Synthetic thyroxine use was associated with lower odds of having a UIC < 50 μg/L ) and lower median thyroglobulin , compared with untreated participants. Frailty was associated with elevated thyroglobulin (p = 0.029), whereas anemia was associated with lower thyroglobulin (p = 0.016). Iodine insufficiency persists in New Zealanders residing in residential aged-care homes despite increasing iodine intake from fortified bread. Research is required to establish optimal iodine intake and status in the elderly.In response to the re-emergence of iodine deficiency in New Zealand, in 2009 the government mandated that all commercially made breads be fortified with iodized salt. There has been no evaluation of the impact of the program on iodine status of the elderly, despite this population group being vulnerable to iodine deficiency or excess. The aim of this study was to describe the iodine status of elderly New Zealanders in residential aged-care homes following the implementation of the bread fortification program. A cross-sectional survey was conducted, involving 309 residents (median age 85 years) from 16 aged-care homes throughout NZ. Information on socio-demographic, anthropometric, dietary and health characteristics were collected. Casual spot urine samples were analysed for urinary iodine concentration (UIC). Blood samples were analysed for serum thyroglobulin, thyroglobulin antibodies, and other biochemical indices. The median UIC (MUIC) of the residents was 72 μg/L, indicating mild iodine deficiency, and 29% had a UIC < 50 μg/L. Median thyroglobulin concentration was 18 ng/mL and 26% had elevated thyroglobulin concentration (>40 ng/mL), suggesting iodine insufficiency. Diuretic use was associated with lower MUIC ( Iodine is an essential component of thyroid hormones, which are required for maintenance of tissues and regulation of the metabolic rate. Inadequate iodine intake can lead to thyroid dysfunction, which in turn causes a range of adverse health conditions collectively referred to as Iodine Deficiency Disorder . AlthougThe elderly are a rapidly growing segment of the population, and it is, therefore, a high public health priority to ensure older adults have sufficient iodine intake to maintain optimal thyroid function and reduce the burden on health care resources. In New Zealand, prior to the 1940s, goiter was endemic in many parts of the country, but was almost eliminated after a salt iodization program was implemented in 1939, whereby table salt was iodized at 50 ppm , resultiIn 2014, we conducted a cross-sectional survey of older adults in residential-care homes across New Zealand, in order to investigate the nutritional status and health of these residents. As part of a full nutritional assessment, dietary iodine intake and biochemical iodine status were measured. Thus, the aim of the present study was to describe the iodine status of elderly New Zealanders in long-term residential care following the implementation of the mandatory fortification of bread program, and to estimate the impact of the program on dietary iodine intakes.The New Zealand Nutrition and Ageing Project was a cross-sectional survey, involving 309 long-term residents from residential-care homes (rest homes) throughout New Zealand. Twenty rest homes were identified from two national aged-care websites, based on having sufficient numbers of residents to recruit approximately 20 participants in each home. Managers of 16 homes agreed to participate, from Auckland, Hamilton, Hawkes Bay, Wellington, Christchurch, Dunedin and Invercargill. Residents who had resided in the home for ≥12 weeks, were aged 60 years and older (with no upper age limit applied), and were receiving residential-level care, were eligible to participate. In New Zealand, rest home level care is for adults who require 24 h supervision with activities of daily living but are generally able to self-feed and are mobile with supervision. Participants were recruited with assistance from rest home staff and by posting posters and information sheets around the rest home. Interested participants were given an information sheet detailing the study protocol. Written, informed consent was obtained from all participants or from a legal representative for those with cognitive impairment. Ethical approval for the study was obtained from the University of Otago Human Ethics  Committee (H13/118).Trained research assistants undertook data collection during two time points in 2014. The first phase was conducted between February to April (late summer/autumn), and the second phase between July to September (late winter/spring). Demographic data  and smoking status (current smoker or non-smoker) were collected from medical records and participants using pre-tested questionnaires. Medical history, prescribed regular medications (medications prescribed pro re nata were not recorded), oral nutritional supplements, and vitamin/minerals supplements use  were recorded from medical records held at the rest home. Participants who were prescribed levothyroxine, antithyroid medications (carbimazole), had a physician diagnosis of recent hyper-, or hypothyroidism, or had ever had a thyroidectomy were classified as having thyroid dysfunction.2).Body weight and ulna length (a surrogate estimate of height ) were taMalnutrition risk was determined using the Malnutrition Universal Screening Tool (MUST)  with infFrailty scores were determined using the Survey of Health, Ageing and Retirement in Europe Frailty Instrument (SHARE-FI) . ParticiDietary intake data were collected by trained research assistants via weighed, three-day diet records (3DDR) using Salter electronic scales accurate to within ±1 g . Diet recording was conducted on non-consecutive days, and covered both week (two) and weekend (one) days. During the 3DDR, all food and beverage items served to the participant by the rest home food service for breakfast, lunch, dinner and morning and afternoon tea were weighed and recorded before each meal, and any leftovers were weighed to determine actual amount consumed. The 3DDR included any energy containing oral nutritional supplements consumed . Additionally, participants were asked prior to mealtimes and the morning following the diet-recording day to recall any foods or beverages consumed during the 24 h or throughout the evening that may not have been weighed and recorded. Portion sizes for this recall were based on the participant’s usual serving size when in the rest home. Rest home staff recorded foods consumed by the participant during supper (an evening snack served at around 7.00 p.m.). Detailed recipes of menu items served to participants were collected from the rest home’s food service. Participants were instructed to use food diaries to record all food and beverages consumed when away from the rest home. A research assistant then discussed and checked these with the participant on their return to the rest home and verified records were included in the 3DDR.Food composition data are not complete for iodine, and therefore measurement of dietary intake from diet records is not accurate. Instead, median urinary iodine concentration (MUIC) is a better estimate of iodine intake in a population. However, it was possible to estimate the amount of iodine in bread pre-fortification, and the additional intake post-fortification. Individual diet records were examined to identify the amount and types of breads consumed daily. The amount of iodine obtained from commercially made bread was then calculated (μg iodine/gram bread) using analytically determined values for the specific type of bread  reported in the Total Diet Survey for pre-fortification values , and by Iodine status was assessed using urinary iodine concentration determined from casual, spot urine samples, and serum thyroglobulin concentration. Because 90% of ingested iodine is excreted in urine, urinary iodine concentration is a good biomarker of iodine intake. However, there are large day-to-day variations in iodine intake, and repeated 24 h urine samples are required to accurately assess an individual’s usual iodine intake and status. It was not logistically possible to collect 24 h urine samples in this study; therefore, we used the MUIC from spot urine samples to estimate population iodine status. This is recognized as a valid indicator of population iodine status if the sample size is sufficient (100 to 500 participants)  to off-sn = 40 participants) due to logistical constraints, and a further 19 participants did not provide urine samples due to difficulties in voiding or refusal to provide a sample. Urinary iodine concentration was measured on an Agilent 7500ce ICP-MS  in the Trace Element Centre, Department of Chemistry, University of Otago. This laboratory participates in Ensuring the Quality of Urinary Iodine Procedures (EQUIP) quality assurance program conducted by the United States Centers for Disease Control and Prevention. Urine samples were diluted 1:20 with 1% (v/v) tetra-methylammonium hydroxide, and 0.01% Triton X-100™ solution spiked with tellurium as a reference element. Calibration solutions were prepared by spiking a pooled sample with various concentrations of analyte prepared from a NIST traceable 10 mg/mL iodine standard. Samples with elevated UIC (>800 µg/L) were diluted with >18.2 MΩcm water and rerun. Analyses of a commercial