F), wall thickness, ratio of wall to lumen of fiber cell, and crystallinity of cellulose had substantial impact on the mechanical properties of LS fiber bundles. Furthermore, the density of fiber bundles of LS ranged within 385.46–468.70 kg/m3, significantly less than that of jute (1360.40 kg/m3) and Arenga engleri (950.20 kg/m3). However, LS fiber bundles demonstrated superior specific modulus than Arenga engleri.The advancement in science and technology has led to luffa sponge (LS) being widely used as a natural material in industrial application because of its polyporous structure and light texture. To enhance the utility of LS fibers as the reinforcement of lightweight composite materials, the current study investigates their water absorption, mechanical properties, anatomical characteristics and thermal performance. Hence, moisture regain and tensile properties of LS fiber bundles were measured in accordance with American Society for Testing and Materials (ASTM) standards while their structural characteristics were investigated via microscopic observation. Scanning electron microscopy (SEM) was used to observe the surface morphology and fractured surface of fiber bundles. The test results show that the special structure where the phloem tissues degenerate to cavities had a significant influence on the mechanical properties of LS fiber bundles. Additionally, the transverse sectional area occupied by fibers in a fiber bundle (S The luffa sponge (LS), commonly referred to as vegetable sponge or luffa cloth, is obtained from matured dried fruit of luffa cylindrica. It consists of crisscrossed fibers and presents a three-dimensional reticular structure. Photographs of luffa cylindrica and luffa sponge are shown in Of particular interest when studying the luffa sponge fibers and their applications in composite materials are the water absorption and mechanical properties of sponge gourd–polyester composites, luffa sponge cellulose, and nanometer composite material, and the structure and mechanical strength of luffa sponge fiber bundles. Boynard et al. investigated water absorption and mechanical properties of sponge gourd–polyester composites . The res3–65 kg/m3) and low density (15 kg/m3–30 kg/m3) LS have been studied.Moreover, a significant number of studies have shown that, as the reinforcing phase of polymer composites, mechanical strength of fibers has a significant impact on the mechanical properties of polymer composites ,24. Zhaiρ is density of luffa sponge columns in kg/m3, M is the mass of luffa sponge column in kg, and v is the volume of luffa sponge columns in m3. S1 and S2 are the areas of the top and bottom transverse section from luffa sponge column (excluding the porous structure on the transverse section), respectively. The transverse section of luffa sponge column is shown in 2, while H, the height of luffa sponge column, is expressed in m.To account for aging contraction, the two ends of luffa sponge were amputated and the middle sections of luffa sponge columns a, which 2 is considered as low density, while the density range of 31 to 65 kg/ m2 is considered as high density.Luffa sponge, on the basis of density, can be classified into two categories; namely, LD and HD. The density range of 15 to 30 kg/mArenga engleri for contrast test. In addition, the eight groups of short fiber bundles (length ~2 mm) were obtained from luffa sponge to prepare frozen microtome sections.As shown in Arenga engleri were dried in an air oven at 100 °C for 24 h, and, thereafter, eight kinds of powder specimens were obtained by ball mailing for X-ray diffraction test (XRD) and thermogravimetric analysis test (TGA). The speed of ball mailing used was 170 turns/min while the ball mailing duration was kept at 5 min.The fiber bundles of four layers from luffa sponge of two densities, jute, and Arenga engleri were measured via digital optical microscope .Subsequent to section collection, diameters of fiber bundles from luffa sponge, jute, and To observe the morphological characteristics of fiber cells in fiber bundles and measure the length of fiber cells in luffa sponge, five to ten fiber bundles were bound tightly together by cotton threads and cut into lengths of 20 mm. Subsequently, the bundles were segregated in solution of 1:1 glacial acetic acid and hydrogen peroxide for duration of 8 h. Thereafter, fiber cells were rinsed several times until neutral pH was reached. A digital optical microscope was used to observe .morphological characteristics of fiber cells. The length measurements were carried out using MIAS image analysis software. To gather significant statistical data, 90 fiber cells from each group were tested.To observe the micromorphological characteristics of transverse sections of fiber bundles, eight groups of fiber bundles (length ~2 mm) from luffa sponge were embedded in tissue freezing medium. The temperature of frozen embedding ranged from 23 to 13 °C below zero. The tissue freezing medium was offered by Amos Scientific Pty. LTD. . Thereafter, frozen microtome sections of 10 µm thickness were cut from embedded specimens using a freezing microtome . A few of the transverse sections were stained with safranin in order to clearly observe the lignified tissue via digital optical microscope. The diameters of fiber cell, and the thickness and diameter of fiber cell wall were measured via Motic Images, an image analysis software.F), and the amount of transverse sectional area occupied by non-fibers including cavity, vessels, and phloem tissue (SN). The SF and SN are shown in The other sections were observed under a polarized-light microscope  to obtain the area of transverse section (S), the amount of transverse sectional area occupied by fiber in a fiber bundles (SArenga engleri were air-dried till their moisture content ranged from 8% to 10% by weight (wt %) and thereafter cut into sections of 30 mm in length. All the tensile tests were conducted on the universal testing machine  with a 1 KN load cell and the crosshead speed of 0.5 mm/min. The testing room conditions were around 25 ± 2 °C with a RH of 70%. To immobilize fiber bundles, in accordance with ASTM D 3379-75 standard [For the tensile strength measurements, the fiber bundles of luffa sponge, jute, and standard ,27,28, adM. The samples were thereafter placed in humidity chamber at 65% RH at 21 °C for 24 h [hM. Finally, MR was determined using Equation (3):hM is the mass of the sample after humidity exposure, and dM is the mass of the dried sample.In accordance with ASTM D 2654-89a standard, bundles of single fibers bound together were weighed and dried in an air oven at 105 °C for 4 h. The samples were weighed using a balance with accuracy to four decimal places (±mg) and recorded as for 24 h ,30. To orCI) of the fiber was calculated using Equation (4) [rCI is relative crystallinity index, I002 is the maximum intensity of diffraction of the (002) lattice peak at 2θ angle between 22° and 23°, and amI is the intensity of diffraction of the amorphous material which is taken at 2θ angle between 18° and 19° when the intensity is minimal.The crystallinity index of the tested fibers was calculated from X-ray Diffraction patterns recorded on the XRD-3 X-ray diffractometer . The diffractograms were obtained by varying angle (2θ) from 10° to 40°. To obtain statistically significant number of samples, three repetitions were carried out for each datum and mean of the data was selected. The crystallinity index (tion (4) ,32:(4)CTo evaluate thermal stability of luffa sponge fibers, TGA was carried using TG209 thermogravimetric analyzer . Samples with weight between 5 and 10 mg were placed in an alumina pan and heated from 30 to 700 °C. To prevent oxidation, TGA analysis was performed under nitrogen atmosphere at a flow rate of 20 mL/min. The heating rate was maintained at 10 °C/min during heating between 30 and 700 °C, apart from keeping at the temperature at 100 °C for 10 min . To obtaArenga engleri was investigated  have been reported to be in the range of 100–400 µm while the typical diameter of coir fiber bundles from the coconut palm (Cocos nucifera) has been reported to be around 200 µm [In addition, the diameters of fiber bundles from d 200 µm . Hence, Arenga engleri and jute are presented in The morphology and characteristics of fiber cells from luffa sponge, Arenga engleri, but shorter than that of the jute. The ratios of wall to lumen for luffa sponge were significantly smaller than that of Arenga engleri and jute. Thus, it can be concluded that in comparison with other common plant fiber cells, the fiber cell of luffa sponge contains less material substance, which is the primary reason for lightness of luffa sponge. Furthermore, the ratio of wall to lumen of fiber cells in inner layer of LD and HD luffa sponges was 0.20 and 0.39, respectively, and is slightly larger than that of other layers.Secondly, the fiber cell of luffa sponge was longer than that of Arenga engleri had smaller diameters than those of luffa sponge. It can be observed that fiber bundles of luffa sponge primarily consisted of fiber cells. As shown in Arenga engleri. Moreover, it was also discovered that there were two or more cavities with uneven distribution in the fiber bundles of HD luffa sponge, while there was only one cavity around the center of fiber bundles in LD luffa sponge.The transverse sections of the safranin-stained fiber bundles clearly revealed lignified tissue. According to F, and SN of a fiber bundle were measured for each of the four layers of luffa sponge. The statistical data are shown in F% is the ratio of SF to S, while SN% is the ratio of SV