variance of the gold standard can be explained by respective short forms.Criterion-related validity were measured by Spearman correlations between short-form total scores and the gold standard—FBIS total scores, with an expected correlation coefficient of above 0.7  curve  and R 3.5.1.Table Reliability and validity results were shown in Table r = −0.34 to −0.48), and significant positive correlations with PHQ-9 score (r = 0.49–0.65) and GAD-7 score (r = 0.45–0.58). Among all the various ZBI forms, the Ballesteros ZBI-12 showed the highest correlations with the scores of GAF, PHQ-9, and GAD-7. A subsequent Fisher r-to-Z test found no statistical differences among those correlations of various short forms, indicating that all short forms performed equally well in concurrent validity.External concurrent validity was in general accordance with expectations and similar across the various ZBI forms, with significant negative correlations with GAF score  except for Higginson ZBI-1 (r = 0.57), which may be explained by the only one item in Higginson ZBI-1. Among all short forms, Gort ZBI-7 showed the highest criterion-related validity (r = 0.75), followed closely by Ballesteros ZBI-12 (r = 0.74) and Higginson ZBI-6 (r = 0.73).For criterion-related validity, all ZBI short forms showed significant high correlations with the FBIS criterion  among family caregivers of people with schizophrenia. We found general support for the psychometric testing of all ten short forms. While previous studies proposed either the Bedard 12-item ZBI . On the one hand, it reflects the property of the McDonald's omega coefficient that is sensitive to the number of items and decreases with reduced items Sijtsma, . On the Second, while all ten ZBI short forms uniformly exhibited desirable concurrent validity correlations and criterion-related validity, there is inconsistency in the result of known groups' validity. Although caregiver burden has been widely proven to be positively associated with physical disease in the literature (Sethabouppha and Kane, Third, our findings found the Ballesteros 12-item and the Gort ZBI-7 outperformed other short forms with almost equally good performance in psychometric testing. This finding partly supports Lin's (Lin et al., Our fourth finding is cut-off values ranging from 4 to 17 for the various short forms of ZBI relative to that of the ZBI-22. The results were slightly different from those previously identified among family caregivers of people with cancer, brain injury, and dementia (Higginson et al., The study falls short in several aspects. First, this is a cross-sectional study with no information on short forms' responsiveness to change, which is important for psychometric property in intervention and longitudinal studies (Kirshner and Guyatt, In conclusion, our observations provide initial support for the psychometric properties of various ZBI short forms for use among family caregivers of people with schizophrenia. The Ballesteros ZBI-12 and the Gort ZBI-7 showed the best performance in reliability and validity, which paves the way for future studies to further utilize and validate the scales.The raw data supporting the conclusions of this manuscript will be made available by the authors, without undue reservation, to any qualified researcher.YY and SX contributed to the conception and design of the study. YY, ZL, WZ, XC, MH, and XZ contributed to the research conduction and data collection. YY and ZL contributed to data analyses and interpretation, analysis tools or data. YY drafted the article while ZL, WZ, XC, MH, XZ, and SX critically appraised it and revised it. All authors approved the final version of manuscript for submission and publication.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.


Rilpivirine, a second-generation non-nucleoside reverse transcriptase inhibitor (NNRTI), is included as an option in first-line antiretroviral therapy (ART) for antiretroviral-naïve individuals in treatment guidelines in high-income countries, including the United States and many European countries. Rilpivirine is available in a single-tablet fixed-dose combination, has a favourable tolerability profile and is of relatively low cost. However, rilpivirine has reduced efficacy in patients commencing ART at high viral loads. Therefore, baseline viral load testing is required before commencing rilpivirine, and it is not recommended for patients commencing therapy with a viral load greater than 100 000 copies/mL. Rilpivirine is not included in the treatment regimens recommended by the World Health Organization (WHO), which form the basis of treatment guidelines in many lower- and middle-income countries. Some patients commencing standard first-line regimens experience treatment-limiting toxicity. A low-cost rilpivirine-containing fixed-dose combination would potentially be a useful addition to treatment options available in South Africa and other countries in the region, for patients who do not tolerate standard first-line ART. In this article, we explore the utility of rilpivirine as an option in ART in South Africa and the region in the context of current public-sector regimens. We consider what role rilpivirine might play if first-line therapy moves to a dolutegravir-based regimen, as has already happened in some lower- and middle-income countries, including Botswana, Kenya and Brazil. Finally, we describe emerging evidence for rilpivirine in the prevention of HIV transmission. Rilpivirine has not been included in the treatment regimens recommended by the World Health Organization (WHO), which form the basis of treatment guidelines in many lower- and middle-income countries. South Africa has the largest antiretroviral programme in the world, and purchases antiretrovirals in quantities similar to both the President’s Emergency Program for AIDS Relief (PEPFAR) and the Global Fund. A low-cost, well-tolerated, single-tablet regimen would potentially be a useful addition to treatment options available in South Africa and other countries in the region.Rilpivirine, a second-generation non-nucleoside reverse transcriptase inhibitor (NNRTI), is currently approved for the treatment of HIV-1 infection in more than 80 countries around the world. It is included as an option in first-line antiretroviral therapy (ART) for antiretroviral-naïve individuals in treatment guidelines in high-income countries, including the United States and many European countries.The suitability of any antiretroviral agent for use within large-scale treatment programmes is determined by a number of factors. These include efficacy; tolerability profile, preferably with no need for laboratory monitoring for safety issues; interactions with commonly prescribed drugs, especially those used to treat coinfections such as tuberculosis and hepatitis viruses; convenience and availability of fixed-dose combinations; availability of paediatric formulations; safety in pregnancy; and affordability.In this article, we explore the utility of rilpivirine as an option in ART in South Africa and the region, in the context of current public-sector regimens. We consider what role rilpivirine might play if first-line therapy moves to a dolutegravir-based regimen, as has already happened in some lower- and middle-income countries, including Botswana, Kenya and Brazil. Finally, we describe emerging evidence for rilpivirine in the prevention of HIV transmission.5 in the phase 3 ECHO6 and THRIVE7 studies 11 and the single-tablet regimen (STaR) study.12 In all of these studies, with the exception of the phase 2b dose-finding study, rilpivirine was associated with fewer adverse events leading to treatment discontinuation than efavirenz .The efficacy and tolerability of rilpivirine compared to efavirenz in antiretroviral-naïve individuals was explored in a phase 2b dose-finding study,5 The study was extended to follow participants out to 192 weeks from 96 weeks and found similar viral suppression and immunological efficacy across the rilpivirine and efavirenz arms, and the rilpivirine 25 mg dose was taken forward into phase 3.The phase 2b study explored three different doses of rilpivirine compared to efavirenz 600 mg. The rilpivirine doses explored were 25 mg, 75 mg and 150 mg, and the study was powered to detect a dose response across the arms at a 5% significance level.13 and 96 weeks.10 In the ECHO and THRIVE studies, 23/686 (3%) of participants taking rilpivirine discontinued because of an adverse event, versus 52/682 (8%) taking efavirenz.13 In a systematic review of randomised clinical trials, comparing safety and neuropsychiatric adverse events of efavirenz with other agents, participants had double the risk of discontinuation because of adverse drug reactions with efavirenz-containing ART regimens than with rilpivirine-containing regimens .14 Side effects of rilpivirine were uncommon; the two most common side effects were headache in 2% and insomnia in 2% of participants.15The ECHO and THRIVE studies demonstrated non-inferior efficacy of rilpivirine compared to efavirenz overall. However, in these studies, which compared rilpivirine 25 mg with efavirenz 600 mg, both in combination with two nucleoside reverse transcriptase inhibitors (NRTIs), rates of virological failure and emergence of viral resistance were higher in individuals with high baseline viral loads (> 100 000 copies/mL) receiving rilpivirine than efavirenz at both 48or > 100 000 copies/mL) and demonstrated superiority of the rilpivirine arm at weeks 48 and 96 overall at viral loads below 100 000 copies/mL .15In the STaR study, both rilpivirine and efavirenz were administered in combination with tenofovir disoproxil fumarate (TDF) and emtricitabine (FTC) as single-tablet regimens. STaR stratified participants at randomisation according to their baseline viral load (≤ 16The switching at low HIV-1 RNA into fixed-dose combinations (SALIF) study demonstrated non-inferior efficacy of rilpivirine (RPV)/TDF/FTC in maintaining virological suppression