control  with an assigned iodine concentration of 304 µg/L and an acceptable range of 260–348 µg/L, gave a mean (SD) of 284 (4) µg/L  1.3%). Regular measurements of an in-house pooled urine control gave a mean (SD) of 57 (1) µg/L .Casual spot urine samples were collected in sterile plastic specimen containers from 250 participants, and transported on ice to the Department of Human Nutrition, University of Otago, Dunedin, where they were stored at −20 °C until analysis. Urine samples were not collected from participants in two rest homes . In addition, blood was drawn into an EDTA-treated vacutainer for a complete blood count (including hemoglobin), which was undertaken immediately by a local health clinic. The remaining samples were transported chilled to the University of Otago, on the same day of collection, where they were immediately centrifuged for 15 m at 4 °C. Aliquots of serum were frozen at −80 °C until analysis.Serum thyroglobulin and TgAb concentrations were determined using an electrochemiluminescent immunoassay (Roche) on an Elecsys 2010 autoanalyser . The standards for the Roche thyroglobulin assay have been standardized against the international reference material CRM-457. The analytical range for thyroglobulin was 0.04 to 500 ng/mL, and 10 to 4000 IU/mL for TgAb. Analysis of controls supplied by the manufacturer gave a mean (SD) of 18.4 (0.8) ng/mL for the normal thyroglobulin control (expected range 13.9 to 24.1 ng/mL), and 75.3 (1.2) ng/mL for the high thyroglobulin control (expected range 54.1 to 94.1 ng/mL). The mean (SD) for the normal TgAb control was 101.9 (3.8) IU/mL (expected range 69.0 to 128.2 IU/mL), and 219.8 (5.6) IU/mL for the high TgAb control (expected range 158.3 to 293.8 IU/mL). Analysis of a pooled serum sample within each batch gave a mean (SD) of 28.0 (0.5) ng/mL (CV 1.7%) and 30.5 (2.9) U/mL (CV 9%) for thyroglobulin and TgAb, respectively.High-sensitivity C-Reactive Protein (hs-CRP), a measure of acute inflammation, was determined by automated immunoturbidimetric assay . Controls provided by the manufacturer (PCCM1) were analyzed with each reagent kit. The mean (SD) for the control was 10.10 (0.14) g/L (CV 1.40), and were within the range of the results provided by the manufacturer.Serum creatinine was measured using Creatinine Jaffé Gen.2 kinetic colorimetric assay . Controls provided by the manufacturer (PreciControl ClinChem Multi 1 and PreciControl ClinChem Multi 2) had target values of 97.8 µmol/L and 365 µmol/L respectively and were analyzed daily. The means and CV (%) for the two controls were 96 (SD 1.0) µmol/L and 1.04% and 367.78 (SD 5.76) µmol/L and 1.57% respectively. Estimated Glomerular Filtration Rate (eGFR), an indicator of renal function, was determined for each participant using serum creatinine, age and sex. These variables were entered in the online Chronic Kidney Disease Epidemiology collaboration (CKD-EPI) eGFR calculator  to obtaip < 0.05. All analyses included rest home sites as clusters using Froot’s extension to Huber-White robust standard errors [Statistical analyses were conducted using Stata . Statistical significance was determined by two-sided d errors ,23.The distributions of urinary iodine and serum thyroglobulin concentrations were positively skewed, and therefore medians (25th and 75th percentile) are reported. Based on the WHO/UNICEF/ICCIDD criteria, population MUIC within the range of 20–49 μg/L is indicative of moderate iodine deficiency, 50–99 μg/L as mild deficiency, and 100–199 μg/L as adequate iodine nutrition, 200–299 μg/L as above requirements, and >300 μg/L as excessive . Iodine p-value < 0.25 from the unadjusted analysis were constructed. The number of variables included in the adjusted logistic regression models was constrained by the 10 EPV rule [Unadjusted quantile regression models were used to initially examine the effect of sex, age, time of data collection, BMI, malnutrition risk, frailty, medications , oral supplement use, and anemia, on urinary iodine and serum thyroglobulin concentrations. Unadjusted logistic regression models were then used to examine the effect of these variables on the odds of having low urinary iodine concentration (<50 μg/L) or elevated serum thyroglobulin concentration (>40 ng/mL). The explanatory variables included in the models were those known or suspected to influence nutrient intake ,28 or ioEPV rule . The onln = 9 with both urinary iodine and Tg results, this was tested because smoking may increase serum thyroglobulin concentration), those on amiodarone , and those prescribed levothyroxine or diagnosed with a thyroid disorder (n = 35).Sensitivity analyses were performed excluding smokers  were prescribed furosemide. Two participants were prescribed amiodarone (antiarrhythmic agent with beta blocker-like actions), providing 75 mg of iodine per day. Oral nutritional supplements were prescribed for 22 (7%) of participants, contributing an average 14 µg of iodine per day, and 29 (9%) were taking supplements containing iodine . Participants at high risk of malnutrition were more likely to be prescribed oral nutritional supplements . The majority of participants (83%) were identified as being either pre-frail or frail. There were no meaningful differences in characteristics between participants with and without a urinary iodine and serum thyroglobulin result.Of the 60 participants diagnosed with any thyroid disorder, 9 were diagnosed with hyperthyroidism, 46 with hypothyroidism, and 5 had a partial thyroidectomy. Fifty participants (16%) were prescribed levothyroxine (synthetic thyroxine) and four prescribed anti-thyroid medications. On average, participants were prescribed a total of 6 regular medications (range 0 to 15). Of the 112 participants prescribed loop diuretics, most , lower percentage with a concentration <50 μg/L (p = 0.031), and a higher proportion with urinary iodine concentration >300 μg/L (p = 0.017), compared with participants not on this medication.The MUIC of participants was 72 μg/L, and 29% had a urinary iodine concentration <50 μg/L at the time of the study, indicating mild iodine deficiency in this population based on the WHO/UNICEF/ICCIDD criteria  Table 2Table 2. n = 35, 13%), the median thyroglobulin concentration was 18 ng/mL and 26% had an elevated thyroglobulin concentration (>40 ng/mL). Both of these values were above the assay-specific recommendations to indicate population iodine sufficiency , with a non-significant tendency for lower odds of having a urinary iodine concentration <50 µg/L (p = 0.056), than during winter/spring. Participants on loop diuretics had lower median MUIC (p = 0.043), and those on levothyroxine had lower odds of having a low urinary iodine concentration (p = 0.030), compared with untreated participants. For serum thyroglobulin (p = 0.057). Frailty was associated with higher odds of having elevated serum thyroglobulin concentration, whereas anemic patients and those treated with levothyroxine had lower odds.In the adjusted analyses , median globulin , adjusten = 35). However, the results for serum thyroglobulin remained largely unchanged. Excluding participants with thyroid disorders or on levothyroxine, or excluding smokers or those on amiodarone, did not appreciably alter the results from the adjusted analyses (data not shown). The mean intake of bread per day was 66 g/day, equivalent to approximately 2 slices of bread (~30 g per slice) (p = 0.001). Bread intake was inversely associated with age, malnutrition risk and frailty, and was positively associated with BMI (p = 0.003). Fortification of bread with iodized salt increased the mean intake of iodine from bread by 31 μg/day.In a sensitivity analysis, MUIC was slightly lower (65 µg/L) when participants who were prescribed levothyroxine and thyroid disorders were excluded (r slice) . Bread iThe findings from our nation-wide survey indicate that despite the implementation of mandatory fortification of commercially baked bread with iodized salt in late 2009, iodine insufficiency persists in this elderly population group residing in long-term residential care. Participants were classified as mildly iodine deficient, based on internationally recognized criteria recommend by the WHO/UNICEF/ICCIDD for assessing population iodine adequacy with urinary iodine concentration . FurtheWhile our finding of iodine insufficiency in this elderly population is strengthened by the use of two objective biochemical indices of iodine status, our results should be interpreted with caution because each index individually has limitations that hinder interpretation in older adults. Specifically, although MUIC is the most widely used index for determining iodine status of a population , the criFurther exacerbating the difficulties in assessing iodine status in institutionalized adults is the high prevalence of disease states or use of medications that may alter nutrient metabolism and nutrient requirements, and influence the validity of nutrient biomarkers. Renal insufficiency decreases urinary iodine excretion through reduced renal filtration of iodine from plasma and increased tubular resorption of the filtered iodine, leading to high levels of iodine in plasma . TherefoIn the current study, loop diuretic use such as furosemide (most commonly prescribed) was associated with lower MUIC, but not with serum thyroglobulin