In the United States, HIV-related kidney disease disproportionately affects individuals of African descent; however, there are few estimates of kidney disease prevalence in Africa. We evaluated the prevalence of kidney disease among HIV-infected and uninfected Rwandan women.2 and proteinuria were assessed in separate logistic regression models.The Rwandan Women's Interassociation Study and Assessment prospectively enrolled 936 women. Associations with estimated glomerular filtration rate (eGFR)<60 mL/min/1.73 m2  and 8.7% had proteinuria ≥1+. The prevalence of decreased eGFR varied markedly depending on the estimating method used, with the highest prevalence by Cockcroft-Gault. Regardless of the method used to estimate GFR, the proportion with decreased eGFR or proteinuria did not differ significantly between HIV-infected and -uninfected women in unadjusted analysis. After adjusting for age and blood pressure, HIV infection was associated with significantly higher odds of decreased MDRD eGFR but not proteinuria.Among 891 non-pregnant women with available data, 2.4% had an eGFR<60 mL/min/1.73 mIn a well-characterized cohort of Rwandan women, HIV infection was associated with decreased MDRD eGFR. The prevalence of decreased eGFR among HIV-infected women in our study was lower than that previously reported in African-Americans and in other Central and East African HIV populations, although there was substantial variability depending on the equation used to estimate GFR. Future studies are needed to optimize GFR estimates and to determine the impact of antiretroviral therapy on kidney disease in this population. In 2008 there were an estimated 33.4 million individuals living with human immunodeficiency virus (HIV) infection. Sub-Saharan Africa bears the greatest burden of disease, with two-thirds of all HIV-infected individuals We examined enrollment data from the Rwandan Women's Interassociation Study and Assessment (RWISA), an observational cohort study of HIV-infected and uninfected Rwandan women, to determine the prevalence of kidney disease in this previously unstudied population.except for exposure to single-dose nevirapine. At study entry, participants provided demographic information and medical and psychosocial history. Physical examinations and bioimpedance analysis were performed by trained research nurses. Specimens were obtained at enrollment for CD4 cell count, serum creatinine and albumin, urine pregnancy test, and dipstick urinalysis.RWISA is an observational prospective cohort study investigating the effectiveness and toxicity of ART in HIV-infected Rwandan women. Nine hundred thirty-six women (710 HIV infected and 226 HIV uninfected) enrolled in 2005. Written informed consent was obtained in accordance with protocols approved by the Rwandan National Ethics Committee and the Institutional Review Board of Montefiore Medical Center, Bronx NY, USA. Inclusion criteria for RWISA included age ≥25 years, willingness to be HIV tested and return for follow-up, and presence in Rwanda in 1994. HIV-infected women were also naïve to ART at entry, 2 to allow comparison with previous observational studies and with current guidelines for the diagnosis of CKD 2, the level at which dose adjustment is recommended for most NRTI. Finally, we considered the impact of eliminating the adjustment factor for black race in the MDRD and CKD-EPI equations, based on evidence that this adjustment may not perform well in African populations Blood pressure was recorded as the average of two sphygmomanometry measures. Total body fat and fat free mass were calculated using established techniques 2 among the cohort overall and in HIV-infected women in separate models. Variables tested for inclusion in the models included HIV status, age, serum albumin, BMI, lean body mass, total body fat, and systolic and diastolic blood pressure. CD4 count was assessed in HIV-infected women. As the primary predictor of interest, HIV serostatus was forced into multivariate models, while other covariates with p-value<0.05 were retained in the final models using backwards selection.Continuous and categorical variables were compared between groups using Student's T-test or Wilcoxon rank sum test and Pearson's Chi-Square or Fisher's Exact test as appropriate. Stepwise multivariable logistic regression evaluated associations with proteinuria and eGFR<60 mL/min/1.73 mversus 43 years, p<0.01). Self-reported diabetes and hypertension were rare, with a trend towards more hypertension among HIV-uninfected women. Median weight was 52 kg and median BMI was 20.9 kg/m2, with no significant difference between HIV-infected and HIV-uninfected women.Eight hundred ninety-one non-pregnant women were included in the current analysis (677 HIV infected and 214 uninfected), including 865 with data available for estimation of GFR and 739 with eligible urine specimens for assessment of proteinuria . HIV-inf2 and 64 women (8.7%) had proteinuria ≥1+ .Overall, 21 women (2.4%) had an MDRD eGFR<60 mL/min/1.73 muria ≥1+ . The preemployed . Similarquations . There wThe proportion of women with decreased eGFR or proteinuria did not differ significantly between HIV-infected and -uninfected women, regardless of the equation used to calculate eGFR. However, after adjusting for age, blood pressure, body composition, and serum albumin , HIV infIn this well-characterized cohort of Rwandan women, HIV infection was independently associated with decreased MDRD eGFR in adjusted, but not unadjusted, analysis. The prevalence of decreased MDRD eGFR among HIV-infected women in this study was lower than that observed in previous studies in HIV-infected African-Americans Both HIV-associated nephropathy (HIVAN) and HIV-related ESRD are known to disproportionately affect African-Americans With expanding access to ART across Africa, including the use of agents with nephrotoxic potential, the local prevalence of HIV-related CKD may be a valuable determinant of the need to screen and monitor for CKD in individuals initiating ART. The Development of ART in Africa Trial (DART) randomized adults initiating ART in Uganda and Zimbabwe to routine laboratory monitoring or clinically driven monitoring, with laboratory data collected for all subjects but only made available to providers in the clinically driven monitoring arm when requested based on clinical signs and symptoms The relatively low prevalence of decreased MDRD eGFR observed in Rwandan women would support the safety of WHO recommendations to forgo universal pre-ART CKD screening in this population Prior studies in Central and East Africa have reported a higher prevalence of decreased MDRD eGFR among ART-naïve individuals than we observed in the current study In addition to the lack of validated GFR estimates for use in an African population, this study has several other important limitations. RWISA enrolled a cohort of HIV-infected women with a broad range of CD4 count and clinical disease, and prevalence estimates derived from this study may not be generalizable to Rwandan men and older women or to individuals with very advanced HIV disease. In addition, we were limited by the use of a single serum creatinine and a single urinalysis to identify women with kidney disease. Guidelines for CKD diagnosis require documentation of decreased eGFR or proteinuria for at least 3 months In a well-characterized cohort of Rwandan women, HIV infection was associated with decreased MDRD eGFR but not with the presence of proteinuria. The prevalence of decreased eGFR among HIV-infected women was lower than that reported in previous studies in Central and East Africa, supporting the WHO's recommended strategy of targeted pre-ART screening for CKD in this setting


Twenty-nine years into the HIV epidemic, several advances have been made; however, there remain several challenges particularly with pediatric HIV in resource-limited countries. The obstacles facing pediatric antiretroviral therapy (ART) delivery in resource-limited countries are multifaceted: lack of health care infrastructure, limited availability of pediatric drug formulations, lack of early HIV diagnostic and monitoring techniques, limited manpower with expertise in pediatric HIV care, limited donor funding, and competing public health priorities with limited health care budget. In this paper, the challenges with various ART monitoring tools in resource-limited countries are discussed. Noninvasive  and invasive  monitoring tools are discussed. Several cheap and technically less complex laboratory tests for monitoring are becoming available. Funding agencies and country programs should invest in validating the use of current technologies to optimize pediatric HIV care in resource-limited countries. The disparity in global coverage of ART,as illustrated in The current state of the HIV epidemic can be likened to the description of the setting of Charles Dickens's novel, “A Tale of Two Cities”—“it was the best of times, it was the worst of times, it was the age of wisdom, it was the age of foolishness, it was the epoch of belief, it was the epoch of incredulity…” Twenty-nine years into the HIV epidemic, several advances have been made; however, there remain several challenges with regard to access and management of antiretroviral therapy (ART), particularly in resource-limited countries. While the birth of an HIV-infected child is rare in resource-rich countries, mother-to-child transmission (MTCT) of HIV continues to fuel the HIV epidemic in resource-limited countries . Two senThe hallmark of HIV infection is progressive CD4+ T cell depletion leading to an increased risk for the development of opportunistic infections, acquired immune deficiency syndrome (AIDS), and death –10. The 3 or %CD4+ ≤25, whichever is lower, irrespective of WHO clinical stage, (iv) HIV-infected children more than 5 years of age with a CD4+ T cell count of ≤350 cells/mm3 (as in adults), irrespective of WHO clinical stage, (v) HIV-infected children with WHO clinical stages 3 and 4, irrespective of CD4 count, and (vi) any child less than 18 months of age who has been given a presumptive clinical diagnosis of HIV infection [http://AIDSinfo.nih.gov/). Due to the lack of accessible and affordable laboratory services, these tests are not routinely available in many resource-limited settings [The goal of HAART is to suppress HIV viral replication and restore immune function. Successful treatment results in virologic suppression, a quantitative increase in the number of CD4+ T cells, and improvement in the clinical well-being of the individual, manifesting as weight gain and resolution or control of opportunistic infections. In resource-limited countries, the World Health Organization (WHO) recommends initiating ART for (i) HIV-infected infants diagnosed in the first year of life, irrespective of CD4 count or WHO clinical stage, (ii) HIV-infected children between 12 and 24 months of age irrespective of CD4+ T cell count or WHO clinical stage, (iii) HIV-infected children between 24 and 59 months of age with CD4+ T cell count of ≤750 cells/mmnfection . Despitenfection , 21–25. nfection . In USA,settings . The WHODirect patient monitoring is the most affordable and cost-effective measure and forms the backbone of clinical care, treatment, and prevention. The WHO has published technical guidelines outlining ART care of infants and children to guide health care delivery programs in resource-limited countries . These gGood record keeping continues to be a perennial problem in most resource-limited countries. Many health care providers are not proficient in basic data management skills, and the few who are proficient in data management are overloaded with work such that data management is not their priority. There is a need for national programs to invest in training data management personnel to assist the providers in collecting, storing, and analyzing data.Clinical events monitoring provides a noninvasive and low-cost measure for following patients on HAART. Since the