at 48 weeks compared to efavirenz (EFV)/TDF/FTC (both administered as a single tablet regimen [STR]) in people living with HIV who were virologically suppressed on a NNRTI-based regimen prior to randomisation. In the SALIF study, there were more discontinuations and treatment-limiting adverse events in the rilpivirine arm. This most likely reflects the effect of being switched to a new rilpivirine-containing regimen, as opposed to continuing on an efavirenz-based regimen .17 These results were similar to those of other observational cohorts assessing switches to the STR.20Observational data from the Swiss HIV cohort followed up patients who were initiated on or switched to the RPV/TDF/FTC STR for two years. The main reasons for switches were for regimen simplification or efavirenz-related neuropsychiatric adverse events. The study population were mainly antiretroviral-experienced and virologically suppressed. At 24 months, 96% of treatment-experienced and 100% of treatment-naïve patients remained virologically suppressed. Among those who were switched because of neuropsychiatric adverse events, 78.3% experienced improvement at 12 months.21 Rilpivirine may therefore be a useful option for patients needing to switch for tolerability issues, especially those relating to neuropsychiatric adverse events.In summary, rilpivirine has lower efficacy than efavirenz in patients with high viral loads at ART initiation. This limits the usefulness of rilpivirine-based regimens in first-line ART in resource-constrained settings. Most large programmes in lower- and middle-income countries do not routinely quantify viral load at baseline, and adding this test in large programmes would add considerable treatment costs. However, switch studies of virologically suppressed patients have shown good efficacy of rilpivirine in maintaining suppression.22Rilpivirine is mainly metabolised by cytochrome P450 3A4, rendering it vulnerable to the effects of drugs that are cytochrome P450 3A4 inhibitors or inducers. Its solubility and therefore absorption are pH dependent, requiring a low pH. Because of this, rilpivirine cannot be co-administered with proton pump inhibitors, and when prescribed with histamine-2 receptor antagonists and antacids, doses need to be separated to allow rilpivirine absorption.23 putting patients at risk of virological failure. There is a similar interaction with rifabutin.22 This means that all patients on rilpivirine who develop rifamycin-sensitive tuberculosis would need to be switched to alternative ART. This adds to programmatic complexity, as well posing a risk to patients who may be switched to a less well-tolerated regimen, potentially risking virological failure. However, this is not a problem unique to rilpivirine, as many ARVs require either a treatment change (such as atazanavir) or a change in dose (such as ritonavir-boosted lopinavir and dolutegravir) when co-administered with rifampicin. With the move to ‘test and treat’ resulting in earlier ART initiation at higher CD4+ counts, and with increased rollout of various TB prevention therapies, this may become less of an issue as incident TB rates are likely to decline.Rilpivirine cannot be administered with rifampicin-containing regimens, which are still the mainstay of tuberculosis management in many lower- and middle-income countries where the burden of tuberculosis is the highest. Rifampicin may reduce the rilpivirine concentrations substantially,25 Unfortunately, none of the rilpivirine fixed-dose combinations, or formulations of either drug containing TAF, are currently available in South Africa.Fixed-dose combinations are preferred in large programmes, not only for their benefits in terms of adherence but also for the benefits they offer in terms of simplicity of supply chain, distribution, stock management, storage and prescription. Internationally, both rilpivirine and efavirenz are available co-formulated with either TDF and FTC, or tenofovir alafenamide (TAF) and FTC. TAF is a prodrug of tenofovir, which is potentially associated with less bone and renal toxicity than TDF because of lower plasma tenofovir exposure.Currently, there are no specific paediatric formulations of rilpivirine available and the adult formulation can only be used in children from 12 years and weighing 35 kg or more. Where possible, within large-scale programmes, harmonisation of adult and paediatric regimens is preferred. This is not currently possible with rilpivirine.26 Rilpivirine concentrations are reduced during pregnancy, especially during the third trimester,27 as is seen with many other antiretrovirals. In two studies that investigated the pharmacokinetic characteristics of rilpivirine in pregnant women, nearly all the women had rilpivirine concentrations above the IC90 . This suggests that no dose adjustment is required despite the reduced rilpivirine exposures during pregnancy. In both studies, the women maintained virological suppression and the infants were not HIV-infected.27Pregnancy can affect rilpivirine concentrations by its effect on cardiac output, protein binding, volume of distribution and cytochrome P450 3A4 activity.28 No specific teratogenic concerns have emerged to date.The Antiretroviral Pregnancy Registry (APR) still has relatively low numbers of rilpivirine-exposed pregnancies. For first trimester exposures to rilpivirine, there was one birth defect in 202 pregnancies ; for second trimester exposures, there were three birth defects in 247 pregnancies .29 Efavirenz is unlikely to decrease in price any further and is therefore unlikely to achieve price parity with rilpivirine. This does not include any costs related to managing side effects related to the use of efavirenz, which is associated with higher adverse event-related discontinuations compared to rilpivirine across several studies.14In South Africa, rilpivirine currently has a ‘single exit’ price of around ZAR 50.00 (around US $3.70) for a 30-day supply versus ZAR 175.00 (around US $13.00) for efavirenz.30 Benefits of ART initiation are modest for those with earlier stage disease, and need to be weighed up against the potential harms, which include side effects and toxicity from ART when initiated in asymptomatic patients at high viral loads.Internationally, treatment guidelines have moved to recommending ART initiation irrespective of WHO clinical stage or CD4+ count.14 Notably, most of the studies included were conducted in predominantly white populations. Black Africans have a much higher prevalence of efavirenz slow metaboliser genotypes than white people (17% vs. 3% in South Africa),31 which may result in more frequent efavirenz-related neuropsychiatric adverse events.A systematic review including 42 randomised controlled trials found that the relative risk for discontinuations because of adverse events was higher for efavirenz compared to most other first-line options, including low-dose efavirenz (400 mg), rilpivirine, TDF, atazanavir and maraviroc, and that neuropsychiatric adverse events were common with efavirenz.32Efavirenz is superior to rilpivirine for programmatic use in a standard first-line ART regimen because it has higher virological efficacy at high viral loads, is available in fixed-dose combination formulations, can be prescribed with rifampicin and is safe in pregnancy. Rilpivirine cannot be prescribed with rifamycin-containing TB treatment. Although rilpivirine is cheap, it has reduced efficacy at high baseline viral loads and cannot therefore be used for first-line therapy without pre-ART initiation viral loads. Pre-ART viral loads are not routinely performed in southern African ART programmes and would considerably increase total cost to the healthcare system of the first-line regimen. In addition, data on rilpivirine use in pregnancy are limited and the reduction in rilpivirine exposure during the third trimester of pregnancy is concerning.8 The only other alternative in current guidelines for patients with high CD4+ counts is to initiate ritonavir-boosted lopinavir. As ritonavir-boosted lopinavir is used in second-line therapy, this limits future treatment options. As rilpivirine has better tolerability than efavirenz,14 a rilpivirine-based regimen would be a very useful alternative for patients with contraindications to efavirenz or treatment-limiting toxicity once initiated on efavirenz-based ART.However, for patients with a contraindication to efavirenz (e.g. history of psychosis) or who experience severe neuropsychiatric side effects on efavirenz, alternatives are currently limited. Nevirapine cannot be prescribed for women initiating ART with CD4+ counts above 250 cells/µL or men initiating ART with CD4+ counts above 400 cells/µL because of the risk of severe hepatotoxicity. In addition, nevirapine is associated with a higher frequency of severe adverse events, particularly treatment discontinuations, than efavirenz.34 In these studies, dolutegravir’s tolerability is likely to have contributed to the superior efficacy demonstrated. The main dolutegravir-related treatment-emergent adverse event reported in these studies was insomnia.34 Dolutegravir was found to be protective of discontinuations because of adverse events in a network meta-analysis that included 34 032 patients on first-line ART.35 Dolutegravir was also shown to have superior efficacy to both efavirenz and rilpivirine in the network meta-analysis.35Dolutegravir is newly included in current WHO guidelines as a recommendation for first-line ART and is starting to be rolled out across several lower- and middle-income countries. Dolutegravir has demonstrated robustness with a formidable barrier to resistance, good tolerability and superiority to both efavirenz and ritonavir-boosted lopinavir in clinical trials, in both antiretroviral-naïve and experienced patients.39 This has been seen with other integrase inhibitors and has been postulated as a possible class effect.43 More recently, data have suggested44 that dolutegravir may also be