concentration. It is possible that increased urinary volume with diuretic use may have diluted urinary iodine concentration. Furthermore, use of furosemide in combination with a low iodine diet may increase thyroidal uptake of iodine , thus reNotwithstanding the above-mentioned limitations in assessing iodine status of the elderly, our findings provide important information on predictors of low iodine status in institutionalized elderly. That frail participants were at higher risk of elevated thyroglobulin concentration is of particular interest. Frailty is an important geriatric syndrome that substantially increases morbidity, health care costs, and reduces quality of life . The criThe lower risk of elevated serum thyroglobulin in anemic participants in our study was unexpected. Iron deficiency with or without anemia impairs the response of iodine deficient children to iodine prophylaxis ; therefoWhile there are no previous data on iodine status of institutionalized New Zealand elderly, comparison of studies conducted pre- and post-fortification in other sectors of the population suggest iodine status has improved since mandatory fortification. The MUIC in the present study (72 μg/L) was slightly higher than the pre-fortification MUIC of 61 μg/L reported for community-dwelling older participants in the nationally representative 2008/2009 Adult Nutrition Survey  but the When developing the mandatory bread fortification policy in New Zealand, strategies such as mandating universal salt iodization, or replacing all salt with iodized salt in processed foods, or in breakfast cereals, biscuits and crackers in addition to bread, were considered . These o


Vitex megapotamica (Spreng.) Moldenke is used in Brazilian folk medicine as hypolipidemic drug no study has been conducted to evaluate the effects of this species in an experimental model of atherosclerosis. So, the aim of this study was to evaluate the possible renoprotective activity of methanolic extract obtained from Vitex megapotamica (MEVM) using C57BL/6 LDLr-null mice submitted to high fat diet (HFD). MEVM was orally administered at doses of 30, 100, and 300 mg/kg, for three weeks, starting from the 2nd week of HFD. Systolic blood pressure (SBP) and diuretic activity were measured weekly. At the end of experiments the serum lipids, atherogenic index serum (AIS), oxidative stress, and markers of renal function were determined. HFD induced a significant increase in the systolic blood pressure, dyslipidemia, increase in AIS, and lipid peroxidation accompanied by an important reduction in renal function. Treatment with MEVM was able to prevent increase in SBP, total cholesterol, triglycerides, AIS, urea, and creatinine levels in LDLr-null mice. These effects were accompanied by a significant reduction in oxidative stress and renal injury. The data reported here support the potential of Vitex megapotamica as candidate to be an herbal medicine used in cardiovascular or renal diseases.Although Atherosclerosis is a process that consists of chronic and progressive alterations in arterial wall characterized by inflammatory and fibroproliferative response. Endothelial dysfunction appears to be the initial step, and dyslipidemia, often caused by high fat diet (HFD), is one of its main triggers. The atherosclerotic lesion may affect several important arterial territories, including renal arteries and abdominal aorta, being an important factor in the development of renal insufficiency (RI). Furthermore, it is noteworthy that kidney, an organ with wide vasculature, could be a sophisticated sensor of subclinical cardiovascular damage induced by endothelial injury .Despite its proven effectiveness, lifestyle changes and hypolipidemic drugs apparently did not prevent RI evolution in all dyslipidemic patients, possibly due to genetic characteristics and/or other comorbidities. Furthermore, the elevated prevalence of adverse effects and poor patient compliance to treatment has reduced its efficacy . In BrazVitex megapotamica (Spreng.) Moldenke (Lamiaceae) occurs in the Atlantic Forest environment, from Bahia down to Rio Grande do Sul, and also in Florestas de Pinhais and Florestas Semideciduas of the Paraná River basin . A  Centro Multidisciplinar para Investigação Biológica na Área da Ciência de Animais de Laboratório  and were kept at temperature- and light-controlled room  with free access to water and food. All experimental procedures adopted in this study were previously approved by the Institutional Ethics Committee of Universidade Paranaense .Male C57BL/6LDLr-null mice were used in the experiments. Animals were provided by the ad libitum to groups of mice from 3 months of age. The animals were used in the study after confirmation of hypercholesterolemia.Dyslipidemia and atherogenesis were induced by administration of commercial high fat diet (HFD) for 6 weeks . The basic formulation contained a mixture of cornstarch, DL-methionine, lard, casein, calcium carbonate, cellulose, cholesterol, soybean oil, AIN-76 mineral premix, AIN-93 vitamin premix, sucrose, and tert-butylhydroquinone. HFD was offeredn = 7) as follows:negative control: C57BL/6LDLr-null mice receiving standard commercial diet and treated for three weeks with vehicle;positive control: C57BL/6LDLr-null mice receiving HFD and treated for three weeks with vehicle; Vitex megapotamica extract at dose of 30 mg/kg;MEVM30: C57BL/6LDLr-null mice receiving HFD and treated for three weeks with Vitex megapotamica extract at dose of 100 mg/kg;MEVM100: C57BL/6LDLr-null mice receiving HFD and treated for three weeks with Vitex megapotamica extract at dose of 300 mg/kg;MEVM300: C57BL/6LDLr-null mice receiving HFD and treated for three weeks withSIMV 40: C57BL/6LDLr-null mice receiving HFD and treated for three weeks with simvastatin at dose of 40 mg/kg.Two weeks after starting the diet, the animals were randomly assigned to one of six experimental groups . Ten preliminary cycles were performed to allow mice to adapt to the inflating cuff. Subsequently, a minimum of five cycles of systolic blood pressure measurements were obtained for each animal. The mean systolic blood pressure of each animal was then calculated. Systolic blood pressure measurements were carried out on a weekly basis from the beginning of experiments for 5 weeks.+, K+, Cl−, and HCO3−), pH, density, and conductivity were estimated using urine samples from each mouse collected at the end of the experiment (8 h).The diuretic activity was determined on a weekly basis from the beginning of experiments for 5 weeks in all experimental groups according to method previously described . Animals(1) Analytical Procedures. For serum analysis, blood samples were collected in conical tubes after decapitation at the end of the experimental period. Serum was obtained by centrifugation  and stored at −20°C until analysis. Plasmatic and urinary Na+ and K+ levels were quantified by flame photometry (Quimis model Q398112). Cl− and HCO3− concentrations were quantified by titration. pH and conductivity were directly determined on fresh urine samples using Q400MT pHmeter and Q795M2 conductivity meter , respectively. Density was estimated by weighing with a Mettler AE163 (±0.1 mg) analytical scale on urine volume measured with Nichiryo micropipette. Plasma urea, creatinine, and total protein levels were determined by enzymatic method using BM/Hitachi 912 automated analyzer .Triglyceride (TG), total cholesterol (TC), and high-density lipoprotein cholesterol (HDL-C) levels were measured using biochemical test kits with semiautoanalyzer by colorimetric method at the end of treatments. The AIS, which is the measure of the extent of atherosclerotic lesions based on serum lipids, was determined in all groups. The atherogenic index is calculated using the following formula: AIS = TC/HDL . E. coli. After the incubation period, samples were centrifuged  to remove bacteria. Then, 100 μL of supernatant was mixed with equal volume of Griess reagent  in a 96-well plate and read at 540 nm in a plate reader. Standard nitrite and nitrate curves (0–150 mM) were performed simultaneously.The plasma nitrite concentration was determined by enzymatically reducing nitrate using nitrate reductase enzyme at the end of the experimental period . Plasma The thiobarbituric acid (TBARS) levels were measured using commercial assay kits  on a spectrophotometer , according to manufacturer's instruction. This method was used to obtain a spectrophotometric measurement of the color produced during the reaction of thiobarbituric acid and malondialdehyde (an indicator of peroxidation of polyunsaturated fatty acids in cell membranes subsequent to reactions with reactive oxygen species) at 535 nm. The TBARS level was expressed as mmol/L.P value less than 0.05 was considered statistically significant. Graphs were drawn and statistical analysis was carried out using GraphPad Prism version 5.0 for Mac OS X .Results are expressed as mean ± standard error of the mean of seven animals in each group. Statistical evaluation was carried out using analysis of variance (ANOVA) followed by Bonferroni's test. A μg/mL) resulted in mean GAE values of 40 and 64 μg using Folin-Ciocalteu and Fast Blue BB methods. Furthermore, the fingerprint obtained from MECS showed five peaks with absorbance at 340 nm  but not simvastatin, SBP was not significantly altered when