ultimate goal of HAART is to restore immune function and halt HIV disease progression, the presence or absence of certain clinical events can be used as surrogates for monitoring the efficacy of HAART. Children starting ART in resource-limited countries are usually severely immunocompromised and very sick –25. The The majority of children starting ART in resource-limited countries have growth deficiencies. Growth failure in HIV-infected children is a multifaceted problem; it is partly due to the underlying HIV infection itself, with its lack of virologic and immunologic control prior to ART, HIV-associated opportunistic infections, and food deprivation resulting from poverty. Several studies have demonstrated weight gain in children after initiating ART , 30. On Clinical algorithms based on signs, symptoms, and simple laboratory assays are being used to identify and treat patients needing ART in resource-limited countries , 37. TheAdherence to treatment regimens is a prerequisite for the efficacy and durability of any antiretroviral therapy regimens , 41. In One study compared the relative performance of various low-cost adherence measures: caregiver recall, pill counts at scheduled visits, and unannounced pill counts at home visits. The proportion of patients who achieved perfect adherence  was 72%, 89%, and 94% when measured by unannounced pill count, caregiver report, and pill count at scheduled visits, respectively . In a stThough the importance of adherence is universally recognized, there is no consensus on how to measure adherence. Several programs have adopted adherence measures based on availability of resources. For example, in Malawi, patients are given a 30-day supply of 60 antiretroviral (ARV) pills, and a pill count is carried out at each visit (every 28 days), and patient adherence is said to be >95% if a patient has eight pills or fewer at each visit . ColumbiCD4+ T cell count remains the single most important parameter in monitoring ART in HIV-infected individuals , 50–52. Because of the well-known large natural decline and variation in absolute CD4+ T cell numbers in early childhood , 64, theHIV viral load is a useful tool for initiation and monitoring of ART . It is nImmunologic and virologic measures are the state of the art for monitoring antiretroviral therapy and should be made available in all settings where HIV infection is treated.With the current ARV scale-up campaign, there is an unprecedented call on scientists to develop simpler, more robust, low-maintenance, and cost-efficient laboratory technologies for monitoring antiretroviral therapy in resource-limited countries. Posterity will not forgive modern science if it does not deliver its promise to help mankind in its dire needs . Moreove3 during the first year of virologic suppression on ART, followed by a gradual increase [HIV primarily targets CD4+ T cells, and CD4+ T cells play an essential role in HIV pathogenesis . Gut-assincrease . Given tincrease . Despite the global effort to make CD4+ T cell determination available in all HIV treatment centers, there are still quite a number of centers in resource-limited countries with no access to reliable CD4+ T cell enumeration. The challenge has been to develop a technology easy to operate, able to withstand the tropical environment that could be hostile to equipments, compatible with intermittent electric power delivery, and affordable . SeveralMany programs in resource-limited countries are using these affordable technologies; however, not all the devices are designed for pediatric HIV management as they do not measure the percentage of CD4+ T cells. The percentage of CD4+ T cells, rather than the absolute number, has been used as a marker of HIV disease progression in children . This isViral load testing that has been shown to optimize HIV care in resource-rich countries is currently unavailable in most resource-limited countries. HIV RNA assays used in resource-rich countries—Abbott m2000 test, the Roche COBAS Taqman test, bioMérieux NucliSens HIV-1 QT Assay, and Versant HIV-1 RNA 3.0 Assay (bDNA)—are not accessible in resource-limited countries due to costly technical equipment, complex technology, expensive reagents, poor laboratory infrastructure, and prohibitive maintenance cost. Unfortunately, the available commercial assays for viral load determination are very expensive (between $50 and $100 per test) making it unaffordable to many centers in resource-limited countries . CD4+ T http://www.iquum.com/products/analyzer.shtml), and the SAMBA assay (http://www.haem.cam.ac.uk/ddu/). The performances of these assays in comparison to assays used in resource-rich settings have received mixed reviews [There are several cheaper viral load assays being developed and evaluated for use in resource-limited countries. Examples of these assays are the ultrasensitive p24 assay , the ExaVir Load reverse transcriptase activity test (an assay that quantify virion-associated reverse transcriptase enzyme), “home-made” real-time PCR HIV-1 RNA assays, the Liat HIV RNA analyzer ( reviews , 82. Eff reviews .There are preponderance of evidence to suggest that the use of CD4+ T cell enumeration and viral load determination in resource-limited countries is the way to go as the use of clinical algorithms are confounded by the protean of infections and diseases that can masquerade as HIV- or AIDS-associated conditions. The arguments against their routine use are sustained more by consideration of cost, technical expertise, and lack of infrastructure . CountryGreat times and innovative technologies are on the horizon for HIV care, particularly for pediatric HIV care in resource-limited countries. The goal is not to abandon the tried and tested monitoring modalities such as CD4+ T cell count and viral load determinations but to develop technologies that will make these affordable, accessible, and acceptable in resource-limited countries. Funding agencies and country programs should invest in validating the use of current technologies to optimize pediatric HIV care in resource-limited countries.


Lichen planus (LP) is a chronic inflammatory disease of probable immune-based etiology. The pathogenesis of LP is unclear, but apoptotic changes in epidermal  cells have been reported. Destruction of the basal cell layer is observed and many changes in cell proliferation, cell repair and cell death occur in the injured mucosal epithelium. The aim of this study was to evaluate and compare the expression of bax and bcl-2 in oral lichen planus (OLP), well differentiated oral squamous cell carcinoma (WOSCC) and normal mucosa. Sixty one paraffin-embedded biopsy including 11 cases of WOSCC, 30 cases of OLP  and 20 normal mucosa were entered in our research. We used immunohistochemistry staining method for assessing bax and bcl-2 expression in epithelial layers. The percentage of stained cells was estimated in 5 randomized microscopic fields and classified as (-): 0%, (+) :< 10%, (++): 10-25%, (+++): 26-50%, (++++): > 50% positive cells. The data were analyzed with Mann-Whitney, Chi Square, and Kruskal-Wallis tests. Significant differences in bax expression were observed among OLP, WOSCC compared to normal mucosa (P=0.008). No significant difference in bax expression between OLP-E and OLP-R compared to WOSCC was seen (P>0.05). Bcl-2 was negative for all OLP and normal mucosa samples, and weak positivity was observed in WOSCC samples. According to the findings of our study, it may be possible to correlate the difference of bax and bcl-2 expression levels among the mentioned lesions to the malignant potential of OLP. RLichen planus (LP) is a chronic inﬂammatory disease of skin and mucosa affecting approximately 1-2% of the adult population  classified OLP as a potentially malignant disorder, but it presents a lower risk of malignant transformation compared to leukoplakia and erythroplakia . Some auApoptosis is a programmed cell death which is induced by cell damage beyond repair, viral infection or stress conditions such as starvation. Apoptosis can be caused by the cell itself, the surrounding tissue or inflammatory cells . The triIt is currently known that alterations in the mechanisms of cell proliferation and apoptosis are essential for carcinogenesis. Alterations in expression and consequently, function of such proteins may be a strong indicator for malignant transformation of a lesion. Among the several proteins involved in cell proliferation and apoptosis processes, bcl-2 and bax deserve greater attention; not only for their known key role in these processes but also for the participation in the human carcinogenesis process especially in oral cavity . DetectiThe increase in expression of bcl-2 is not only essential for oral carcinogenesis, but also influences the progression of the disease. Because it increases the survival rate of neoplastic cells, allowing new genetic mutation to occur and granting their higher resistance to chemotherapy and radiotherapy , 17. ConSamples A total of sixty paraffin-embedded biopsy samples with diagnosis of OLP and OSCC were collected from the archive of oral and maxillofacial pathology department of Babol dental school. The specimens included 30 of OLP, 20 samples of normal mucosa (Periphery of OLP samples)  and 11 oImmunohistochemical staining2O2 in methanol for 20 min to block the endogenous peroxidase activity. Slides were then washed with Tris-buffered saline (TBS) and heated for 15 min at 100°C in 10 mM sodium citrate buffer (pH 6.0) and boiled in a microwave oven (700 W) for antigen epitope retrieval. Non-specific binding was blocked by incubation of slides with 1% BSA for 1 h. Sections were incubated with primary antibodies  overnight at 4 °C, then biotinylated horse antimouse IgG secondary antibodies were used at 1: 200 dilution for 30 min, then visualized using diaminobenzidine (DAB) as chromogen. Slides were washed with TBS after each step. Finally, they were counter-stained with Mayer’s hematoxylin, dehydrated and mounted with DPX mountant. Negative control samples were processed in parallel to the test samples by replacing the primary antibody with phosphate buffer saline (PBS). We used breast carcinoma and normal tonsil tissue as positive control for bax and bcl-2 respectively.Immunohistochemistry procedure was used to detect the expression of bax and bcl-2 markers. Briefly, 4 µm thick sections from formalin-fixed and paraffin-embedded samples were prepared. The peroxidase-antiperoxidase (PAP) technique was used, performing immunohistochemical analysis by means of the avidin-biotin method. Slides were deparaffinized in xylene, rehydrated and incubated with 0.5% (v/v) HMicroscopic examination was performed by a pathologist under Olympus BX41  light microscope. Expression index was determined based on the percentage of stained cells in basal and parabasal layers in five high power fields. Cases were assigned to one of the following categories: 0% positive cells (-), <10% positive cells (+), 10-25% positive cells (++), 26-50% positive cells (+++) or >50% positive cells (++++) . Statistical analysisSPSS Version 18.00 was used for statistical analysis. The data were analyzed using the Mann-Whitney, Chi-Square, and Kruskal-Wallis tests.Significant differences in bax expression were observed among OLP and WOSCC compared to normal mucosa (P=0.008). No significant diff-erence in bax expression was seen between OLP-E and OLP-R compared to WOSCC  . There was no significant difference in bax expression between OLP-E and OLP-R (P=0.91). Bax expression in OLP was significantly higher than normaloral mucosa (P=0.007), but no statistically significant difference between OLP and WOSCC in bax expression level was seen (P=0.089)  Fig. 2,. No exprDuring the last few decades, there has been a large debate on the malignant transformation of OLP and the results are still conflicting. According to WHO definition, a precancerous lesion is a morphologically altered tissue in which cancer is more likely to occur than in its