to S. The SN% of luffa sponge is in the range of 13–28%. The SN% of fiber bundles of corresponding layer in HD luffa sponge is larger than that of LD The value of SN% represents the immaterial substance in the fiber bundles; in other words, the lower is the value of SN%, the higher is the amount of substantial fibers in fiber bundles. Zhai et al. have reported that the amount of substantial fibers has an important influence on the mechanical properties of fiber bundles [Hence, S, S bundles .N% of fiber bundles from four layers in low density (or high density) luffa sponge were significantly different. Meanwhile, there was a significant difference in S and SN% of fiber bundles between LD and HD.In addition, variance analysis results of characteristic index values of fiber bundles of luffa sponge are shown in Arenga engleri, jute, and four layers in luffa sponge were obtained , and elongation. In other words, the mechanical properties of single fiber bundles in LD luffa sponge were superior to HD luffa sponge. The phenomenon may be explained by the values of SN%, since the SN% of the fiber bundles in each layer (excluding middle layer) of HD luffa sponge were higher than the corresponding layer of LD luffa sponge. The presence of fibers predominantly contributes to the mechanical strength of the fiber bundles while the presence of cavities vessels and phloem tissue tends to reduce the mechanical strength [N% in fiber bundles, lower is the amount of substantial fibers in fiber bundles, resulting in worse mechanical properties. In the case of same kind of luffa sponges, the mechanical properties of fiber bundles in each layer also decreased with the increase of SN% in fiber bundles. In addition, N%. Therefore, the analysis of Pearson’s correlations further demonstrate that mechanical properties of luffa sponge fiber bundles decrease with the increase in SN%.The typical stress–strain curves for fiber bundles from obtained . The curstrength . In otheN%. There are several factors responsible for these results, one of which is the presence and contribution of cavities in the transverse section of luffa sponge. The simplified models for transverse section of fiber bundles taken from two-density luffa sponge are shown in the Moreover, the mechanical properties of fiber bundles from HD luffa sponge decreased dramatically with a slight increase in S3 and was far lower than that of fiber bundles from Arenga engleri (950.20 kg/m3), and jute (1360.40 kg/m3). It is possible that the low density for luffa sponge fiber bundles is due to the hierarchical polyporous structure of fiber bundles and fiber cells as shown in Arenga engleri and jute, the specific modulus of luffa sponge fiber bundles were in a normal range. Specifically, the specific modulus of L.D. luffa sponge was higher than that of Arenga engleri fiber bundles. The natural plant fiber with higher mechanical strength and specific modulus, as the reinforcement of the composite material, can be used to manufacture the polymer matrix composite material with advantages of portability and good mechanical properties [In addition, it is interesting to note that the density of fiber bundles taken from luffa sponge was in the range of 385.46–468.70 kg/moperties ,40.To further understand the fracture mechanism, the fractured surface of broken fiber bundles was observed under scanning electron microscopy (SEM). As shown in Furthermore, as shown in In Arenga engleri, and jute is presented in Arenga engleri and jute. The higher moisture regain can possibly be attributed to the presence of the porous structure, surface groove, and micro cracks in luffa sponge fiber bundles. Tan et al. have discovered that slender hole exists in the bamboo fiber surface and indicated that these were important for fine moisture regain and moisture dispersion [The moisture regain of fiber bundles from luffa sponge, spersion . In compspersion ,43. AccoArenga engleri, and jute. The relative crystallinity of each layer of LD luffa sponge was higher than that of corresponding layer in HD luffa sponge, leading to better mechanical strength of LD luffa sponge. Moreover, the trend of variation in relative crystallinity is in accordance with the variation trend of mechanical strength of luffa sponge, indicating that relative crystallinity had significant influence on the mechanical properties of luffa sponge. However, in comparison with Arenga engleri or jute, luffa sponge fiber bundles had higher relative crystallinity but lower mechanical properties. The possible reason could be the existence of cavities and smaller ratio of wall to lumen for luffa sponge than Arenga engleri or jute. The luffa sponge fibers, as natural fibers, have complex chemical components with a complex crosslinking of lignin and hemicellulose. All the above factors significantly affect the mechanical properties of luffa sponge fiber bundles.Arenga engleri, and jute. As shown in Arenga engleri and jute were similar. The biomass combustion includes four main phases: water evaporation stage, the devolatilization and combustion stage, the fixed carbon combustion stage, and the burnout stage [Arenga engleri. In the case of jute, initial degradation temperature was 325.6 °C, final degradation temperature was 379.3 °C and the peak degradation was 365.7 °C, while those for Arenga engleri were 300.9 °C, 383.0 °C and 357.4 °C, respectively. In 2004, Tang et al. reported that, for the bamboo fibers, the initial degradation temperature is 342.6 °C, final degradation temperature is 380.4 °C and the peak degradation is 368.8 °C [Pennisetum purpureum is 364.7 °C. Hence, in regards to thermal stability, it is evident that the fiber of HD luffa sponge is the preferred natural fiber material.ut stage . As showut stage . However368.8 °C . In 20163, which is significantly lower than that of Arenga engleri (950.20 kg/m3) and jute (1360.40 kg/m3). Furthermore, luffa sponge fiber bundles had excellent specific modulus. Specifically, specific modulus of luffa sponge fiber bundles of LD (2.07–4.05 MPa*m3/Kg) was even higher than that for Arenga engleri, depsite the fact that luffa sponge fiber bundles have lower tensile strength.Luffa sponge fiber bundles are natural fiber materials of light texture with a density range of 385.46–468.70 kg/mN and the number and contribution of cavities in the transverse section of luffa sponge fiber bundles. In other words, luffa sponge fiber bundles can have excellent mechanical properties if they have high ratio of SN, even-distribution, and high aggregation degree of fiber cell.Special structural characteristics of luffa sponge fiber bundles had a significant impact on the mechanical properties. The phloem tissues of vascular bundle degenerated to cavities leading to a reduction in the mechanical strength of luffa sponge fiber bundles. Interestingly, only one cavity was observed in transverse section fiber bundles from LD luffa sponge, while two or more cavities were observed in fiber bundles from HD luffa sponge. The tensile tests proved that luffa sponge fiber bundles of HD possess lower mechanical strength than luffa sponge fiber bundles of LD. The mechanical properties of the fiber bundles were affected by the ratio of SArenga engleri fiber bundles. The luffa sponge fiber cells had higher ratio of wall thickness to lumen than jute or Arenga engleri; in other words, the luffa sponge fiber cells had more substantive material. Accordingly, fiber bundles from HD luffa sponge should ideally possess great mechanical strength. However, this is in contrast with our results that fiber bundles from LD luffa sponge have superior tensile strength than that of HD luffa sponge. The probable reason for the discrepancy could be the high crystallinity of cellulose in LD luffa sponge.The smaller wall thickness of fiber cell and the cavity in the transverse section contributed to lower density of luffa sponge fiber bundles as compared to jute or The luffa sponge fiber bundles had relatively higher moisture regain in comparison with the common fibers. The possible explanation for the results could be the porous structure, the surface grooves, and the surface micro cracks in the luffa sponge fiber bundles. The moisture regain of HD luffa sponge fiber bundles (7.1–9.3%) was lower than that of LD luffa sponge fiber bundles (10.2–10.9%). Moreover, each layer fibers of luffa sponge had significantly different moisture regain in the case of HD luffa sponge while the corresponding difference was negligible in LD luffa sponge.The biomass combustion of luffa sponge fiber consisted of four main phases: the water evaporation stage, the devolatilization and combustion stage, the fixed carbon combustion stage, and the burnout stage. There were remarkable differences in the thermal degradation temperatures between LD and HD luffa sponge fibers. The HD luffa sponge fiber demonstrated better thermal performance than LD luffa sponge fiber due to lower crystallinity of cellulose. These results are in contradiction with the widely accepted notion that the higher is the crystallinity of cellulose, the better is the thermal stability of fiber. The difference in the content of cellulose, hemicellulose, and lignin in two kinds of luffa sponge are considerable factors affecting thermal performance. The HD luffa sponge fiber has relatively more lignin.This study investigated the relationship between the structural characteristics and mechanical properties of luffa sponge fiber bundles, and their moisture regain and thermal performance as the reinforcement of lightweight composite. From the above discussions, the following conclusions can be drawn.