compared to the beginning of treatments .P < 0.05), urinary conductivity , and sodium , chloride , and potassium  excretion values after 5 weeks of treatment  were, respectively, 0.97 ± 0.09 mL/10 g, 1005 ± 0.6 g/L, 15.75 ± 0.11 mS/cm, 0.16 ± 0.02, 0.14 ± 0.01, and 0.06 ± 0.01 mmol/8 h/10 g. The administration of atherogenic diet in LDL-null mice was able to induce an expressive reduction in urinary volume . Similarly, a significant reduction in TC levels was also evident in HFD mice treated with Vitex megapotamica extracts. In animals that received MEVM (300 mg/kg), TC reduced to levels of 563 ± 51 mg/dL (P < 0.05). In addition, HDL-C levels were not significantly changed after treatment with all MEVM doses. Additionally, triglyceride levels were significantly reduced when compared to positive control group  after prolonged MEVM administration. Triglycerides levels measured in MEVM-treated groups were close to those found in SIMV group.Serum total cholesterol (TC), high-density lipoprotein cholesterol (HDL-C), and triglycerides (TG) values are presented in P < 0.05). The values found at the dose of 300 mg/kg were close to those found in SIMV or negative control groups (The AIS was significantly higher in HFD positive controls after 5 weeks of experiment. Treatment with HEMV (300 mg/kg) provided a significant reduction in AIS when compared to HFD positive control groups . In LDL-null mice, MEVM was able to reduce the TBARS levels by approximately 50%. Additionally, the nitrite levels increased by approximately 85% when compared to positive control groups Figures .In recent years, atherosclerosis has received notable attention for triggering significant changes in renal function because glomerular cells mimic some of the characteristics of cells in the vessel wall; atherosclerosis and glomerulosclerosis are postulated as comparable processes. Furthermore, it is well established that renal injury is aggravated by HFD and atherosclerosis. On the other hand, progressive deterioration of the renal function may lead to dyslipidemia, which can induce production of reactive oxygen species (ROS) and activate proinflammatory and fibrogenic factors, leading to vascular endothelial cell dysfunction, favoring the development of atherosclerosis. Therefore, kidney can be a villain or a victim during atherogenesis , 16.Atherosclerotic changes in the renal artery are evident in 50% of patients with previous atherosclerotic disease and in 6.8% of adults aged 65 years or older; it can induce significant reduction in renal function . EvidencWhen considering an ideal model to study atherosclerosis-induced renal failure, several difficulties are found. One of them is the fact that rodents, in general, are very resistant to HFD-induced renal injury. In this sense, a mice strain highly sensitive to atherosclerotic lesions was used in this study (LDLr-null). This mice strain mimics atherosclerotic lesions and other resulting changes in a similar way to what occurs to humans. Thus, after 5 weeks of HFD, all mice in our study showed dyslipidemia and significant increase in lipid peroxidation, accompanied by a reduction of nitric oxide bioavailability with consequent elevation of SBP. As hypertension, dyslipidemia and oxidative stress can directly damage the kidney and by promoting intrarenal atherogenesis even in the absence of obstructive lesions in the renal artery, important decrease in the renal function was also observed, with significant reduction in urine volume and renal electrolyte excretion, accompanied by significant changes in serum creatinine, urea, and total protein levels.Although renal changes are evident, treatment for 3 weeks with HEMV (300 mg/kg) was able to prevent reductions in renal function observed in all untreated animals. In this case, urine elimination, density, conductivity, and renal excretion of potassium, chloride, and bicarbonate remained with values close to those obtained for control animals. In addition, treatment with HEMV was able to normalize serum creatinine, urea, and total protein, important biochemical markers of renal function. Regarding the renoprotective effect observed, what most attracted attention was the fact that HEMV causes an expressive urinary sodium excretion, significantly higher than in all experimental groups. Possibly, this natriuretic effect, along with the other activities, can be corroborated for the reduction of cardiovascular changes, especially in reducing blood pressure levels observed in the last two weeks of study.In addition to activities directly renoprotective, MEVM treatment was able to reduce the TC levels in LDLr-null mice without affecting the elevation of HDL levels. Furthermore, a significant reduction in serum triglyceride was also observed, as previously reported . Treatme Vitex megapotamica extract (mainly polyphenolic compounds) may also have contributed to elevate NO levels and prevent SBP elevation.Another very significant finding in this study was the reduction in the oxidative stress, which plays a critical role in the endothelium dysfunction and in the LDL oxidation, characterizing the initial step of changes that lead to atherosclerosis and renal injury. Oxidation biomarkers such as TBARS are markedly increased during HFD consumption and may represent independent indicators of risk for patients with atherosclerosis. The fact that MECS increased NO levels (measured as nitrite), it may be able to reduce oxidative insults and lipid peroxidation caused by HFD. On the other hand, the antioxidant properties of the secondary metabolites ofA frequent question in our study was about which HEMV components could be involved in the activities observed. Phytochemical analysis of HEMV revealed the predominant presence of flavonoid glycosides and other polyphenols. Currently, it is well established that flavonoids and other polyphenols may have antioxidant, diuretic, natriuretic, and antihypertensive activity, suggesting several cardioprotective effects, including decreased oxidation of LDL cholesterol and endothelial damage , 19, 20. Vitex megapotamica as candidate for phytomedicine to be used in cardiovascular or renal diseases where antioxidant, natriuretic, and hypolipidemic effects are desired.In short, we showed that MEVM might present compounds responsible for reducing serum lipids and oxidative stress when orally administered. In addition, it was able to prevent renal injury induced by HFD in LDLr-null mice. Despite all the evidence that phenolic compounds can contribute to these effects, other metabolites that may be operating in an integrated manner in the cardioprotective effects of this specie should not be excluded. Moreover, the data reported here collaborate with preclinical investigations of this species and support the potential of MEVM from


There is great impetus to achieve elimination of mother-to-child transmission of HIV (eMTCT) by 2015, and part of this is to identify factors to target to achieve the goal. This study thus identified key patient factors for MTCT in a high HIV prevalence setting in Johannesburg, South Africa. Between November 2010 and May 2012, we conducted a case–control study among HIV-infected women with HIV-infected (cases) and uninfected (controls) infants diagnosed around six weeks of age as part of routine, early infant diagnosis. Mothers and infants were identified through registers in six healthcare facilities that provide antenatal, postpartum and HIV care. Structured interviews were conducted with a focus on history of HIV infection, antenatal, intrapartum and immediate postpartum management of the mother-infant pair. Patient-related risk factors for MTCT were identified.p < 0.001); accessing antenatal care after 20 weeks gestation ; less than 12 years of formal education ; and unplanned pregnancy . Mean age at first HIV test was 6.6 weeks (SD = 3.5) for infants who were diagnosed as HIV-infected, and the mean age at antiretroviral treatment initiation was 10.8 weeks (SD = 4.4). HIV-uninfected infants were diagnosed at a mean age of 6.0 weeks (SD = 0.2).A total of 77 women with HIV-infected infants and 154 with –uninfected infants were interviewed. Among HIV-infected cases, 13.0% of the women knew their HIV status prior to conception, and 83.1% reported their pregnancies as unplanned. Antenatal antiretroviral coverage was high in the control group – only 1/154 (0.7%) reported receiving no prophylaxis or treatment compared with 17/74 (22.9%) of cases. In multivariate analysis, key patient-related risks for HIV transmission were: unknown HIV status prior to conception (adjusted odds ratio [AOR] = 6.6; 95% CI = 2.4 – 18.4; Undiagnosed maternal HIV infection prior to conception, unplanned pregnancies, delays in accessing antenatal care, and low levels of education were the most significant patient risk factors associated with MTCT. While the emphasis has been on increasing availability and coverage of efficacious antiretroviral regimens, and strengthening health systems within eMTCT initiatives, there is a need to also address patient-related factors if we are to achieve eMTCT goals. In 2009, UNAIDS, the Joint United Nations Programme on HIV/AIDS, made a global call for the elimination of mother-to-child transmission of HIV (eMTCT) by 2015, and there is great impetus to achieve the target as the deadline approaches . CoupledPatient and health