associated with weight gain in a number of cohorts as well as clinical studies. Potentially, rilpivirine could be used in people living with HIV who experience intolerance to dolutegravir as the transition to dolutegravir-based first-line ART rolls out.Because of the relatively small number of carefully selected participants included in registrational studies of newer antiretrovirals, more information regarding the safety profile may emerge only after registration, once the use of the antiretroviral becomes more widespread. Since dolutegravir’s approval, observational cohorts have reported neuropsychiatric adverse events, including depression, anxiety and suicidal ideation in patients receiving dolutegravir.45 If confirmed, this signal will raise a dilemma regarding the use of dolutegravir in women at risk of falling pregnant.Furthermore, a prospective study was set up in Botswana to quantify the incidence of neural tube defects with efavirenz exposure. This cohort also considers other birth outcomes and includes a number of patients on dolutegravir. It recently showed a worrying signal of increased incidence of neural tube defects with periconception use of dolutegravir.46 The SWORD studies randomised virologically suppressed participants with no history of virological failure to continue their current ART regimen or switch to dolutegravir and rilpivirine. Switching to the dual therapy regimen was found to be non-inferior to continuing the initial regimen over 48 weeks. This is despite the inherent bias of the switch study design against the drug being studied, where switching may result in adverse events that could result in virological failure because of non-adherence. In addition, observational data from several cohorts have demonstrated the efficacy of this regimen in achieving and maintaining virological suppression in patients with varying degrees of antiretroviral experience.49 A fixed-dose combination of rilpivirine and dolutegravir was recently approved by the Food and Drug Administration (FDA),50 based on the results of the SWORD studies. However, the inability to co-administer with rifamycin-containing TB treatment limits the usefulness of this coformulation in lower- and middle-income settings with high TB burdens.Recent data from the SWORD 1 and 2 studies of dolutegravir in combination with rilpivirine suggest that this dual therapy regimen may be effective maintenance regimens in virologically suppressed patients.51 Further studies, such as first long-acting injectable regimen (FLAIR) and ART as long-acting suppression (ATLAS), are currently underway to evaluate this dual therapy injectable regimen. However, there is still significant research needed before this regimen could be considered for programmatic use in lower- and middle-income countries. This would need to include data on TB co-infected and pregnant patients.The combination of long-acting rilpivirine and the integrase inhibitor cabotegravir is being studied in an injectable therapy for the treatment and prevention of HIV-1 infection. The phase 2b LATTE 2 study randomised patients to oral cabotegravir plus abacavir plus lamivudine and long-acting cabotegravir plus rilpivirine injected 4 weekly, and found that the injectable dual therapy regimen was well tolerated and had efficacy similar to the oral regimen.30 which has demonstrated its efficacy in preventing HIV infection in multiple randomised controlled trials52 and demonstration projects in different target populations, with more evidence continuing to accumulate. However, there are those for whom oral tenofovir-based PrEP is not an appropriate option, either on account of contraindications to the drug itself, or on account of other factors related to oral formulation or the requirement to take pills regularly. For such individuals, alternative PrEP options are essential.Currently the only approved and WHO-recommended pre-exposure prophylaxis (PrEP) option is oral tenofovir-based PrEP,54 Plasma, rectal and cervical fluid sampling and limited rectal and vaginal biopsies after single doses of 300 mg – 1200 mg long-acting rilpivirine in one of these studies demonstrated prolonged rilpivirine exposure in plasma as well as the genital tract for 84 days. In this study, one female participant subsequently experienced incident HIV-1 (wild-type virus) infection after a single episode of unprotected vaginal intercourse approximately 41 days after she received the 300 mg rilpivirine injection. Viraemia peaked on day 115, and at this point, a mixed population of 101 K/E was detected and ART was initiated. Resistance was selected by high levels of viral replication in the face of low rilpivirine concentrations. The viral population reverted to predominantly wild-type by day 199. This incident infection illustrates the risk of subtherapeutic concentrations of long-acting agents that are not high enough to prevent infection but are sufficient to select for resistance.56Early studies of long-acting rilpivirine  confirmed the initial safety, acceptability and pharmacokinetic characteristics of the formulation.57A subsequent phase 1 study enrolled 36 HIV-negative participants and alternately assigned them to receive one intramuscular dose of long-acting rilpivirine, either 1200 mg or 600 mg. The safety and acceptability findings were in line with previous studies. These findings were confirmed in a multiple dose phase of this study.90. Currently, HPTN 076 study has only reported safety, acceptability and pharmacokinetic findings,59 and the long-acting rilpivirine will not be taken forward into PrEP efficacy studies at this stage.HPTN 076 is a double-blind, randomised study, which compared the safety of long-acting rilpivirine1200 mg every 8 weeks to placebo, following a 4-week run-in oral phase, for PrEP in low-risk, sexually active HIV-uninfected women. The study demonstrated no significant differences between the two arms with respect to adverse events. It also showed that for 92% of participants, plasma rilpivirine concentrations were above the protein-adjusted ICTo date, no studies using rilpivirine oral formulations as PrEP have been conducted, except where it has been used as an initial run-in phase to establish tolerability prior to progressing onto the administration of injectable formulations.While a number of PrEP randomised controlled trials have been conducted with various drug regimens, there are no randomised studies on antiretroviral regimens for post-exposure prophylaxis (PEP). Most data supporting the use of PEP are derived from animal transmission models, prevention of mother-to-child transmission trials, observational studies of healthcare workers receiving PEP following occupational HIV exposure, and observational cohorts and case studies of PEP following potential sexual exposure.t2 0.25) of those eligible completing the course,60 and lower in adolescents than in adults. A significant proportion of PEP discontinuation is related to adverse events, indicating that better tolerated PEP regimens are needed. A systematic review of observational data concluded that tenofovir-based PEP regimens were better tolerated than those using zidovudine, while the optimal third drug to use was a little less clear. While raltegravir was well tolerated, other factors such as twice daily dosing, availability and cost were identified as limitations to the use of raltegravir as the third drug, particularly in resource-limited settings.61Adherence to the full 28-day course of PEP has been shown to be poor, with only 56.6%  by pill count. Discontinuations for adverse events were low (1%).In these studies, adverse events were commonly reported by participants but were of low grade, and there were no seroconversions. With the high number of participants completing their PEP regimens in these studies, rilpivirine is an attractive option as a third drug for PEP regimens, offering the advantages of cost and coformulation . With more lower- and middle-income countries introducing dolutegravir into first-line ART, another potential advantage of rilpivirine-based PEP is the lack of overlapping resistance profiles between rilpivirine and dolutegravir.This article followed all ethical standards for a research without direct contact with human or animal subjects.Many lower- and middle income countries use efavirenz-based regimens for first-line ART. Efavirenz has good efficacy and relatively good tolerability, is available in fixed-dose combination STR at low cost, is safe in pregnancy and can be used concomitantly with rifampicin-containing TB treatment. However efavirenz causes treatment-limiting toxicity in some individuals and should be used with caution in psychiatric disease.Rilpivirine cannot replace efavirenz in standard first-line therapy. Rilpivirine is not optimal for patients with high baseline viral loads because of reduced efficacy, and cannot be prescribed with rifampicin. In addition, there is a paucity of rilpivirine safety data in pregnancy, and the decrease in rilpivirine concentrations during pregnancy is concerning: more data in pregnancy are required to inform recommendations on use in pregnancy. However, rilpivirine is generally well tolerated and may be a useful alternative for people living with HIV who cannot tolerate efavirenz or in whom it is contraindicated. If rilpivirine is initiated in treatment-naïve patients, a baseline viral load is mandatory because of reduced efficacy at high viral loads in phase 3 trials, and if the baseline viral load is more than 100 000 copies/mL, an alternative drug is preferable.With increasing use of dolutegravir as more country programmes transition to dolutegravir-based first-line ART, emergent neuropsychiatric adverse events are being reported, suggesting an overlapping toxicity profile with current efavirenz-based regimens. For patients who experience neuropsychiatric or other toxicity or with contraindications to current or future first-line ART regimens, rilpivirine may be a useful alternative.