In the FANTOM5 project, transcription initiation events across the human and mouse genomes were mapped at a single base-pair resolution and their frequencies were monitored by CAGE  coupled with single-molecule sequencing. Approximately three thousands of samples, consisting of a variety of primary cells, tissues, cell lines, and time series samples during cell activation and development, were subjected to a uniform pipeline of CAGE data production. The analysis pipeline started by measuring RNA extracts to assess their quality, and continued to CAGE library production by using a robotic or a manual workflow, single molecule sequencing, and computational processing to generate frequencies of transcription initiation. Resulting data represents the consequence of transcriptional regulation in each analyzed state of mammalian cells. Non-overlapping peaks over the CAGE profiles, approximately 200,000 and 150,000 peaks for the human and mouse genomes, were identified and annotated to provide precise location of known promoters as well as novel ones, and to quantify their activities. The initial key technology driving the project was to make full-length cDNA clones, representing complete primary structure of transcribed RNA molecules. Sequencing of the full-length cDNA clones uncovered unexpected number of long non-coding RNAs as well as protein coding genes2–6. The CAGE 8 protocol, combination with high-throughput sequencing, was developed to monitor frequencies of transcription initiation by determining 5′-end of capped RNAs. The technology was devised to uncover complexity of the transcriptome4–6 and elucidate transcriptional regulatory networks by focusing on promoter elements9–12. By taking advantage of single molecule sequencer, HeliScopeCAGE was recently developed to provide more sensitive and accurate monitoring of transcription initiation activities8.Since the completion of the human genome sequencing, role of individual bases has been a central question. An international collaborative effort, FANTOM 13. Our central focus was on human primary cells, while cell lines, tissues and mouse samples were chosen to cover cells inaccessible as isolated human primary samples. The resulting data provided an atlas of promoter and enhancer activities in wide range of cell states14, which is a baseline of understanding complex transcriptional regulation. In the second phase, we focused on transitions of cell states by monitoring ‘time course’ samples, such as activations, differentiations, and developments at sequential time points15. The monitored activities of promoters and enhancers demonstrated that enhancer activities is the earliest event during dynamic changes of transcriptome. These data sets are being utilized in many other studies inside and outside of the FANTOM5 consortium.In the fifth round of the FANTOM projects, FANTOM5, the challenge was to capture the transcriptome of many varieties of cell states as possible, to understand the implication of each genomic bases in different contexts. In the first phase of the FANTOM5 project, we targeted cells in steady state, called ‘snapshot’ samples8 and a robotic workflow for samples with standard requirements7. The assay pipeline started with checking RNA quality , which provides a uniform quality assessment of the profiled RNA extracts. The resulting CAGE libraries were sequenced by HeliScope in RIKEN and also in Helicos Biosciences, and the obtained data were processed by the MOIRAI system16. Quality of the resulting CAGE profiles was checked with several statistics as well as manual inspection by using the ZENBU browser17. Finally CAGE profiles were shared among the consortium for further analysis.The data production scheme was implemented based on the FANTOM5 collaboration. Sample collection was performed at individual institutes, since specific types of samples require dedicated systems with special expertise or settings, as well as through purchase from commercial sources. RNA quality was firstly examined at the place where the samples were obtained . The CAGE assay pipeline established in RIKEN GeNAS  employed two workflows of HeliScopeCAGE, a manual workflow for samples with small amount of total RNAshttp://fantom.gsc.riken.jp/5/)18. Here we describe the data with the processing details and quality metrics.In the course of the two phases focused on ‘snapshot’ and ‘time course’ samples, we profiled 1,816 human and 1,016 mouse samples in total, and obtained approximately four millions of single-molecule reads successfully aligned to the genome per sample on average. Based on frequencies of the observed 5′-ends of individual capped RNA molecules at a single base-pair resolution, we identified 201,802 and 158,966 peaks for human and mouse respectively, where promoters are defined as the sequence immediately upstream of the peaks and frequencies of observed CAGE reads reflect activities of the promoters. All data generated during the course of the project were deposited to a public repository  and/or provided at the FANTOM5 web resource  was used for RNA extraction. Human post mortem tissue RNAs were purchased or obtained through the Dutch Brain bank. Tissues collected through the consortium were snap-frozen in liquid nitrogen, transferred into Lysing Matrix D tubes  containing chilled Trizol (Gibco), homogenized by FastPrep Homogenizer (Thermo Savant), and centrifuged. miRNeasy kit (QIAGEN) was used for RNA extraction from cultured cell lines as well as frozen cell line stocks.Sample collection was performed as described previouslyFor the purchased samples, lot or catalogue numbers were recorded where available. Of the collected RNAs, those with more than 1 μg, were measured by Agilent BioAnalyzer  and Nanodrop spectrophotometer  to check RIN (RNA integrity) score and the absorbance ratio of A260/A230 and A260/A280. The rest of the samples were directly subjected to the CAGE library production to avoid wasting material. All 2,832 profiled samples are summarized in 15. Most of the RNAs were subjected to the automated HeliScopeCAGE protocol7, except for RNAs with less than 1 μg that were subjected to the manual protocol optimized for low quantity RNAs8. The resulting libraries were measured by OliGreen fluorescence assay kit (Life Technologies), and sequenced by following the manufacturer’s instructions , remaining reads were aligned to the reference genome of human and mouse (hg19 or mm9) by using Delve25, and alignments with a quality of less than 20 (<99% chance of true) or a sequence identity of less than 85% were discarded. Frequencies of the CAGE read 5′ ends were counted to give a unit of CAGE tag start site (CTSS), a single base-pair on the reference genome. The entire flow of the data is illustrated in The produced data were processed as previously describedhttps://github.com/hkawaji/dpi1/) method and annotated as previously described15. A ‘robust’ threshold, for which a peak must include a CTSS with more than 10 read counts and 1 TPM (tags per million) at least one sample, was employed to define a stringent subset of the CAGE peaks. The robust peaks were associated with known transcripts, such as RefSeq26, UCSC known gene27, GENCODE28, Ensembl29, and mRNAs (full-length cDNA clones), based on their 5′-end proximity to the peaks. Official gene symbols, Entrez Gene IDs, and protein (UniProt) IDs associated with the transcripts were retrieved and assigned as part of annotation. In addition to these associations, human readable names and descriptions were assigned to each of the CAGE peaks. Peaks were given a name in the form pN@GENE, where GENE indicates gene symbol or transcript name and N indicates the rank in the ranked list of promoter activities for that gene. For example, p1@SPI1 represent the peak with the highest number of observation  in all of the FANTOM5 CAGE profiles, among the peaks associated with SPI1 gene.Non-overlapping peaks based on the all CAGE profiles were identified by using DPI , and the second was for the entire samples from both the ‘snapshot’ and ‘time course’ studies (phase 2). We integrated these two peak sets into a hybrid set consisting of all the phase 1 peaks over the robust threshold and a subset of phase 2 peaks that did not overlap with the phase 1 peaks. Annotation of phase1 peaks was used in the hybrid set, called phase 1+2 peaks, which provide a consistent reference in the definition of promoters.30 method by edgeR31, and tags per million  was computed as expression levels.All the obtained CAGE profiles were subjected to the peak identification, even if they have some issues in quality, since all of them still represent independent observations of RNA 5′-ends. However promoter activities  were quantified only in the samples satisfying the following criteria: RIN score greater than 6, more than 500,000 successfully aligned reads to the genome, and more than 50% of the successful alignments are close to 5′-end of RefSeq gene model, for expression analysis requiring reliable quantification. After discarding a few CAGE profiles of low quality, read counts for individual CTSSs belonging to the same peak were summed up, normalization  factors were calculated with RLE (Relative Log Expression)15.The RLE normalization was first performed within the phase 1 samples. The naïve application of this to the entire data sets, consisting of phase 1 and phase 2 samples, might cause inconsistencies in expression levels between the two normalizations. To avoid this, we took the geometric mean of CAGE peak read counts across the phase 1 samples and used it as the reference expression for a normalization factor calculation in the same manner as RLE method. This enabled us to keep the expression levels of phase 1 as they were, and to adjust the expression levels of the phase 2 samples to be comparablehttp://fantom.gsc.riken.jp/5/suppl/rRNAdust/. Mapping software Delve is available at http://fantom.gsc.riken.jp/5/suppl/delve/. The program to perform DPI, decomposition-based peak identification, method is available at https://github.com/hkawaji/dpi1/.All software used in this study are publicly available. rRNAdust, for removing ribosomal RNA, is available at 32. Sample metadata for human and mouse are ‘HumanSamples2.0.sdrf.xlsx’ and ‘MouseSamples2.0.sdrf.xlsx’, respectively. The metadata for the CAGE assay are available as ‘*sdrf.txt’.Two types of metadata are available at figshare and LSDB Archive . One is for the samples, including their origins and extracted RNA. The other is for the CAGE assay, including the result of RNA quality check, library production, and post-processing of the CAGE tag sequences. Both of them are described in SDRF (Sample and Data Relationship Format)All of the CAGE sequences, their alignment to the genomes, and CTSS frequencies are available at DDBJ DRA (DDBJ Sequence Read Archive) (Data Citations 2–9). The accession number of each file is summarized in ‘DRA*.txt’ at figshare (Data Citation 1).https://sourceforge.net/projects/osctf/.Genomic coordinates, annotations and expressions of the CAGE peaks are available as ‘*phase1and2combined_coord.bed.gz’, ‘*phase1and2combined_ann.txt.gz’, and ‘*phase1and2combined_tpm.osc.txt.gz’ respectively at figshare (Data Citation 1). Genomic coordinates are formatted in BED format, and the others are formatted in OSCtable (Order Switchable Column table). The detail of the OSCtable format is available at Measured RNA qualities at the second check  are shown in 13. The average ratio of promoter-hitting reads is 76.5, and 98.6% of the all profiles  have more than 50% promoter-hitting rate, which was another criterion of profiles used for expression analysis13.The number of CAGE reads successfully aligned with the genome and the ratio of CAGE reads hitting conventional promoters are shown in 13 within the phase 1 was shown in 13 was in Hierarchical clustering of the 126 mouse primary cells33. TET (Table Extraction Tool) provides an interface to obtain a subset of data by specifying the desired columns and rows. The BioMart interface34, and FANTOM5 SSTAR  provides the metadata of the profiled samples35. The CAGE profile on the genomic axis is visible in ZENBU17 with its interactive interface and also in the UCSC genome browser36 via track data hub37.As well as providing access to individual data files, we also set up a series of interfaces as described in the FANTOM web resourceHow to cite this article: Noguchi, S. et al. FANTOM5 CAGE profiles of human and mouse samples. Sci. Data 4:170112 doi: 10.1038/sdata.2017.112 (2017).Publisher’s note: Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.