system factors are critical in determining success of PMTCT programmes and attainment of eMTCT goals -9. WhileBetween November 2010 and May 2011, consecutive mothers with HIV-infected infants who were referred to a paediatric HIV clinic for ART initiation were enrolled (cases). Mothers of uninfected infants (controls), identified through clinic registers, were recruited at five primary care facilities between December 2011 and May 2012. Mothers of both HIV-infected and –uninfected infants were all HIV-infected. The decision to obtain controls was taken after analysis of data on mothers of infected infants showed interesting patterns on patients’ health-seeking behaviour and care accessed during pregnancy. The controls and cases were similar with respect to site of antenatal care, place and date of delivery, and where infant HIV testing was done. Both group of infants were also born in the same period, but controls were recruited slightly later than cases.Twice as many controls as cases were enrolled and a convenience sample was selected. The initial plan was to enrol more controls, but due to difficulties with recruitment of mothers with uninfected infants and concerns about recall bias from the lengthy period between the cases and controls, the ratio was decreased to 2:1. Of the controls that were contacted, a quarter of them could be reached and were available to be interviewed. There were several reasons why mothers of uninfected infants were unavailable for interview, and these included the women having returned to work and unable to take time off; migration; and contact number unavailable or changed. The 2:1 ratio was deemed adequate for detecting differences between the two groups.Participants were interviewed using a structured questionnaire and data on the following parameters were collected from the interviews: history of HIV infection – whether preconception HIV testing was done, and whether ART was initiated in those identified as HIV-infected; baseline CD4 cell count; knowledge of partner’s HIV status; whether the pregnancy was planned; previous exposure to PMTCT interventions; antenatal and intrapartum prophylaxis; infant prophylaxis and feeding option; and timing of early infant diagnosis. Additional data were collected on management of infant HIV infection in cases of HIV-infected infants. Infants diagnosed as either HIV-infected or –uninfected, through early infant diagnosis, were identified through facility registers. Interviewers were fluent in the local vernacular languages used in the interviews. Internal audit processes were conducted on the study data, including validation of information collected from interviews against facility records.Within routine care, all facilities in Soweto, Johannesburg where the women accessed care provided PMTCT services during the antenatal and postnatal periods. HIV testing was routinely offered to all pregnant women, and if HIV-infected, either antiretroviral prophylaxis or lifelong treatment was initiated, depending on a woman’s CD4 cell count. All antenatal clinics provided antiretroviral prophylaxis, while ART initiation for those eligible occurred only at selected sites over the study period. Postnatal testing was offered if a woman’s HIV status was unknown, and also in those who tested HIV negative during pregnancy and did not have a repeat test antenatally. A free six months’ supply of infant formula was given to HIV-infected women who elected to formula feed. All health facilities offered routine early infant diagnosis around six weeks of age, but management of infected infants occurred only at one paediatric HIV clinic at the time of the study.3. There was also a transition from zidovudine to nevirapine syrup for infant prophylaxis.Over the study period, uptake of HIV testing within the antenatal clinics was 99%, and the HIV prevalence in pregnant women was around 25% (unpublished programme data). MTCT risk around six week was 2.7% in 2010 and 1.1% in 2011. The study period coincided with PMTCT guideline changes (Table p < 0.10) were included in the initial multivariate logistic regression models using backward-fitting. Variables with p < 0.05 were used in the final model, and those that did not markedly alter the model fit were removed.Data were analysed with Stata® version 12.0 . Continuous data were summarized using means and medians as appropriate. Standard statistical methods were utilised to assess differences between children with and without HIV infection. Descriptive analyses included variable description and cross tabulation, and inferential analyses included tests of association by chi-square test. Multivariate logistic regression analysis was done to identify factors associated with risk of MTCT and results presented as adjusted odds ratios (AOR) with 95% confidence intervals (CI). Potential confounding factors associated with the outcome and exposure  had unplanned pregnancies, compared with 56.5% (87/154) of women with uninfected infants, p < 0.001. Median gestational age at first antenatal visit was 16.0 weeks (interquartile range (IQR) =12 – 20) for controls, and 24.0 weeks (IQR = 16 – 26) for cases, p < 0.001. The proportion of women who did not access any antenatal care was 1.9% (3/154) for controls and 14.3% (11/77) for cases. Of the women who did not access antenatal care and had an HIV-infected infant, six knew that they were HIV-infected. Most reasons for not accessing antenatal care revolved around fear of stigmatisation by either health workers or family.In total, 77 women with HIV-infected infants (cases), and 154 mothers with HIV-uninfected infants (controls) were interviewed. Mean age for the cases was 28.1 years (standard deviation (SD) = 6.4), and for the controls 30.9 years (SD = 5.5), p < 0.001. Slightly more than half of the women with HIV-uninfected infants knew their partner’s HIV status , and of the known, three-quarters were HIV-infected (73.6%), while in the group with infected infants, 37/77 (48.1%) knew their partner’s HIV status, and 94.6% were HIV-infected. Median baseline CD4 cell count was 315 cells/mm3 (IQR: 203 – 420) for the cases (n = 58), and 355 cells/mm3 (IQR: 210 – 480) for the controls (n = 111). Of women with HIV-infected infants, 22.9% (17/74) received no antenatal antiretroviral prophylaxis or treatment, while in the group with uninfected infants only one reported no antenatal antiretrovirals. In the cases, 11.7% (9/77) of the women received antenatal ART, while 42.9% (66/154) received ART in the control group.Of women with uninfected infants, 43.5% (67/154) knew that they were HIV-infected prior to the index pregnancy compared to 13.0% (10/77) of women with infected infants, p = 0.044). In the control group, 147/148 (99.3%) infants received prophylaxis, while 72/76 (94.7%) of the cases did. The mean infant age at first HIV test was 6.0 weeks (SD = 0.2) for the uninfected infants, and 6.6 weeks (SD = 3.5) for the infected infants, p = 0.200. At time of interview, 73/77 (94.8%) of the infected infants had already been initiated on ART, and the mean age at ART initiation was 10.8 weeks  in the group with HIV-uninfected infants, and 6 (7.8%) in the group with infected infants. Fewer women with infected infants  than with uninfected infants elected to formula feed (147/154, 95.4%; In multivariate analysis, unknown HIV status prior to conception, unplanned pregnancy, accessing antenatal care after 20 weeks gestation, and less than 12 years of formal education were all identified as important risk factors for MTCT Table . The oddThis study identified several patient groups at high risk of MTCT. These were patients with unknown HIV status prior to conception; those with unplanned pregnancies; accessing antenatal care after 20 weeks gestation; and having less than 12 years of formal education. Slightly more mothers of HIV-infected infants elected to breastfeed – 11.7% compared to 4.6% of mothers with –uninfected infants, but this difference was not significant. While causality may not be definitively ascertained from this study, the findings highlight several important risk factors that must be targeted for eMTCT; availability of antiretrovirals alone is not enough.Of women with HIV-infected infants, only 13.0% knew that they were HIV-infected prior to conception. The lowest risk of MTCT is with preconception ART and the duration of ART is directly related to MTCT risk ,15. HIV-If we are to eliminate MTCT, there needs to be routine HIV testing for all women and men of reproductive age, and ART initiation for those found to be HIV-infected and eligible for treatment. South Africa implemented large population-based HIV-testing campaigns in recent years, but it is uncertain if these have impacted on PMTCT and linkage to care. However, recent unpublished programmatic data from the Soweto PMTCT programme, where this study was conducted, shows an increasing proportion of pregnant women presenting with an already known HIV status, and an increasing number already on treatment. As HIV testing and treatment programmes expand and become functional, more women will know their HIV status preconception. They will however still need to present for antenatal care timeously for early initiation and continuation of appropriate PMTCT interventions. Healthcare services need to be able to manage the increased demand for both HIV testing and