At the Low dose, no induction of the SULT, NAT, and EH was noted, whereas UDP level was elevated. At the Medium dose, only SULT level was increased, whereas at the High dose marked increase in EH level was observed. It is concluded that PEITC modulates carcinogen-metabolising enzyme systems at doses reflecting human intake thus elucidating the mechanism of its chemoprevention.Phenethyl isothiocyanate (PEITC) is an isothiocyanate found in watercress as the glucosinolate (gluconasturtiin). The isothiocyanate is converted from the glucosinolate by intestinal microflora or when contacted with myrosinase during the chopping and mastication of the vegetable. PEITC manifested protection against chemically-induced cancers in various tissues. A potential mechanism of chemoprevention is by modulating the metabolism of carcinogens so as to promote deactivation. The principal objective of this study was to investigate in rats the effect of PEITC on carcinogen-metabolising enzyme systems such as sulfotransferase (SULT), N-acetyltransferase (NAT), glucuronosyl transferase (UDP), and epoxide hydrolase (EH) following exposure to low doses that simulate human dietary intake. Rats were fed for 2 weeks diets supplemented with PEITC at 0.06  At the end of the treatment period, rats were sacrificed and the livers were removed. Tissue samples were immediately frozen in liquid nitrogen and stored at −80°C until required. Hepatic S9 of liver (25% w/v), in 0.154 M KCl containing 50 mM Tris-HCl, pH 7.4, was prepared prior to microsomal and cytosolic separation by differential centrifugation. The following assays were carried out on isolated microsomes: glucuronosyl transferase (UDP) using 1-naphthol as substrate [Male Wistar albino rats (180 ± 20 g) were obtained from B&K Universal Ltd . The animals were housed at 22 ± 2°C, 30–40% relative humidity, in an alternating 12 h light: dark cycle with light onset at 07.00 h. After a week's acclimatization, the rats were randomly assigned into 4 groups of 5 rats each. Animal doses were chosen so that the low dose responses the average human daily intake of glucosinolates (75 mg/person/day or 1.07 mg/kg bw) . Three gubstrate  as well ubstrate , and N-aubstrate ; proteinubstrate .Results are presented as mean ± standard deviation of groups of five rats each. Statistical evaluation was carried out by one-way ANOVA followed by the Dunnett's test.in vivo modulation of carcinogen-metabolising enzymes by PEITC, as this emerged as an impressing chemoprevention mechanism in the studies employing precision-cut rat [μmol PEITC/g diet for 14 days. The low dose is proportionate with human dietary intake of total glucosinolates, 75.5 mg/person/day or 1.07 mg/kg body weight for a 70 kg individual [The present study investigated the -cut rat  and huma-cut rat . Rats wedividual , which idividual . Earlierdividual , 37. Studividual .S-transferases have been well reported both in vitro and in vivo, their capability to modulate other phase II enzyme systems involved in carcinogen metabolism has received little attention. Glucuronosyl transferases are a very essential phase II detoxifying enzyme system involved in the metabolism of chemical carcinogens including aromatic amines and polycyclic aromatic hydrocarbons [Even though the effects of isothiocyanates on quinone reductase and glutathione ocarbons . The curocarbons . Similarocarbons . In addiocarbons , while iocarbons .Epoxide hydrolase is the phase II enzyme involved in the detoxification of many epoxides, the reactive intermediates of chemical carcinogens including polycyclic aromatic hydrocarbons, aflatoxin B1, and halogenated aliphatic compounds . The pre3−) group, normally to a hydroxyl on an acceptor molecule, which is catalysed by sulfotransferases [Sulfotransferases are the enzymes that catalyse sulfonation, an important reaction involved in the metabolism of numerous xenobiotics, drugs, and endogenous compounds . The prosferases . It was N-acetyltransferases are cytosolic conjugating enzymes which transfer an acetyl group from acetyl coenzyme A to a xenobiotic acceptor substrate . Our finThe present studies allow us to infer that phenethyl isothiocyanate modulates carcinogen-metabolising enzyme systems at doses reflecting human intake as a marked induction of epoxide hydrolase which was seen at the high dose, while at the low and medium doses, glucuronosyl transferase and sulfotransferase levels were upregulated, respectively. Increased levels of detoxification enzymes such as epoxide hydrolase, glucuronosyl transferase, and sulfotransferase are the likely one of the mechanisms for chemoprevention of PEITC.


Root to shoot ratio (RS) is commonly used to describe the biomass allocation between below- and aboveground parts of plants. Determining the key factors influencing RS and interpreting the relationship between RS and environmental factors is important for biological and ecological research. In this study, we compiled 2088 pairs of root and shoot biomass data across China’s terrestrial biomes to examine variations in the RS and its responses to biotic and abiotic factors including vegetation type, soil texture, climatic variables, and stand age. The median value of RS (RSm) for grasslands, shrublands, and forests was 6.0, 0.73, and 0.23, respectively. The range of RS was considerably wide for each vegetation type. RS values for all three major vegetation types were found to be significantly correlated to mean annual precipitation (MAP) and potential water deficit index (PWDI). Mean annual temperature (MAT) also significantly affect the RS for forests and grasslands. Soil texture and forest origin altered the response of RS to climatic factors as well. An allometric formula could be used to well quantify the relationship between aboveground and belowground biomass, although each vegetation type had its own inherent allometric relationship. Belowground biomass (BGB) is an important component of global terrestrial ecosystem carbon stocks and plays a critical role in global carbon cycling. Belowground biomass is more difficult and costly to measure and is a major source of uncertainties in large-scale biomass estimation and global carbon cycles Biomass partitioning between belowground and aboveground parts can be predicted by plant allometric relationships 2, soil texture, soil moisture, and nitrogen), biotic factors , and forest origins Recent studies have indicated that RS changes with environmental factors  how RS varies across China’s terrestrial biomes, 2) how RS responds to biotic and abiotic variables, and 3) how well the allometric theory performs in comparison with estimates of the empirical relationship between RS and environmental variables.We collected 2088 measurements of root and shoot biomass across China from hundreds of published papers . In the For each data set, we recorded the biomass data and whatever supporting information was available, including (1) shoot, root, and total biomass (dry weight of biomass per unit area); (2) site descriptions , and soil texture); (3) vegetation descriptions , age, height, density of stems, and mean diameter at breast height (DBH)); (4) descriptions of shoot and root biomass sampling methods .r2 = 0.92, n = 77, p<0.01), and extracted MAT was in good agreement with the measurements  as well. We computed mean annual potential evapotranspiration (PET) using the FAO Penman–Monteith equation The climatic variables mean annual precipitation (MAP) and temperature (MAT) at each biomass-sampling site were determined from the nearest surface meteorological stations across China . HistoriThe categorization of data into vegetation types relied primarily upon a soil texture classification scheme Descriptive analysis was used to determine the statistical characteristics  of categorical data. Linear and nonlinear analyses were performed to develop regressions for RS dependent on the vegetation type, soil texture, and climatic variables. The significance of differences between slopes  and y-intercepts  of the log-log transformed linear functions was evaluated by analyses of variance The biomass and RS values shown in The median RS of forests tended to increase from planted to secondary to primary stands. In addition, forests growing in sandy soil had a larger median RS than those in loam and clay soils. Further, loam soil forests had approximately the same median RS value as the clay soil forests .For grasslands, RS changed significantly with different grassland types. The median RS of alpine grassland was much higher than that of temperate grassland . There wp<0.01) with increased MAP. A similar trend was found in RS for forests where MAP was less than 1250 mm·yr−1; however, RS values tended to increase significantly (p<0.01) where MAP was over 1250 mm·yr−1  for all forests  as MAP increased; however no trend existed between MAP and RS for planted forests (p<0.01) as PWDI increased for both natural and planted forests (p<0.01). In contrast, no significant trend existed between RS and MAP (p<0.01) with increasing MAT  different from each other between China’s major terrestrial ecosystems  and all slopes were significant (p<0.01)  ; Table 1p<0.05) different from each other and all slopes were significant (p<0.01) (p<0.01) greater than that of both loam and sandy grasslands. The allometric relationship for loam soil is not significantly different from that of sandy soil (p<0.01) (p<0.01) than that of temperate grasslands. The allometric relationship for alpine grasslands was significantly different from that of temperate grasslands (p<0.01)  ; Table 1(p<0.01) ; Table 1(p<0.01) ; Table 1(p<0.01) .We reported that the overall median values of AGB were 76.7, 1.0 and 10.6, and the median of BGB were 17.0, 5.2 and 9.4 for China’s forests, grasslands and shrublands, respectively . As a coBiomass allocation is one of the most successful theories in modern ecology Majority of previous studies reported that RS can be either positively or negatively and linearly correlated and even nonlinearly related with the increase in annual precipitation at relatively larger regional or national scales One of key contributions of this study is that we comprehensively examined the responses of RS to multiply abiotic and biotic factors, including climatic variables , soil texture and vegetation type and age. The integrated analysis provided comprehensive understanding on the variations of RS and their response of RS to environmental factors. We found that RS could be significantly impacted by any of considered abiotic or biotic factors. Compared with any single factor from climate, a comprehensive index PWDI could be better to describe the dependency of RS on environmental factors. Biomass partition is commonly viewed as a result impacted by multiple environmental factors. Variation in RS and difference in their responses to individual or combined environmental factors supported the optimal partitioning hypothesis Differing from the analysis between RS and environmental factors, allometric equations have been also widely accepted as an effective method for investigating biomass partitioning between aboveground and belowground components e.g., . As an ap<0.05) influenced by vegetation type, soil texture, climatic variables, and stand age.This paper systematically examined the variation in RS across China’s terrestrial biomes and its influencing factors including vegetation type, soil properties, climatic variables, and stand age. We found that median RS tended to decrease from grasslands (6.0) to shrublands (0.73) to forests (0.23) in China. Although primarily decided by the plants’ inherent isometric relationships, RS were significantly Click here for additional data file.