apparently normal counterpart -21. The In our study, a significant difference in Bax expression between OLP and normal mucosa was found. This finding was similar to Abdel-Latif et al. , Bloor eAccording to our research findings, the expression of bax was significantly different in OLP compared to WOSCC. Bax expression showed no significant differences between OLP-E, OLPR and WOSCC. Sousa et al. found that Bax expression was significantly higher in epithelial dysplasia compared to OLP with a similar Bax expression in OSCC and OLP , 27.This fact can indicate a deregulation of the apoptotic mechanisms in OLP, preventing the death of genetically damaged cells and consequently, increasing the malignant transformation risk -28. SomeIn 21 cases (70%) of OLP, Bax protein was expressed, but the percentage of cells expressing Bax in OLP-E was not significantly different from OLP-R. Bascones-Ilundain et al. found that the expression of bax in the erosive-atrophic type of OLP was similar to reticular type . If atroIn this study, bcl-2 was not expressed in any of OLP samples, similar to the findings of Sklavounou et al.  and LeyvTissue growth depends on the relative rates of cell proliferation and cell death. Decreasing the percentage of apoptotic cells may contribute to tumor formation and progression by increasing cell survival. Higher bax expression not only compen-sates the increase of the cell proliferation rate but also allows the elimination of cells with irreversible genetic damages, which may reduce the effect of carcinogens on the epithelium .Both antiapoptotic Bcl-2 and proapoptotic Bax belonged to apoptosis regulatory proteins. Bcl-2 can form homodimers (Bcl-2 and Bcl-2) and heterodi-mers (Bcl-2 and Bax). In normal conditions, antiapoptotic Bcl-2 forms heterodimers with proapoptotic Bax and inhibits the activation of Bax. When Bcl-2 is over expressed, Bcl-2 homodimers dominate and cells are protected against death. When Bax is in excess, Bax homodimers are predominant and cells can undergo apoptosis. The ratio of Bcl-2⁄Bax regulates the release of cytochrome C from the mitochondria. The follo-wing activation of the caspase and proteolytic cascade leads to cell death. So, cell apoptosis depends on the ratio of these two proteins .For some authors, the small number of apoptotic cells detected in OLP is explained by the brief duration of the apoptotic process (2-3 h) or by the so-called section plane effect, according to which some of the nuclei of some keratinocytes are not observed due to the histologic sectioning, so that even if they are in apoptosis, apoptosis signs are not detected -14, 35. The observation that Bax was more exten-sively distributed than Bcl-2 may be consistent with the concept that Bax regulates apoptosis by forming heterodimers with Bcl-2. In those cases of lichen planus in which Bcl-2 was absent, Bax may have bound with other regulatory proteins, including other members of the Bcl-2–related family, such as Bcl-x, McL-1, Bad or Bak. It is conceivable that in OLP, apoptotic cell death may be controlled by extracellular instead of molecular regulators, such as Fas and its ligand (FasL) , 37. IndAuthors declare no conflict of interest.


Expression of microRNAs (miRs) has been shown to be altered in many solid tumours and is being explored in melanoma. The malignant potential of some melanocytic lesions is difficult to predict. We hypothesised that characterisation of miR expression in borderline melanocytic proliferations would lead to the identification of a molecular profile that could be used with known prognostic factors to differentiate lesions with high malignant potential.The miR expression profile of melanocytic lesions  was evaluated by real-time PCR.P<0.0001). In situ hybridisation confirmed these results. miR-21 and miR-155 were significantly overexpressed within borderline lesions . When borderline lesions were categorised by mitotic activity and Breslow thickness, miR-21 was associated with mitotic activity and miR-155 was associated with thickness (P<0.025). Among 14 patients with borderline lesions who underwent sentinel lymph node biopsy (SLNB), positive SLNB was associated with increased miR-21 and miR-155 in the primary lesion compared with lesions with a negative SLNB.PCR analysis revealed primary cutaneous melanomas had an 8.6-fold overexpression of miR-21 and a 7.5-fold overexpression of miR-155 compared with benign naevi (MicroRNA expression profiles can be used to characterise atypical melanocytic lesions. MicroRNAs (miRs) are a recently discovered class of small non-coding RNAs . The binEach miR is believed to regulate multiple genes. Hundreds of miR genes have been identified in humans, and thus the regulatory potential of miRs is enormous .Melanocytic proliferations are among the most diversified of cutaneous lesions ranging from completely benign naevi such as the junctional naevus, congenital naevus and blue naevus to those with overtly malignant features. This group of proliferations is nebulous both clinically and morphologically. These so-called borderline  melanocytic lesions manifest architectural features and cytologic atypia, which exceeds those encountered in naevi. In such cases, the potential for an aggressive biological course arises. A categorical approach to the borderline melanocytic proliferation has been proposed by Borderline lesions pose a therapeutic dilemma for clinicians, as a false-negative reading of a benign naevus could lead the clinician to recommend against further therapy. Under-treatment of a melanocytic lesion with malignant potential could thus adversely impact survival. Conversely, over-treatment of a false-positive reading of malignancy could lead to needless morbidity from surgery or adjuvant therapy. Therefore, we sought to identify molecular markers that could be used to further characterise these lesions and predict their clinical behaviour. Current prognostic indicators for primary melanoma lesions include Breslow depth and ulceration . The melanomas were classified according to established criteria with recognition of the presence or absence of the radial growth phase and/or vertical growth phase. The cases were derived retrospectively and reflect consecutive encounters from the routine and consultative dermatopathology practice of the Ohio State University Medical Center's Department of Pathology. The cases were encountered between 2000 and 2006 (IRB no. 2007 C0015). For RNA isolation, four to eight unstained 20 Paraffin-embedded tissue was harvested utilising the RecoverAll Total Nucleic Acid Isolation Kit as per the manufacturer's recommendations . Nuclease-free water was used to elute the RNA.−ΔCT) compared with internal control RNU6B.Single tube TaqMan MicroRNA Assays were used to detect and quantify mature miRs. All reagents, primers and probes were obtained from Applied Biosystems . PCR for RNU6B, a small ubiquitous RNA, was used to normalise all RNA samples. Reverse transcriptase reactions and real-time PCR were performed according to the manufacturer's protocols. Gene expression levels were quantified using the ABI Prism 7900HT Sequence Detection System (Applied Biosystems). Comparative real-time PCR, using the Ct method, was performed in triplicate, including no-template controls  (yes vs no) using an adjusted α=0.025 level of significance to control for the two miR comparisons for each parameter.For the comparisons of miR expression between benign naevi and malignant melanoma cases, summary statistics for the fold change  were first calculated for benign naevi and malignant melanoma separately. Two sample vs RNU6B=25.9±22.4 and 1.5±1.9, respectively) as compared with benign naevi . Significant overexpression of four of the other miRs was also observed  compared with benign naevi , however, this finding was not significant (P=0.5474)  . Examinain situ hybridisation was used to evaluate the expression of miR-21 and miR-155 in a subset of samples. miR-21 and miR-155 expression was not detected in normal skin  and miR-155  were significantly overexpressed. Interestingly, a statistically significant positive correlation between the expression of miR-21 and the expression of miR-155 was observed in borderline melanocytic lesions  and the atypical Spitz tumours (n=22) manifested significantly increased levels of miR-21 . miR-155 was upregulated in both the nevoid borderline lesions and atypical Spitz tumours; however, the increase was not significant .MicroRNA expression was further analysed according to lesion type in the two largest groups of borderline lesions as compared with benign naevi (ratio of fold change). The nevoid borderline lesions (n=19) expressed significantly higher levels of miR-21 (using RNU6B as a control) as compared with lesions with no mitotic activity (n=15)  had significantly higher levels of miR-155 expression as compared with lesions with a depth <1 mm   was 15.37±11.37 in SLNB-positive patients vs 5.39±4.28 in SLNB-negative patients. For miR-155, the fold change was 0.83±1.09 in SLNB-positive patients vs 0.46±0.53 in SLNB-negative patients . Plans are underway for a prospective analysis of the expression of miR-21 and miR-155 and other candidate miRs in patients that undergo SLNB for indeterminate lesions.It is difficult to make a definitive determination of malignant potential in some patients with borderline melanocytic lesions, and in some cases the regional lymph nodes will be assessed via SLNBs. In an exploratory analysis, we examined the expression of miR-21 and miR-155 in 14 of the 49 patients who had undergone a SLNB after being diagnosed with a borderline melanocytic lesion. Patients with a positive SLNB were found to have higher levels of miR-21 and miR-155 expression in the primary lesion as compared with lesions from patients who had a negative SLNB. For miR-21 the fold change . Using a highly sensitive PCR-based method, they found that miR-146, miR-204 and miR-211 were uniquely expressed in these melanoma cell lines as compared with normal tissues and the other 51 cell lines in the panel. In contrast, we found that miR-211 was downregulated in primary tumours  while the expression of miR-146 and miR-204 was not upregulated. The discrepancy between the two studies can likely be ascribed to the unique make-up of the NCI-60 panel.Several studies have examined miR expression in malignant melanoma. A few of these have identified miR-21 and miR-155 as being dysregulated. Using high-resolution array-based comparative genomic hybridisation, vs metastasis), and the applicability of data obtained from cell lines to the clinical situations. Given that overexpression of miR-21 and miR-155 in melanoma primary tumours was confirmed using three distinct assays, we feel that further analysis of these miRs in the setting of melanoma is highly warranted.A series of recent studies largely agree with the present report. Histopathological evaluation is currently the standard method for the classification of borderline lesions. Few studies have examined methods to characterise the malignant potential of borderline melanocytic lesions. in vitro studies have shown that increased miR-21 expression promoted invasion and metastasis and could modulate chemosensitivity (miR-21 has been shown to be upregulated in a variety of solid malignancies including cancers of the brain, breast, colon, lung, pancreas, prostate, stomach and haematolymphoid tissues, while increased miR-155 expression has been observed in cancers of the thyroid, lung, breast, colon, pancreas and haematolymphoid tissues (We have demonstrated that miR-21 correlates with mitotic activity and miR-155 correlates with lesion depth of borderline lesions. Although SLN-positive borderline lesions showed higher expression of miR-21 and miR-155, additional cases must be examined before any firm conclusions can be drawn. In the future, miR profiles may be utilised to help differentiate between lesions, establish prognosis, and prompt a more thorough search for foci of invasion.