initiation of ART in those found to be eligible.One area that is under-researched, but increasingly shown to be important in the success of PMTCT interventions, is male partner involvement -21. EncoRates of unplanned pregnancies were high, especially amongst women who had infected infants – 83.1% of the pregnancies were unplanned. Family planning, and consequently prevention of unintended pregnancies, has long been the most underutilised PMTCT intervention, with only modest progress to date . In addiTiming of antenatal care influences diagnosis and appropriate management of maternal HIV infection. In our study, accessing antenatal care beyond 20 weeks gestation was associated with an increased MTCT risk. This is consistent with findings from other studies where late presentation for antenatal care delayed initiation of appropriate PMTCT interventions, increasing the risk of perinatal transmission ,17. LackWhile there is increased public knowledge of HIV infection, stigma remains a reality for many, especially women. In our study, there were women who knew that they were HIV-infected, but still did not access antenatal care due to fear of being stigmatised by either health workers or family. There’s a need to address stigma at all levels, as it has been shown to impact health-seeking behaviour and adherence to treatment . PatientDespite the challenges identified, the study provides several reassuring findings. Routine early infant diagnosis, and ART initiation in those found to be HIV-infected were timeous. At the time of the study, 94.8% of the HIV-infected infants had already been initiated on ART, and the mean age at ART initiation was 10.8 weeks.While this study makes an important contribution to our knowledge of the requirements for an effective PMTCT programme, and highlights the importance of patient factors as we work towards elimination of MTCT, there are limitations. Causality cannot be inferred between the negative patient factors identified and risk of MTCT. There was also a lag period between the interviews of cases and that of controls, and this could have contributed to recall bias amongst the controls as they were interviewed at a much later period post-delivery. The sample of controls might also not have been representative as there was a high percentage that could not be reached, and some of the infants might have died during the lag period as it is a recognised fact that despite being uninfected, the morbidity and mortality rate in HIV-exposed infants remains significant. We also relied on self-reported information, but this was found to be reliable when compared to hospital records.Despite the limitations, the study provides important insights as we work towards eMTCT. As much as availability and implementation of efficacious PMTCT interventions are key in preventing HIV infection in children, individual patient factors are also important and need to be targeted. Undiagnosed maternal HIV infection prior to conception, unplanned pregnancies, delays in accessing antenatal care, and low levels of education were the most significant patient risk factors associated with MTCT in our study. The focus in resource-constrained settings has largely been on establishing functioning systems to facilitate implementation of efficacious PMTCT interventions, and great strides have been made in this regard, including in South Africa ,32. WhilAIDS: Acquired Immune Deficiency Syndrome; AOR: Adjusted odd ratio; ART: Antiretroviral therapy; AZT: Zidovudine; CI: Confidence intervals; C-section: Caesarean section; EFV: Efavirenz; eMTCT: Elimination of mother-to-child transmission of HIV; FDCs: Fixed dose combinations; HIV: Human Immunodeficiency Syndrome; IQR: Interquartile range; MTCT: Mother-to-child transmission of HIV; NVD: Normal vaginal delivery; NVP: Nevirapine; PMTCT: Prevention of mother-to-child transmission of HIV; SD: Standard deviation; sdNVP: single-dose nevirapine; UNAIDS: Joint United Nations Programme on HIV/AIDS; WHO: World Health Organization.We declare that we have no conflicts of interest.CNM conceptualised the study and wrote the manuscript. AS performed the statistical analysis. MC helped to draft the manuscript. JM assisted with the statistical analysis. JAM participated in the study design and helped to draft the manuscript. All authors read and approved the final manuscript.


Obese patients (OB) with COPD may better tolerate exercise as compared to normal weight (NW) COPD patients, even if the reason for this is not yet fully understood. We investigated the interactions between obesity, lung hyperinflation, fat-free mass (FFM) and exercise capacity in COPD.Forty-four patients  were assessed by resting lung function and body composition and exercised on a cycle-ergometer to exhaustion.2), when expressed as absolute value (p < 0.05), but not when corrected by FFM. OB compared to NW experienced lower leg fatigue (p < 0.05), but similar dyspnea on exertion. In all patients, the regression equation by stepwise multiple regression analysis for peak workload and VO2, as dependent variables included both FFM and IC/TLC at rest, as independent variables .Twenty-two OB and 22 NW patients did not differ in age, gender and airflow obstruction degree, but in FFM (p < 0.05). OB had significantly higher values in inspiratory capacity/total lung capacity ratio (IC/TLC) at rest (p < 0.01), but not at peak of exercise and showed significantly higher values in peak workload (p < 0.05) and in peak oxygen uptake (VOOB with COPD, as compared to NW patients matched for age, gender and airflow obstruction, had greater FFM and less resting lung hyperinflation and showed greater maximal exercise capacity. Pulmonary and non-pulmonary factors may explain the preservation of exercise tolerance in patients with COPD associated with obesity. Obesity, an independent risk factor for reduced survival, is a frThe impact of obesity on exercise capacity is not completely understood. Previous studies have shown that the combined mechanical effects of obesity and COPD may reduce operating lung volumes at rest and during exercise with favourable influences on breathlessness perception and peak oxygen uptake,8. On thInterestingly, in obese subjects, FFM may be increased,14 as adst Second/Vital Capacity ratio (FEV1/VC) < 70% and FEV1 ≤ 80% of predicted value, were included. Eligibility criteria were: 1) stable clinical condition (exacerbation free for at least 4 weeks); 2) no oxygen therapy; 3) absence of any comorbidity affecting exercise performance ; 4) ability to perform a symptom-limited cycle ergometry cardio pulmonary test (CPET) with a peak of respiratory exchange ratio (RER) ≥ 1.05 in order to exclude poor motivation; 5) CPET stopped for muscle fatigue and/or dyspnoea.We consecutively enrolled patients affected by COPD, who were admitted to a pulmonary rehabilitation program. All patients underwent routine blood and urine analysis as an initial screening prior to the rehabilitation program. COPD was diagnosed according to the GOLD criteria and patiAll the procedures and their risks were explained to the patients, who gave their written informed consent to enter the study. The protocol was approved by the ethical committee of the University Hospital of Parma. All participants' data were analysed and reported anonymously.st Second (FEV1), Forced Expiratory Flow measured at 50% of Forced Vital Capacity (FVC) (FEF50 in L/s) and Forced Inspiratory Flow measured at 50% of FVC (FIF50 in L/s) were recorded. FEV1/VC and FEF50/FIF50 ratios were taken as indices of airway obstruction and airway collapsibility, respectively.Pulmonary function tests were performed according to international recommendations,17. A flFunctional Residual Capacity (FRC) was measured by body plethysmography with the subject panting against a closed shutter at a frequency slightly lower than 1 Hz whilst supporting their cheeks with their hands. Total Lung Capacity (TLC) was obtained as the sum of FRC and linked Inspiratory Capacity (IC). Residual Volume (RV) was obtained by subtracting VC from TLC. IC/TLC ratio was taken as an index of hyperinflation of the lung. At least three measurements were taken for each spirometry and lung volume variable to ensure reproducibility and the highest value obtained was used in subsequent calculations. The flow-sensor was calibrated before each test using a three-litre syringe.1 and TLco were expressed as a percentage of the predicted values, which were obtained from regression equations by Quanjer et al.