Platycodi Radix, on mice collagen-induced arthritis (CIA). A daily dose of 200, 100, and 50 mg/kg platycodin D was administered orally to male DBA/1J mice for 40 days after initial collagen immunization. To ascertain the effects administering the collagen booster, CIA-related features  was measured from histopathological changes in the spleen, left popliteal lymph node, third digit, and the knee joint regions. CIA-related bone and cartilage damage improved significantly in the platycodin D-administered CIA mice. Additionally, myeloperoxidase (MPO) levels in the paw were reduced in platycodin D-treated CIA mice compared to CIA control groups. The level of malondialdehyde (MDA), an indicator of oxidative stress, decreased in a dose-dependent manner in the platycodin D group. Finally, the production of IL-6 and TNF-α, involved in rheumatoid arthritis pathogenesis, was suppressed by treatment with platycodin D. Taken together, these results suggest that platycodin D is a promising new effective antirheumatoid arthritis agent, exerting anti-inflammatory, antioxidative and immunomodulatory effects in CIA mice.The object of this study is to observe the effects of platycodin D, a saponin purified from  The rawycodin D . Prepareα neutralizing antibody,  was used as reference drug. In the present study, 200, 100, and 50 mg/kg of platycodin D were orally administered, once a day 40 days in a volume of 5 mL/kg of distilled water. In case of Enbrel, it subcutaneously injected three day-intervals from immunization to sacrifice diluted using saline at 10 mg/kg levels. In intact and CIA control, only distilled water was orally administered instead of test materials, once a day for 40 days from immunization.In this study, we selected 200 mg/kg of platycodin D as the highest dosage, and 100 and 50 mg/kg were selected as the middle and lowest dosages using common ratio 2. In addition, 10 mg/kg Enbrel, TNF-μg of type II collagen  emulsified with an equal volume of Freund's complete adjuvant  and intraperitoneally boosted with type II collagen (100 μg in 0.05 M acetic acid) emulsified with an equal volume of Freund's incomplete adjuvant  at 23 days after the initial immunization. In intact control mice, only vehicle, 0.05 M acetic acid was intradermally injected instead of collagen immunization and intraperitoneally administered instead of antigen boosting, respectively.CIA was induced according to the previous methods . Mice weChanges of body weight were calculated at 1 day before immunization (Day −1), at immunization (Day 0), 1, 7, 14, 21, 23 (at antigen boosting), 28, 35, and 39 days after immunization with at a termination using an automatic electronic balance . At immunization (initiation of administration) and at a termination, all experimental animals were overnight fasted  to reduce the differences from feeding.The clinical severity of arthritis in all four paws of mice was evaluated in a triple-blind fashion by a previous published scoring system . BrieflyThe thickness of left hind paw and knee was measured using an electronic digital caliper  and recorded at antigen boosting (Day 23), 24, 25, 26, 27, 30, 33, 36 and 39 days after immunization. In addition, to reduce the individual differences from start of measurements, the changes after antigen challenges were also calculated.At sacrifice, the spleen, left hind paw and left popliteal lymph nodes were collected after connective tissues, muscles, and debris were removed. The weight of organs or paw was calculated at g levels regarding absolute wet-weights. To reduce the individual body weight differences, the relative weight (%) was calculated using body weight at sacrifice and absolute weight.μL) was mixed with a solution of 1.6 mM tetra-methyl-benzidine  and 1 mM hydrogen peroxide . Activity was measured spectrophotometrically as the change in absorbance at 650 nm at 37°C, using a microplate reader [Collected paws were homogenized (50 mg/mL) in 0.5% hexadecyltrimethylammonium bromide  in 10 mM 3-N-morpholinopropanesulfonic acid  and centrifuged at 15,000 g for 40 min. The suspension was then sonicated three times for 30 seconds. An aliquot of supernatant , 1.5 mL 20% acetic acid (pH 3.5), and 600 μL distilled water. The mixture was then heated at 90°C for 45 min. After cooling to room temperature, the samples were cleared by centrifugation  and their absorbance measured at 532 nm, using 1,1,3,3-tetramethoxypropane as an external standard [MDA formation was utilized to quantify the lipid peroxidation in the mouse paws and measured as thiobarbituric acid-reactive material. Tissues were homogenized (100 mg/mL) in 1.15% KCl buffer. Two hundred microliters of the homogenates were then added to a reaction mixture consisting of 1.5 mL 0.8% thiobarbituric acid , 200 standard . The levμL of a TRIS-HCl buffer containing protease inhibitors. Samples were centrifuged for 30 min and the supernatant was frozen at −80°C until assay. Cytokine levels were determined using commercial ELISA kit [Paws were snap frozen in liquid nitrogen; the sample was then homogenized in 700 LISA kit .6 cells/well. Isolated splenocytes were cultured for 72 h. The amounts of TNF-α and IL-6 in the culture supernatants were measured by ELISA [α and IL-6. The absorbance was determined with an ELISA microplate reader at 405 nm.Mouse spleens were collected for cell preparation and washed twice with PBS. The spleens were minced and the red blood cells were lysed with 0.83% ammonium chloride . The cells were filtered through a cell strainer and centrifuged at 1300 rpm at 4°C for 5 min. The cell pellets were resuspended in RPMI 1640 medium and plated in 24-well plates  at a concentration of 1 × 10by ELISA . The amoμm) and stained with hematoxylin and eosin (H&E). The histological profiles of the knee joints and third digits were observed as compared with the intact control. In addition, spleen and left popliteal lymph nodes were sampled and fixed in 10% neutral buffered formalin. After paraffin embedding, 3-4 μm sections were prepared. Representative sections were stained H&E for light microscopical examination. After that the histological profiles of individual organs were observed.The knee joints parts were sampled with the joint capsules preservation with total left hind paw and fixed in 10% neutral buffered formalin. After 5 days of fixation, they were decalcified using decalcifying solution (24.4% formic acid and 0.5 N sodium hydroxide) for 5 days . After that, median joint parts were longitudinally trimmed or third digits were crossly trimmed, and embedded in paraffin, sectioned (3~4 Histomorphometry. The thickness of articular surface (including compact bone and articular cartilages) of tibia and femur (μm/bone), articular cartilage thickness of tibia and femur (μm/bone), infiltrated inflammatory cell numbers of left knee cavity and cutaneous regions of third digits (cells/mm2), dorsum digit skin thicknesses around third digits (μm/digit), and cortical bone thickness of third digits (μm/digit) were measured as histomorphometrical analyses at prepared knee joint and third digit samples for RA analysis using digital image analyzer . In addition, total  and white pulp (mm/pulp) thicknesses of spleen with numbers of white pulp (pulps/mm2) and total  and cortex thicknesses (mm/lymph node) of left popliteal lymph were measured as histomorphometrical analyses for immune response at prepared spleen and thymus samples using digital image analyzer according to the previous report [s report . The hisU (MW) test was conducted to determine the specific pairs of group comparison, which are significantly different. Statistical analyses were conducted using SPSS for Windows .Multiple comparison tests for different dose groups were conducted. Variance homogeneity was examined using the Levene test. If the Levene test indicated no significant deviations from variance homogeneity, the obtained data were analyzed by one way ANOVA test followed by least-significant differences (LSD) multicomparison test to determine which pairs of group comparison were significantly different. In case of significant deviations from variance homogeneity being observed at Levene test, a nonparametric comparison test, Kruskal-Wallis H test was conducted. When a significant difference is observed in the Kruskal-Wallis H test, the Mann-Whitney Significant decreases of body weight were detected from 28 days after immunization (5 days after antigen boosting) in CIA control as compared with intact control. Body weight gains were also significantly decreased after antigen boosting and during experimental periods. However, the body weight of Enbrel mice and mice treated with the three dosages of platycodin D increased markedly from 28 days after immunizations, as did the body weights after antigen boosting and during experimental periods .Clinical arthritis scores were significantly higher from 24 days after immunization (1 day after antigen boosting) in CIA control compared with intact control. However, significant decreases in clinical arthritis scores were detected from 25 days after immunization in Enbrel, from 26 days after immunization in platycodin D 200 mg/kg treated mice, and from 30 days after immunization in platycodin D 100 and 50 mg/kg treated mice as compared with CIA control mice, respectively .There were a significant increases in paw thicknesses and knee thickness from 24 days after immunization (1 day after antigen boosting) in CIA control as compared with intact control. Paw and knee thickness after antigen challenges were also increased significantly.Paw thickness in Enbrel and 200 mg/kg platycodin D treated mice were decreased significantly from 25 and 26 days after immunizations, respectively. Mice treated with 100 and 50 mg/kg platycodin D also exhibited decreased paw thickness from 27 days after immunization. In addition, after antigen challenge, paw thickness decreased in Enbrel group, and in all three platycodin D-treated groups, as compared with the CIA control .Knee thickness in Enbrel and 200 mg/kg platycodin D treated mice decreased significantly from 25 and 26 days after immunizations, respectively, and from 27 days after immunization in 100 and 50 mg/kg platycodin D-treated mice as compared with CIA control mice. The changes on the knee thicknesses after antigen challenges were also significantly decreased in Enbrel and all three different dosages of platycodin D treated mice as compared with CIA control .The absolute and relative weights of the left paw, spleen, and left popliteal lymph nodes were significantly increases in CIA control, compared with the intact control. However, in the Enbrel treated group, and in all three different dosages of platycodin D treated groups, these weights were lower than in the CIA control group .MPO and MDA contents in right hind paw were higher in CIA control as compared with intact control at sacrifice, respectively. However these paw MPO and MDA contents of Enbrel and all three different dosages of platycodin D treated group were significantly decreased as compared with CIA control mice, respectively .α and IL-6 contents in right hind paw were detected in CIA control as compared with intact control at sacrifice. In addition, splenocyte TNF-α and IL-6 productions increased in the CIA control compared with the intact control.There was significant increment of TNF-However, for the Enbrel group, and all three different dosages of platycodin D treated group were significantly lower as compared with CIA control mice Figures .Marked decreases in articular cartilages and bones surfaces were detected in both knee articular, femur, and tibia surfaces, where there was marked inflammatory cell infiltration into the synovial cavity in the CIA control mice. There were also dramatic edematous changes, inflammatory cell infiltrations, and erosive damages of digital bones on the third digits of the CIA control mice. However, these classic histopathological changes indicative of CIA were dramatically decreased by treatment of Enbrel and all three different dosages of platycodin D, respectively Figures  and 6.The semiquantitative scores in the femur, tibia, and third digits of the CIA control group were increased significantly compared with the intact control. However these scores of Enbrel and all platycodin D treated mice were significantly decreased compared with CIA control mice .Knee articular surface thickness, including compact bone and cartilage, and knee articular cartilage thickness were significantly less in the femur and tibia of the CIA control compared with the intact control, whereas the thickness of these sites in the ENBREL and platycodin D-treated mice were markedly higher than in CIA control mice Figures .The numbers of inflammatory cells infiltrated into the knee synovial cavity and third digits were significantly changed by platycodin D treatment. Significantly higher numbers of inflammatory cells infiltrated the knee synovial cavity and third digit cutaneous regions in the CIA control mice compared with the intact control; however, in the ENBREL and platycodin D-treated mice the numbers of infiltrated cells were lower compared with the CIA control mice .Significant increases of the third digit dorsum pedis skin and cortical thickness thicknesses were detected in platycodin D treated mice. The third digit dorsum pedis skin thicknesses was significantly higher in the CIA control; however there were significant decreases in the Enbrel, platycodin D-treated mice compared with the CIA control mice .Marked enlargement of spleen and popliteal lymph nodes were detected in CIA control mice. It is related to hyperplasia of lymphoid cells in the white pulp of spleen or cortex of lymph nodes. However, these histopathological changes of immune enhances were dramatically decreased by treatment of Enbrel and platycodin D Figures  and 9. AAccording to the results, platycodin D significantly improved CIA-related features, including poly-arthritis , body weA marked reduction of body weights and gains have been detected in CIA mice after antigen exposures , 36, andRA is characterized by the inflammation of synovial joints infiltrated by CD4+ T cells, macrophages, and plasma cells, neutrophils that play major roles in the pathogenesis of the disease , 37. BesInflammations were directly correlated with oxidative stress  and oxidα have been involved in the pathogenesis of RA [α, produced by a variety of cell types, including splenocytes, was found to be associated with critical events leading to T-lineage commitment and differentiation [α can enhance the in vivo immune response at doses much lower than those that cause weight loss or tissue toxicity. It enhances proliferation of B and T cells and promotes the generation of cytotoxic T cells. In addition, it enhances IL-2-induced immunoglobulin production and augments IL-2 stimulated natural killer cell activity and proliferation of monocytes [α contents were also observed with increases of splenocyte IL-6 and TNF-α productions. However, these increases of cytokine activities and productions were dose-dependently inhibited by treatment of platycodin D like Enbrel. These results are considered as one of indirect evidence that platycodin D has some immunomodulatory effects as already known [Abnormal increases of cytokine, IL-6, and TNF-is of RA , 42. Thentiation . TNF-α conocytes . IL-6 haonocytes . IL-6 isonocytes –48. IL-6onocytes . In the dy known , 25 and Clinical arthritis score system based on the gross edematous changes and inflammations have been used as a valuable scoring system to detect the efficacy of test materials on CIA . In addiThe importance of secondary lymphoid organs in the development of RA was demonstrated in early studies . GeneralThe results obtained in this study suggest that oral treatment of platycodin D 200, 100, and 50 mg/kg showed relatively good favorable effects on the CIA mice mediated by anti-inflammatory, antioxidative, and immunomodulatory effects. These data suggest that platycodin D promise as a new effective antirheumatoid arthritis agent. Since marked favorable anti-CIA effects were also detected in platycodin D 50 mg/kg treated mice, the minimal effective dosage of platycodin D on CIA mice after oral administration is considered as below 50 mg/kg.