Prostate cancer (PC) remains the second-most frequently diagnosed cancer among men worldwide and the fifth leading cause of cancer deaths . DespiteCells have the ability to commit suicide initiated by a finely tuned signal network after the influence of stimuli that require the cell to die. This is why we are talking about “programmed” cell death or apoptosis. In multicellular organisms apoptosis serves to eliminate surplus or damaged cells to preserve tissue and organ homeostasis .Apoptosis can be triggered by two different pathways. The “extrinsic” apoptotic pathway is initiated through the stimulation of transmembrane death receptors. The “intrinsic” apoptotic pathway is initiated after internal cell damage and marked by the release of cytochrome C from mitochondria . Key regPC therapies like radiation, androgen deprivation, and chemotherapy aim to activate the intrinsic apoptotic pathway by causing cellular stress –7. This The fact that the activation of the effectors Bax and Bak is prevented by Bcl-2, Bcl-xl, and Mcl-1 leads to an alternative therapeutic strategy to induce the programmed cell death by direct inhibition of the anti-apoptotic proteins. In principle, this can be done without previous cell damage and without consideration of upstream signaling pathway elements, which could be altered in advanced stages of the disease.in vivo tumor models were seen -Gossypol (AT-101), Apogossypolone (ApoG2), BI-97C1 (Sabutoclax), or GX15-070 (Obatoclax Mesylate). They are known as pan-BH3 mimetics, because they can bind Bcl-2, Bcl-xl, and Mcl1. In preclinical experiments, they successfully induced apoptosis in PC cells –35. Due ClinicalTrials.gov, Identifier: NCT01828476).Second generation BH3 mimetics were therefore created by structural-based design to bind with high affinity and specificity to individual members of the anti-apoptotic proteins , 40. TheDespite the recognition that a combination of specific BH3 mimetics with other drugs is necessary to achieve complete inhibition of the anti-apoptotic proteins Bcl-2, Bcl-xl, and Mcl-1 for the induction of apoptosis, these combinations have only hardly been used in clinical trials against PC to date. The main reason for this is that the combinations tested so far are not tumor-specific, but also can affect healthy cells. Second, most drugs, which showed synergistic effects with BH3 mimetics, target signaling pathways, e.g., androgen receptor (AR) or receptor tyrosine kinase (RTK) pathways, that are altered in advanced tumor stages . It is tIn recent years, new strategies were therefore developed to make the targeting of apoptosis more tumor-specific for enhanced efficacy and reduction of adverse side-effects. One such approach is the “BH3 profiling” of tumor cells, in which BH3 peptides interacting with Bcl-2, Bcl-xl, or Mcl-1 are used to identify the dependence of tumor cells on the respective anti-apoptotic Bcl-2 proteins. As a consequence, specific inhibitors could be selectively used to inhibit these proteins in the context of a personalized therapy. Specific Bcl-2 signatures for hematological tumors could be identified [reviewed in ]. It remA tumor specific therapy can generally be performed by using antibodies, peptides, or inhibitors against markers on the surface of tumor cells. With regard to a targeted induction of apoptosis, a direct coupling of Bcl-2 antagonists to tumor specific antibodies or a combination of Bcl-2 antagonists with immunotoxins represent promising, new therapeutic approaches. Berguig and colleagues generated an antibody-peptide drug conjugate consisting of an anti-CD22 antibody and a BIM peptide, targeting all anti-apoptotic proteins, to treat B cell lymphoma. The conjugate was applied via a multifunctional polymeric delivery system containing ethylene glycol segments to optimize safety and tumor biodistribution and butyl methacrylate (BMA) and diethylaminoethyl methacrylate (DEAEMA) for enhanced endosomal release. An inhibition of tumor growth marked by an increased apoptosis rate and an enhanced overall survival was reached with this construct in a B cell lymphoma mouse xenograft model . In anotPseudomonas Exotoxin A (PEA) based immunotoxins can be significantly increased by the combination with the BH3 mimetic ABT-737/ABT-263 , in human ribosome complexes followed by inhibition of protein biosynthesis and induction of apoptosis (In various tumor entities it was shown that the toxicity of /ABT-263 –46. PEA poptosis . Initialpoptosis . For thepoptosis . In our poptosis . To our The direct induction of the intrinsic apoptotic pathway is a promising new therapeutic option for advanced PC. In recent years, various drugs have been developed that can directly inhibit anti-apoptotic Bcl-2 proteins and induce apoptosis, independently of potentially altered upstream signaling pathways. Since these drugs could also affect healthy cells and lead to severe adverse side effects, future research must focus on strategies to make the induction of the intrinsic apoptotic pathway tumor-specific.The author confirms being the sole contributor of this work and has approved it for publication.The author declares that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


The aim of this study was to determine the phenolic compounds and antioxidant capacity in crude extracts and several SPE fractions from methanolic extract of defatted dabai pulp and peel. Based on SPE, Sep-Pak® cyanopropyl and C18 cartridges were used to fractionate the antioxidant-rich crude extracts into water and methanolic fractions. Analyzed using LC-MS, flavonoids, anthocyanins, saponin derivatives and other unknown antioxidative compounds were detected in the defatted dabai crude extracts and their SPE fractions. Anthocyanins were the major phenolic compounds identified in the defatted dabai peel and detected in most of the SPE fractions. Methanolic fractions of defatted dabai parts embraced higher total phenolics and antioxidant capacity than water fractions. This finding also revealed the crude extracts of defatted dabai peel have the most significant antioxidant properties compared to the methanolic and water fractions studied. The crude extract of defatted dabai parts remain as the most potent antioxidant as it contains mixture of flavonoids, anthocyanins and other potential antioxidants.Solid phase extraction (SPE) using Sep-Pak In laboratory research, SPE is commonly performed using a silica-fused column that chemically bonded. Cyanopropyl (CN), alumina, silica and C18 bonded-phase cartridges had been used for separation and purification of pesticides and dioxins − at m/z 419) and hirsutidin 3-O-glucoside ([M−2H]− at m/z 505) were found to co-exist in peak 5. Moreover, malvidin 3-O-glucoside ([M−2H]− at m/z 491) was co-identified with glucosides of apigenin from peaks 6 and 7.Among the peaks detected, peak 1 was identified as an apigenin derivative . This iset al. , that th369, 309  were spo01, 285) . Similar  et al. , where tC-glucoside (vitexin-peak 6) (C-glucoside (isovitexin-peak 7). Similar findings were reported by Sánchez-Rabaneda et al. − at m/z 529 and the fragment ions at m/z 511, 367, 349 (m/z 529 and 349 is a loss caffeic acid at m/z 180. The molecular structure of this compound (peak 11a) is a combination of a methyl quinate and two caffeic acid. This compound  has been characterized by Ma et al. [m/z 529 and 367. The fragment ions at m/z 511 and 349 are part of the other fragment ions found. The compound for peak 11b has [M−H]− at m/z 434 and the fragment ions at m/z 398, 382, 329  was isolated from cacao liquor, which has [M+H]+ at m/z 435. One of the unknown major peaks (peak 11a) were identified as methyl 4,5-dicaffeoylquinate in the defatted dabai pulp, while quercetin 3-bai peel . Both co367, 349 . The dif382, 329 . Sanbong . Peaks 12, 13 and 15 were the potentially unknown antioxidants. These peaks were not able to identify as either phenolics or terpenes due to the fragments ions were not matched for any of the known phenolic compounds (O glucoside) was not occurred in defatted dabai pulp that without the peel. Moreover, peaks 18 and 19 were not found in the defatted dabai peel. Future studies are required to identify and characterize these unknown peaks using NMR.From the result obtained, peaks 12 to 20 were determined as unknown compounds, except for peak 14 (saponin derivative). Some of these peaks had large molecular ions  and C18-methanol (C18-MeOH) fractions. Cyanidin 3-O-rutinoside, cyanidin 3-O-sophoroside and hirsutidin 3-O-glucoside were not detected in all SPE fractions. Identification of anthocyanins in the defatted dabai parts was further confirmed based on a method described by Abad-García et al. [Fractionated using SPE, anthocyanins were detected in all SPE fractions of the defatted dabai pulp and peel crude extracts, except for cyanidin 3-a et al. . Four maO-arabinopyranoside (peak 11b) is a semi-polar compound, which is able to solublilize in both methanol and water. Comparing the two Sep-Pak® cartridges used, CN stationary phase was not able to completely retain the antioxidant compounds detected in defatted dabai parts. The possible reason is that based on the sequential design of SPE, the non-retained antioxidants collected from CN cartridges were finally retained in C18 cartridges. Besides, both methanol and water fractions obtained from CN and C18 cartridges have similar intensity for most of the peaks observed. The results also revealed that the other non-identified (unknown) compounds (peaks 15–20) that were detected in the methanolic fractions were not detected (trace) or found to occur in low levels. The compounds identified as in peaks 9 and 10 were predicted