Visual evoked potentials (VEPs) assess the integrity of the visual pathways from the optic nerve to the occipital cortex. Optic disc cupping and visual field loss have been associated with prolongation of latency of VEP in primary open angle glaucoma (POAG). Pattern reversal and flash VEP tests were done in consenting 20 primary open angle glaucoma eyes and 40 normal control eyes.p = 0.001], cup-disc ratio in percent , intraocular pressure , and automated visual field pattern standard deviation  were significantly more than in control. The visual acuity , foveal visual sensitivity , and automated visual field mean deviation  were significantly less in cases than in control. Among VEP variables, pattern reversal latency N145 , flash amplitude N75 , and flash amplitude N145  were increased in cases. The pattern reversal amplitude N75 , amplitude P100 , and amplitude N145  were decreased in cases. In POAG cases, the refractive error [3.51 ± 1.88 versus 1.88 ± 1.11, D,  POAG caused glaucomatous damage to optic pathway. The visual evoked potential (VEP) is the potential recorded from the occipital region in response to visual stimuli with a long latency response. It is the evoked response that is visible without averaging . Its stiPrimary open angle glaucoma is generally a bilateral but not always symmetrical disease characterized by adult onset, an IOP more than 21 mm Hg at some point in the course of the disease, an open angle of normal appearance, glaucomatous optic nerve head damage, and visual field loss . It is aThe VEP is very useful in detecting an anterior visual conduction disturbance; however, it is not specific with regard to etiology. It is very useful in evaluating visual function. It is noninvasive and has excellent temporal resolution. It can be used to assess the integrity or maturational state of the visual pathway in infants and preverbal children . For recVEP stimulation has been used in diagnosis of glaucoma. It is used for the assessment of optic nerve diseases . VEP latThe objective of this paper is to study visual evoked potentials (VEPs) in primary open angle glaucoma.n = 40, m = 24, f = 16) and 20  POAG eyes. All the patients were on β-blocker (timolol) for intraocular pressure control.This case-control study was conducted in 20 eyes diagnosed as primary open angle glaucoma (POAG) in patients aged 45 to 74 years and 40 control aged 38 to 72 years in the Electrodiagnosis Lab II (Neurophysiology Lab) of Department of Physiology, BPKIHS. The patients in BPKIHS Ophthalmology OPD meeting the inclusion criteria and controls (staffs and patient attendant) were enrolled in our study after the necessary ophthalmic assessment so as to exclude the other types of glaucoma and eye disorders. The control to case ratio was 2 : 1, that is, 40 control (2) of the subjects were recorded. Ophthalmic variables such as visual acuity, refractive error, foveal visual sensitivity, cup-disc ratio in percent, intraocular pressure, automated visual field mean deviation, and automated visual field pattern standard deviation were recorded by using VFA .Experimental setup was checked with the room temperature maintained at the thermoneutral zone (25 ± 2°C). Informed written consent was taken from each subject and they were familiarized with the laboratory conditions. The recording room was kept dark. Anthropometric variables such as age (yrs), weight (kg), height (cm), and BMI (kg/mCz) and another on the left hand. Active electrode was placed on the scalp over the visual cortex at Oz with the reference electrode at Fz and ground electrode positioned at forehead, vertex (Cz).The electrodes were placed using Elefix gel after proper cleaning. According to the 10–20 international system, left occipital (LO) and right occipital (RO) electrodes were placed 5 cm left and 5 cm right, respectively, from midline occipital region. Midline-frontal (MF) electrode was placed 12 cm above the nasion, and two earthing electrodes were placed, one on vertex (The subjects were asked to sit on a chair at a distance of 100 cm from the television (ONIDA 14′′ color) monitor. The monitor displayed pattern reversal checkerboard with check size of 1 degree (60 min of arc) and a small square point in the board's center was used for monocular fixation (covering one eye with a hand without pressing it) of eye at the central fixation point. This was connected to the Nihon Kohden machine  used for recording VEP. The reversal pattern rate was set at a frequency of one per sec with 300 ms of analysis time. Averaging was done for 200 times to minimize the signal-to-noise ratio. The PR-VEP recording was done twice to check the repeatability of the VEP waves produced.The subjects were made to lie down in a supine position with their eyes closed. They were asked to wear a led visual stimulator (SLS-3500) which was connected to the machine. Strobe light from the stimulator was used for monocular stimulation and the flash VEP recording was done twice.In both pattern reversal and flash VEP, peak latencies of N75, P100, and N145 and amplitudes of N75, P100, and N145 were recorded. VEP latencies were measured from the origin of recording and amplitudes were measured by drawing a baseline and measuring from baseline to peak. U test was used for comparing variables between cases and controls.Data collected were first entered in the Microsoft Excel Worksheet (MS Office 2007 version). Mean and standard deviation were calculated. Depending on their distribution, Mann–WhitneyAmong the ophthalmic variables age was significantly less in control group, whereas weight and body mass index were less and height was more in control but they were not significant. The reason for the difference in age may be correlated with onset of glaucoma in old aged person see .Among the ophthalmic variables, refractive error, cup-disc ratio in percent, intraocular pressure, and automated visual field pattern standard deviation were significantly more in cases, whereas visual acuity, foveal visual sensitivity, and automated visual field mean deviation were less in cases than in control see .Among the VEP variables, pattern reversal latency N145, flash amplitude N75, and flash amplitude N145 were significantly increased in the cases than in control. Pattern reversal amplitude N75, pattern reversal amplitude P100, and pattern reversal amplitude N145 were significantly decreased in the cases than in control group see .This study was an attempt to compare visual evoked potentials (VEPs) in primary open angle glaucoma (POAG) patients and controls so as to find any evidence of differences in VEP latencies and amplitudes. VEP latencies are a measure of early glaucomatous damage before retinal ganglion cell death. Rodarte et al. reported an increase in multifocal VEP latencies in open angle glaucoma as compared to the control .p = 0.001) which meant that the corrections applied to the cases were very high and the cup-disc ratio of the cases were abnormally high which is supported by the study done by Korth [In our study, the visual acuity of the primary open angle glaucoma (POAG) patients was 0.41 ± 0.29 which is contrary to Korth  who founby Korth , Bergua by Korth .Pattern reversal VEP latency N145 was significantly more in cases Grippo et al.  (2006), Surprisingly, the flash VEP amplitude (N75 and N145) was significantly higher in cases. The flash VEP latencies  were longer in cases but were not significant. Similarly, the flash VEP amplitude P100 was lesser in cases but was also not significant.When pattern reversal VEP was compared with the flash VEP variables, P100 and N145 latency pattern reversal latency was significantly less. However, the pattern reversal N75 latency was also less but was not significant. The pattern reversal amplitudes  were significantly higher as compared to the flash VEP. This indicates that pattern reversal VEP is more reliable than flash VEP in clinical diagnosis (Aminoff) [r = 0.559, p = 0.001); N75 and N145 ; and P100 and N145 . The pattern reversal VEP latency P100 showed positive correlation with pattern reversal amplitude P100 . Similarly, the flash VEP latencies N75 and P100 ; P100 and N145 ; N75 and N145 ; and flash VEP amplitudes N75 and P100  showed positive correlation.A positive correlation was seen between pattern reversal VEP latencies N75 and P100 . A certain degree of peripheral vision loss in each individual with the advancement of age is natural. So, exact age matched normal could not be taken. Accordingly in a study by Aminoff , controlIt is concluded that POAG caused deterioration in all the ophthalmic variables measured with increase in latency. The amplitude is different between pattern reversal and flash methods.Further study can be done to make flash VEP more conclusive and useful for clinical interpretation. Also, the VEP of the subjects of different age group can be studied to evaluate the effect of age on VEP.


The main manuscript of this dataset is "Acute repeated sessions of bifrontal transcranial direct current stimulation for treatment of intractable tinnitus: a randomized controlled trial"  Transcranial direct current stimulation (tDCS) has reportedly shown promising therapeutic effects for tinnitus   Specifications TableValue of the data•Data presented in this paper are collected from a double blind randomized placebo controlled clinical trial with one month follow-up.•This dataset presents the data on the effects of acute multisession tDCS on intractable chronic tinnitus with one month follow-up.•The data consist of the tDCS effects on THI, tinnitus loudness and distress, as well as comorbid depression and anxiety as well as comprehensive demographic information, tinnitus characteristics and audiometric assessment.•Using these data other researchers can perform advanced statistical analyses and modeling to shed more light on the efficacy and nature of tDCS efficacy in tinnitus treatment.•The data can be used to develop treatment response predicting indexes.1n=42). The data consist of two main categories including demographic information, tinnitus characteristics, and audiometric assessments of the patients and the second group data are the values of response variables at prior intervention and post intervention. The The data of this study were collected from a double blind randomized placebo controlled clinical trial investigated the therapeutic efficacy of tDCS in intractable chronic tinnitus (22.1n=42) were divided into two groups of real =14, males (M)=11, age: 46.68±6.87 years, disease duration: 7.8±2.84 years), and sham tDCS . Both groups were matched for age, gender, ethnicity, and audiometric main characteristics. To reduce the procedure and subjective bias, the patients, the researchers who collected the data, and the researchers who performed statistical analyses and interpretations were blinded on the type of protocol. Before the intervention, the patients underwent complete audiometric and neurologic examinations by experienced specialists. The experimental procedures of the present study including tDCS sessions, outcomes evaluations were performed in the Bioelectromagnetic Clinic in Ahvaz Imam Hospital, an affiliated Hospital to Ahvaz Jundishapur University of Medical Sciences (AJUMS), Iran. All of the experimental procedures of this study were approved by the local ethics committee of AJUMS, Ahvaz, Iran (registration code: IR.AJUMS.REC.1394.639) which were in accordance with the ethical standards and regulations of human studies of the Helsinki declaration (2014) In a double blinded randomized controlled clinical trial, patients with chronic intractable tinnitus . The hearing thresholds were recorded over the frequency ranges of 250 to 8000 Hz for air conduction and 500 to 4000 Hz for bone conduction pathways, using the modified Hughson–Westlake Method as recommended by ANSI 2005 2.32) and delivered by a battery-driven, constant current stimulator with a maximum output of 4 mA . The real tDCS consisted of twice daily sessions  of 2 mA current for 20 min for 5 consecutive days through 35 cm2 electrodes. The anode was placed over the right DLPFC (F4), and the cathode over the left DLPFC (F3). In the sham group, the electrode montage was identical, but the device was turned off after 30 s without the participant's knowledge. The THI was assessed pre and post intervention, and at one month follow-up. Tinnitus loudness and distress were scored using a 0–10 rating numerical visual analogue scale prior to intervention, and immediately, one hour, one week, and at one month after the last stimulation session. Depression and anxiety scores were determined pre and post intervention using the Beck Depression (BDI-II) and Anxiety Inventories (BAI). Moreover, blinding quality of the study was assessed. During treatment, the patients were asked to remove all metal-based jewelry from the head and neck.The tDCS was performed through carbon electrodes embedded in a saline-soaked pair of sponges  prior to intervention, and immediately, one hour, one week, and at one month after the last stimulation session. Depression and anxiety scores were determined pre and post intervention using the BDI-II and BAI.