Macrophomina phaseolina is an emerging and devastating fungal pathogen that causes significant losses in crop production under high temperatures and drought stress. An increasing number of disease incidence reports highlight the wide prevalence of the pathogen around the world and its contribution toward crop yield suppression. In cowpea [Vigna unguiculata (L) Walp.], limited sources of low-level host resistance have been identified, the genetic basis of which is unknown. In this study we report on the identification of strong sources of host resistance to M. phaseolina and the genetic mapping of putative resistance loci on a cowpea genetic map comprised of gene-derived single nucleotide polymorphisms (SNPs) and amplified fragment length polymorphisms (AFLPs).2), were identified using plant mortality data taken over three years in field experiments and disease severity scores taken from two greenhouse experiments. Based on annotated genic SNPs as well as synteny with soybean (Glycine max) and Medicago truncatula, candidate resistance genes were found within mapped QTL intervals. QTL Mac-2 explained the largest percent R2 and was identified in three field and one greenhouse experiments where the QTL peak co-located with a SNP marker derived from a pectin esterase inhibitor encoding gene. Maturity effects on the expression of resistance were indicated by the co-location of Mac-6 and Mac-7 QTLs with maturity-related senescence QTLs Mat-2 and Mat-1, respectively. Homologs of the ELF4 and FLK flowering genes were found in corresponding syntenic soybean regions. Only three Macrophomina resistance QTLs co-located with delayed drought-induced premature senescence QTLs previously mapped in the same population, suggesting that largely different genetic mechanisms mediate cowpea response to drought stress and Macrophomina infection.Nine quantitative trait loci (QTLs), accounting for between 6.1 and 40.0% of the phenotypic variance (REffective sources of host resistance were identified in this study. QTL mapping and synteny analysis identified genomic loci harboring resistance factors and revealed candidate genes with potential for further functional genomics analysis. Macrophomina phaseolina (Tassi) Goid. is a soil-borne deuteromycete fungal pathogen with a worldwide distribution and a host range that includes more than 500 crop and non-crop plant species [ species . The fun species . Major c species -8, whichMacrophomina result in significant yield losses [Macrophomina infection under drought stress being a major yield-suppressing factor in this agro-ecological zone.In the arid sub-Saharan region of West Africa where cowpea is a crop of major economic importance for resource poor farmers, seedling damping-off and ashy stem blight diseases of cowpea caused by d losses . Cowpea d losses . The subd losses . As a reMacrophomina on elite drought-tolerant cultivars in breeding programs. In evaluations of drought-tolerant cowpea genotypes, Ndiaye [Macrophomina infection. With the exception of the stay-green trait in sorghum [Macrophomina.The synergism between disease severity and drought stress is important in breeding programs which are developing drought tolerant cultivars. In cowpea, as in other crops, significant investments continue to be made in the genetic improvement of crop productivity under limited water conditions . However, Ndiaye  reported sorghum , there aMacrophomina is a potential option for resource-poor farmers. However, in cowpea, only minor sources of resistance have been reported among a few genotypes evaluated in India [Macrophomina than early-maturing varieties [Host plant resistance-based management of in India  and Senein India , and no in India -18, soybin India ,20, and in India ,22. Furtarieties  and sorgarieties .Macrophomina infection in a diverse set of fourteen cowpea genotypes as well as identifying and mapping quantitative trait loci (QTL) associated with resistance to Macrophomina infection in a recombinant inbred line (RIL) population, IT93K-503-1 × CB46. We used a genetic map developed by merging an AFLP-based map [Macrophomina resistance loci in cowpea was also evaluated.The purpose of this study was to evaluate the levels of resistance against ased map  and an eased map  for the ased map  incorporased map , the extMacrophomina-induced ashy stem blight on cowpea in the plots used for the experiments coupled with high temperatures and lack of significant precipitation in the study area enabled adequate disease development to facilitate phenotyping. Average maximum daily temperatures during the experimental periods were 33, 32, and 33°C for the 2006, 2007, and 2008 seasons, respectively, whereas average minimum temperatures were 17, 16, and 17°C, respectively. For the same periods, total precipitation received was 1.0, 0.5, and 6.1 mm, respectively.Sufficient disease incidence for differentiation of cowpea genotypes was observed in drought-stressed field experiments conducted in each of the three years. The historically high incidence of Macrophomina infection among the diverse set of fourteen cowpea genotypes over the two experiments conducted in 2006 and 2007 . Further, both greenhouse experiments were correlated r = 0.6217) for disease severity, however correlations between field and greenhouse experiments were mostly insignificant with the exception of the field experiment conducted in 2007 and greenhouse experiment 1  and Mat-1 , respectively [Macrophomina resistance allele was associated with lateness in maturity.QTLs ectively ,  gene, co-located with the QTL peak in two of the three experiments in which the QTL was identified  delayed senescence gene as well as a homolog of the ELF4 (Early Flowering 4) gene were found contiguous to the LHCB4.3 locus  were identified. LG7 and LG8 which harbored the two maturity QTL based on the AFLP-only map [QTL ne Table . Syntenyonly map  were cononly map . EMBL acMac-1 to Mac-8) were selected for the single and pair-wise analysis based on their consistency in map location across experiments. In general, mean percent mortalities for the null genotypes were higher than genotypes with favorable alleles. However, in the analysis based on single QTLs, only Mac-1, Mac-2 and Mac-7 showed statistically significant differences out of the eight QTLs . Individually, Mac-2 and Mac-5 resulted in reductions of mean percent mortality of 19.6% and 22.5%, respectively, suggesting an additive effect in genotypes carrying both favorable alleles. This QTL combination was chosen for further analysis using the 2006 and 2007 data. The Mac-2/Mac-5 combination resulted in a 65.6% reduction in mean percent mortality based on 2006 data and 58.5% for the 2007 data , grapevine (Vitis vinifera) and Arabidopsis [Macrophomina and B. cinerea share similar pathogenicity mechanisms involving pectin degradation as described above, these results suggest an important role for pectin-related genes in defense against Macrophomina. However, this cannot be addressed in the present study, and additional functional genetic studies will be required to validate this potential role. QTL Mac-2 coinciding with a pectin esterase inhibitor had the highest level of expression and statistical significance of all eleven resistance loci mapped in this study, making it a suitable target for molecular characterization. The significant effect of Mac-2 on Macrophomina resistance will likely result in noticeable and quantifiable change in phenotype sufficient to support its role as a Mendelian factor. Several other QTL mapped in intervals where disease resistance genes were found based on the cowpea genic-SNP markers and synteny with soybean and Medicago. These provide excellent additional candidate gene targets for functional characterization.Furthermore, genic SNP markers with disease resistance gene annotation and disease resistance-associated genes were found in the genomic intervals defined by the QTL and these were located within syntenic regions in soybean and escribed , and Radescribed  demonstr cinerea . Similarbidopsis . Since MMacrophomina resistance and maturity related senescence QTL in the RIL population used for mapping. This finding in cowpea supports the suggested association between early maturity and susceptibility to Macrophomina in other crops [Phytophthora infestans [Medicago, both flowering and chlorophyll-metabolism related candidate genes were identified within the two maturity-associated QTL intervals and no apparent disease resistance genes were identified. Although this does not exclude the role of other genes within these QTL intervals, these findings may provide additional molecular evidence for the association between early maturity and Macrophomina susceptibility that has been described previously.This study demonstrated the co-location of er crops ,19,23. Tnfestans -32. Siminfestans ,32. Gebhnfestans  suggesteMacrophomina susceptibility was demonstrated further by the locus carrying Mac-7 and Mat-1. This locus had the largest effect on maturity-induced senescence in a previous study [Macrophomina response QTL on this locus may limit its potential application in marker-assisted breeding programs due to tight linkage and possible pleiotropic effects. Breeding for Macrophomina resistant early-maturing varieties that are an important drought escape strategy in parts of West Africa will be complicated by the opposite effects that this locus confers to earliness and Macrophomina resistance. In our simulation study we selected Mac-2 and Mac-5 QTLs as possible target QTLs for pyramiding to improve Macrophomina resistance. The presence of these two QTLs resulted in a doubling