to highly soluble in water due to the high peak intensity observed for the water fractions studied. Conversely, peak 11a  was highly solubilized in methanol. The carboxyl group of methyl 4,5-dicaffeoylquinate should have enhanced its solubility in water ; howeverpost-hoc comparison revealed that methanol and water fractions obtained from the defatted dabai peel crude extract had significantly lower levels of TPC, TAC and TEAC than the crude extract (p < 0.05). Among the fractions studied, both CN-MeOH and C18-MeOH fractions had higher levels of TPC, TAC and TEAC as compared to the water fractions. LSD post-hoc comparison also revealed that the antioxidant properties found in the CN-MeOH fraction of defatted dabai peel were significantly higher than the other SPE fractions, except for TAC where no significant difference was found between the CN-MeOH and C18-MeOH fractions. Residual fractions were mainly consisted of phytochemicals that unretained by CN and C18 bonded-phases. These fractions had lower levels of TPC, TAC and TEAC as compared to other SPE fractions. It shows that the Sep-Pak® cartridges have successfully fractionated the crude extracts of defatted dabai peel and pulp-peel, thus recovered most of the antioxidant compounds. Similar as found for the crude extract of defatted dabai peel, LSD post-hoc test showed that the crude extract of defatted dabai pulp-peel had significantly higher levels of TPC and TEAC than the SPE fractions, except for TAC where C18-MeOH fraction had significantly higher of level of TAC than the crude extract.TPC, TAC and antioxidant capacity of defatted dabai crude extracts and their SPE fractions (water and methanolic fractions) are shown in 18-bonded stationary phase had the highest antioxidant properties as compared to the other SPE fractions. Water fraction from CN-bonded stationary phase (CN-H2O) of the defatted dabai pulp-peel had the lowest levels of TPC, TAC and TEAC as compared to other SPE fractions; while the residual fraction of defatted dabai pulp-peel crude extract had significantly higher levels of antioxidant properties than the CN-H2O fractions. This is one of the exceptions that some antioxidants from the defatted dabai pulp were not fully recovered from Sep-Pak® CN and C18 cartridges. It is suggested that other types of SPE cartridge should be used to fractionate and recover the potential antioxidants in different parts of fruit sample.In general, methanolic fraction of defatted dabai pulp-peel that was obtained from C18 cartridges. Russo et al. [On the other hand, the levels of TPC or TAC determined in all SPE fractions were not significantly differed from the levels of TPC or TAC from the non-fractionated crude extracts of defatted dabai peel (data not shown). This shows that the phenolic compounds in all SPE fractions were fully recovered from SPE. For the antioxidant capacity, TEAC levels of all SPE fractions were 0.7-times lower than the levels determined in the non-fractionated crude extract of defatted dabai peel. It might due to some of the other non-phenolic antioxidants were not recovered from SPE. For defatted dabai pulp-peel, the levels of TPC, TAC and TEAC determined in the non-fractionated crude extract were significantly higher than the SPE fractions. Thus, moderately high recovery of phenolic compounds was assumed for the SPE fractions of defatted dabai pulp. Based on this finding, we postulated that the defatted dabai pulp contains other non-phenolic antioxidants. From our observation, there could have some antioxidant compounds remain absorbed in the CN and C18-MeOH fraction from the defatted dabai pulp-peel crude extract had significantly higher levels of TPC, TAC and TEAC than the CN-MeOH fraction. The high TPC determined in the C18-MeOH fraction might have some contribution from some unknown phenolic compounds detected in the peaks 12, 13 and 15 . Besides, the levels of phenolic compounds were found to be higher in CN-MeOH fractions than C18-MeOH fractions obtained from the defatted dabai peel crude extract, which accessed by both spectrophotometric and chromatographic methods. Spectrophotometric methods may overestimate the TAC determined in the crude extracts of defatted dabai peel and pulp-peel. Khoo et al. [Surprisingly, C3 and 15 . These po et al. , have mepost-hoc comparison showed that CN-MeOH fractions of defatted dabai peel had significantly higher TPC and antioxidant capacity than other fractions studied. However, the TAC in CN-MeOH fraction of the defatted dabai peel was lower than its C18 counterpart, but not significantly different (p > 0.05). As mentioned earlier, spectrophotometric method tend to overestimate the TAC in the defatted dabai peel, especially from C18-MeOH and C18-water (C18-H2O) fractions. Based on the MS results, some of the water soluble (polar) phenolic derivatives were poorly retained in the CN-bonded stationary phase. Conversely, anthocyanins were able to retain in the CN-bonded stationary phase. Besides, the anthocyanins detected in the defatted dabai peel were highly soluble in water. Similarly, saponin derivatives that identified in the samples were highly soluble in water, except for the compound that discovered in peak 14. The residual fractions also consisted mainly of saponin derivatives that obtained from both of the defatted dabai peel and pulp-peel crude extracts. In this study, LSD w/w) was collected as residual together with some of the phenolic compounds and saponin derivatives. Therefore, before using Sep-Pak® cartridges to fractionate or to concentrate any phenolic compounds from fruit extract, several measures are needed to be considered. Even using multiple cartridges to retain the specific antioxidant compound, there will be a loss of the compound where some of the researchers have overseen it. The use of SPE for fractionation or purification of phenolic compounds has pros and cons [® C18 cartridge had been reported by Hong and Wrolstad [18 cartridge was used to adsorb the anthocyanin compounds before eluted by acidic methanol for HPLC analysis. Sep-Pak® C18 cartridge had been used to concentrate the anthocyanins isolated using preparative HPLC [18 cartridges, other SPE cartridges are also recommended to be used in fractionation of phenolic compounds in fruits for future studies.As we have seen in this study, the anthocyanins that not able to be adsorbed by the stationary phase were considered as waste or residual fraction. In this study, a relatively high amount of anthocyanin . The lyophilized samples (peel and pulp-peel) were ground into powder form and defatted using hexane  by soaking overnight. In this study, the sample, pulp-peel refers to dabai pulp without the peel removed. ® cartridges.Extraction of defatted dabai parts (peel and pulp-peel) was based on RSM optimized method, where 2.0 g of the sample was added with 20 mL of 62.25% methanol (Fisher Scientific), and sonicated for 1 min using a Power Sonic 405 Ultrasonicator  at 40 kHz to assist extraction. The extraction procedure was previously optimized for obtaining maximum levels of total phenolics and antioxidant capacities (data not shown). All extraction was performed in triplicate. Removal of methanol was done using a rotary evaporator and freeze-dried to remove water. The lyophilized crude extracts were then performed for fractionation of antioxidant compounds using Sep-Pak® CN and C18 cartridges from Merck  containing 100 mg adsorbent were used to fractionate the crude extracts of defatted dabai peel and pulp-peel. Fractionation of anthocyanin was performed based on a sequential design using Sep-Pak® CN and C18 cartridges. The idea for fractionation of phenolic compounds from the defatted dabai crude extracts was adapted from Russo et al. [® CN cartridge was connected in “series” with another Sep-Pak® C18 cartridge for elution of the compounds. In this study, the elution was performed in stages as shown in Visprep SPE vacuum manifold 12-ports)  connected to a vacuum pump was used. Sep-Pak-ports  was loaded into the activated CN cartridge and the eluent was collected as fraction “A”. Fraction “A” was then loaded to the activated C18 cartridge and the eluent was collected as “residual”. The adsorbed or retained phenolic compounds in both of the CN and C18 cartridges were eluted by passing 2.0 mL of methanol through the cartridges, followed by 2.0 mL of deionized water. The fractions were collected as CN-H2O, CN-MeOH, C18-H2O and C18-MeOH fractions. In this study, equal volumes of the eluent (2 mL each) were collected directly from the cartridges and labeled as the fractions mentioned earlier. A total of five fractions were obtained from each crude extract of either defatted dabai peel or pulp-peel. The fractions were determined for their TPC, TAC and antioxidant capacity (FRAP assay); while potential flavonoids, anthocyanins, and other phytochemicals were detected using LC-MS. Residual fractions were compared with the water and methanolic fractions to ensure all phenolic compounds in the defatted dabai crude extracts have fully recovered from the Sep-Pak® cartridges.Sep-PakTotal phenolic content (TPC) of the samples were estimated using Folin-Ciocalteu reagent assay . Defatteet al. [Total anthocyanin content (TAC) of the defatted dabai crude extract and the SPE fractions was determined at 535 nm as described by Khoo et al. . Briefly535nmA is the absorption value measured at 535 nm, V is the total volume (mL), N is the dilution multiple, 98.2 is the extinction coefficient at 535 nm, and m is the mass of crude extract/ SPE fraction.where TAC is the total anthocyanin content in the crude extract or the SPE fractions (μg/mg), Defatted dabai crude extracts