The use of synthetic mesh for ventral hernia repair under contaminated conditions is a controversial issue due to the considerable risk of surgical site infection (SSI). This study aimed to review the outcomes of repair of incarcerated and strangulated ventral hernias with or without synthetic mesh in compliance with established clinical guidelines regarding the incidence of SSI and hernia recurrence.The records of patients with complicated ventral hernias who were treated with or without synthetic mesh repair were reviewed. Variables collected included the characteristics of patients and of ventral hernias, type of repair, and incidence of SSI and recurrence.One hundred twenty-two patients  of a mean age of 56 years were included. Fifty-two (42.6%) and 70 (57.4%) patients presented with incarcerated and strangulated ventral hernias, respectively. Sixty-six (54%) patients were treated with on-lay mesh repair, and 56 (46%) were managed with suture repair. Twenty-one patients required bowel resection. SSI was detected in eight (6.5%) patients. There was no significant difference between both groups regarding the incidence of SSI (7.5% for mesh group vs 5.3% for suture group). Recurrence occurred in seven patients. Median follow-up period was 24 months. The suture repair group had a significantly higher incidence of recurrence than the mesh group. Diabetes mellitus, previous recurrence, and intestinal resection were significant predictors for SSI.Following established guidelines, synthetic mesh repair of incarcerated and strangulated ventral hernias attained lower recurrence rate, comparable incidence of SSI, and higher rate of seroma formation than suture repair.researchregistry1891Research Registry,  Ventral hernias include all hernias arising from a defect in the anterior abdominal wall as epigastric, umbilical, and incisional hernias. Ventral hernias are susceptible for various complications, particularly incarceration and strangulation, that warrant urgent operative intervention which is usually associated with high rates of postoperative recurrence and complications .The diagnosis of incarceration/strangulation on the verdict of clinical examination alone is not an easy task. Strangulation should be recognized in a timely manner as it warrants immediate surgical intervention. Early operative intervention for strangulated hernia is crucial since any delay in the diagnosis can lead to further compromise of the bowel viability and eventually bowel resection. In addition to the risk of anastomotic leak after bowel resection and anastomosis, strangulation increases the contamination of the operative field which subsequently increases the incidence of postoperative surgical site infection (SSI) and hernia recurrence .The World Society for Emergency Surgery (WSES)  has issuThe use of prosthetic mesh in potentially-contaminated and contaminated settings is not frequently described in the literature. Despite the wide variations of data and the conflicting reports, prosthetic materials are not generally recommended for the repair of ventral hernias in contaminated settings. Choi and colleagues  used theXourafas et al.  evaluateThe present study aimed to review the outcomes following the repair of incarcerated and strangulated ventral hernias with or without synthetic mesh in compliance with the established clinical guidelines of WSES in terms of the incidence of SSI and recurrence of hernia postoperatively.Prospectively collected data of consecutive patients with incarcerated or strangulated ventral hernia who were treated with or without synthetic mesh were reviewed. The study took place at the general surgery departments of Mansoura University principal hospital and Emergency hospital. Data collection involved patients treated between January 2014 and June 2016.www.researchregistry.com under the unique identifying number (UIN): researchregistry1891.Ethical approval for the study was obtained from the institutional review board of Mansoura Faculty of medicine. The study was registered on Adult patients of both genders who presented with incarcerated or strangulated ventral hernia were included. Ventral hernias comprised all hernias arising from a defect in the anterior abdominal wall including umbilical, epigastric, incisional, and Spigelian hernias. Patients who underwent resection of gangrenous bowel and anastomosis were also included.We excluded patients with other types of hernia other than ventral hernias, patients who underwent elective hernia repair after manual reduction of irreducible hernia, patients who underwent bowel resection with stoma formation, patients with incarcerated or strangulated omentum only without bowel involvement, and patients with associated necrotizing fasciitis of the anterior abdominal wall. Patients with incomplete records were also excluded.Incarcerated ventral hernia was defined as irreducible hernia associated with symptoms of bowel obstruction, yet with no compromise of the blood supply of the bowel. Strangulated hernia presented with partial or complete interruption of the blood supply of the intestine. After application of hot fomentation to the doubtful bowel loop, it was considered either viable and returned to the peritoneal cavity or non-viable and resection with anastomosis of the bowel ends was conducted.Incisional hernias were defined as hernias occurring at the site of abdominal incision performed for procedures other than hernia repair. Recurrent hernias are the hernias occurring at the site of incision made for previous hernia repair. According to the Center for Disease Control and Prevention (CDC) surgical wound classification , incarceAnesthetic fitness of patients, especially those with associated comorbidities , was classified according to the American Society of Anesthesiologists (ASA) score into class I to class V. Perioperative antibiotics  were administered to patients in both groups in accordance with Surgical Care Improvement Project protocol. The bio-burden reduction technique was followed by careful debridement of all non-viable tissues and removal of mesh in the cases of complicated recurrent hernias after prior mesh repair. The surgical field was thoroughly irrigated with gentamycin-saline solution. Upon completion of repair, subcutaneous drains were routinely placed above the mesh in all patients per hospital protocol and were removed when their drainage was less than 30 cc per day.Prosthetic mesh repair was performed by approximation of the edges of the abdominal wall defect using continuous running polyprolene 0 sutures then the abdominal wall was reinforced by using a synthetic polyprolene 15 × 15 cm or 30 × 30 cm mesh  according to the size of the defect. The on-lay technique of mesh repair was used in all patients. Non-mesh suture repair was performed either by direct approximation of the edges of the abdominal wall defect (simple primary repair) or by overlapping the abdominal wall fascia (Mayo’s repair).The decision on the technique of repair was made by the attending staff surgeon in accordance with the WSES guidelines  and depeFollow-up was conducted at the outpatient clinic by a surgical resident to eliminate risk of investigator bias, and then by one of the operating consultants at 1 week, two weeks, one, six, and 12 months postoperatively then every six months after the first year. Surgical site occurrence (SSO) was defined as SSI, cellulitis, necrosis, chronic and/or non-healing wound, serous or purulent drainage, seroma, hematoma, wound dehiscence, or fistula at the surgical site . SSI wasThe records of the patients were searched for the following data: patients’ characteristics as age, sex, ASA grade, and associated comorbidities, type of ventral hernia and type of emergent presentation (incarceration or strangulation), operation performed and whether intestinal resection was done or not, operation time, incidence of SSO, SSI, and recurrence of hernia. The primary outcome of the study was the incidence of postoperative SSI. Secondary end points included the incidence of hernia recurrence after the procedure, SSO, and other postoperative complications.t test was used to compare the quantitative data of the two groups. Fisher’s exact test and Chi square test were used for the analysis of qualitative variables. Multivariate analysis of the risk factors for SSI was performed using the binary logistic regression test. P value less than 0.05 was considered significant. Post-hoc analysis of the incidence of recurrence of ventral hernia in both groups (0 vs 12.5%) revealed a study power of 83% with alpha set at 0.05.Excel program and SPSS  version 21 under Microsoft Windows were used to analyze the data. The data was described in the form of mean ± standard deviation (SD) for quantitative data, while frequency and proportion were used to describe qualitative data. Student Among 145 patients with complicated ventral hernias who were treated within the study period, 122 patients fit the eligibility criteria and were included. Patients were 56 (46%) males and 66 (54%) females. The mean age of patients was 56 ± 10.3  years. Ninety-seven (79.5%) patients had associated comorbid conditions: 30 (24.6%) had diabetes mellitus (D.M), 33 (27%) had chronic liver disease (CLD), and 34 (27.8%) had cardiac problems. Eleven (9%) patients had more than one comorbidity. Ninety-nine (81.1%) patients had ASA grade of I-II, whereas 23 (18.9%) patients had ASA grade III-IV. Both groups had comparable demographic data (Table One hundred and three (84.4%) hernias were umbilical, six (5%) were epigastric, ten (8.1%) were incisional, and three (2.4%) were Spigelian. Thirteen patients (10.6%) had a recurrent umbilical hernia after previous operations (four previous mesh repairs and nine suture repairs). The median size of hernia defect was 7  cm.Fifty-two 42.6%) and 70 (57.4%) patients presented with incarcerated and strangulated ventral hernias, respectively. No significant differences were noted between the two groups regarding the characteristics of ventral hernias as illustrated in Table .6% and 7Sixty-six (54%) patients were treated with prosthetic mesh repair, and 56 (46%) were managed with suture repair (simple primary repair in 39 and Mayo’s repair in 17 patients). Mesh repair was done in 31 (60.7%) of 52 incarcerated hernias and 35 (50%) of 70 strangulated hernias (Table Twenty-one (17.2%) patients underwent resection of gangrenous bowel with anastomosis of the bowel ends. Two (9.5%) of those 21 patients were treated with mesh hernioplasty and 19 (90.5%) were treated with suture repair.n = 88), small bowel and omentum (n = 12), large bowel alone (n = 8), large bowel and omentum (n = 14).The suture group had a significantly higher rate of contaminated (CDC class III) wounds. Overall, there were 52 (42.6%) class I wounds, 49 (40.1%) class II wounds, and 21 (17.2%) class III wounds. Contents of the incarcerated and strangulated hernia comprised small bowel alone (n = 8), seroma (n = 19), hematoma (n = 4), and wound dehiscence (n = 3). The mesh hernioplasty group had significantly (p = 0.038) higher rate of SSO overall, particularly seroma formation, than the suture group.SSO was detected in 34 (27.8%) patients including SSI  patients, seven of them presented with strangulated ventral hernia and one with incarcerated hernia, three (5.3%) of which were in the non-mesh group and five (7.5%) were in the mesh group. Patients who developed SSI were treated conservatively on outpatient basis with antibiotics for 7–14 