in reduction of Macrophomina-induced mean percent mortality compared to the presence of either QTL individually. This gain in effect was, however, much less significant (gain of 1% - 3%) when we added a third QTL to this combination, suggesting that for breeding purposes, the value of pyramiding three loci compared to two may be markedly diminished.The association between early maturity and us study , and in Macrophomina infection. This represented a relatively small proportion of overlap considering the ten QTLs mapped for the drought response [Macrophomina infection. Whether this co-location is due to linkage or pleiotropy will require further experimentation especially for Mac-5 QTL where both osmotic stress and disease resistance genes were found in the corresponding syntenic soybean genomic region. Similar findings were reported in sorghum where the non-senescence drought tolerance trait was shown to be largely independent from the Macrophomina resistance trait [Macrophomina can cause significant crop losses even under mild drought stress conditions, and introgression of Macrophomina resistance loci should constitute an important component of the breeding schemes targeting genetic improvement with drought tolerance. Furthermore, because early maturing varieties are used as a drought escape strategy in rain-fed production systems, the introgression of non-maturity related resistance loci will be required to mitigate their susceptibility.Genetic overlap was observed in cowpea only between three QTLs mapped in response to drought-induced premature senescence and response to response  and ninece trait . These fMacrophomina phaseolina resistance in cowpea were identified and QTLs for trait determinants of the resistance were located on the EST-derived SNP map. Our observations of candidate genes in the QTL regions with annotations commensurate with the respective phenotype used in revealing the QTL, support this QTL-based approach in identifying genetic determinants of important traits in cowpea. The added resolution provided by synteny with reference legumes makes this approach highly effective. However, because numerous candidates were identified for each QTL, there is a need for effective complementary strategies such as virus-induced gene silencing (VIGS) to validate gene function. Functional analysis also will require a robust greenhouse screening protocol, which based on the inconsistent correlation with field experiments, must be optimized to facilitate such studies. The quantitative nature of Macrophomina resistance highlighted by the number of QTL identified in this study as well as the relatively low contribution of individual loci toward overall resistance makes breeding for this trait difficult. As such, targeting subsets of loci with higher cumulative effects followed by marker-assisted breeding offers an avenue to start incorporating resistance in economically important cultivars. However, the advent of high density marker-based breeding approaches such as whole-genome and genome-wide selection should enhance the ability of breeders to introgress numerous QTL within the context of the same breeding scheme.Important sources of 2:8 RILs developed by single seed descent from a cross between the drought tolerant medium-maturing breeding line IT93K-503-1 and drought susceptible early-maturing CB46 genotypes were evaluated in three field and two greenhouse experiments conducted in 2006, 2007, and 2008 for QTL mapping.Fourteen diverse cowpea genotypes were evaluated in two field experiments conducted in 2006 and 2007. The following genotypes were chosen from the University of California, Riverside cowpea germplasm collection: IT98K-499-39, Suvita 2, Mouride, Bambey 21, UCR24, IT98K-556-6, UCR232 (IT82E-18), CB27, CB46, IT93K-503-1, UCR779, 24-125B-1, 524B, and IT84S-2049. Lines having an 'IT' prefix are advanced breeding lines developed at the International Institute of Tropical Agriculture (IITA) whereas lines having a 'CB' prefix and UCR24 are cultivars and breeding lines developed in California for production of blackeye-type cowpeas. Genotype 24-125B-1 is an advanced breeding line developed by Institute of Agricultural Research for Development (IRAD) in Cameroon and UCR779 is a landrace accession from Botswana. The accessions represented genotypes with prostrate and erect growth habits, early and late-maturity, and photoperiod sensitivity and insensitivity. These genotypes also belong to high, moderate and low seedling drought tolerance classes as described by Muchero et al . In addiMacrophomina infestation and long-term cultivation of cowpea crops. The soil is classified as an Arlington fine sandy loam  [Macrophomina infection without the confounding effects of overly rapid onset of severe drought stress.Three field experiments were conducted from June to September of 2006, 2007, and 2008 at the Citrus Research Center-Agricultural Experiment Station (CRC-AES) of the University of California Riverside , USA. The experiments were planted alternately in 2 adjacent field plots with a history of ixeralf) . The quiMacrophomina plus non-stress treatment, while the stressed field block was considered the Macrophomina plus drought-stress treatment. The same set-up was adopted in 2008 except only RILs and the parental genotypes were evaluated and the well-watered comparison block was not included. Seedling emergence for the Macrophomina plus drought-stress treatment was recorded one week after planting. Macrophomina infection was allowed to occur naturally after which disease evaluation was conducted after 3 to 4 weeks from planting when symptoms of infection started to occur. At this stage, plant mortality counts were recorded for each plot every 7 days until the budding stage. Percent mortality was calculated using the final cumulative mortality counts for each RIL and genotype using the formula: % mortality =  ×100.For all field experiments, 200 greenhouse-grown seeds per genotype were distributed equally in 5 replicates, each planted on 5-m-long plots spaced 0.75 m apart. A subset of 57 RILs, two parental genotypes, and 14 diverse genotypes were evaluated in 2006 and 2007, whereas 108 RILs, which included all the 57 RILs evaluated before, and parental genotypes were evaluated in 2008. The experimental design was a randomized complete block. Drought stress was imposed by growing the crop with only two irrigations, a pre-irrigation about 7 days prior to planting, and a single post-planting irrigation applied 7 days after emergence. These irrigations were applied to furrows and of sufficient duration to fill the soil profile. No further irrigations were applied to the stress treatment. In 2006 and 2007, adjacent blocks having the same experimental material were grown under 'full' irrigation by applying irrigation to field capacity once every seven days for the duration of the active growing period. The well-watered block had 4 replicates and was considered as the M. phaseolina was carried out using the method described by Aboshosha et al [2 PDA plugs with microsclerotia were kept in sterile deionized water at room temperature for long-term storage. Koch's postulates were fulfilled using the isolated M. phaseolina cultures by inoculating greenhouse grown cowpea plants, observing disease development and re-isolating the fungal pathogen from diseased plants.Isolation and identification of ha et al  with min2 plug from long-term storage to a fresh PDA plate. PDA plates were incubated for 5 days at 35°C for maximum microsclerotia development. PDA with fungal mycelia and microsclerotia was then macerated in sterile water and filtered using quadruple layer cheesecloth to collect the microsclerotial suspension. Microsclerotia were counted under a light microscope and the suspension was adjusted to a final predetermined inoculum concentration of 250 ± 10 microsclerotia per ml de-ionized water.Inoculum for greenhouse studies was prepared by transferring a 1-cmMacrophomina-induced wilting and stem discoloration started to appear. From this stage, plants were rated every 3 days for the characteristic ashy-stem symptom by rating the progression from the soil line up the stem of stem discoloration resulting from infection. Symptoms appeared as a deep red to brown lesion that was visible initially just above the soil line. Disease severity was scored on a scale of 1 to 10 .Genotypes IT93K-503-1, CB46 and the set of 57 RILs were used in the greenhouse experiments. Greenhouse temperatures were maintained at 30°C during the day and 25°C during the night. Each experiment was carried out using 878-ml plastic pots filled with 750 g of steam-sterilized UC-MIX B  potting QTL analysis was conducted with the Kruskal-Wallis and Multiple-QTL Model Mapping (MQM) packages of MapQTL 4.0  using a Macrophomina resistance QTL on the cowpea high-density consensus map [http://www.harvest-web.org) as well as Glycine max and Medicago truncatula synteny relationships described by Muchero et al [Placement of nsus map  was faciro et al . Cowpea ro et al  in the EMac-1), 1_0853 (Mac-2), 1_0604 (Mac-3), 1_0201 (Mac-4), 1_0079 (Mac-5), 1_0804 (Mac-6), 1_0678 (Mac-7), and 1_0030 (Mac-8) were used in the genotypic classification exercise based on their association with the respective QTL (Table Data were analyzed for frequency distribution and Spearman Rank correlation using the Statistix 8.0 software . The eff0853 Mac-, 1_0604 WM, JDE, and PAR conceived and designed the experiment. WM and JDE conducted the experiment. WM, JDE, TJC, and PAR analyzed the data. WM, JDE, TJC, and PAR wrote the paper. All authors read and approved the final manuscript.