and the SPE fractions were determined for Trolox equivalent antioxidant capacity (TEAC), which based on ferric-reducing antioxidant power (FRAP) assay as described previously ,27. TrolLC-MS analyses were performed on a Thermo Quest Finnigan LCQ Deca integrated with a Finnigan Surveyor LC system  and coupled on-line with a Shimadzu QP 8000 API mass spectrometer. PDA and MS data were acquired and processed using Xcalibur software (Thermo Finnigan). The column used was a reversed phase Lichrospher C-18 column  (Merck) with a guard-cartridge packed with the same stationary phase. et al. [m/z 100 to 1,000 in 10 s. The present study has a high repeatability as the average relative standard deviation was lower than 10%.The chromatographic method was performed based on a method described by Chew et al. , with soet al. . PDA detet al. . Data wep < 0.05.TPC, TAC and antioxidant capacity of the defatted dabai peel and pulp-peel crude extracts and their SPE fractions were expressed as means ± standard deviations. Significant differences between the means of different samples were determined by one-way analysis of variance and further compared using LSD post-hoc test. Statistical software used was Minitab version 15 . The significant difference was set at 18 bonded-phases cartridges used have provided new knowledge on the type of phenolic compounds fractionated from defatted dabai samples. Hesperetin glucoside was not detected in the defatted dabai pulp, while two unknown phytochemicals were not found in the peel of the defatted dabai. A high TPC was determined in CN-MeOH fractions from the defatted dabai peel as compared to the other SPE fractions. Some unknown phytochemicals were not detected in the methanolic fractions of defatted dabai pulp-peel; however, these compounds were spotted in the water fractions, and vice versa. Higher level of anthocyanins was retained by the CN bonded-phase than the C18 bonded-phased, while water had higher ability to elute anthocyanin glucosides from the defatted dabai peel compared to methanol. Applying SPE for fractionation of defatted dabai crude extract, a different profile of phenolic compounds was observed. The used of SPE in extraction and fractionation of phenolic compounds is not advisable as a lost of phenolic compounds was observed in this study. The best way to determine the phenolic compounds or antioxidant capacity of any fruits of interest is to analyze the crude extract instead to fractionate or purify it. Extraction and fractionation of phenolic antioxidants based on SPE enable separation of specific phenolic compounds, such as flavonoids and anthocyanins. CN and C


Stiff Person Syndrome (SPS) is an under-diagnosed disorder that affects mobility and the quality of life of affected patients. The aim of the study is to describe the natural history of SPS, the extent of accumulated disability and the associated clinical and immunological features in patients followed for up to 8 years in a single center.Our collective cohort included 57 SPS patients. Additionally, 32 of these patients were examined every 6 months for a two-year period in a longitudinal study protocol, to assess disease progression using quantitative measures of stiffness and heightened sensitivity.p < 0.0001), consistent with worsening functional status and quality of life. High-titer anti-GAD antibodies were present in serum and CSF with elevated intrathecal GAD-specific IgG synthesis, but they did not correlate with clinical severity or progression.The most frequent initial symptom was leg stiffness, followed by paraspinal muscle rigidity and painful spasms in 95% of the patients. Although none of the patients required assistance for ambulation during the first 2 years of disease onset, 46 patients (80%) lost the ability to walk independently during our follow-up, despite symptomatic medications. In the longitudinal cohort, the number of stiff areas increased (This large study on SPS patients, combining an eight-year follow-up at a single center by the same leading neurologist and his team, is the first to provide longitudinal data in a large patient subgroup using objective clinical measures. One of the main findings is that SPS is a progressive disease leading to physical disability over time. Stiff Person Syndrome (SPS) is characterized by rigidity of the truncal muscles with superimposed episodic and often painful muscle spasms, heightened sensitivity to external stimuli, particularly tactile and auditory, and high-titer anti-GAD antibodies –6. Co-coSeveral clinical variants have been described including: ‘stiff-limb syndrome’, a limited form that spares the trunk , 12; a cThe symptoms are fluctuating and it is unclear whether SPS patients accumulate disability over time. We describe a series of patients, evaluated for up to 8 years in a single center with clinical, immunological, imaging and neurophysiological measures and provide prospective longitudinal data, in a subgroup of patients, on disease progression using validated scales that quantified stiffness and spasms.n = 21) or performed by us (n = 36). Brain MRI was performed in 44 patients and was selectively repeated during the follow-up period to exclude other processes or search for cerebellar atrophy in those with concurrent cerebellar ataxia.Fifty seven SPS patients were recruited 1999–2006) at the Neuromuscular Diseases Section of the National Institutes of Health (NIH) after signing informed consent. All patients were evaluated by the same senior clinician (MCD) and his fellows  and fulfilled the following criteria , 6: 1) i at the NDuring the follow-up visits, all disease-related factors were recorded, including frequency and condition of falls, ability to work or carry out daily activities, concurrent medical and psychiatric illnesses, other neurological or autoimmune diseases and response to medications.Thirty-two patients were enrolled in a distinct longitudinal study protocol, where Stiffness and Heightened Sensitivity scores were systematically recorded using previously validated scales , every 6All patients were assessed for neuropsychiatric symptoms through structured interviews. The validated Structured Interview for the Diagnostic and Statistical Manual for Mental Disorders (DSM-IV) Axis I (SCID-I/P) was additionally administered to 10 consecutive patients to explore the origin of anxiety and frequency of phobic or other psychiatric disorders and assess their personality characteristics and cognitive functioning, as described .Immunogenetic associations were investigated by HLA-I and II allele-specific oligonucleotide typing in genomic DNA extracted from peripheral blood of 34 patients and compared to healthy controls from the NIH database matched for age, ethnicity, and Type-I diabetes.The following autoantibodies were tested: anti-thyroid, anti-parietal cell, anti-gliadin, intrinsic factor blocking antibody, anti-islet cell, ANA, anti-cardiolipin, anti-RNP, anti-SSA/SSB, anti-SM, anti-striated, anti-smooth muscle, anti-microsomal, anti-mitochondrial, anti-acetylcholine receptor, anti-GM1, hepatitis B/C, HIV, HTLV-I and CMV. Immunoglobulin and complement levels were also tested.Anti-GAD antibodies were initially tested in all patients and serially thereafter, in the 32 patients enrolled in the longitudinal protocol, by radioimmunoassay (RIA) using a commercial kit . Lumbar puncture was performed in 48 patients but CSF could not be obtained from 5 due to severe lumbar stiffness. CSF was examined for GAD antibodies, total immunoglobulins, oligoclonal bands, IgG index and intrathecal GAD-specific IgG synthesis, as previously described , 25, 26.Among the 57 patients, 39 were women and 18 men (ratio 2:1); 46 were Caucasians and 11 African Americans. The mean age of disease onset was 42 years  and the mean disease duration at enrollment 11 years . The duration between symptom onset and time of diagnosis was 5 years (range: 1–19).The most common initial symptom was insidious onset of proximal leg stiffness, reported by 19 patients (33%). The second most common symptom was rigidity in the lumbosacral paraspinal muscles , followed by rigidity in the thoracic and abdominal muscles . When first examined, axial muscle stiffness , lumbar hyperlordosis and impaired gait were detected in 39 patients (68%); sixteen of them (28%) had also various degrees of facial muscle stiffness ; they too developed typical SPS after a mean period of 5 years (SPS-Cer) with prominent cerebellar symptomatology. All 5 SPS-Cer patients were positive for anti-GAD antibodies.Exaggerated reaction to various external stimuli and ‘startle response’ was present in all patients except 2 without episodes of muscle spasms. Marked anxiety related to unprotected falls or in anticipation of physically challenging situations was reported in 52 of 57 patients Table . Three pSeveral patients had been earlier misdiagnosed with conversion or functional disorder because their falls were attributed to avoidant behavior and heightened mental anticipation. Other common misdiagnoses were spinal disease, dystonia or Parkinsonism.Three patients used alcohol as muscle relaxant prior to diagnosis and finally became alcohol-dependent; two others used cannabis and stimulants . Many patients reported muscle pain along with painful spasms and some had been on narcotics.Several patients exhibited diurnal fluctuations of stiffness and spasms with worsening during periods of physical or emotional stress, cold weather or concurrent infections. The stiffness often spread to the adjacent truncal muscles sparing the distal and facial muscles until late in the disease. Episodes of truncal stiffness were often perceived as ‘freezing