Eurycoma longifolia is reputed as an aphrodisiac and remedy for decreased male libido. A randomized, double-blind, placebo controlled, parallel group study was carried out to investigate the clinical evidence of E. longifolia in men. The 12-week study in 109 men between 30 and 55 years of age consisted of either treatment of 300 mg of water extract of E. longifolia (Physta) or placebo. Primary endpoints were the Quality of Life investigated by SF-36 questionnaire and Sexual Well-Being investigated by International Index of Erectile Function (IIEF) and Sexual Health Questionnaires (SHQ); Seminal Fluid Analysis (SFA), fat mass and safety profiles. Repeated measures ANOVA analysis was used to compare changes in the endpoints. The E. longifolia (EL) group significantly improved in the domain Physical Functioning of SF-36, from baseline to week 12 compared to placebo (P = 0.006) and in between group at week 12 (P = 0.028). The EL group showed higher scores in the overall Erectile Function domain in IIEF (P < 0.001), sexual libido (14% by week 12), SFA- with sperm motility at 44.4%, and semen volume at 18.2% at the end of treatment. Subjects with BMI ≥ 25 kg/m2 significantly improved in fat mass lost (P = 0.008). All safety parameters were comparable to placebo. Sexual health is an important issue in quality of life of males and females. In males' sexual well-being, dissatisfaction in sexual life is significantly caused by erectile dysfunction (ED), which is defined as a consistent or recurrent inability of a man to attain and/or maintain penile erection sufficient for sexual activity . AlthougReviews as well as multinational surveys for Asian countries showed the prevalence of self-reported moderate ED in aging males 40–70 years) ranging from 17.7% (Taiwan), 22% , 28.3% (China), 32.2% (Korea), and 34% (Japan) . Another0 years rEurycoma longifolia Jack, from the Simaroubaceae family, also known traditionally as Tongkat Ali has been reputed by Malays as a traditional remedy used as an adaptogen for vitality and energy and is well-known for its aphrodisiac activities [E. longifolia also exhibits anxiolytic (antianxiety) effects suggesting medical use for overall physical well-being. In Malaysia, one of the most popular herbs, tivities . Numeroutivities –16. BesiE. longifolia, where a wide range of bioactive compounds have been isolated including phenolic compounds, polypeptides, diterpenoids, alkaloids, quassinoids, and others [E. longifolia root extract on the sexual qualities in male rats, measured using an electrical copulation cage, had in general not much difference in sexual performance, possibly due to the existence of the bioactive compounds in several of the fractions tested [Traditionally used remedies for enhancing testosterone level in man are (water) extracts of the roots of d others , 17. In s tested . HoweverE. longifolia with its aphrodisiac and ergogenic potency are limited. Previous human investigations have shown that this herb has various beneficial effects on health and can act as an “energy-booster” [E. longifolia water extract improved LOH expressed by a significant decrease in Aging Males Symptoms score (AMS) and increased serum testosterone levels [Clinical trials to support and substantiate the traditional use of booster” , 19. Rece levels . E. longifolia in intense strength training programs, general sport activities, for example, endurance running programs and health-related fitness exercises in recreational males and athletes are to some extent inconsistent; however, previous open and placebo-controlled studies with small sample sizes support various positive properties of this herb as an anabolic remedy [Literature-based evidence on the alleged ergogenic potency of (water) extracts of c remedy , 21, 22.E. longifolia can only be demonstrated by robust randomized, controlled trials. Since these data are missing, the present RCT was performed to analyze the improvement of the quality of life, physical performance, and sexual well-being in men during intake of a freeze-dried water extract from the roots of E. longifolia. The potential of the therapeutic efficacy as well as safety/tolerability of This 12-week randomized, double-blind, placebo-controlled and parallel group designed trial in Malay males was conducted in accordance with the Guideline for Good Clinical Practice (ICH-6) and Declaration of Helsinki. The study protocol was evaluated and approved by the Human Research and Ethics Committee for Clinical Studies of Universiti Sains Malaysia (USM) . The intervention was carried out from January 2009 (first patient in) to August 2010 (last patient out) at the Clinical Trial Unit (CTU), Hospital Universiti Sains Malaysia (HUSM), Kubang Kerian, Malaysia.After signed informed consent, healthy married men between 30 years and 55 years of age or those with stable chronic medical illnesses, for example, controlled diabetes mellitus and/or hypertension on monotherapy or low dose combination therapy were included . Subjects were excluded with major uncontrolled psychiatric disorders, history of alcohol or drug abuse, history of major hematological, renal or hepatic disorder, stroke or myocardial infarction within the last six months, peptic ulcer or bleeding disorder, elevated blood pressure beyond the range of 90/50 to 170/100 mmHg, clinically relevant baseline laboratory abnormality, and/or use of herbal products or drugs that could contain testosterone or any androgenic activity in the last month before start of trial. These products and alcohol were also not permitted during trial. E. longifolia water extract or unable to comply with the scheduled treatment dose of at least 80% of the dose during the trial period. Subjects were given the option of withdrawing from the study for any reason at any time or, for example, evidence of intolerance towards E. longifolia extract on the improvement of physical and vitality of adult men were unknown to the date of this study. A study [Panax ginseng in enhancing physical endurance in randomly selected young adults was taken as reference in sample size calculation. The calculation was based on the two-mean formula of between groups (independent t) and also prepost trial groups (paired t). Level of significance (α) of 0.05 and power (1−β) of 80% were considered while ratio between trial and control group was taken as 1 (m = 1). Considering 10% drop-out rate for the highest calculated sample size of between and within group subject effects, the minimum number of subjects needed in each group arm (verum or placebo) was determined to be 50 with the final sample for this trial was 100 subjects. The sample size estimation for this trial was based on data of efficacy studies performed with other traditional herbal medicines since effects of  A study  on the eE. longifolia water extract or two capsules matching placebo 2 times a day after lunch and dinner for 12 weeks.The subjects adhered to a total of four visit intervals for screening , recording of measurements at baseline , at week 6 , and end of study at week 12  followed by a follow-up visit . At screening (visit 1), clinical examinations and interviews were conducted to select subject who fulfilled the study criteria. Blood samples were collected from the subjects for hematological, renal, and liver parameters such as hemoglobin, white blood count, platelet, creatinine, urea, serum electrolyte, liver enzymes , and Prostatic Specific Antigen (PSA). At baseline (visit 2) all eligible subjects were randomly assigned to the two treatment groups to receive either two capsules of Eurycoma longifolia root  manufactured under Good Manufacturing Process requirements (GMP) with continuous quality control (DER 20 : 1). The total amount of daily intake equals to 300 mg/day herbal extract. Placebo medication corresponded  to the active medication without the herbal extract.During the intervention, each subject consumed four capsules per day containing either verum or placebo. One verum capsule contains as active ingredients 75 mg of the special freeze-dried water extract of Primary endpoints were taken as the efficacy parameters of Quality of Life (SF-36) questionnaire and physical fitness tests such as flexibility (sit and reach), muscular strength , muscular endurance (sit-up and push up), and cardiovascular endurance as well as the safety profiles which were measured at each visit after enrollment.The SF-36 QOL scale, validated for use in Malaysia , includeEach session of the physical fitness tests contained of a battery of different types of tests so that various physiological and muscular parameters could be activated/stimulated, finally leading to an improvement of these fitness activities: flexibility—(type of test: sit and reach), muscular strength , muscular endurance (sit-up and push up), body composition , and cardiovascular endurance/cardiorespiratory fitness. All these tests were carried out on the same day for each participant and the duration took approximately two hours for each session of five to eight subjects. The safety assessments reflected the documented Adverse Events , physical examination, clinical and laboratory measures including blood urea serum electrolytes (BUSE), creatinine, Serum Glutamate-Oxalacetate Transaminase (AST), Serum Glutamate-Pyruvate Transaminase (ALT), alkaline phosphatase (ALP), total protein, albumin, globulin and bilirubin, Prostatic Specific Antigen, glucose, uric acid, lipid profile, full blood count, and the ratio testosterone : epitestosterone. 