To compare anterior segment parameters measured using a semi-automatic software  applied to anterior segment optical coherence tomography (AS-OCT) images, with commonly used instruments.Cross-sectional study of a total of 1069 subjects (1069 eyes) from three population-based studies of adults aged 40–80 years. All subjects underwent AS-OCT imaging and ZAP software was applied to determine anterior chamber depth (ACD), central corneal thickness (CCT), anterior and keratometry (K) – readings. These were compared to auto-refraction, keratometry and ocular biometry measured using an IOLMaster, ultrasound pachymeter and auto-refractor respectively. Agreements between AS-OCT (ZAP) and clinical instrument modalities were described using Bland-Altman, 95% limits of agreement (LOA).The mean age of our subjects was 56.9±9.5 years and 50.9% were male. The mean AS-OCT (ZAP) parameters of our study cohort were: ACD 3.29±0.35 mm, CCT 560.75±35.07 µm; K-reading 46.79±2.72 D. There was good agreement between the measurements from ZAP analysis and each instrument and no violations in the assumptions of the LOA; albeit with a systematic bias for each comparison: AS-OCT consistently measured a deeper ACD compared to IOLMaster ; and a thicker CCT for the AS-OCT compared to ultrasound pachymetry . AS-OCT had good agreement with auto-refractor with at least 95% of the measurements within the prediction interval .This study demonstrates that there is good agreement between the measurements from the AS-OCT (ZAP) and conventional tools. However, small systematic biases remain that suggest that these measurement tools may not be interchanged. The anterior segment optical coherence tomography (AS-OCT) is increasingly being used to assess a number of common parameters of the anterior segment in various clinical settings. Anterior segment assessment is important for planning of surgical procedures. One of the limitations of AS-OCT is that there is no easy way to analyze the images rapidly and accurately. To address this gap, the Zhongshan Angle Assessment Program , a research, non-commercial software when applied to AS-OCT images, has been shown to reliably assess ACD and other anterior segment parameters. The aim of this study was to compare the anterior segment parameters derived from rapid assessment of AS-OCT images using the ZAP software, with conventional methods of assessment such as ultrasound pachymetry or biometry. Our multi-racial population representing three major racial groups in Asia provides a unique opportunity to study these anterior segment parameters. Our study subjects were recruited from the Singapore Epidemiology of Eye Disease Study, which comprises three population-based studies: the Singapore Malay Eye Study , the Singapore Indian Eye Study , and the Singapore Chinese Eye Study . Details of the study methodologies are published elsewhere. Ethnic Malays, Indians, and Chinese aged 40–80 years were randomly sampled to be included in each of these studies. For this particular study, we recruited subjects by systematically sampling (every fifth subject) who met the study eligibility criteria as described previously. We prospectively performed consecutive, anterior segment scans of the right eye from each participant using the AS-OCT  under standardized conditions of light (20 lux) by an operator who was masked to the results of the clinical ophthalmic examinations. r) were calculated to illustrate the strength of the linear relationship between various anterior segment parameters. Agreement between parameters from the ZAP AS-OCT images and the reference instruments was assessed using the method described by Bland and Altman, with 95% limits of agreement (LOA = mean difference ±1.96 SD) and its 95% confidence intervals calculated and assumptions checked. p-values were compared at a significance level of 5%.All analyses were performed using SPSS version 20 . Mean with standard deviation (SD) were calculated for continuous anterior segment variables. Mean differences in measurements between groups were assessed using independent and paired samples t-tests, where appropriate. Biases (%) were calculated by dividing mean differences over means of the anterior segment parameters. Pearson correlation coefficients  were analyzed in our study, of which we obtained reliable anterior segment measurements from 1069 eyes (96%) . The mean age of our subjects was 56.9±9.5 years and 50.9% were males. The demographics of our study subjects and their anterior segment parameters using each instrument are detailed in We summarized the anterior segment parameters comparing AS-OCT (ZAP) and the respective reference instruments in p-value <0.001), K-readings had a relatively lower Pearson correlation coefficient.In terms of K-readings, we found that there was good agreement as at least 95% of the data points were in prediction interval, with a proportional bias observed between the AS-OCT (ZAP) and the auto-refractor. The AS-OCT (ZAP) overestimated the K-readings compared to the auto-refractor by a mean of 2.81±2.36. The difference between the K-readings of the two methods was regressed on the average of K-readings of the two methods with its 95% prediction interval drawn – Although there were biases in the measurements, our study has demonstrated that the ZAP analyses of AS-OCT images produce measurements that are generally of good agreement with the reference instruments since at least 95% of the data points and differences were within the 95% prediction intervals and 95% LOA respectively. AS-OCT (ZAP) consistently measured a deeper ACD compared to IOLMaster (0.16±0.20 mm) and a thicker CCT compared to ultrasound pachymetry (16.8±0.53 µm). We also found that the AS-OCT (ZAP) had good agreement with auto-refractor measurements for K-readings, with at least 95% of the measurements within the prediction interval . Using this population-based study we are able to describe the relationship between the results using the ZAP software on the AS-OCT scans, and each instrument.The biases that we observed are likely due to either a fundamental difference in the principles of measurement between tools, or differences that have arisen from the actual analysis from the ZAP software. However, the aim of this study was not to determine why these observed differences exist, or if any one tool is superior – but instead, to demonstrate the usefulness of a rapid diagnostic software which may be used for AS-OCT image analysis and how the parameters compare to conventional tools used in our daily clinical practice. The ZAP software works by extracting the gray-scale images from the AS-OCT images and uses image processing and algorithms to define the anatomical landmarks, which has been described in detail before. Accurate ACD measurements are important for accurate biometric calculations, surgical planning and predicting risk of diseases such as angle closure. Previous studies have shown that anterior segment measurements using the AS-OCT are highly reproducible and show good repeatability, compared to the IOLMaster. Together with ACD, CCT is a clinically important parameter in the diagnosis of glaucoma, Keratometry, another important parameter used in IOL calculation, could also be directly calculated from AS-OCT using the ZAP software. Our population-based study demonstrated that despite the generally good agreement between AS-OCT measurements and the auto-refractor, there exists a proportional bias. This means that the AS-OCT may measure a lower K-reading compared to the auto-refractor for lower readings ; and a higher reading for measurements in the upper range . This may be due to differences in the way each tool makes the measurements: unlike the auto-refractor which assumes the cornea to be a convex mirror and uses reflected corneal mires to compute the radius of corneal curvature, the AS-OCT (ZAP) objectively measures the anterior and posterior corneal curvatures to derive the keratometry readings. The inability to detect the scleral spur, in suboptimal images and where the sclera formed a smooth continuous line, is another recognized limitation in all studies involving ZAP. However, we were able to reliably measure 96% of all our AS-OCT scan images. The advantage of the ZAP software is that once these scleral spurs are identified, the rest of the measurements are produced automatically. Only horizontal nasal–temporal AS-OCT scans were used, as these have been shown to be the most consistent with respect to obtaining high-quality images for the ZAP software to analyze. However, this ensured that there was a very high rate of scleral spur visibility and thus more valid scans, compared to if we had chosen vertical scans. In conclusion, we found a good agreement between the anterior segment parameters from AS-OCT ZAP analyses with conventional instruments. However, small systematic biases remain which suggest that these measurement tools may not be interchanged. Nevertheless, with further modifications, our study suggests that semi-automated software such as ZAP, applied to AS-OCT imaging, may improve the usability of a single imaging device to assess a set of anterior segment parameters in an objective way.


To explore the expected long-term health and economic outcomes of telaprevir (TVR) plus peginterferon alfa-2a and ribavirin (PR), a regimen that demonstrated substantially increased sustained virologic response (SVR) compared with PR alone in adults with chronic genotype 1 hepatitis C virus (HCV) and compensated liver disease in the Phase III studies ADVANCE (treatment-naïve patients) and REALIZE .A decision-analytic model was developed to assess the cost-effectiveness of TVR+PR vs. PR in the United States (US).Patients first moved through the 72-week decision-tree treatment phase of the model and then entered the cyclic Markov post-treatment phase. Clinical data  were obtained from ADVANCE and REALIZE. Health-state transition probabilities, drug and other costs (in 2012/2013 US dollars), and utility values were obtained from the trials, published studies, and publicly available sources. Outcomes were discounted at 3% per year.Regardless of treatment history, patients receiving TVR+PR were projected to experience fewer liver-disease complications, more life-years, and more quality-adjusted life-years (QALYs) than patients receiving PR. In prior relapsers, TVR+PR was dominant, with lower total medical costs and more QALYs. For the other patient subgroups, incremental costs per QALY gained were between $16,778 (treatment-naïve patients) and $34,279 (prior null responders). Extensive sensitivity analyses confirmed robust model results.At standard willingness-to-pay thresholds, TVR+PR represents a cost-effective treatment option compared with PR alone for patients with chronic genotype 1 HCV and compensated liver disease in the US. Future analyses are needed to compare TVR+PR with all existing HCV treatment options. Of the worldwide population, 2% to 3% (130–170 million people), including approximately 3.2 million in the United States (US), are chronically infected with the hepatitis C virus (HCV) The primary goal of treatment of chronic HCV infection is sustained virologic response (SVR), defined as undetectable HCV RNA 24 weeks after completion of treatment. Genotype 1 HCV infection accounts for about 75% of all cases in the US and is the most difficult to treat of the six identified genotypes Telaprevir (TVR) is an HCV NS3/4A protease inhibitor, which in combination with PR is indicated for the treatment of genotype 1 chronic HCV in adults with compensated liver disease, including cirrhosis, who are treatment naïve or who have been previously treated with interferon-based regimens. The efficacy and safety of TVR+PR compared with PR alone were investigated in the Phase III, randomized, double-blinded, multicenter trials ADVANCE (treatment-naïve patients) and REALIZE (previously treated patients) Achievement of SVR in patients with chronic HCV infection treated with PR has been shown to slow or arrest the progression of liver disease and reduce the associated risk of morbidity and mortality A two-phase (treatment and post-treatment) lifetime decision-analytic model