attacks’ and the sudden falls (due to painful contractions) as seizures necessitating Emergency Room visits for intravenous muscle relaxants. The number of falls during the ambulatory phase averaged up to four per month.Although none of the patients required assistance for ambulation during the first 1–2 years of disease onset, 46 (80%) lost the ability to walk independently during the course of the disease, and despite receiving symptomatic therapies 26 of them used a cane, 14 a walker and 9 a wheel-chair (Table status spasticus), as described [The frequency of painful spasms also progressed over time but varied from twenty per day to a few per year and their duration from minutes to hours  and the heightened sensitivity to 3.65 (p < 0.5)  and Heightened Sensitivity scales (maximum 7). The mean number of stiff areas at entry was 3.25 and the mean heightened sensitivity score 3.40. Two years later, without immunotherapy, the mean number of stiff areas had increased to 4.15 (Seventeen of 57 patients (30%) developed autoimmune thyroiditis Table ; eight bAll patients had high-titer anti-GAD antibodies , but their titers tested over time varied even in the same patient. There was no correlation between antibody titers and clinical severity or fluctuation as assessed by Stiffness Index and Heightened Sensitivity scores , 25. Eiganti-GAD CSF/ serum was 0.01  and the mean ratio of CSF/ serum IgG was 0.002  indicating a 4-fold increase of specific intrathecal GAD-IgG production. In 10 patients, CSF was also repeatedly tested in a two-year period. The mean titer after 2 years was lower  but this difference was not statistically significant   ranged from 9000 to 62,000  and their CSF from 30 to 2000 . The mean titer ratio of anti-GAD CSF/ serum was 0.03  and the mean ratio of CSF/ serum IgG was 0.002 , indicating a 10-fold increase of intrathecal antibody production, 2.5-fold higher compared to typical SPS [In five SPS patients with cerebellar disease (SPS-Cer), the mean ratio of ical SPS , suggestSeveral patients with prominent muscle rigidity and attacks of muscle spasms showed persistently elevated creatine kinase up to 1000 U/L, but with normal muscle strength. Muscle biopsies in 2 patients showed mild lymphocytic infiltrates and up-regulation of MHC-I, indicative of an indolent inflammatory autoimmune process also affecting the muscle, as reported , 9, 21.Electrophysiological work-up showed the typical for SPS continuous firing of normal-appearing motor unit potentials at rest with simultaneous co-activation of motor units in agonist and antagonist muscles in 32 of 36 tested patients. Four patients did not complete the EMG because they could not tolerate the procedure due to stiffness and/or pain. Five mildly affected patients or those responding favorably to symptomatic therapy with GABA-enhancing drugs, exhibited normal electromyography. MRI imaging (44/57 patients) was generally uninformative including the patients with SPS-Cer where no atrophy was observed.Alleles in the HLA-DR or DQ haplotype region, were found in 33/57 tested patients, confirming previous observations , 28, 29.We present detailed clinical and immunological 8-year follow-up data from SPS patients examined in a single center by the same leading clinician along with his team. Most importantly, we present 2-year longitudinal data in 32 patients, without immunotherapy, which in spite of variability in disease severity within the same patient, demonstrate that SPS is a progressive disease that leads to physical and social disability. The findings are important in the design of future therapies.The delay in establishing diagnosis and initiating treatment ranged from 1 to 19 years , confirming that SPS still remains a largely under-recognized entity. Symptoms usually started subtly in patients below the age of 50 and progressed slowly thereafter to permanent stiffness or impaired gait; in 15 patients with disease onset > 50 however disability developed much sooner. At first evaluation, the majority of patients (68%) already had diffuse axial muscle stiffness with spasms, hyperlordosis and impaired gait. 23% of patients who started asymmetrically (‘stiff-limb syndrome’) or with mild gait difficulties, ocular disturbances and cerebellar symptomatology, eventually developed the typical SPS phenotype. Anxiety alone or combined with task-specific phobias and depressive mood were eventually universally present resulting in severe social disability .The main novelty of our study is the longitudinally obtained quantitative clinical data from 32 patients which unequivocally demonstrate that SPS is a progressive disease. This was complemented by increasing frequency of falls, need for assistance in walking and daily activities and progressively impaired ability to work in 84% of these patients over the 2-year period. In spite of fluctuations, the overall mean number of stiff areas increased from 3.25 to 4.15  presence of high-titer antibodies against GAD in serum and CSF; b) glycine receptor antibodies present in a patient subset; c) frequent association with other autoimmune diseases and autoantibodies, including thyroiditis and Type-1 diabetes; and d) a strong immunogenetic association with DRB1*0301 and DQB1*0201 haplotypes. Serum and CSF anti-GAD titers, including serial 2-year assessment, did not correlate with clinical severity confirming prior observations in smaller cohorts , 21, 25.The pathogenetic potential of anti-GAD antibodies remains unsettled. The high rate of intrathecal synthesis of GAD-specific IgG signifies B-cell in-situ stimulation in the CSF compartment and possibly in-situ action of antibodies within the CNS, but it is unclear what drives their CNS persistence and why rituximab is ineffective . The reaA wide range of medications were used in our series for symptomatic relief, most commonly GABA-enhancing drugs such as sedative-anxiolytics, anti-spasticity and anti-epileptic drugs. Among immunotherapies, high-dose IVIg, as confirmed in a controlled study  was effeThe progressive and disabling nature of SPS as confirmed in this series  indicate


To examine factors associated with non-adherence during 5 years of endocrine treatment, including the possible influence of comorbidity burden and specific medical conditions.From all women diagnosed with stage I–III, ER-positive breast cancer in Stockholm-Gotland, Uppsala–Örebro and Northern Sweden between 2006 and 2009, we included 4645 women who had at least one dispensation of tamoxifen or aromatase inhibitors (AIs) and 5 years of follow-up without distant recurrence. A medical possession ratio of < 80% was used to define non-adherence. Logistic regression was used to estimate odds ratios (ORs) and 95% confidence intervals (CIs) of non-adherence.During follow-up, 977 (21%) women became non-adherents. Non-adherence was associated with greater comorbidity burden assessed by Charlson comorbidity index (CCI) during follow-up , pre-diagnostic HRT use , not married , high educational level , and use of symptom-relieving drugs. HER-2 positivity  and adjuvant chemotherapy  were associated with lower odds of non-adherence. Similar patterns were observed for the presence of lymph node metastasis, higher tumour grade, and use of AIs compared to tamoxifen. Myocardial infarction and chronic pulmonary disease was suggested as leading conditions associated with non-adherence in women with increasing CCI.We identified subgroups of women with breast cancer at increased risk of non-adherence. Our findings related to comorbidity suggest the importance of focusing on the presence of specific co-existing conditions when monitoring adherence. Adjuvant endocrine treatment (ET) is part of the standard therapy for oestrogen receptor (ER)-positive breast cancers . SurvivaWe have previously reported on non-adherence and early discontinuation patterns of use of adjuvant endocrine treatment among women with breast cancer in Sweden . FollowiOur study was based on information in the breast cancer research database BCBaSe generated by record linkage between four Swedish population-based registers. Details on period and data covered by each register are shown in Fig. We identified all women residing in the Uppsala/Örebro, Stockholm-Gotland and Northern regions of Sweden with a diagnosis of stage I–III ER-positive invasive breast cancer between July 1, 2006 and June 30, 2009 and at least one dispensation of oral tamoxifen (ATC code: L02BA01) or aromatase inhibitor  after diagnosis  as the ratio of the number of days for which a patient has medication on hand divided by the total number of days of follow-up, and multiplied by 100%. Non-adherence was defined as having an MPR of < 80%.We classified potential determinants of adherence based on the World Health Organization (WHO) multidimensional adherence model Fig.  11]. Fi. Fi11]. For the purpose of the present study, health system-related factors included region where breast cancers were diagnosed and whether surgery or follow-up was conducted in university hospitals.Patient-related factors included age at diagnosis, educational level, menopausal status, marital status, comorbidities and prior medications. Educational attainment was categorised into low, medium and high, corresponding to less than high school (≤ 9 years), high school graduate (10–12 years) and higher education (> 12 years), respectively.Comorbidities were assessed by calculating the Charlson comorbidity index (CCI)  based onWe collected information on drugs commonly associated with adverse effects of cancer treatments. Included in this category were analgesics (ATC code: N02), hypnotics or sedatives (ATC code: N05C), antidepressants (ATC code: N06A), gastrointestinal (GI) drugs (ATC code: A02–A07) and topical oestrogen for vaginal use (ATC code: G03C). Use of these drugs was calculated during the run-in period to assess baseline use, and during follow-up using information from the Prescribed Drug Register. Baseline use of oral hormone replacement therapy  was collected since 1 year prior to breast cancer diagnosis until the end of the run-in period. Drugs used during follow-up may reflect adverse effect of cancer treatment and, therefore, they were classified under treatment-related factors. Other treatment-related factors were type of primary surgery, radiotherapy, chemotherapy and type of endocrine treatment used.Condition-related factors included tumour size, lymph node involvement, tumour grade based on Elston grading system, progesterone receptor (PR) and human epidermal growth factor receptor 2 (HER2) status.Univariable logistic regression analysis was performed to estimate odds ratios (OR) and their 95% confidence intervals (CI) of non-adherence to ET for each potential determinant, with women who remained adherent as the reference group. Analyses were repeated following adjustment of age at baseline, and a further analysis was conducted while additionally adjusting for SES. A sensitivity analysis was performed by excluding women without records of any dispensation of ET during the final year of follow-up, representing those who discontinued treatment. To tease out the potential role of specific medical conditions for a given comorbidity group in CCI, Fisher’s exact test was used to assess differences in the proportion of non-adherents by whether women never had, or had the condition at baseline, or were diagnosed with the specific co-existing disease during follow-up.A total of 4645 women with ER-positive breast cancers treated with ET were included in our analysis. During the 5-year follow-up, 977 women 21%) became non-adherent, i.e. having MPR < 80%. Table % became The likelihood of non-adherence increased with older age , an increase in the comorbidity burden during and at the end of 5-year observation , prior use of HRT , use of analgesics  or hypnotics and sedatives  at baseline. Use of GI drugs at baseline was inversely associated with non-adherence . Following adjustment for age, associations remained for increases in CCI during follow-up, prior HRT use, use of hypnotics and sedatives and GI drugs at baseline . Also, the likelihood of non-adherence was elevated in women with high compared to low educational level , an association that remained virtually unchanged following adjustments for tumour size, presence of lymph node metastasis and pre-diagnostic use of HRT (data not shown).While there was evidence of regional variations with the lowest odds of non-adherence observed in Northern Sweden , no differences were observed between university hospitals and other types of hospitals. Results remained unchanged following adjustment for education Table .The presence of lymph node metastasis , higher tumour grade  and HER2-positive tumours  were associated with lower odds of non-adherence to ET. These associations remained following adjustment for age and education (Table n = 55) compared to sector resection , use of AI or both AI and tamoxifen compared to tamoxifen only , starting out ET with AI rather than tamoxifen , and in women receiving adjuvant chemotherapy (age-adjusted OR 0.42 95% CI 0.35–0.52).We found lower odds of non-adherence in women undergoing mastectomy and in women without a record of surgery , antidepressants , GI drugs  and vaginal oestrogens  during follow-up. These associations remained following adjustment for education (Table P = 0.01). A higher proportion of non-adherent women (P = 0.007) was also observed in those diagnosed with myocardial infarction (MI) during follow-up (37%) compared to women without a history of MI (21%) or with a record of MI before ET (33%). No difference in the proportion of non-adherence was observed across women who had diabetes before diagnosis, during follow-up, or those without the condition.In a final step, we assessed whether non-adherence varied between women who did not have a specific co-existing medical condition, those who had the comorbidity prior to treatment, and women diagnosed with the condition during follow-up. These analyses were repeated for all disease entities included in the CCI domain, and results for the ten major comorbidities are shown in Table In Swedish women undergoing adjuvant endocrine treatment for ER-positive non-metastatic breast cancer, we found a broad range of factors associated with non-adherence to ET including age, region, increases in comorbidity burden, marital status, educational level, use of HRT and symptom-relieving drugs, tumour characteristics, adjuvant chemotherapy and type of ET.While we found no strong association between younger age and non-adherence to ET, our results support earlier evidence of lower adherence in both younger and older age groups , 7. It hWe found that women with a previous history of HRT use were less likely to adhere to ET. Earlier findings indicate that HRT use is associated with an increased risk of adverse effects from ET , 19, posChemotherapy preceding ET was associated with better adherence, a finding that may be explained by a more advanced tumour stage and a high motivation to remain adherent.We also found associations between use of hypnotics and sedatives both at baseline and during follow-up, and non-adherence to ET, possibly reflecting that quality of life influences the likelihood to use ET as prescribed. However, further research is needed to confirm the direction of this association.In part, the present results support previous evidence of a role of socioeconomic factors as predictors of non-adherence to ET . Our finWe found some evidence of regional differences in adherence proportions. Regional differences may reflect variation in patterns of breast cancer management, includinWe found that women that had undergone mastectomy, and those without a history of surgery, were less likely to be non-adherent compared to sector resected women. In women undergoing mastectomy, a more advanced tumour stage may explain an adherent medication-taking behaviour, in particular, since we also found evidence of better adherence in patients with large tumour size and grade, or lymph node metastasis. On the other hand, in women not undergoing surgery, ET may be the only treatment, for instance, elderly and/or frail women. Thus, a low rate of non-adherence in this group of women could reflect a high motivation to use ET in the absence of other treatments.We did not have information on subjective patient-related factors which may influence the decision-making on ET . Among tStrengths of our study included the population-based setting covering three Swedish health care regions. Individual level information was available for a broad range of potential determinants spanning from patient-related to health system-related factors. In contrast to many prior studies based on short follow-up periods, we were able to assess adherence during a 5-year period for all women. Furthermore, the availability of information on comorbidity added to prior evidence by pointing to a possible role of specific medical conditions that increase the likelihood of non-adherence to ET.Several limitations need mentioning. We measured adherence by drug dispensation/filings of prescriptions rather than by actual use, which may result in misclassification. However, direct measurements of drug use is costly, and bias has also been reported with other indirect measures such as patient self-report and pill count, especially in patient with chronic diseases . CombinaAlso, we were unable to explore the possible influence of psychological factors. However, we assessed associations between use of hypnotics, sedatives and antidepressants and non-adherence. Additionally, using objective measures of factors affecting adherence have been recommended instead of patient-centred measures which tend to stigmatise women as solely responsible for being non-adherent . Future We conclude that predictors of non-adherence to ET extend beyond patient-related factors, supporting the notion that aspects of medication taking behaviours need to be addressed in a multidimensional fashion. Subgroups of women more likely to be non-adherent may benefit from tailored information on treatment benefit and risks, monitoring and repeated counselling throughout the planned course of endocrine treatment. Prospective studies are needed to determine the benefit of specific components of interventions to improve adherence.


The rural interdisciplinary team training (RITT) program has provided in-person training for almost 2000 VA providers and staff at 125 rural clinics since 2011. The multi-modal workshop, accredited for 6.5 hours for a number of disciplines, focuses on the recognition of common issues facing older Veterans, red flags prompting further assessment, how to administer screening instruments and team-based approaches for improving patient outcomes. Participants develop an improvement action plan improvement project based on common challenges faced by clinic patients. A program evaluation found an increase in geriatrics knowledge and a modest improvement in teamwork after the education program. It also found that participants self-identified an enhanced ability on average to use red flags after the 6.5 hour training in areas such as polypharmacy, falls and caregiver stress. The action plans were often not implemented at follow-up. The evaluation results will be discussed, as well as challenges, limitations, and implications.