[Lung diffusion capacity for carbon monoxide (TLco) was measured by the single breath method using a mixture of carbon monoxide and methane; this measurement was done at least in duplicate. TLC, VC, IC, FEVr et al. and Coter et al..2 in L/min), carbon dioxide production (VCO2 in L/min), tidal volume (VT in L) and minute ventilation (VE in L/min) were recorded during the test . Patients were continuously monitored with a 12-lead electrocardiogram  and a pulse oximeter . Blood pressure was measured at 2 minute intervals. Stopping criteria consisted of symptoms such as unsustainable dyspnoea or leg fatigue, chest pain, ECG significant ST-segment depression, a drop in systolic blood pressure or oxygen saturation (SpO2) ≤ 84%.CPET was performed prior to the rehabilitation program according to a standardized procedure. After c2 were recorded as the mean value of watts and VO2 during the last 20 seconds of the test. Peak VO2 was expressed as absolute value in mL/min. Anaerobic threshold (AT) was non-invasively determined by both V-slope and ventilatory equivalents methods , as the respiratory exchange ratio approximated 1.0[2Pulse, in mL/bpm) was calculated by dividing instantaneous oxygen uptake by heart rate[Peak workload and peak VO2  was measured as the mean of PETCO2 during the 3-minute rest period and during the last 20 seconds of the test and the difference between PETCO2 peak and PETCO2 rest (PETCO2 peak-rest) was recorded.Changes in operational lung volumes were assessed every two minutes during exercise and at peak of exercise, taking the IC measured at rest as the baseline. After a full explanation of the procedure to each patient, satisfactory technique and reproducibility of IC manoeuvres were established during an initial practice session at rest. Assuming that TLC remains constant during exercise in COPD, changesnone” placed at the left end of the scale and the word “very severe” placed at the right end of the scale. The VAS scored from 0 to 100, but the subjects were unaware of the numbers. Dyspnoea and muscle fatigue ratings were then divided by the maximal workload [Daily living activity-related dyspnoea was evaluated with the Italian version of the five-point MRC scale modified by the ATS. At the m/watts).2) was calculated in all patients. Body composition was assessed by a bioelectrical impedance analysis (BIA) method, which is based on the conductance of an electrical sinusoidal alternating current through body fluids. BIA measures the impedance or resistance to the signal as it travels through the water that is found in muscle and fat. Foot-to-foot BIA was measured using a SC-331S Body Composition analyzer . Patients were measured in a standing position with bare feet on the analyzer footpads. The algorithms used to estimate lean body mass from impedance are those given by Segal et al.[2, kg/m2).Body height and weight were measured anthropometrically and body mass index  and linear regression analysis. Comparisons between variables were determined by unpaired t test and χ2 test, when appropriate. Stepwise multiple regression analysis was used to determine the best predictor variables for peak workload and VO2 as dependent variables. Percentage of total variance in the dependent variable, accounted for by the predictor variables, is expressed as the adjusted square of the multiple correlation coefficient (r2).This is a cross-sectional pilot study. Due to the explorative nature of the study no formal sample size calculation was performed. Data are reported as mean ± standard deviation (SD), unless otherwise specified. The distribution of variables was assessed by means of the Kolmogorov-Smirnov Goodness-of-Fit test. Relationships between variables were assessed by the Pearson’s correlation coefficient (2) and obese  patients. According to IC/TLC, patients of both groups were also divided in two categories: patients with IC/TLC ≤ 0.25 or > 0.25 both at rest and at peak of exercise. In COPD a IC/TLC ratio > 0.25 at rest is an established favourable prognostic indicator[According to the BMI value, populatndicator and at pndicator.p value of less than 0.05 was taken as significant.A 2). Twenty-two NW patients (BMI range: 19.0–24.9 kg/m2) and 22 OB patients with COPD (BMI range: 30.1–44.8 kg/m2) were studied. Twenty-nine  out of 44 patients (66%) suffered from controlled arterial hypertension and were taking diuretics (38%), Ca-antagonists (34%), beta-blockers (34%), and ACE-inhibitors (28%). The prevalence of arterial hypertension was not different between NW and OB patients (64% vs 68%). Additionally, the percentage of patients on beta-blockers was not different.Sixty consecutive stable COPD patients , aged between 42 and 75 years were screened. All of them were ex-smokers. Sixteen patients were excluded because of their BMI  . In addition, IC/TLC was significantly higher at rest (p < 0.01), but not at peak of exercise in OB as compared to NW , but not in PETCO2 peak-rest . As compared to NW, OB experienced lower leg fatigue (p < 0.05), but similar dyspnea on exertion.All the included patients completed the exercise test without any complications. The work rate increments during the exercise were not different between OB and NW patients (8.9 watts ± 2.9 vs 8.5 watts ± 2.5). When patients were asked to name the predominant symptom limiting the exercise test, 13 OB and 10 NW named exertion dyspnea, 6 OB and 8 NW named leg fatigue, whereas 3 OB and 4 NW named both symptoms. Exercise data are summarized in Table 2Pulse values, but they significantly differed in peak O2Pulse and in peak-rest O2Pulse values (7.6 ± 3 vs 5.6 ± 3 mL/bpm), which were both significantly higher in OB patients than in NW patients (p < 0.05) .The two groups of patients were not different in rest O2 and FFM  and IC/TLC at rest . Moreover, when all patients were categorized into two groups according to the median value of FFM , patients with a FFM value higher than that of the median showed higher values in peak workload , peak VO2  and in IC/TLC at rest . The regression equation generated by stepwise multiple regression analysis for peak workload and VO2, as dependent variables, included FFM and IC/TLC at rest. This model accounted for 43% and 37% of the total variance of the peak workload (in watts) and of VO2 (in mL) respectively, according to the following regression equations: W = -26.46 + 1.39 (FFM) + 126.85 (IC/TLC rest) and VO2 = -111.8 + 18.2 (FFM) + 1436.1 (IC/TLC rest).Lastly, in all patients significant positive correlations were found between peak workload and FFM  and IC/TLC at rest  and between VOThe main finding of the present study is that obese patients with COPD, as compared to normal weight patients matched for age, gender and airflow obstruction, show greater fat-free mass and less lung hyperinflation at rest, as assessed by the IC/TLC ratio. When performing a maximal exercise test by cycling, obese patients compared to controls have greater exercise capacity both in terms of peak workload and in terms of oxygen uptake at peak, expressed as absolute value, but not when corrected for fat-free mass. In all patients, by means of multiple regression analysis fat-free mass and resting lung hyperinflation were found to be determining factors of the peak workload and oxygen uptake at peak. Lastly, as compared to controls obese patients experienced a comparable degree of dyspnoea and less leg fatigue on exertion.Obesity may affect respiratory physiology both at rest and during exercise. Obese individuals show decreased respiratory system compliance, which results in a restrictive ventilatory defect. Low functional residual capacity and reductions in expiratory reserve volume increase the risk of expiratory flow limitation and airway closure during quiet breathing, especially in the supine position. Moreove2 value. Despite this, obese patients showed greater maximal exercise capacity both in terms of peak workload and in terms of oxygen uptake, thanks to their better starting conditions consisting in less lung hyperinflation at rest. Our results confirm and extend those of previous reports[In the present study, as compared to normal weight patients with COPD, the COPD patients with combined obesity developed during exercise, as assessed by the IC/TLC ratio at peak of exercise, dynamic hyperinflation of comparable magnitude and a similar degree of ventilatory limitation, as assessed by the difference in peak-rest PETCO reports,8. In thIt is not surprising to find a greater amount of fat-free mass in obese patients in comparison to normal weight controls, since the increase in fat-free mass represents an adaptation to the sustained loading effect from excessive adipose tissue. Previously, Babb et al. by invesLean body mass may have favourable effects on exercise tolerance in patients with wasting diseases, such as COPD. NotablyThis study has some limitations. Firstly, our obese patients showed mild-to-moderate obesity and our results cannot be generalizable to all obese patients, including those with morbid obesity. Secondly, in our study patients experienced maximal exercise capacity by using cycle ergometry, therefore, our results cannot be applicable to other forms of exercise, such as running on a treadmill, where the metabolic load is greater. Thirdly, in our patients body composition was assessed by bioelectrical impedance analysis, which is sensitive to the hydration status of the subject whereas, distribution of body fat was not analysed. However, our patients showed normal hydration status, as assessed by means of urinalysis, including urine specific gravity. Moreover, in both men and women with obesity the decrease in end-expiratory lung volume appears to be related to the cumulative effect of increased chest wall fat rather than to any specific regional chest wall fat distribution. Lastly,OB with COPD, as compared to NW patients matched for age, gender and airflow obstruction, had greater FFM and less resting lung hyperinflation and showed greater maximal exercise capacity. Pulmonary and non-pulmonary factors may explain the preservation of exercise tolerance in patients with COPD associated with obesity.50: Forced expiratory flow measured at 50% of FVC; FEV1: Forced expiratory volume in the 1st second; FIF50: Forced inspiratory flow measured at 50% of FVC.; FFM: Fat-free mass; FFMI: Fat-free mass index; FM: Fat mass; FRC: Functional residual capacity; FVC: Forced vital capacity; HR: Heart rate; IC: Inspiratory capacity; O2Pulse: Oxygen pulse; RV: Residual volume; SD: Standard deviation; TLC: Total lung capacity; TLco: Lung diffusion capacity for carbon monoxide; VAS: Visual analogue scale; VC: Vital capacity; VCO2: Carbon dioxide production; VE: Minute ventilation; VO2: Oxygen uptake; VT: Tidal volume.AT: Anaerobic threshold; BMI: Body mass index; COPD: Chronic obstructive pulmonary disease; CPET: Cardiopulmonary exercise test; FEFThe authors declare that they have no competing interests.MA served as the primary author. She developed the study protocol, participated in the patient recruitment and statistical analysis and drafted the manuscript and she is the guarantor of the entire manuscript. PT, SR, ET and MRG participated in the design of the study and helped with patient recruitment. EM participated in the coordination of the study. AC developed the study protocol, interpreted study data, contributed to and reviewed drafts of the manuscript. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2466/14/96/prepub