4), sex hormone binding globulin (SHBG), Seminal Fluid Analysis  and International Index of Erectile Function (IIEF-15), hormonal profiles, that is, free testosterone, serum total testosterone, Insulin-like Growth Factor 1 (IGF-1), dehydroepiandrosterone sulfate (DHEA-SOllection ), and faThe SHQ used in this study contains questions divided into two domains “Sexual Libido” and “Sexual Satisfaction”. The IIEF-scale which is useful to evaluate erectile dysfunction of a population consists of 15 questions divided into five domains: “Erectile Function”, “Orgasmic Function”, “Sexual desire”, “Intercourse Satisfaction”, and “Overall Satisfaction”. The scores correspond to clinical interpretations ranging from “severe” to “no dysfunction”. The IIEF-scale is culturally adapted and validated for use in Malaysia .Blood tests were analyzed at the Gribbles's clinical laboratories . DEXA scan and SFA (single lab technician) were conducted at Hospital Universiti Sains Malaysia (HUSM). Physical fitness tests were conducted by Sport Science Lab personnel at HUSM.E. longifolia group (primary and secondary outcomes) versus placebo at week 6 and/or end of treatment after 12 weeks in comparison to baseline values by using the Intention-to-Treat (ITT) analysis approach. Only data sets from subjects who took at least one dose of study drug and had at least one postbaseline efficacy evaluation were included. Missing values were handled by last observation carried forward (LOCF). As a secondary approach, data were analyzed from the Per Protocol (PP) population following subjects who completed all of the three visits  without violation or major deviations and who were at least 80% compliant in taking medication.The main aim of the statistical analysis was to explore the safety profiles and to show the effectiveness of the trial drug measured by changes of the parameters in the t-test, chi-square (χ2) analyses, and nonparametric Mann-Whitney test (as appropriate) were used for baseline comparison of the two randomized groups. Repeated measure ANOVA (mixed design) was conducted for changes over time for the continuous outcomes (within groups difference), between-groups differences and also across the two treatment groups , from baseline to week 6 and week 12. Further procedure was followed when repeated measures ANOVA (within subject effects) were found to be statistically significant on primary continuous outcomes using paired t-tests with Bonferroni pair wise comparisons between time periods. Adjustment of the outcome parameters for certain confounders or covariates (including the baseline differences) was carried out using analysis of covariance (ANCOVA). Data was explored and descriptive statistical analysis was conducted by variables especially on the safety profiles. Mean  was described for continuous variables of normality distributed data and median  for nonnormal distribution, while frequency and percent (%) were described for categorical data. Independent α = 0.10 (two-tailed) (10% level of significance) was also conducted if no significant result of initial analysis seen at α = 0.05 Additionally, an age-dependent subgroup analysis was done for age groups of 30 years to 44 years and 45 years to 55 years. Further efficacy analysis on selected outcome parameters at significance level All data were documented in the case report forms (CRF). Data entry was done at Clinical Trial Unit (CTU), School of Medical Sciences, Universiti Sains Malaysia USM. Results from the trial were analysed and stored at School of Medical Sciences, Universiti Sains Malaysia. The statistical analysis was performed using Statistical Package Social Sciences, SPSS (PASW 18.0) under license of USM, Malaysia. E. longifolia and placebo medication. Subjects were omitted for analysis if they had no baseline data and/or without at least one postbaseline evaluation at week 6 or week 12. The Intention-to-Treat (ITT) population is shown in A total of 122 male subjects were screened for eligibility and 109 subjects were randomized toE. longifolia and placebo show no statistical difference (2 to 40.1 kg/m2 with mean (SD) of 26.14 (3.71) kg/m2. The BMI proportions between normal (<25), overweight (≥25 to <30), and obese (≥30) were 36.7% (40/109 subjects), 53.21% (58/109), and 10.09% (11/109), respectively. Regarding the Fasting Blood Sugar the values range from 4.3 mmol/L to 12.1 mmol/L, with 83.33% (90/108) below the value of 5.5 mmol/L. The remaining proportion had elevated glucose levels. Blood pressure ranged between SBP 90 mmHg to 160 mmHg and DBP from 59 mmHg to 94 mmHg; approximately 45% (49/109) of the subjects showed values above SBP 120 mmHg and 5.5% (5/109) had values above SBP 140 mmHg. Baseline comparisons on demographic and physical examination data on study participants between randomized groups of fference . The BodE. longifolia group (16.5 (5.8) nmol/L) (P = 0.026). SHBG levels are slightly elevated in the placebo (30.6 (10.3) nmmol/L) compared to the herbal group (26.8 (11.5) nmmol/L) (P = 0.073). Seminal Fluid Analysis (SFA) and DEXA  show no difference between groups at baseline.There is no significant difference between groups with respect to hematological or clinical blood chemistry parameters including Fasting Blood Sugar, liver function, full blood counts, Prostate Specific Antigen (PSA), lipid profile, and hormone profile except for total testosterone, whereby subjects in the placebo group had significantly higher total testosterone values (mean 18.8 (4.6) nmol/L) compared to E. longifolia and 50 placebo) were used including the three cases  with missing data on week 12, treated with LOCF principle. The general analysis shows no overall significant mean differences over time between E. longifolia and placebo. However, significant improvements and group differences as well as trends are observed in various items in several domains of the Quality of Life SF-36 scale.For the ITT-analysis, data from 102 subjects , “role physical”, and “vitality” showed significant improvements. E. longifolia group, there was a significant improvement of overall scores of Physical Functioning domain from baseline to week 12 (P = 0.006) as compared to placebo (P = 0.028). No age-related effect is observed. The score values of the single items from the Physical Functioning domain for herbal and placebo groups correspond to the clinical interpretation that the activities during a typical day “yes, limited a little” to “no, not limited at all”. In the  placebo . In addi, an overall significant change from baseline to end of study at week 12 was observed in the herbal group as compared to placebo (P = 0.009). In contrast, no significant changes were seen in placebo group. Analysis by age stratification (30 yrs to 44 yrs and 45 yrs to 55 yrs) showed no significant changes or differences between groups over time, however, an increasing trend was seen in younger males (30 yrs to 44 yrs). The mean score values for subjects in both groups corresponded closely to the answer “about the same as one year ago”. On Reported Health Transition E. longifolia subjects but the changes were not statistically significant.In other SF-36 domains, increasing trends are seen in role physical, vitality, and general health in EL) were not included in the analysis due to no (at least one) postbaseline evaluation. Thus, 91 subjects (43 placebo and 48 EL) were analyzed including three cases  with missing data treated as LOCF principle.Eighteen subjects . However, a similar trend was also shown in the placebo group. Changes in other physical tests including cardiovascular endurance are not significant.Comparison on each physical test outcomes between For the analysis, 102 subjects (52 EL and 50 placebo) were included where three cases  with missing data on week 12 were treated with LOCF principle.For all analyzed subjects the scores in the five domains at baseline correspond to clinical interpretation as having “no” or “mild” “erectile dysfunction”.P < 0.001), indicating a meaningful improvement on erectile functioning in subjects on E. longifolia, however still within the score range of “no dysfunction” at score values of 25 to 30 . Age-related effects are not seen in both herbal and placebo groups. In the herbal group the overall Erectile Function score increases significantly from baseline to week 12 as compared to placebo ” to “almost always or always” (P = 0.001) were observed in subjects on E. longifolia, whereas there was no significant difference in placebo group. Similar results can be seen for item Q3 “Over the past 4 weeks, when you attempted sexual intercourse, how often were you able to penetrate (enter) your partner?”, with a significant difference (increase by 7.2%) in E. longifolia subjects from baseline to week 12 (P = 0.004). The placebo group showed no significant differences and the effect under E. longifolia is independent of age.Analysis of individual questionnaire items under the Erectile Function domain reveals for item Q1 “In the other IIEF domains no significant changes were observed between both groups.For the analysis, 102 subjects (52 EL and 50 placebo) were included where three cases  with missing data on week 12 were treated with LOCF principle. E. longifolia and placebo at baseline, week 6 and week 12. At baseline, the analyzed subjects had in both groups score values of approximately 67% to 73% of the maximum score points . No significant difference on Sexual Libido and Sexual Satisfaction mean scores is detected between P < 0.001) after first declining from baseline to week 6, with similar results for placebo. Looking at selected items, the score difference of item IA of the Sexual Libido domain “Over the last 4 weeks, how is your interest towards sexual relationship?”, increased significantly by 8.4% within the range of “moderate”  to “high” (score 4) (P = 0.009) between baseline  and week 12 (3.481 ± 0.093) for subjects in the herbal group. Values of item IB “Over the last 4 weeks, as compared to the previous 4 weeks, how is your interest towards sexual relationship?”, significantly improved by an 10.8% increase from baseline (score 3.058 ± 0.075) and week 6  and between baseline and week 12 (3.500 ± 0.097) by 14.4%, ranging between the answers “no change” (score 3) to “slightly increasing” (score 4) (P < 0.001). Similarly, the score of item IC “Over the last 4 weeks, as compared to the previous 4 weeks, have you had sexual dreams?”, significance is reached between baseline and week 12 by an elevated score of +24.4% (P = 0.005) corresponding to improvement within the range from “no” dreams to “1-2 times” dreams. However, the overall Sexual Libido score for subjects in the herbal group significantly increased between week 6 and week 12 as compared to placebo (E. longifolia group shows a significant change between baseline and week 12 due to an increase score by 7.2% (P = 0.001). For the selected item IIB of the Sexual Satisfaction domain “Over the last 4 weeks, as compared to the previous 4 weeks, the frequency of your sexual relationship is increased?”, there is a significant increase score by 14.4%  and 17.1% from baseline (2.923 ± 0.066) to week 12 . The frequency of sexual relationship improved from “decreased moderately” (score 2) at baseline to “neither increased nor decreased” (score 3) and “increased moderately” (score 4) at the end of the study.Regarding the overall Sexual Satisfaction scores, the DEXA scan was performed in 97 subjects (49 placebo and 48 EL) for ITT analysis (8 LOCF from baseline and 12 LOCF from week 6) and considered as a secondary endpoint.E. longifolia and placebo groups in fat mass ratio at baseline, week 6 and week 12 could be evaluated after start of the trial. However, there is a reducing trend in overweight subjects with BMI > 25 kg/m2 of fat mass loss (trunk area) during herbal intake as compared to placebo (P = 0.008).No significant difference between E. longifolia subjects or differences to placebo are seen in hormonal profiles . Analysis of covariance (ANCOVA) shows that there are no differences between groups at week 6 and week 12 in total testosterone and free testosterone after adjusting to their baseline values. During the trial the mean values of total testosterone level are in the range of 15.079 nmol/L to 16.604 nmol/L in subjects on the