days according to the culture results and drainage if necessary. Only one patient in the mesh group was re-admitted for 3 days to have his mesh surgically removed owing to resistant SSI unresponsive to conservative treatment. All cases of SSI were detected within 30 days after surgical repair; there were no cases of latent mesh infection on further follow-up for at least 12 months.p = 0.72) between both groups regarding the overall incidence of SSI (7.5% [95%CI: 2.9–16.9%] for the mesh group vs 5.3% [95%CI: 1.2–15.1%] for the suture group). Similarly, on subgroup analysis, no significant differences in the rates of SSI were observed between mesh and suture repairs in the cases of incarcerated hernias (p = 1) and strangulated hernias (p = 1).There was no significant difference (p = 0.003) higher incidence of recurrence than the mesh group (Table Seven (5.7%) patients developed recurrence of ventral hernia within a period ranging from 6–18 months after repair, all recurrences were in the suture repair group. The suture repair group had a significantly p = 0.00 higher iThe median duration of follow-up was 24 months . Ninety-two (75.4%) patients were followed for more than 18 months, 21 (17.3%) were followed for 12-18 months, and nine (7.3%) were followed for less than 12 months.p = 0.02), previous recurrence (p = 0.04), and intestinal resection (p = 0.03) were the significant predictors for SSI. All previously recurrent hernias that developed SSI had prior mesh repair. Four of 21 patients who had resection of gangrenous bowel with re-anastomosis developed SSI, two of which had mesh repair and another two had suture repair.Univariate analysis Table  of the rp = 0.004), previous recurrence , and intestinal resection with CDC class III wound .Binary logistic regression analysis revealed the most significant risk factors for SSI included D.M  had comparable patients’ demographics and hernia characteristics which can minimize the inherent risk of selection bias associated with retrospective studies. Although according to WSES guidelines, incarcerated hernias are recommended to be managed with synthetic mesh repair invariably, only 60% of these patients were treated with mesh repair in our study. The reason for this can be the overall general condition and associated comorbidities of the patients that called for a rapid maneuver such as simple suture repair. On the other hand, only half of the patients with strangulation and around 10% of the patients with concomitant bowel resection underwent mesh repair which is in line with the WSES recommendations to use synthetic mesh cautiously in these potentially contaminated conditions.Although mesh hernioplasty had higher incidence of SSO overall, there was no significant difference in the incidence of SSI between mesh repair and suture repair. The overall 30-day SSI after mesh repair in our series was 7.5% ranging between 3% for incarcerated hernias and 11.5% for strangulated hernias. The rates of SSI after prosthetic repair of strangulated hernias are generally higher than those of incarcerated hernia which can be attributed to the ischemia of the bowel wall that predisposes to bacterial translocation, as well as the risk of bowel resection that can further increase the contamination of the surgical field. That is why the operative field in the cases of strangulated hernias was classified as clean-contaminated or contaminated .A randomized controlled trial  found prThe incidence of SSI in the present series was comparable to that disclosed by Nieuwenhuizen et al. , slightlThe relatively low incidence of SSI after synthetic mesh repair in the current study can be attributed to the combined application of clinical guidelines along with the use of good clinical judgment. As a general rule, following guidelines and applying evidence-based medicine can serve to achieve better outcomes in the surgical practice. The incidence of SSI after prosthetic mesh repair of complicated ventral hernias can be further reduced by employing different techniques of mesh placement  and negative pressure wound therapy.Despite the low rates of SSI in our report, chronic infection after the use of synthetic mesh under contaminated conditions remains one of the most concerning consequences. Chronic infection can compromise the wound healing resulting in chronic draining sinuses. Additionally, involvement of the underlying abdominal viscera can sometimes result in enterocutaneous fistulas. Furthermore, re-admission and reoperation for the management of mesh-related infection, including mesh extraction, are linked with added morbidities to the patient and higher treatment-related costs.Another controversial issue is the feasibility of synthetic mesh repair when bowel resection is being conducted in the same setting. Less than 10% of patients with bowel resection in our study were treated with a synthetic mesh. We found bowel resection and anastomosis to be a significant independent risk factor for SSI whether a mesh was used or not. Four of 21 patients with bowel resection developed SSI, attaining a rate of 19% close to the incidence (22%) reported by Xourafas and colleagues  when simConversely, other investigators found the use of synthetic mesh to be acceptable with bowel resection. Geisler and affiliates  examinedIn addition to bowel resection, D.M and previous hernia surgery were recognized as significant predictors for SSI. D.M has been known to be associated with higher rates of infection after mesh repair of hernia  since itAlthough on-lay mesh hernioplasty was reported to have higher rates of recurrence and SSI than the sub-lay technique , we founReviewing the current literature, two opposite perspectives can be noted; the first discourages the use of mesh repair for ventral hernias at any level of contamination , and theEven with bowel resection, patients should not be denied the option of reinforcing the abdominal wall with mesh to minimize the likelihood of recurrence. Some options were devised in this context as the retro-rectus positioning of the polyprolene mesh. Proper preparation, washing, and accurate drainage of the preperitoneal space in addition to perfect hemostasis and local antibiotic treatment are crucial to guarantee the success of this method .The use of bioprosthesis has been proposed as a safe and efficient approach for abdominal wall reconstruction under contaminated conditions, yet the long term durability of biologic mesh has not been verified . Other aLimitations to the present study include being a single-institution, retrospective study, the small number of patients who had bowel resection, and the lack of some essential parameters as the body mass index, cigarette smoking, and steroid use that may have an impact on the incidence of SSI after the treatment of complicated ventral hernias. Furthermore, the technique of prosthetic repair used (on-lay mesh) is not widely used which may limit the generalizability of the study. Finally, the non-randomized nature of the study and the selection of patients for each treatment group according to the established guidelines and clinical judgment may have been the cause of the better outcomes reported, rather than the type of repair per se.Following the WSES clinical guidelines in conjunction with good clinical judgment, synthetic mesh repair of incarcerated and strangulated ventral hernias achieved lower recurrence rate than suture repair. Although mesh hernioplasty was followed by a higher incidence of SSO and seroma formation, the incidence of SSI was comparable in both groups.Bowel resection, D.M, and previously recurrent ventral hernias were the significant independent risk factors for SSI after repair of complicated ventral hernias. Well-powered randomized trials are needed to reach a strong conclusion about the safety of synthetic mesh when simultaneous bowel resection is conducted; until then, synthetic mesh should be used with caution in these conditions.


No reports have been published on synchronous multifocal necrotizing fasciitis (SMNF), a multifocal presence of necrotizing fasciitis in different extremities. We evaluated the clinical characteristics and outcomes of SMNF.Eighteen patients  diagnosed with SMNF of the extremities between January 2004 to December 2012 were enrolled and evaluated.Vibrio species were the most commonly  isolated; others were two cases (11%) of Aeromonas spp., one case (6%) of group A β-hemolytic streptococcus, and one case of coagulase-negative staphylococcus. SMNF was in the bilateral lower limbs , bilateral upper limbs , and one patient with one upper and one lower limb (11%). Non-surviving patients had more bilateral lower limb involvement and thrombocytopenia.Most patients with SMNF were male and had bilateral lower limb and marine Gram-negative bacteria involvement. The mortality of SMNF remained extremely high in patients with involvement of bilateral lower limb and initial thrombocytopenia. Necrotizing fasciitis (NF) is an uncommon deep soft tissue infection characterized by a rapidly spreading necrosis of superficial fascia and subcutaneous tissue . AlthougWe reviewed the records of patients diagnosed with and treated for SMNF at our hospital from January 2004 to December 2012. SMNF was defined as a multifocal presence of necrotizing fasciitis (NF) in different extremities at the initial visit. It was defined using surgical findings: the presence of grayish necrotic skin, subcutaneous fat and fascia, no resistance of normally adherent fascia to digital blunt dissection, and a purulent discharge resembling foul-smelling dishwater. Histopathological tissue specimens were obtained to confirm the diagnoses. Exclusion criteria were: (1) monofocal necrotizing fasciitis, (2) central necrotizing fasciitis (involvement of trunk or perineum), (3) a negative microbiological culture of the infected specimen, (4) concomitant chronic infections , and (5) a preexisting chronic wound .The treatment protocol included adequate antibiotic therapy and prompt radical debridement. All patients underwent emergency surgery within 1 h of admission when necrotizing fasciitis was suspected. Patients with multiple comorbidities, or an unstable hemodynamic status  were transferred to the intensive care unit for postoperative intensive care. Surgical debridement was done every other day if progressive necrotic changes combined with a deteriorating clinical presentation. Initial empiric broad-spectrum antibiotics were administered and adjusted based on blood and tissue culture results. Soft tissue reconstruction was done until the infected necrotic tissue was controlled and stabilized.Patient characteristics, presenting signs and symptoms, location of infection, underlying comorbidities, laboratory findings at the time of admission, bacteriologic results, and final outcomes in all patients were reviewed using the electronic database at our hospital. In regard to laboratory analysis, leukocytosis was defined as a white blood cell count greater than 12,000/μl, and thrombocytopenia was defined as a platelet count lower than 150,000/μl of blood. To assess clinical outcomes after antibiotic therapy and surgical debridement, mortality was defined as death because of progressive sepsis or medical complications within 12 months after surgery. To evaluate the predictive factors of mortality in SMNF, the variables were analyzed between survivors and non-survivors.t test was used for numerical data. A χ2 analysis or a Fisher’s exact test was used for categorical