It was hypothesized that naked neck chickens could have a lower methionine requirement according to their reduced feather coverage. The hypothesis was examined by nitrogen balance studies and non-linear model application for estimating methionine requirement data of naked neck chickens. It was concluded that naked neck birds do not require less methionine than normally-feathered birds.Na/Na) and heterozygous (Na/na) naked neck meat type chicken utilized 144 birds of average weight (50% each genotype and sex) within two N balance experiments involving both the starter (d10–20) and grower period (d25–35). The birds were randomly allotted to five experimental diets with graded protein supply and Met as the limiting amino acid. The proportion of native feed protein sources  was kept constant to ensure a uniform protein quality in all diets. The Met requirement depending on genotype, sex, age period and growth performance (protein deposition) was estimated using a non-linear modeling procedure of N utilization in monogastric animals. On average, 0.47% (Na/Na) and 0.45% (Na/na) dietary Met was established as adequate in the starter diet, as well as 0.37% (Na/Na) and 0.36% (Na/na) Met in the grower diet for both of the sexes. In conclusion, the Met requirement of the naked neck chicken is not significantly different from its normally-feathered counterparts. In addition, the low feather production was not reflected by reduced requirement for Met in naked neck birds. However, these conclusions are valid only at the given Met:Cys ratio (1:1) in the experimental diets.Methionine (Met) requirement studies with homozygous ( It was concluded that the growth rate of both genotypes was similarly influenced by the dietary supply of SAA under uniform climate conditions.Previous protein requirement studies in naked neck birds came to inconsistent results. Ajang et al.  suggeste [et al.  observed [et al.  also sus [et al.  examinedNa/Na) and heterozygous (Na/na) naked neck meat type chicken depending on age and gender by application of a non-linear N utilization model [The present studies aimed at determining the Met requirement data for both homozygous  were selected for the N balance experiments involving both starter (d10-20) and grower period (d25-35). The birds were individually housed in metabolic cages with wire floor, equipped with individual feeder and self-drinking system. The temperature in the experimental room was gradually reduced from 32 to 23 °C with increasing age. Humidity was maintained between 60%–70% and monochromatic light was provided for 23 h following 1 h darkness.The birds were reared under standardized housing and feeding regimes up to the start of the experiments. Afterwards, a total of 144 birds of average weight  created by application of principles of the diet dilution technique [et al. . Howeveret al. , 6 to 10® Computer + Programme GmbH & Co. KG, Hessisch Oldendorf, Germany) was applied. The dietary AA ratios were adjusted to be near to the ideal AA ratio (IAAR) as derived from literature data [Consequently, the dietary AA pattern was kept unchanged independent on protein level in the diets of both age periods. To create optimal dietary AA ratios based on conventional feed ingredients only, a feed optimization program  and CP was calculated with factor 6.25. AA analyses were conducted by ion-exchange chromatography  following acid hydrolysis with and without an oxidation step for quantitative determination of sulfur-containing amino acids.Two N balance experiments during starter and grower period were conducted for each genotype and sex, respectively. The individual experimental period was divided into an adaptation period (5 d) and 2 consecutive collecting periods (each 5 d). Excreta collection was conducted 2 times a day to prevent ammonia losses from un-acidified excreta. Excreta samples were immediately frozen and stored at −20 °C until further analysis. Dietary ingredients, experimental diets and excreta were analyzed according to the German standards . The N ckg0.67); NRmaxT = theoretical daily maximum for NR (mg/BWkg0.67); NR = nitrogen retention (mg/BWkg0.67); b = slope of the N retention curve ; c = concentration of the LAA in the dietary protein (g/16 g N); bc−1 = slope between c and b . The multiplier 16 results from LAA concentration in the dietary protein (g/16 g N).According to current applications of our modeling procedure based on individual AA efficiency ,7,9, Metet al. [maxT). During starter period, 500 g mean BW was applied for modeling both in males and in females, respectively. According to lower growth potential during grower period, for female chickens 1400 g mean BW was applied .Further modeling of Met requirement data according to Equation (1) utilized both age, genotype and sex specific model parameters  and corret al. . Due to Results of modeling Met requirement data for graded daily PD and feed intake within starter and grower period are summarized in Na/Na and 0.41% Met in the diet for Na/na chicken was observed as requirement level for male chicken, assuming 10 g daily body PD and 60 g daily feed intake (Na/Na) and 0.39% Met (Na/na) in the diet were needed at 130 g daily feed intake to yield 17.5 g daily body PD. However, the results of modeling Met requirements need some further discussion in general, due to observed effects of varying model parameters as applied (−1) in male Na/Na chicken , the derived Met requirement data for male naked neck chickens are in line with GRRS [et al. [Generally, comparisons between our results of modeling and current recommendations are questionable according to the direct effect both of modulated PD and of Met efficiency data on our estimates. However, for male chicken at 10 g/d PD and 60 g/d feed intake our data are in the range of GRRS  recommenet al.  for fullith GRRS  and NRC ith GRRS  recommenith GRRS  and Kali [et al.  for 3–6 It is well documented that derived AA requirements of growing chickens depend on many factors such as genotype, gender, age and investigated response parameters ,20,21,22et al. [Na/na birds is not different from full-feathered chickens. Furthermore, Yalcin et al. [Na/na) chicken to study the response to different dietary Met concentrations from 0.57% and 0.33% under spring and summer conditions, respectively. They concluded that the Met content needed in diets of Na/na birds did not differ from that of their normally-feathered counterparts under both ambient temperature conditions. In addition, no interaction between genotype and dietary Met concentration was observed. These observations are in agreement with our current results. Indifferent requirement data for Met by naked neck birds compared to normally-feathered counterparts are also supported by investigations of Pesti et al. [For comparison of the current data with results in naked neck genotypes, the available database is extremely scarce. However, Yalçin et al.  concluden et al.  conductei et al. .et al. [Na/na and Na/Na over their normally-feathered sibs. They also found that the Na/na and Na/Na gained 4.5% and 8.1% more BW in grower period than na/na birds. Huyghebaert and Pack [et al. [Na gene [et al. [Additionally, Yalçin et al.  observedet al.  stated aand Pack  identifiand Pack  and late[Na gene . Accordi [et al. , a reduc [et al. . Met may−1) and feed intake pattern. A further conclusion was that lower feather production did not reduce the requirement for Met in naked neck birds of the genotype under study. However, the reported results of modeling Met requirement data are valid only for the given dietary ratio Met:Cys (1:1) in the experimental diets. Final recommendations for Met requirement data of naked neck birds with special reference to ideal dietary amino acid pattern for these particular genotypes need further investigations. In this context, the role of dietary Cys supply to maximize dietary Met efficiency will gain special attention.The estimated optimal Met concentration (percentage of diet) was in the data range given in literature, but influenced by age, aimed PD level, observed Met efficiency (bc