was developed in Microsoft Excel to estimate the costs and health outcomes of TVR+PR combination therapy versus PR alone for parallel hypothetical cohorts of patients with chronic genotype 1 HCV infection with baseline METAVIR fibrosis scores F0 through F4 Patients entered the model at treatment initiation and moved through the treatment and post-treatment phases sequentially. The treatment phase tracked patients for 72 weeks in 4-week time intervals, using a decision-tree structure consistent with prescribing recommendations and with the designs of ADVANCE and REALIZE  [13], , [1The primary efficacy measure used in the model was achievement of SVR. SVR rates were stratified by baseline METAVIR fibrosis  and obtained from ADVANCE and REALIZE  [15]  were derived from separate retrospective analyses of managed care administrative claims data All costs are presented in 2012 US dollars (USD), except drug costs which are reported in 2013 USD ; where nUtility values quantify individual well-being on a scale from 0  to 1  and were used to convert time spent on treatment and in each health state into estimates of quality-adjusted life-years (QALYs). For the treatment phase, mean utility values by treatment and patient subgroup were calculated by applying US-specific valuation weights to response data from the EQ-5D-3L Health and economic outcomes derived from the model for both treatment arms included life-years, QALYs, cases of liver-disease complications, deaths, and total direct medical costs by type and overall. Additionally, the model used differences in these outcomes between the treatment arms to derive incremental cost-effectiveness ratios (ICERs), including the incremental cost per QALY gained. All outcomes are reported by patient subgroup and were discounted at an annual rate of 3% unless otherwise noted Sensitivity analyses were performed to assess the robustness of the model results and to determine the impact of parameter uncertainty. In one-way sensitivity analyses, input parameter values were varied individually across realistic ranges; in probabilistic sensitivity analyses (PSAs), all input parameter values were sampled from appropriate probability distributions and varied simultaneously in 10,000 Monte Carlo simulation runs. SVR rates were varied across estimated 95% confidence limits, assuming clinical trial values were beta-distributed. Because uncertainty information for other input parameters  was limited, the model utilized triangle distributions (in the PSAs) and relatively wide ranges . Scenario analyses also were performed to determine the impact of changes in model assumptions  and to assess the cost-effectiveness of TVR+PR in various patient subpopulations . All sensitivity analyses were performed on the model's primary cost-effectiveness outcome, incremental cost per QALY gained.Although the model projected higher HCV-treatment drug costs for patients who received TVR+PR than for patients who received PR alone, these costs were offset completely (for prior relapsers) or partially  by lower medical costs associated with chronic HCV care, liver disease, and its sequelae.The calculation of ICERs showed that TVR+PR dominated PR alone  in prior relapsers and exhibited incremental costs per QALY gained of $16,778 for treatment-naïve patients, $24,173 for prior partial responders, and $34,279 for prior null responders at the full acquisition costs of the products.The one-way sensitivity analyses showed that the incremental cost per QALY gained for TVR+PR compared with PR alone remained below $40,000 for treatment-naïve patients and below $50,000 for most input parameter values tested for prior partial responders and prior null responders; TVR+PR remained dominant for prior relapsers for most input parameter values tested. Model results were most sensitive to changes in the base-case SVR rates and transition probabilities for disease progression  in prior relapsers and cost-effective in all other patient subgroups at commonly cited willingness-to-pay thresholds in the US  Sensitivity analyses indicated that model results were robust to input parameter uncertainty. Similar to other models, scenario analyses found that our cost-effectiveness results stratified by sex, age, and starting METAVIR fibrosis score showed substantial differences Cost-effectiveness results also were sensitive to the model time horizon. The cost of HCV treatment is incurred in the near term, and while achieving SVR has short-term benefits A few studies have assessed the cost-effectiveness of PR alone in treatment-naïve patients. To validate the accuracy of our model, we compared results from our PR-alone arm to the corresponding results from these published studies. For treatment-naïve patients with genotype 1 HCV infection treated with PR alone, our model's estimated life expectancy, quality-adjusted life expectancy, and discounted lifetime direct medical costs  were similar to those reported in previous US models for similar populations  The cost-effectiveness ratios estimated by the model for TVR+PR versus PR alone were within the range reported for peginterferon plus ribavirin versus interferon plus ribavirin for patients with genotype 1 HCV infection  An important strength of our study is that we avoided some of the simplifying assumptions made in previous HCV models, which have been shown to bias cost-effectiveness results in favor of HCV treatment. These assumptions included assigning a utility value of 1.0 and assuming no further disease progression or liver-disease complications for patients achieving SVR Several limitations of this analysis should be mentioned. As with any economic model, the accuracy of the results depends on the robustness of the data inputs and assumptions. Long-term data on the natural progression of HCV infection and the impact of SVR are limited because HCV infection progresses slowly. The best available data were used, including a long-term observational study that followed 384 patients with HCV-related cirrhosis up to 12 years Another limitation of our study was the use of efficacy and drug-use inputs from two Phase III clinical trials, which represented controlled environments rather than real-world conditions. However, efficacy and drug costs in the model did account for discontinuation due to eRVR, treatment futility, and all other reasons, in accordance with the recommended clinical use of the treatment regimens. As a result, average per-patient treatment costs in our model  were substantially lower than the cost of a full course of TVR+PR therapy . Persistency and its relationship to treatment effectiveness in real-world settings is the subject of ongoing studies.Characteristics of our modeled population also were based on those of participants in the two Phase III clinical trials . Further, our analysis for previously treated patients considered prior therapy with pegylated interferon  plus ribavirin only (non-pegylated interferon was excluded), consistent with REALIZE. Thus, the model's results may not be generalizable to all US HCV patients seeking treatment. However, because genotype 1 accounts for about 75% of all cases of HCV infection in the US Although our model investigated the cost-effectiveness of TVR+PR compared with PR alone in a variety of interesting subgroups based on level of treatment experience, age, sex, and initial fibrosis score, there are additional subgroups that may merit further investigation. For example, race has been shown to be associated with SVR, and ADVANCE demonstrated a significant difference in SVR for TVR+PR versus PR alone (62% vs. 25%) among black participants Finally, our analysis focused on TVR+PR compared with PR alone and did not consider other comparisons. Our analysis was based on head-to-head data from Phase III, randomized, double-blinded, multicenter trials in treatment-naïve patients (ADVANCE) and treatment-experienced patients (REALIZE) with chronic genotype 1 HCV infection This decision-analytic model estimated that the higher SVR rates observed for TVR+PR, compared with PR alone, led to fewer HCV-related complications and deaths as well as increased survival and quality-adjusted survival in all patient subgroups. Within the limitations of our model, TVR+PR was projected to be a cost-effective or cost-saving strategy compared with PR for the treatment of adults with chronic genotype 1 HCV infection and compensated liver disease from a US payer perspective. Additionally, our model projected that higher HCV-treatment drug costs for patients receiving TVR+PR compared with PR alone would be offset largely or completely, depending on patient subgroup, by reductions in medical costs associated with liver-disease complications. Future analyses are needed to compare TVR+PR with all existing HCV treatment options.Appendix S1Additional Information, Tables, and Figures.(PDF)Click here for additional data file.


Few studies have evaluated possible racial/ethnic disparities in chronic disease prevalence among US Air Force active-duty members. Because members have equal access to free health care and preventive screening, the presence of health disparities in this population could offer new insight into the source of these disparities. Our objective was to identify whether the prevalence of 4 common chronic diseases differed by race/ethnicity in this population.We compiled de-identified clinical and administrative data for Air Force members aged 21 or older who had been on active duty for at least 12 months as of October 2008 . Multivariate logistic regression models were used to determine the prevalence of hypertension, dyslipidemia, type 2 diabetes, and asthma by race/ethnicity, controlling for rank and sex.Hypertension was the most prevalent chronic condition (5.3%), followed by dyslipidemia (4.6%), asthma (0.9%), and diabetes (0.3%). Significant differences were noted by race/ethnicity for all conditions. Compared with non-Hispanic whites, the prevalence of all chronic diseases was higher for non-Hispanic blacks; disparities for adults of other minority race/ethnicity categories were evident but less consistent.The existence of racial/ethnic disparities among active-duty Air Force members, despite equal access to free health care, indicates that premilitary health risks continue after enlistment. Racial and ethnic disparities in the prevalence of these chronic diseases suggest the need to ensure preventive health care practices and community outreach efforts are effective for racial/ethnic minorities, particularly non-Hispanic blacks. Non-Hispanic black active-duty members of the military are 87% more likely to be hospitalized for asthma  and twicThroughout the US Air Force (USAF) health care system, standards for health care access are the same, regardless of geographic area, which helps to ensure each active-duty member receives the same level of health care. Additionally, every USAF active-duty member has at least a high school diploma and has been screened for pre-existing health conditions; once on active duty, each member is provided an equal housing benefit (based on rank) and has the same community resources, regardless of race/ethnicity. Collectively, the active-duty population in the USAF provides a unique opportunity to examine the presence of health disparities in a homogenous population of different racial/ethnic backgrounds.Despite some evidence of disparities in asthma control and diabetes incidence, each military member receives the same comprehensive health care benefits with a regular household income, adequate housing, and an additional food allowance as part of his or her military benefits. Because of these factors, we hypothesized that no clinically significant disparities would be noted.Although consistent racial/ethnic disparities in chronic diseases have been identified outside of the military, and 2 studies have found disparities for military members in asthma hospitalization and the incidence of type 2 diabetes, the prevalence of asthma and diabetes, by race/ethnicity, has not been established. Similarly, disparities in prevalence of cardiovascular diseases, including hypertension and dyslipidemia, have not been determined in the