data. Descriptive data are presented as the mean with standard deviation for quantitative variables and as frequency for categorical variables. Statistical significance was set at p < 0.05. SPSS 12.0 for Windows  was used for all statistical analyses.Univariate analysis was used to determine factors associated with the survivors and non-survivors. An independent Student’s Vibrio species [14 (78%) cases] were the most common. Others were Aeromonas spp. [2 (11%) cases], group A β-hemolytic streptococcus [1 (6%)], and coagulase-negative staphylococcus [1 (6%)]. Twelve (67%) of the 18 enrolled patients presented in shock on admission and required aggressive resuscitation. The extremity distribution of NF included the bilateral lower limbs (72%), bilateral upper limbs (17%), and one patient with one upper and one lower limb (11%)  patients  (Table p = 0.005)  Table . Differep = 0.013) (Table p = 0.004). Bacteremia occurred in 50% of survivors and in 83% of non-survivors (p = 0.268). The levels of serum hemoglobin, C-reactive protein, and albumin were not significantly different between the two groups.Survivors had a higher rate of leukocytosis than did non-survivors  Table . The preVibrio vulnificus. There was no significant difference in bacterial species between the groups  and 52% type II  in El-Khani et al. [Vibrio spp. and Aeromonas spp.) are often found in the warm coastal areas of Asia , the Gulf of Mexico, South America, and Australia [This is the first report of a case series of SMNF and analysis of its predictive factors for mortality. In the current study, SMNF accounted for 5% of NF. The main characteristics of our patients with SMNF were male sex, lower limb involvement, and marine Gram-negative bacterial infection. The incidence of SMNF in noncontiguous sites is not clear in the literature. Park et al. , in a cai et al. . Marine ustralia –12. Alsoustralia , 14. OurThe overall mortality rate of our patients with SMNF was 67%. Most of the literature focuses only on monofocal NF and reports a cumulative average mortality rate of 34%. The survival rate for NF patients has risen to as high as 85% as the awareness of monofocal NF has increased and as more-frequent aggressive treatment and adjuvant therapy for the disease have increased. In contrast, multifocal NF remains highly fatal. Park et al. , an immeIn the present study, non-survivors had a higher prevalence of involved bilateral lower limbs and thrombocytopenia than did survivors. There is a paucity of reports on the risk factors for SMNF mortality. However, the mortality rate in cases of monofocal NF with upper extremity involvement is not significantly different from that in cases with lower extremity involvement , 17. El-Consistent with our findings for multifocal NF, thrombocytopenia has also been a predictive factor for mortality in monofocal necrotizing deep soft tissue , 24. PhyThis study has some limitations. This is a case series study with a small number of patients, because NF is a rare disease and our inclusion criteria were restricted to peripheral NF (involvement of extremities). Central NF  was excluded, because its etiology and surgical procedures are not similar to those of peripheral NF. NF of the head and neck often arises from an odontogenic infection with mixed aerobic and anaerobic abscesses , 29. NF In conclusion, the incidence of SMNF of the extremities was 8% for all subtypes of NF. Male sex, bilateral lower limb involvement, and marine Gram-negative bacteria were the most frequently found factors in SMNF. The mortality of SMNF was as high as 67%, which was more frequently associated with initial thrombocytopenia and bilateral lower limb involvement. It is essential to detect a multifocal presence of NF in the extremities to justify an immediate fasciotomy and the radical removal of necrotizing tissue after prompt antibiotic therapy and sufficient resuscitation.


Adjuvant chemotherapy for early breast cancer has improved outcomes but causes toxicity. The UK TACT2 trial used a 2×2 factorial design to test two hypotheses: whether use of accelerated epirubicin would improve time to tumour recurrence (TTR); and whether use of oral capecitabine instead of cyclophosphamide would be non-inferior in terms of patients' outcomes and would improve toxicity, quality of life, or both.2 epirubicin either every 3 weeks (standard epirubicin) or every 2 weeks with 6 mg pegfilgrastim on day 2 of each cycle (accelerated epirubicin), followed by four 4-week cycles of either classic cyclophosphamide, methotrexate, and fluorouracil  or four 3-week cycles of 2500 mg/m2 capecitabine (1250 mg/m2 given twice daily on days 1–14 of each cycle). The randomisation schedule was computer generated in random permuted blocks, stratified by centre, number of nodes involved (none vs one to three vs four or more), age (≤50 years vs >50 years), and planned endocrine treatment (yes vs no). The primary endpoint was TTR, defined as time from randomisation to first invasive relapse or breast cancer death, with intention-to-treat analysis of standard versus accelerated epirubicin and per-protocol analysis of CMF versus capecitabine. This trial is registered with ISRCTN, number 68068041, and with ClinicalTrials.gov, number NCT00301925.In this multicentre, phase 3, randomised, controlled trial, we enrolled patients aged 18 years or older from 129 UK centres who had histologically confirmed node-positive or high-risk node-negative operable breast cancer, had undergone complete excision, and were due to receive adjuvant chemotherapy. Patients were randomly assigned to receive four cycles of 100 mg/mFrom Dec 16, 2005, to Dec 5, 2008, 4391 patients (4371 women and 20 men) were recruited. At a median follow-up of 85·6 months (IQR 80·6–95·9) no significant difference was seen in the proportions of patients free from TTR events between the accelerated and standard epirubicin groups . At 5 years, 85·9% (95% CI 84·3–87·3) of patients receiving standard epirubicin and 87·1% (85·6–88·4) of those receiving accelerated epirubicin were free from TTR events. 4358 patients were included in the per-protocol analysis, and no difference was seen in the proportions of patients free from TTR events between the CMF and capecitabine groups . Compared with baseline, significantly more patients taking CMF than those taking capecitabine had clinically relevant worsening of quality of life at end of treatment  and at 12 months  and had worse quality of life over time (p<0·0001). Detailed toxicity and quality-of-life data were collected from 2115 (48%) of treated patients. The most common grade 3 or higher adverse events in cycles 1–4 were neutropenia (175 [16%]) and fatigue (56 [5%]) of the 1070 patients treated with standard epirubicin, and fatigue (63 [6%]) and infection (34 [3%]) of the 1045 patients treated with accelerated epirubicin. In cycles 5–8, the most common grade 3 or higher adverse events were neutropenia (321 [31%]) and fatigue (109 [11%]) in the patients treated with CMF, and hand-foot syndrome (129 [12%]) and diarrhoea (67 [6%]) in the 1044 patients treated with capcitabine.We found no benefit from increasing the dose density of the anthracycline component of chemotherapy. However, capecitabine could be used in place of CMF without significant loss of efficacy and with improved quality of life.Cancer Research UK, Amgen, Pfizer, and Roche. Evidence before this studyAt the time this study was designed in 2004, a series of meta-analyses of individual patients' data had established that the use of adjuvant chemotherapy improved survival in those with early breast cancer. No optimum regimen had been established and, although the benefits of adding taxanes to the previously established standard anthracycline-based chemotherapy regimens had been shown, the absolute benefit for patients varied. Some evidence suggested that specific tumour types were not associated with much benefit. Findings from some studies indicated that shortening the interval between chemotherapy cycles by using growth factors to hasten the recovery of peripheral neutrophil concentrations improved efficacy. This approach was called accelerated chemotherapy, and was becoming the standard of care in parts of the world, but the designs of the trials on which use was based did not make it clear whether the benefits were due to the accelerated regimen alone. Perhaps the most important study that had been reported when we designed TACT2 was the US CALGB 9741 study, in which the schedule of the paclitaxel component (for which growth factor support is not needed) was also changed, but the relative contribution of that component was unclear. This is important because the use of growth factors not only adds to the cost of chemotherapy but also increases the risk of toxic effects. Toxicity of adjuvant chemotherapy was, and remains, an important issue for patients, and in particular for one of the standard UK regimens, epirubicin followed by cyclophosphamide, methotrexate, and fluorouracil (CMF), it was observed in an analysis of two trials that all treatment-related deaths occurred while patients were taking CMF. We designed TACT2 to investigate whether use of accelerated epirubicin chemotherapy would improve time to tumour recurrence and whether using oral capecitabine instead of CMF would be non-inferior for efficacy but superior for toxicity, quality of life, or both.Added value of this studyWe found no benefit from accelerating the anthracycline component of a standard UK chemotherapy regimen. Furthermore, detailed analysis of the toxicity and tolerability of accelerated chemotherapy showed that accelerated epirubicin was not associated with fewer hospital admissions than standard epirubicin, as had been hoped, nor with better quality of life from the patients' perspective. Use of capecitabine instead of CMF after epirubicin was not associated with inferior disease outcomes, and was, as hypothesised, associated with a different and generally better tolerated toxicity profile. Importantly, this difference was confirmed by better patient-reported quality of life scores for women during capecitabine treatment than during CMF treatment. A notable effect was that fewer women receiving capecitabine became permanently menopausal than those taking CMF.Implications of all the available evidenceSeveral studies have indicated benefits or otherwise with accelerated chemotherapy in early breast cancer, but the regimens and schedules assessed have differed. A meta-analysis will be important to determine circumstances in which clear benefits can be achieved. The large size of TACT2 means it will be an important contributor to such an analysis. Our observations on the lack of subjective benefit on quality of life with accelerated epirubicin will be important to form part of any discussion between patients and doctors about the possible benefits and risks of using an accelerated chemotherapy regimen. We found also that capecitabine can be used after epirubicin without loss of efficacy and with improved toxicity and quality of life outcomes compared with CMF. Furthermore, for premenopausal women concerned about retaining ovarian function, epirubicin followed by capecitabine seemed to reduce the risk of permanent chemotherapy-induced menopause.Current outcomes for patients with early breast cancer reflect advances in diagnosis and therapy, including the standardisation of adjuvant systemic therapy.Further improvements in chemotherapy efficacy were sought by shortening the interval between