herbal product and in the placebo group these values range from 18.120 nmol/ to 19.051 nmol/L.Throughout the study no significant changes among the Analysis was performed in 36 subjects (22 EL and 14 placebo) who have participated in both SFA examinations (at baseline V2 and week 12 V4).Between group comparisons on all SFA parameters  at baseline and after week 12 showed no significant difference at 5% and 10% level of significance. The changes and differences between groups with regard to time were not significant even after controlling the baseline values, age, smoking status, number of children, and marriage duration as shown by ANCOVA analysis. E. longifolia . In contrast, there was no change in mean values of SFA volume over time, for subjects in the placebo group  with lower starting values. Total Seminal Fluid Analysis volume shows a slight increasing trend during intake of the herbal product (baseline to V2: 3.273 mL and V4: 3.454 mL) in contrast to stable values or a declining trend for placebo subjects . However, subgroup analysis with different baseline values reveals relevant and significant improvement of SFA volume in subjects who tookngifolia . The resE. longifolia subjects (n = 11) with lower baseline values by an average increase of 44.4% (P = 0.010) from baseline value of 33.8% to 48.8% sperm motility after 12 weeks treatment with no significance in interaction in placebo group .Similar results were obtained from a subgroup analysis of SFA motility parameters, when their baseline values were divided between low and high starting points  . The resP = 0.009). There is also an increasing trend in the SFA sperm Ova-shaped parameters in the herbal group as compared to placebo for . However, there are significant changes in some renal functions parameters  in both herbal and placebo groups but without any clinical relevance.All safety parameters obtained from clinical, laboratory, and physical examinations reflect no significant difference between E. longifolia with mild to moderate severity (Two Serious Adverse Events (SAEs) occurred in 1 subject at the end of trial (V4) in the herbal group and were not related to treatment . A total of 31 Adverse Events (AEs) were recorded in 26 subjects: 20 AEs in 15 subjects from the placebo group and 11 AEs in 11 subjects during intake of severity . All AEsEurycoma longifolia is a well-known traditional herb in South-East Asian countries and used as a popular medicinal product in daily life in Malaysia. Extracts of this herb are considered in the management of male's sexual dysfunction and health-related quality of life. Besides the traditional evidence, robust data from randomized controlled clinical trials on a larger study population on the efficacy and safety of water extracts of E. longifolia are lacking. The present randomized controlled clinical trial in 109 male subjects aged 30 years to 55 years for 12 weeks on a special aqueous Eurycoma longifolia root extract 300 mg/daily or placebo was conducted as a result. E. longifolia, although assessment over time was limited due to the so-called ceiling effect already established at the beginning (baseline) of the trial. During daily intake of the herbal extract, the quality of life, physical fitness, erectile functioning and sexual health, sexual libido, and sexual satisfaction improved in various domains over time and several items of these questionnaires showed meaningful changes and statistically significant trends compared to placebo. In spite of score values at approximately 70% of the maximum attainable scores at baseline, scattered but remarkable efficacy results were seen in quality of life, physical fitness, and sexual well-being in men treated with E. longifolia for the treatment of erectile dysfunction (ED) and overall sexual well-being. The International Index of Erectile Function (IIEF-15) scale was used to evaluate ED within the study population. The total score showed at baseline for subjects in both groups values within the range of either “mild dysfunction” or “no dysfunction”. However, comparison of the two treatment groups resulted in a significant increase of total IIEF score in subjects who took the herbal product from baseline to end of trial after 12 weeks, compared to placebo. Selected IIEF items on erection during sexual activity or frequency of penetration during intercourse, increased significantly during a 12-week intake of E. longifolia when compared to placebo. When using the Sexual Health Questionnaire (SHQ) the preceding observations are consistent with a significant increase of interest towards sexual relationship, more frequent sexual dreams and sexual relationship as well as satisfaction improvement, all in favor of the herbal treatment. This trial provided important results on males' erectile functioning and sexual health, substantiating the traditional use of E. longifolia), which is also known to improve overall well-being [n = 64/76 Malaysian) with low-onset of hypogonadism with mean age 51 years (range 28 yrs–70 yrs), 200 mg/daily of the same aqueous E. longifolia root extract as used in the present study, significantly improved Aging Male Symptoms (AMS-score) from score values corresponding to “mild complaints” at baseline to “no complaints” after one month of intake (P < 0.001). This was also significantly correlated with an increase in serum testosterone levels. These data support the attitudes of Malaysian men of preventing or treating erectile dysfunction with traditional herbal medicine including Tongkat Ali  levels at baseline were considered to be in the normal range with a marginal increase at end of the study. The volume of seminal fluid and the sperm motility for a subgroup with lower starting values at baseline revealed significant increases at end of trial when treated with E. longifolia , whereas no changes were observed in the placebo group. Increasing trends were observed also in the sperm-shape parameters where more normal-shaped compared to abnormal-shaped sperms were observed. In the present study, Seminal Fluid Analysis (SFA) showed remarkable but unexpected results in primarily healthy subjects who tookE. longifolia is known to improve males' fertility. In a recent open clinical study performed by Bin and Imran, 2010 [E. longifolia extract used in the present trial improved significantly the semen parameters over a 3-month (n = 75) to 9-month (n = 17) treatment period. Compared to baseline, sperm volume increased significantly up to 9 months (+19%), whereas sperm concentration (+54%) and motility (+12%) significantly peaked after 3-month treatment with E. longifolia. The corresponding values of the sperm parameters are almost similar to the ones observed in the present randomized trial when analysed with lower starting point: sperm volume at baseline and after 3-month treatment: Bin and Imran [E. longifolia root extract is more effectively in semen parameters.an, 2010 , in younnd Imran : mean ± nd Imran , this vand Imran : mean ± E. longifolia are described as being safe. This is supported by the present trial showing no differences in all analyzed safety parameters and Adverse Events (AEs) monitoring as compared to placebo. It is so far known that the traditionally used water extracts of the root of Eurycoma longifolia (Physta), significant improvements in libido, sexual performance, satisfaction, and physicial functioning. E. longifolia has a strong impact on seminal fluid parameters, for example, semen volume and sperm motility. The daily dose of 300 mg of E. longifolia extract for three months is well-tolerated and safe compared to placebo. For the first time a placebo-controlled clinical trial with 109 randomized male subjects demonstrated for a freeze-dried water extract of the roots of


Decreases in health care–related isolates accounted for all reductions in MRSA during 2007–2010. Staphylococcus aureus (MRSA) infections in Connecticut, with emphasis on 2007–2010, after legislation required reporting of hospital infections. A case was defined as isolation of MRSA from normally sterile body sites, classified after medical record review as hospital onset (HO), community onset, health care–associated community onset (HACO), or community-associated (CA). Blood isolates collected during 2005–2010 were typed and categorized as community- or health care–related strains. During 2001–2010, a total of 8,758 cases were reported , and MRSA incidence decreased (p<0.05) for HACO and HO, but increased for CA. Significant 3- to 4-year period trends were decreases in all MRSA (–18.8%), HACO (–12.8%), HO (–33.2%), and CA (–12.7%) infections during 2007–2010, and an increase in CA infections during 2004–2006. Decreases in health care–related isolates accounted for all reductions. Hospital infections reporting may have catalyzed the decreases.We examined trends in incidence of methicillin-resistant  Medscape, LLC is pleased to provide online continuing medical education (CME) for this journal article, allowing clinicians the opportunity to earn CME credit.This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education through the joint sponsorship of Medscape, LLC and Emerging Infectious Diseases. Medscape, LLC is accredited by the ACCME to provide continuing medical education for physicians.AMA PRA Category 1 Credit(s)TM. Physicians should claim only the credit commensurate with the extent of their participation in the activity.Medscape, LLC designates this Journal-based CME activity for a maximum of 1 www.medscape.org/journal/eid; (4) view/print certificate.All other clinicians completing this activity will be issued a certificate of participation. To participate in this journal CME activity: (1) review the learning objectives and author disclosures; (2) study the education content; (3) take the post-test with a 70% minimum passing score and complete the evaluation at Release date: May 15, 2012; Expiration date: May 15, 2013Upon completion of this activity, participants will be able to:Identify the most common classification of MRSA recorded in 2001 to 2010Evaluate the epidemiology of MRSA between 2001 and 2010Distinguish the classification of MRSA which increased between 2001 and 2010Analyze the bacteriology of MRSA infections in the current studyCarol E. Snarey, MA, Technical Writer/Editor, Emerging Infectious Diseases. Disclosure: Carol E. Snarey, MA, has disclosed no relevant financial relationships.Charles P. Vega, MD, Health Sciences Clinical Professor; Residency Director, Department of Family Medicine, University of California, Irvine. Disclosure: Charles P. Vega, MD, has disclosed no relevant financial relationships.Disclosures:James L. Hadler, MD, MPH; Susan Petit, MPH; Mona Mandour, BS;andMatthew L. Cartter, MD, MPH,have disclosed no relevant financial relationships. Staphylococcus aureus (MRSA) was first identified in 1961 in England , funded by the Centers for Disease Control and Prevention (CDC), became interested in better defining MRSA dynamics from a population-based perspective and established pilot surveillance systems at sites in 4 states for either all MRSA infections  or for invasive disease (Connecticut)  to describe the epidemiology of invasive MRSA in Connecticut and trends over time by place of illness onset  and relationship to health care, and 2) to describe MRSA strain subtypes associated with place of onset and trends over time.Connecticut participates in the Active Bacterial Core Surveillance project of the EIP at CDC. As part of this surveillance project, statewide active surveillance for invasive MRSA began in 2001. A case of invasive MRSA infection was defined as isolation of MRSA from a normally sterile body site   a history of hospitalization (including admissions >24 hours’ duration), surgery, dialysis, or residence in a long-term care facility in the year before the culture date, or 2) a central venous catheter present at the time of culture. Patients with community-associated (CA) cases had none of the HO or HACO risk factors listed above.Cases were classified into 3 mutually exclusive categories according to place of onset and relationship to health care. Hospital-onset (HO) MRSA cases were those for which cultures were collected >2 days after hospital admission (day of admission = day 0). Health care–associated community-onset (HACO) cases were those for which cultures were collected from outpatients or >100,000 (n = 5); medium-sized towns had a population of 50,000–99,999 as estimated in 2005 (n = 12); and small towns had a population <50,000 (n = 152). Connecticut has 32 acute care hospitals. Hospital volume was categorized according to total annual number of Connecticut resident bed-days in 2009 as reported to the Connecticut Office of Health Care Access. High-volume hospitals (n = 7) averaged >80,000 patient bed-days per year and included both Connecticut tertiary care hospitals; medium-volume hospitals (n = 12) averaged 40,000–79,999; and low volume hospitals (n = 13) averaged <40,000.Connecticut is divided into 169 towns. Large towns were defined as those with a population From April 1, 2005, through December 31, 2010, a sample of MRSA isolates from blood was systematically collected from 8 sentinel hospital laboratories . These laboratories represented 4 metropolitan areas. Isolates were only collected from specimens from case-patients who resided in towns in which >90% of residents received health care at 1 of the 8 hospitals. In 3 metropolitan areas, all available blood isolates were collected. In the fourth area, with both high-volume participating hospitals, collection was limited to 3 blood isolates per month from each laboratory.S. aureus by performing a catalase test using 3% hydrogen peroxide, followed by a tube coagulase test using rabbit plasma with EDTA . If the tube coagulase result was equivocal, a rapid latex kit  was used to confirm the result. Kirby-Bauer disk diffusion with a cefoxitin disk was conducted to confirm methicillin resistance.Isolates were submitted to the Connecticut Department of Public Health Laboratory for confirmation of SmaI using the standard PulseNet method (Isolates were subtyped by pulsed-field gel electrophoresis (PFGE) with the restriction endonuclease Incidence rates by year were calculated by using US Census Bureau yearly population estimates, except for 2010, for which the 2010 census counts were used. Rates were calculated overall for each MRSA category and for strata defined by age and race/ethnicity within the categories. Rates for HO MRSA were also calculated by using hospital specific resident bed-days as reported to the Connecticut Office of Health Care Access for 2001–2009. For 2010, bed-days from 2009 were used because 2010 data were not available. One hospital was excluded from the bed-day analysis because that facility does not report patient bed-days to the Office of Health Care Access.2 test. Ten-year incidence trends were examined by using the χ2 test for linear trend. To examine changes in trends within the overall 10-year period, we analyzed trends by χ2 separately for 2001–2003, 2004–2006, and 2007–2010, in part because MRSA received substantial national publicity in 2007 after an article reported incidence at EIP sites . Percentages of cases in different demographic categories were compared by using the χ>65 years . The incidence in men was 1.6 times that in women. In addition, the incidence in non-Hispanic blacks was 1.4-fold higher than in whites, and the incidence in Hispanics was 0.64 that of whites. Furthermore, residents of large towns had 1.2 and 1.4 times the incidence of residents of medium-size and small towns.The incidence of MRSA overall and average annual incidence rates by each of the 3 categories are reported in The descriptive epidemiology of HO, HACO, and CA MRSA infections had similarities and differences. For each, incidence was higher with increasing age, and in men, blacks, and large town residents . However<0.002): all MRSA (−14.2%), HO (−48.4%), and HACO (−3.8%) decreased while CA (+124.8%) increased. The trends were not constant over the entire 10 years, however. When 3-year intervals were considered , the only statistically significant trends were decreases in all MRSA, HO, and HACO infections during 2007–2010  and an increase in CA during 2004–2006 (p = 0.001). During 2007–2010, overall MRSA incidence dropped 18.8%, HO dropped 33.2%, and HACO dropped 12.8%. During 2004–2006, CA increased 64.7%. However, during 2007– 2010, CA decreased 12.7% (p = 0.30).The overall incidence of MRSA infections by year and the yearly rates for each of the 3 categories of MRSA are shown in >10% occurred in each demographic group. For HO MRSA, >10% decreases occurred in all groups except blacks (−7.3%). For HACO, >10% decreases occurred in all groups except those <18 years (+1%) and those 18–34 years of age (+14.2%). For CA, all groups showed decreases, except persons >50 years (+1%) and small town residents (+6.4%).When we assessed which demographic groups were most and least affected by these changes during 2007–2010, we found the following. For all MRSA infections during 2007–2010, a decrease We also examined incidence of HO MRSA infections by hospital volume . IncreasWe examined the percentage of all MRSA isolates from the leading isolation sites by MRSA category. Blood isolates were most common (89.1%), followed by joint isolates (6.0%) and bone isolates (2.7%). CA infections were less likely than either HO or HACO infections to have a sterile-site isolate from blood , but more likely to have an isolate from a joint . When 10-year trends were examined for each isolate site and place of onset category, 2 trends (at 2 sites) were significant. Joint isolates increased for HO and HACO MRSA infections, from 1.5% in 2001 to 5.4% in 2010 (p = 0.002) and from 4.7% in 2001 to 8.5% in 2010 (p = 0.005), respectively.During 2005–2010, a total of 616 case-patients had blood isolates tested by PFGE at CDC; 609 had PFGE types in the range of USA100 to USA1100, inclusive. Of all PFGE types, 93 (15.3%) were community strains, of which USA300 was predominant . A total of 516 (84.7%) were health care strains, of which USA100 was predominant . There were 91 CA, 369 HACO, and 149 HO cases . IsolateTo estimate trends in incidence of MRSA due to community and to health care strains, we applied the percentages of each to statewide incidence of CA and of health care–associated MRSA for each year during 2005–2010 . For bot,Invasive MRSA infections comprise at least 2 distinct MRSA groups: those caused by strains that evolved and spread in hospitals over the past 4 decades, and those caused by strains that evolved in the community and ≈15 years ago began to spread widely, causing community and institutional outbreaks of skin and soft tissue infections , and HO and HACO MRSA decreased during 2005–2008 (−20% each). The additional years of data in Connecticut help clarify the situation for hospital and health care–associated infections before and after the EIP study and the situation for CA infections since 2007. HO MRSA infections appeared to begin to decrease during 2003–2004 and have remained on a downward trajectory since, while HACO infections appeared to be increasing during 2001–2004 and then began a generally downward trend. CA MRSA, after the large and generally continuous increase during 2001–2007, plateaued during 2007–2009 and then dropped 12.2% in 2010. The net effect of these varying trends on overall invasive MRSA infection has been an irregular, but net increase in, incidence during 2001–2007, and a large, persistent drop since 2007.The typing data suggest that these varying trends in Connecticut can be connected. The subset of blood isolates typed during 2005–2010 showed that the percentages of all HO, HACO, and CA infections caused by community PFGE types are increasing, and those caused by health care–associated types are decreasing. When the percentages of community and health care–associated strains were applied to the statewide incidence of CA and of health care–associated MRSA for those years, statewide community-strain estimated incidence increased over time in each category, while statewide health care–associated strain estimated incidence decreased in each. Thus, the decrease in invasive MRSA infection can likely be explained by a reduction in disease incidence with health care–associated strains, while disease and, presumably, prevalence of community strains continue to increase.,Although our surveillance data analysis cannot directly address why health care strains and related invasive disease decreased while community strains and related disease did not, several explanations are possible. Since 2006, Connecticut laws have been passed that required the reporting of hospital infections and MRSA control policies in hospitals  credits are accepted in the US as evidence of participation in CME activities. For further information on this award, please refer to http://www.ama-assn.org/ama/pub/category/2922.html. The AMA has determined that physicians not licensed in the US who participate in this CME activity are eligible for AMA PRA Category 1 Credits™. Through agreements that the AMA has made with agencies in some countries, AMA PRA credit may be acceptable as evidence of participation in CME activities. If you are not licensed in the US, please complete the questions online, print the certificate and present it to your national medical association for review.To obtain credit, you should first read the journal article. After reading the article, you should be able to answer the following, related, multiple-choice questions. To complete the questions (with a minimum 70% passing score) and earn continuing medical education (CME) credit, please go to Staphylococcus aureus (MRSA) over the 10-year study period of the current research?1. What was the most common classification of methicillin-resistant A. Hospital onset (HO)B. Health care-associated community onset (HACO)C. Community-associated (CA)D. Undefined2. MRSA was most common among which of the following patient groups?A. Younger patientsB. Non-Hispanic black patientsC. Hispanic patientsD. Residents of small towns3. Which classification of MRSA was the only one to increase between 2001 and 2010?A. All MRSA casesB. HOC. HACOD. CA4. Which of the following statements regarding the bacteriology of MRSA infections in the present study is most accurate?A. Blood isolates of MRSA were the most common infectionB. Joint isolates were more likely in HACO vs CA cases of MRSAC. Most PFGE types were community strains of MRSAD. The prevalence of community pulsed-field gel electrophoresis (PFGE) types declined between 2005 and 2010