military population. The purpose of this study was to determine whether disparities exist in the prevalence of hypertension, dylipidemia, diabetes, and asthma among active-duty USAF members.We conducted a secondary analysis of existing clinical and administrative data for this descriptive, correlational study. The institutional review board (IRB) at Johns Hopkins University, the USAF Surgeon General’s Research Oversight and Compliance Division, the IRB at the Uniformed Services University of the Health Sciences, and the USAF Clinical Informatics Branch approved the study. The USAF Clinical Informatics Branch compiled data in October 2008 for the preceding 24 months.Active-duty members are carefully screened before enlistment to ensure they are healthy enough for a military deployment . AnnuallWe compiled de-identified clinical and administrative data from all USAF members aged 21 or older and on active duty at least 12 months as of October 2008 . Higher ranks  were not included in the original sample because of their small numbers (n = 204) and the personalized health care support they receive. Members on active duty less than 12 months were also excluded because newly enlisted or commissioned members have up to 12 months to get an annual preventive health assessment . MembersSex, race/ethnicity, and rank category were identified through the Defense Enrollment Eligibility Reporting System. Five categories were used to identify race/ethnicity: American Indian/Alaska Native, Asian/Pacific Islander, non-Hispanic black, non-Hispanic white, and Hispanic. Rank was also categorized to ensure that people in the data set could not be identified by their demographic information. The 4 rank categories were junior enlisted (from airman basic [E-1] through senior airman [E-4]), senior enlisted (from staff sergeant [E-5] through chief master sergeant [E-9]), junior officer (from second lieutenant [O-1] through captain [O-3]), and senior officer (from major [O-4] through colonel [O-6]). A category of Other included remaining enlisted personnel .International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) code beginning with 401 , followed by dyslipidemia (4.6%), asthma (0.9%), and diabetes (0.3%) . After aCompared with non-Hispanic whites, Asian/Pacific Islander and Hispanic members aged 30 or younger had a lower prevalence of hypertension. Both American Indian/Alaska Native and non-Hispanic black members had a higher prevalence of hypertension in every age category compared with non-Hispanic whites. After the age of 25, hypertension prevalence for non-Hispanic blacks was more than double that of non-Hispanic whites in every age range.Non-Hispanic whites had a significantly lower prevalence of dyslipidemia in every age range compared with every minority racial/ethnic group.Similar to the differences noted with hypertension, both Hispanics and non-Hispanic blacks had a significantly higher prevalence of diabetes in all age groups compared with non-Hispanic whites. After age 30, the prevalence of diabetes for non-Hispanic blacks was more than twice that of non-Hispanic whites in every age range.The overall prevalence of asthma was significantly lower for non-Hispanic whites in every age range than for all racial/ethnic groups.Compared with non-Hispanic white active-duty members in the USAF, non-Hispanic blacks are consistently and significantly more likely to be diagnosed with hypertension, dyslipidemia, diabetes, or asthma. Disparities were also noted for other racial/ethnic minorities, although these were less consistent.The overall prevalence of hypertension in this population 5.3%) is consistent with a published prevalence of 6.7% for hypertension among 20- to 39-year-olds from the National Health and Nutrition Examination Survey (NHANES) IV .3% is co.The overall prevalence of dyslipidemia in this sample was 4.6%, which was much lower than the overall prevalence of 16.4% among employed NHANES IV participants aged 20 to 39  , non-Hispanic blacks were significantly more likely to have a current preventive health assessment compared with non-Hispanic whites (P < .05) .Outside of the military, racial/ethnic health disparities are attributed to interconnected factors, including racism , social The reasons for persistent racial and ethnic disparities in the prevalence of chronic diseases among a prescreened USAF population with equitable health care and living conditions are complex. However, because disparities have been identified outside of the military setting , pre-enlTargeted interventions are effective at addressing disparities in the prevalence of chronic diseases . Just asRelying on existing clinical and administrative data has several inherent disadvantages, primarily the inability to completely account for the unique circumstances and risk factors of each person. A factor that should be considered is the overall rate of medical discharges from the military for these chronic diseases; however, these data were not available for analysis or comparison. Also, differences in personal health care–seeking behaviors may directly influence the findings because the diagnosis of these chronic diseases in this study relies on existing data from individual encounters. Some members may have met diagnostic criteria for 1 of the 4 chronic diseases included in this study but avoided screening activities.We were, however, able to use data collected on every active-duty member in the USAF who met eligibility criteria, and to compare among all race/ethnicity, sex, and rank categories. Therefore, we were not bound by selection bias or a limited sample size. Our findings provide a reference point for future research examining health outcomes of active-duty military members by race/ethnicity.The racial and ethnic disparities in the prevalence of the 4 chronic diseases we studied suggest the need to ensure effective preventive health care practices and community outreach efforts for racial/ethnic minorities, particularly non-Hispanic blacks.This study was funded by the TriService Nursing Research Program (grant no. N08-001). The Air Force Institute of Technology Civilian Institution Program and the Johns Hopkins University School of Nursing provided additional academic support.


We applied the quality-adjusted time without symptoms of disease or toxicity (Q-TWiST) analysis to provide an integrated measure of clinical benefit, with the objective of comparing quality-adjusted survival between the two arms. As the trial design allowed patients on BSC alone to receive panitumumab after disease progression, which confounded overall survival (OS), the focus of this analysis was on PFS.Panitumumab+best supportive care (BSC) significantly improved progression-free survival (PFS) For each treatment group, the time spent in the toxicity , time without symptoms of disease or toxicity (TWiST), and relapse  states were estimated by the product-limit method, and adjusted using utility weights derived from patient-reported EuroQoL 5-dimensions measures. Sensitivity analyses were performed in which utility weights (varying from 0 to 1) were applied to time in the TOX and REL health states.vs 5.8 weeks, respectively, P<0.0001) and quality-adjusted OS (P=0.0303).There was a significant difference between groups favouring panitumumab+BSC in quality-adjusted PFS (12.3 weeks KRAS mCRC, panitumumab+BSC significantly improved quality-adjusted survival compared with BSC alone.In patients with chemo-refractory wild-type  KRAS mCRC  for the vast majority of patients is rarely curative, and thus the aims of treatment in this setting extend beyond prolongation of survival to include the improvement of tumour-related symptoms, prevention of tumour progression and/or maintenance of quality of life  analysis reflects that cancer therapy is frequently associated with toxicities that may reduce the benefits of increased survival . QualityKRAS tumours collected during the phase 3, open-label, randomised, controlled study comparing the use of panitumumab+BSC with BSC alone in patients with chemo-refractory mCRC. The patient population and design for this trial have been described elsewhere  at specified time points from weeks 8 to 48 using Response Evaluation Criteria in Solid Tumours (RECIST), then every 3 months thereafter. Overall survival was a secondary end point. All subjects continued to be followed for survival approximately every 3 months for up to 2 years after their randomisation into the study. Safety was assessed every 2 weeks and at a 30-day follow-up visit. Health-related quality of life was reported by patients at baseline and monthly until disease progression using the EuroQoL 5-dimensions (EQ-5D) index , time without symptoms of disease or toxicity (TWiST) and relapse   is set to zero. Differences between treatment groups  in mean Q-TWiST were calculated. A 95% confidence interval (CI) and two-sided P-value for testing the null hypothesis of no difference between treatment groups was performed based on the normal approximation (Z-test) with standard errors calculated by the bootstrap method. The bootstrap was conducted by repeated sampling, with replacement, from the sample of patients included in the study, to obtain a new sample. The means for the new sample were calculated from the area under the Kaplan–Meier curve. This process was repeated 1000 times. Based on the means obtained by the bootstrap, the standard errors were calculated  were applied to time in the TOX and REL health states, while holding the utility of TWiST at 1 (representing the highest utility that can be expected for a patient with mCRC) (KRAS status was ascertained in 427 (92%) of patients. Of these, 243 patients had wild-type KRAS tumours  and were included in the Q-TWiST analyses. Baseline demographics of these patients have been described elsewhere and were well balanced between groups: median age was 63 years and 69% of patients had colon rather than rectal cancer in both groups , while utility values were similar in the two groups for the REL state.Observed utility data for each health state based on the EQ-5D index are shown in P=0.0006); however, patients on panitumumab+BSC spent 13.3 weeks in the TWiST state compared with 8.0 weeks for patients on BSC alone and the difference of 5.3 weeks was statistically significant (P<0.0001). Patients on BSC alone had a longer duration during REL; however, the duration of REL for BSC alone was confounded by the cross-over design of the trial.Partitioned survival plots for panitumumab+BSC and BSC alone, restricted to median follow-up, are presented in vs 5.8 weeks, respectively), which was statistically significant (P<0.0001)  was statistically significant (P=0.0303) with a point estimate of 2.1 weeks.Applying the utility values from <0.0001) . FollowiP<0.0001).Using a range of hypothetical utility weights for the TOX and setting the utility for the REL to zero  hypothetical utility levels . ResultsKRAS mCRC, panitumumab+BSC provided statistically significant improvements in PFS compared with BSC alone   , we consKRAS tumours receiving panitumumab+BSC compared with patients on BSC alone had 6.5 more quality-adjusted weeks for PFS. These results closely reflect the difference in unadjusted PFS reported by In our analysis, using utility scores based on EQ-5D assessments collected during the phase 3 study, patients with wild-type In the primary analysis, we used utility scores based on actual EQ-5D assessments made during this study. We noted that EQ-5D scores were higher for patients on panitumumab+BSC compared with patients on BSC alone during periods of both TOX and TWiST, which is supported by the demonstration of better maintenance of overall HRQoL in patients on panitumumab+BSC compared with BSC alone , which is the most established method of combining quality and quantity of life used extensively in cost-effectiveness analysis . In Q-TWKRAS mCRC, panitumumab+BSC provided significant improvements in quality-adjusted PFS and quality-adjusted OS compared with BSC alone, illustrating that the toxicities associated with panitumumab are more than offset by the associated increase in time without severe toxicity.In conclusion, in patients with wild-type