TCP) in critically ill patients, with special emphasis on norepinephrine (NE) administration and the time interval between calibrations.Continuous cardiac output monitoring is used for early detection of hemodynamic instability and guidance of therapy in critically ill patients. Recently, the accuracy of pulse contour-derived cardiac output (PCCO) has been questioned in different clinical situations. In this study, we examined agreement between PCCO and transcardiopulmonary thermodilution cardiac output  requiring invasive hemodynamic monitoring on a non-cardiac surgery intensive care unit. PCCO was recorded immediately before calibration by COTCP (±SD) was 8.2 ± 2.0 L/min. PCCO had a mean bias of 0.16 L/min with limits of agreement of -2.81 to 3.15 L/min  when compared to COTCP. Whereas the bias between PCCO and COTCP was not significantly different between NE dosage categories or categories of time elapsed between calibrations, interchangeability (percentage error <30%) between methods was present only in the high NE dosage subgroup (≥0.1 μg/kg/min), as the percentage errors were 40%, 47% and 28% in the no NE, NE < 0.1 and NE ≥ 0.1 μg/kg/min subgroups, respectively. PCCO was not interchangeable with COTCP in subgroups of different calibration intervals. The high NE dosage group showed significantly increased central artery stiffness.A total of 330 data pairs were analyzed. For all data pairs, the mean COTCP. Only in the measurements with high NE dosage (representing the minority of measurements) was PCCO interchangeable with COTCP.This study shows that NE dosage, but not the time interval between calibrations, has an impact on the agreement between PCCO and CO Calibration of PCCO is performed by intermittent transcardiopulmonary thermodilution cardiac output (COTCP). It has been demonstrated that PCCO agrees with pulmonary artery thermodilution CO [TCP [Cardiac output (CO) monitoring in high-risk patients has gained increasing interest because early detection of hemodynamic instability can reduce morbidity in these patients -3. Invesution CO -8 and wi CO [TCP ,10 in ca CO [TCP , changes CO [TCP , increas CO [TCP  or time  CO [TCP . TherefoTCP is affected by different NE dosages or by the time interval between calibrations. On the basis of the existing literature, we generated the following two hypotheses: (1) Increasing NE dosage results in decreased agreement between PCCO and COTCP, and (2) increasing the time interval between calibrations of PCCO results in decreased agreement between PCCO and COTCP.The present prospective observational study investigated a large group of critically ill patients with regard to whether agreement between PCCO and COOnly rare data are available about the usage of PCCO calibrations in clinical practice. Therefore, we retrospectively evaluated whether NE dosage or severity of disease as measured by the Acute Physiology and Chronic Health Evaluation II score (APACHE II score) had an influence on calibration frequency on our intensive care unit (ICU).plus system (version 6.0) on our noncardiac ICU between September 2007 and July 2008 were included. The study was approved by our institutional review board in compliance with the Helsinki Declaration . Patients and/or relatives gave their informed consent for the patients' data to be used in the analysis. Invasive hemodynamic monitoring was performed according to the judgment of the attending physician on the ICU. Exclusion criteria were cardiac arrhythmias, a permanent pacemaker or any other mechanical cardiac support and known valvular heart disease.In this prospective observational study, critically ill patients equipped with invasive hemodynamic monitoring by the PiCCOet al. [TCP. Calibrations were regularly performed by an ICU physician at defined time points  with the patient in a supine position during a time period without acute hemodynamic instability using three subsequent boluses of 15 mL of ice-cold saline injected into the central venous line as proposed by the manufacturer [TCP. Global end-diastolic volume index (GEDI) and systemic vascular resistance index (SVRI) were derived upon thermodilution. SV was calculated as COTCP divided by heart rate. The PP to SV (PP/SV) relationship was used to examine the influence of NE dosage on central arterial stiffness as reported previously [In all patients, a central venous catheter and a thermistor-tipped arterial catheter  inserted via femoral artery were present upon enrollment. The PiCCO device uses pulse contour analysis according to a modified algorithm originally described by Wesseling et al.  to deteret al. . This alfacturer . During eviously . Our ICUt-test. Comparison of PCCO and COTCP was performed by using Bland-Altman statistics for multiple observations per individual [t-test. The percentage error was calculated as reported by Critchley and Critchley [TCP) was analyzed according to the method described by Cecconi et al. [TCP) was analyzed against ΔCOTCP  by linear regression analysis including the first pair of measurements of each patient. The influence of NE dosage and the severity of the patient's medical condition (APACHE II score) on calibration frequency was analyzed using the Spearman correlation for nonparametric data. P < 0.05 was considered statistically significant.Statistical analysis was performed using the statistical software R  and Gradividual , calcularitchley , and inti et al.  from theSeventy-three patients were included in this study. The median (interquartile range) APACHE II score of all patients was 24  at the time of inclusion. Detailed patient characteristics are given in Table 2O and a mean positive end-expiratory pressure of 9 ± 3 cmH2O. In the remaining 65 data pairs, patients breathed spontaneously and received oxygen via face mask. Calibration interval was 9 ± 6 hours . The precision of the three bolus injection -COTCP values was 7%, according to the method of Cecconi et al. [We obtained 330 data pairs. In 265 of 330 data pairs, patients received mechanical ventilation with a mean tidal volume of 8 ± 1 mL/kg, a mean fraction of inspired oxygen of 0.6 ± 0.1, a mean peak airway pressure of 23 ± 6 cmHi et al. .TCP, 27 data pairs were excluded from further analysis because of additional dobutamine or epinephrine administration. In 161 of 303 data pairs, NE was administered in doses ranging from 0.01 to 4.29 μg/kg/min. The hemodynamic data and calibration intervals of different NE subgroups are presented in Table Concerning the effect of NE dosage on the agreement between PCCO and COTCP only during high NE dosage and not at low or no NE dosage. The results of the Bland-Altman analysis are presented in Table Bias between NE subgroups did not differ significantly. However, PCCO was interchangeable with COr ), between ΔPCCO and ΔCOTCP was 0.46  for all patients, 0.19  for no NE, 0.37  for NE < 0.1 μg/kg/min and 0.78  for NE ≥ 0.1 μg/kg/min subgroups, respectively. In the NE ≥ 0.1 μg/kg/min subgroup, a statistically significant (P < 0.05) higher PP/SV relationship  was observed compared to the no NE or NE < 0.1 μg/kg/min subgroups, respectively , respectively.On our ICU, we recorded a mean (±SD) time interval after the preceding calibration of 9 ± 6 hours. In 151 (46%) recordings, the time interval exceeded the recommended 8-hour interval. In 14 (4%) recordings, the time interval was as long as 24 hours. The time interval did not correlate with NE dosage or APACHE II score , as well as before and after any major change in therapy. We found that in only 54% of recordings were institutional guidelines of recalibration met. We did not observe a correlation of calibration frequency with APACHE II score or NE dosage, indicating that calibration of PCCO may not be dependent on the severity of critical illness. These findings are surprising, since recalibration may increase agreement between methods . HoweverThere are some limitations to our study. To avoid additional risk due to a more invasive methodology of CO measurement, we used the PiCCO integrated transcardiopulmonary thermodilution instead of the pulmonary artery thermodilution method as a reference technique for PCCO as previously described ,14. The TCP. Therefore, the accuracy of PCCO measurement relies on important clinical circumstances.This study demonstrates further limitations of the PCCO method for the determination of continuous CO. Only during high NE dosage (≥0.1 μg/kg/min) was PCCO interchangeable with COTCP measurements cannot be used interchangeably in patients who are either not on vasopressor treatment or on a low dose of vasopressors.• During clinical conditions, PCCO and CO• Acceptable agreement between the methods was observed only during an increased dose of norepinephrine, representing the minority of measurements. Even then the limits of agreement were rather large.• The time interval between calibrations of PCCO does not improve the reliability of PCCO within a period of 24 hours.TCP: transcardiopulmonary thermodilution cardiac output; CVP: central venous pressure; GEDI: global end-diastolic volume index; HR: heart rate; ICU: intensive care unit; MAP: mean arterial pressure; NE: norepinephrine; PCCO: pulse contour cardiac output; PE: percentage error; PP/SV: pulse pressure to stroke volume ratio; r: coefficient of correlation; SD: standard deviation; SV: stroke volume; SVRI: systemic vascular resistance index.Δ: delta, change in CO between actual and preceding calibration; APACHE II: Acute Physiology and Chronic Health Evaluation II score; CI: cardiac index; CO: cardiac output; COBB is a member of the advisory board of Pulsion Medical Systems. MG, PM, JR, AC, OB, NW, JS and MS declare that they have no competing interests.MG conceived of the study design, carried out statistical analysis and drafted the manuscript. PM, OB and JR helped to draft the manuscript. AC supported statistical analysis. NW, JS and MS coordinated the study. BB conceived of the study design, coordinated the study and helped with statistical analysis and drafting of the manuscript. All authors read and approved the final manuscript.


The lowest effective dose of EC providing gastroprotective effects was 50 mg/kg in the ethanol-induced gastric ulcers and 25 mg/kg in the indomethacin-induced gastric ulcers. The gastroprotection seen upon treatment with EC was significantly decreased in rats pretreated with a SH compound reagent or an α2-receptor antagonist, but not with a K+ATP channel blocker. Furthermore, oral treatment with EC increased mucus production and decreased H+ secretion. Immunohistochemistry demonstrated the involvement of superoxide dismutase (SOD), nitric oxide (NO), and heat shock protein-70 (HSP-70) in the gastroprotection. These results demonstrate that EC provides gastroprotection through reinforcement of the mucus barrier and neutralization of gastric juice and this protection occurs through the involvement of SH compounds, α2-adrenoceptors, NO, SOD, and HSP-70.Previous studies of the gastroprotective activity of plants have highlighted the importance of the polyphenolic compound epicatechin (EC) in the treatment of gastric ulcers. This paper aimed to evaluate and characterize the gastroprotective mechanism of action of EC using male rats. The gastroprotective action of EC was analyzed in gastric ulcers induced by ethanol or indomethacin. The involvement of sulfhydryl (SH) groups, K Helicobacter pylori infection, poor diet, alcohol ingestion, and the use of nonsteroidal anti-inflammatory drugs (NSAIDs). Protective factors include the following: an intact mucosal barrier, adequate mucus secretion and blood flow, cellular regeneration, prostaglandin secretion, and epidermal growth factor release [Gastric ulcers affect thousands of people worldwide and are considered a global health problem. The pathophysiology of gastric ulcers is related to the disequilibrium between harmful and protective factors in the gastric mucosa. Agents that may initiate the development of an ulcer include the following: acid and pepsin secretion,  release , 2.The current treatment options for patients suffering from gastric ulcers include antacids, sucralfate, prostaglandins, muscarinic antagonists, histamine-2 receptor antagonists, and proton pump inhibitors. However, the long-term use of these drugs may cause side effects such as hypersensitivity, arrhythmia, impotence, gynecomastia, and hematopoietic disturbances . AdditioH. pylori infection has been implicated in the pathogenesis of active and chronic gastritis, peptic ulcer, and gastric carcinoma [H. pylori infections [H. pylori resistance to antibiotics [arcinoma . The trifections –7. Standfections . There aibiotics .This circumstance evidences the need for new research to discover substances that would effectively heal gastric ulcers with fewer side effects. The medicinal plants are attractive sources of new biomolecules, particularly in the developing world where infectious diseases are endemic and modern health facilities are not always accessible . AlthougPolyphenols, which include flavonoids and tannins, are a group of phytochemicals that have been intensely researched and are known to exert beneficial effects on health , includiMouriri pusa [Epicatechin EC, , an isomiri pusa  in which(−)-Epicatechin  was purchased from Sigma Chemical Co. . In ethanol and indomethacin-induced gastric ulcers, the following doses were tested: 25, 50, and 75 mg/kg. The lowest effective dose was used for all subsequent experiments.Saline +10% absolute ethanol was used as a vehicle, as EC is insoluble in 0.9% saline. To avoid differences between groups, all drug compounds were solubilized in this vehicle, including the positive controls.Male Wistar rats (200–250 g) from the Central Animal House of UNESP were fed a certified diet with free access to tap water under standard light-dark cycles (12 h dark-12 h light), humidity (60 ± 1%), and temperature (21 ± 2°C). All rats were fasted prior to each experiment as treatments were orally administered. Additionally, the rats were housed in cages with raised floors of wide mesh to prevent coprophagy. All experimental protocols followed the recommendations of the Canadian Council on Animal Care and were approved by the UNESP Institutional Animal Care and Use Committee.n = 7). Animals were then orally dosed with vehicle (10 mL/kg), carbenoxolone (100 mg/kg), or EC . The sixth group (sham) did not receive either drug or vehicle. After 1 hour, the animals received an oral dose of 1 mL of absolute ethanol. One hour after ethanol treatment, the rats were sacrificed and their stomachs were removed. The stomachs were then opened along the greater curvature and washed. The flattened stomach samples were scanned and the ulcer area (mm2) was measured using AVSoft BioView software. A small fragment of each stomach was collected for glutathione measurement. Stomach samples were collected for histological slide preparation and stained with hematoxylin and eosin (HE) to analyze the morphological and histological characteristics, or the slides were used for immunohistochemical analyses. A microscopic score [Male Wistar rats that had been fasted for 24 h were distributed into six groups , the sections were incubated in secondary antibody . The sections were then washed in PBS buffer, the ABC complex was applied, and the reaction was carried out in a DAB solution  containing 0.01% H2O2  in PBS buffer. After immunostaining, the sections were lightly counterstained with hematoxylin and the immunoreactive cells were observed under a Leica microscope using Leica QWin Software . In the control reaction, the slides were processed without the primary antibody or in the absence of all antibodies. The slides were stained with antibodies for heat-shock protein 70 (HSP-70), superoxide dismutase (SOD), and nitric oxide (NO) (Santa Cruz Biotechnology). The marked area (μm2) in each slide was measured using AVSoft BioView software. Six slides were used for each antibody. Each slide was deparaffinized, rehydrated, and immunostained by the ABC method. Nonspecific reactions were blocked with HThe total glutathione content in the stomach was quantified using the recycling assay . Stomachn = 7). Two groups of rats were intraperitoneally treated with NEM (7 mg/kg), an SH compound blocker. The other two groups were treated with vehicle (10 mL/kg). One hour later, either vehicle or EC (50 mg/kg) was orally administered to two groups each. The ulcers were induced following the ethanol-induced gastric ulcer model and the ulcer area (mm2) was determined with the aid of AVSoft BioView software.Rats were distributed into four groups (n = 7). Two groups of rats were subjected to intraperitoneal treatment with the following drugs: the K+ATP channel blocker glibenclamide (3 mg/kg), the α2-receptor antagonist yohimbine (3 mg/kg), or vehicle (10 mL/kg). One hour later, either vehicle or EC (50 mg/kg) was orally administered to two groups each. The ulcers were induced following the ethanol-induced gastric ulcer model and the ulcer area (mm2) was determined with the aid of AVSoft BioView software.Rats were distributed into six groups (n = 7). Vehicle (10 mL/kg), cimetidine (100 mg/kg), or EC  was orally administered 30 minutes prior to the induction of gastric lesions by oral administration of the ulcerogenic agent indomethacin (100 mg/kg). The animals were sacrificed 5 h after treatment with indomethacin [2) was determined using AVSoft BioView software.The rats were distributed into five groups (methacin . The ston = 7). Thirty minutes after oral treatment or immediately after the intraduodenal administration of a single dose of vehicle (10 mL/kg), cimetidine (100 mg/kg), or EC (50 mg/kg), the rats were subjected to pyloric ligation [Male rats were randomly divided into 6 groups (ligation . Four hon = 7) were subjected to longitudinal incisions slightly below the xiphoid apophysis to place a pyloric ligature. Oral administration of vehicle, carbenoxolone (200 mg/kg), or EC (50 mg/kg) was performed 1 h before the ligature. After 4 h, the animals were sacrificed and the glandular portion of the stomach was weighed and immersed in Alcian Blue solution for the mucus quantification procedure. The absorbance was measured in a spectrophotometer at a wavelength of 598 nm, and the results were expressed as μg Alcian Blue/g tissue [After 24 h of fasting, anesthetized rats  followed by Dunnett's test or Tukey's test and compared to the vehicle group. The results were presented as the mean ± standard error of the mean (SEM). Nonparametric data (histology scoring) were analyzed by the Kruskal-Wallis (nonparametric ANOVA) test followed by a Dunn multiple comparison test. The results were presented as the median (range). All analyses were performed using GraphPad InStat software. A value of 2. The three doses of EC  tested exhibited gastroprotective effects (P < 0.05 for the lowest dose and P < 0.01 for 50 and 75 mg/kg); however, the 50 mg/kg dose exhibited the greatest gastroprotective effect (94.83% gastroprotection). According to Tukey's test, there was no significant difference between the ulcer areas of the groups treated with 50 mg/kg or 75 mg/kg; therefore, the dose of 50 mg/kg was used for all subsequent experiments. The ulcer areas (mm2) are represented in The vehicle group presented several hemorrhagic bands, with an average ulcer area of 520.41 ± 81.46 mmThere was no microscopic evidence of eosinophilic infiltration and hemorrhage, but there was mild desquamation and glandular damage in the group treated with 50 mg/kg EC. The HE staining of the ulcers is displayed in P < 0.01) than those in the control group. These data indicate their involvement in the gastroprotective effect of treatment with EC  maintained the total glutathione level near that of the vehicle and carbenoxolone groups after the total glutathione-depleting ethanol administration . Howeverα2-receptor antagonist) also exhibited a reversal in gastroprotection upon treatment with EC (α2-receptors in the protective mechanism of action of EC (50 mg/kg). However, in rats pretreated with glibenclamide (a K+ATP channel blocker), the gastroprotective effect of EC (50 mg/kg) was maintained (84.14%), indicating that there is no involvement of the K+ATP channels in the gastroprotective effects of EC (In rats pre-treated with NEM (an SH compound reagent), the gastroprotective effect of EC (50 mg/kg) was reversed , indicat with EC , indicatts of EC .2. In this model, the most effective dose of EC was 25 mg/kg, which had a 67.83% gastroprotective effect . A dose of 50 mg/kg offered 57.90% gastroprotection  and the highest dose (75 mg/kg) was not gastroprotective (43.87%)  .+ concentration in the gastric juice without modifying its volume. In comparison, the intraduodenal administration was not able to decrease the H+ concentration, but it did diminish the volume of the gastric juice (A comparison of the gastric juice parameters of the rats that were treated with EC (50 mg/kg) administered by oral or intraduodenal routes demonstrated that the oral treatment was able to diminish the Hic juice .μg/g, P < 0.01) versus the vehicle-treated group (2211.73 ± 98.04 μg/g)  group (2763.07 ± 117.7 04 μg/g) .Commonly used therapies for the treatment of gastric ulcers often fail to completely heal the ulcers and additionally present with many side effects. Furthermore, patients are searching for new and natural methods of healing their diseases. Therefore, there has been an increased interest in the search for natural products to treat gastric ulcers. The goal of this work was to characterize the gastroprotective mechanism of action of epicatechin (EC), which is a polyphenolic compound found in several plant species.2  synthesis, resulting in a decline in mucus production and subsequent hemorrhagic ulcers [Motawi et al.  previousc ulcers . In the c ulcers –25. Thisc ulcers .Orally administered ethanol causes injury to the gastric mucosa by decreasing local blood flow . It also+ ions [The mechanisms that could be responsible for the gastroprotective effects were investigated as follows. Endogenous SH compounds are key agents in mucosal protection against ethanol-induced gastric injury . These S+ ions .+ concentration in the gastric juice without modifying its volume, an effect which did not occur in the intraduodenally treated rats. These results lead to the conclusion that EC acts via a local rather than a systemic mechanism. Furthermore, we suggest that the decrease in H+ concentration in the orally treated rats can also be explained by the increase in the gastric mucus production stimulated by EC, given that the mucus barrier is able to neutralize secreted H+.The pyloric ligation model permits the evaluation of the antisecretory actions of an experimental substance for local or systemic activity. This assay induces ulcers by an increase in gastric hydrochloric acid secretion, leading to autodigestion of the gastric mucosa and breakdown of the gastric mucosal barrier. Orally administered EC exhibited antisecretory activity by decreasing the HGastric cells produce several antioxidants, including SOD and endogenous glutathione, which scavenge reactive oxygen species (ROS). An excessive generation of ROS enhances lipid peroxidation and depletes antioxidant enzymes . SOD is The increase in the immunoreactive area for NO and HSP-70 is also an important result. NO has attracted considerable attention as a gastric defensive factor. There is substantial evidence that NO, a gas signaling molecule secreted by the gastric epithelial cells, acts by increasing mucosal blood flow, regulating the secretion of mucus and bicarbonate, and inhibiting the secretion of gastric juice . It is a+ATP) provide a gastric defense by inhibiting neutrophil activation and superoxide production and by enhancing gastric microcirculation [+ATP channels are not involved in the mechanism of action of EC because the blockade of these channels with glibenclamide did not reverse the gastroprotective effects of EC.ATP-sensitive potassium channels (Kculation . Our datα2-adrenoceptors mediate several responses in the gastrointestinal tract, including antisecretory action and mucosal protective effects [α2-receptor antagonist, suggesting an active role for α2-adrenoceptors in gastroprotection.Our investigation of gastric mucosal protective mechanisms was not focused solely on local mucosal processes. Presynaptic  effects , which rα2-adrenoceptors, SOD, NO, and HSP-70, in addition to antioxidant effects seen upon treatment with this compound.Taken together, these findings suggest that EC mediates gastroprotection through a mechanism that includes the reinforcement of the mucus barrier and the neutralization of gastric juices. Furthermore, this occurs with the involvement of SH compounds, presynaptic