cycles from the standard 21 days, a concept that was termed accelerated chemotherapy. The CALGB 9741 trialWe designed the TACT2 trial to investigate two questions using standard epirubicin followed by CMF: whether efficacy could be improved without increasing toxicity when the pure anthracycline chemotherapy component was accelerated; and whether capecitabine instead of CMF would improve tolerability without loss of efficacy. We used a pragmatic 2×2 factorial study design, which allowed TACT2 to run throughout the National Institute for Health Research (NIHR)-funded National Cancer Research Network in England and affiliated research networks supported by the Departments of Health in other parts of the UK permitting recruitment of breast cancer patients from both teaching and district general hospitals across the UK.TACT2 is a multicentre, phase 3, randomised, controlled trial with a 2×2 factorial design testing two hypotheses: first that accelerated epirubicin regimen will be superior in terms of time to tumour recurrence; and, second, that substituting CMF with the oral prodrug capecitabine will not worsen patients' outcomes and will offer advantages in terms of toxicity, quality of life, or both . PatientThe study was approved by the Scotland Multi-Research Ethics Committee (MREC 04/MRE00/88) and local research and development offices. Patients provided written informed consent before enrolment. The Clinical Trials and Statistics Unit at The Institute of Cancer Research, London, UK (ICR-CTSU), had overall responsibility for trial coordination with three collaborating clinical trials units  that were responsible for randomisation and data management of patients within their geographical regions. Safety and efficacy data were reviewed regularly by an independent data monitoring committee. An independent trial steering committee provided trial oversight on behalf of the funders and sponsors. The trial management group was responsible for the day-to-day running of the trial. ICR-CTSU did all central statistical monitoring and the interim and final analyses.vs one to three vs four or more), age (≤50 years vs >50 years), and planned endocrine treatment (yes vs no). TACT2 was open label because the different treatment schedules made a double-blind design impractical.The randomisation schedule was generated by computer at ICR-CTSU in permuted blocks with sizes of eight and 12. Patients were assigned in a 1:1:1:1 ratio to receive standard epirubicin followed by CMF, accelerated epirubicin followed by CMF, standard epirubicin followed by capecitabine, or accelerated epirubicin followed by capecitabine. Randomisation was performed via a telephone call to one of the four clinical trials units. Patients were stratified by centre, number of nodes involved  or four 3-week cycles of 2500 mg/m2 capecitabine per day (1250 mg/m2 given twice daily on days 1–14 of each cycle).Patients assigned to the standard epirubicin group received four treatment cycles with 100 mg/m9 cells per L or more and platelet counts were 100×109 platelets per L or more. Supportive care was provided as per the local policy. The protocol stressed the need to maintain the interval between cycles, such that during standard epirubicin and CMF chemotherapy, any delay of longer than 7 days required a 20% dose reduction to minimise the risk of further dose delays  was done every 1 or 2 years for at least 10 years, in accordance with local practice. Patients in selected centres participated in a quality-of-life and toxicity substudy, for which data were obtained via questionnaires completed by patients and by collection of detailed information by clinicians. Due to logistical issues, collection of quality-of-life data was temporarily suspended part way through the trial and, therefore, lower numbers of patients are available for this analysis than that for acute toxicity. We used the European Organisation for Research and Treatment of Cancer (EORTC) QLQ-C30-BR23,The primary endpoint was time to tumour recurrence (TTR), defined as the time from randomisation to first invasive relapse or breast cancer death. Patients who remained free from TTR events, including those who died from other causes in the absence of breast cancer relapse, were censored at their date of last follow-up or death. Deaths occurring after distant recurrence were classified as breast cancer deaths, irrespective of stated cause. Secondary endpoints were overall survival (time from randomisation to death from any cause), invasive-disease-free survival , time to distant tumour recurrence , and tolerability of the regimens (assessed by treatment adherence and frequency and nature of acute adverse events).We assumed the 5-year proportion of patients free from TTR events would be 80% after standard epirubicin followed by CMF. To test whether accelerated epirubicin was superior to standard epirubicin, we calculated that 3876 patients would be needed to detect a 4% absolute improvement from 80% to 84% (hazard ratio [HR] 0·78) with 5% two-sided significance and 90% power. To test the second hypothesis that capecitabine would be non-inferior to CMF, we calculated that 4400 patients would be needed to provide 80% probability that the lower 90% CI for the difference between the regimens would exclude 3% if the groups were truly equivalent. Owing to a lower than expected number of TTR events, the independent data monitoring committee revised the hazard ratio threshold as the trial evolved. Therefore, a target accrual of 4400 patients was chosen, giving approximately 92% power for the comparison of standard versus accelerated epirubicin .For survival-related endpoints, we plotted Kaplan-Meier curves and compared treatment groups with the log-rank test. HRs and 95% CIs were calculated with Cox proportional hazards regression models, with HRs less than 1·0 taken to favour accelerated epirubicin or capecitabine. Unless stated otherwise, analyses were unadjusted and stratified by the companion randomisation. Analyses adjusted for randomisation stratification factors are also presented; all centres that assigned fewer than 25 patients to treatment are grouped into one category. Superiority analyses for all efficacy endpoints were done by intention to treat. The non-inferiority analysis and additional sensitivity analyses of the primary endpoint were done per protocol . We did further analyses in a priori defined subgroups: companion randomisation regimen, oestrogen-receptor status, HER2 status, nodal status, age, tumour grade, tumour size, and vascular invasion. We also did exploratory subgroup analyses by menopausal status and molecular subtype .For the standard epirubicin versus accelerated epirubicin comparison, we calculated the actual fraction of the intended dose density for epirubicin, defined as the observed dose density divided by the protocol planned dose density for standard epirubicin, with the mean expected to be 1·5 times higher than that in patients who received standard epirubicin. For CMF and capecitabine, we calculated relative dose intensities (separately for each drug), defined as the observed dose intensity divided by protocol planned dose intensity. For both comparisons, for each chemotherapy cycle not received a relative dose intensity of zero was assumed.2 test for trend. The proportion of patients experiencing grade 3 or 4 adverse events in each treatment group was compared with Fisher's exact test. We took p values lower than 0·01 to be significant, which allowed some adjustment for multiple testing of safety endpoints.The acute safety analysis population included all patients in the quality-of-life and toxicity substudy who received at least one cycle of allocated chemotherapy. The analysis of late toxicities compared all signs and symptoms reported 12 months or later after randomisation. The worst grades of adverse events were compared between treatment groups using the χThe protocol specified two primary quality-of-life outcomes by which to compare CMF and capecitabine: overall quality of life, measured with the EORTC QLQ-C30 global health status quality-of-life scale (GHS/QOL), and HADS total score. Secondary prespecified measures of interest included EORTC QLQ-C30 subscales for physical function, role function, and fatigue; EORTC QLQ-C30-BR23 subscales for sexual function and systemic therapy side-effects; and the FSI, Wu Cancer Fatigue Scale, and TACT2-specific toxicity questions. Here we report only the findings from the primary quality-of-life assessment with EORTC QLQ-C30 GHS/QOL and the questions on TACT2-specific toxicity to supplement the adverse event data. The other findings will be reported separately. Cross-sectional analyses were done of differences in continuous EORTC QLQ-C30 GHS/QOL scores at the end of standard or accelerated epirubicin treatment, at the end of CMF or capecitabine treatment, and at 12 and 24 months after the end of the chemotherapy. For analyses of changes in EORTC QLQ-C30 GHS/QOL scores between baseline and these timepoints, subscales were taken to be continuous and were dichotomised by whether or not a patient's quality of life had worsened by ten or more points.ClinicalTrials.gov, number NCT00301925.Analyses presented here are based on a database frozen on Aug 25, 2015. All analyses were done with STATA version 13.0. This study is registered with the ISRCTN, number 68068041, and with The funders of the study had no role in study design, data collection, data analysis, data interpretation, or writing of the report. The corresponding author had full access to all data in the study and had final responsibility for the decision to submit for publication.Between Dec 16, 2005, to Dec 5, 2008, 4391 patients from 129 hospitals were enrolled, with 2221 patients allocated to receive standard epirubicin (1116 followed by CMF and 1105 followed by capecitabine) and 2170 to receive accelerated epirubicin  of 4391 patients received all eight cycles of allocated treatment, with proportions being similar in the standard and accelerated epirubicin groups . The meaMedian follow-up in patients was 85·6 months (IQR 80·6–95·9), with 3193 (85%) of 3748 known to be alive without withdrawing consent followed up within the previous 15-month period. Median follow-up was 85·8 months (IQR 80·7–96·1) in the standard epirubicin and CMF group, 85·3 months (80·2–95·7) in the standard epirubicin and capecitabine group, 85·8 months (81·5–95·9) in the accelerated epirubicin and CMF group, and 85·6 months (79·8–95·8) in the accelerated epirubicin and capecitabine group. TTR events were reported in 724 (17%) of 4391 patients in the intention-to-treat population and in 716 (16%) of 4358 in the per-protocol population . There wThe proportion of patients free from TTR events at 3 years was 90·8% (95% CI 89·5–92·0) for the standard epirubicin group versus 91·1% (89·8–92·2) in the accelerated epirubicin group, and 91·0% (89·7–92·1) for the CMF group versus 91·2% (90·0–92·3) in the capecitabine group. The proportions of patients free from TTR events at 5 years were 85·9% (95% CI 84·3–87·3) for the standard epirubicin group versus 87·1% (85·6–88·4) for the accelerated epirubicin group, and 86·5% (85·0–87·9) for the CMF group versus 86·7% (85·2–88·1) for the capecitabine group. When the HR for TTR events was adjusted for factors known to affect prognosis  the value for accelerated epirubicin compared with standard epirubicin was 0·95 . We found no evidence of heterogeneity in treatment effect by subsequent treatment with CMF or capecitabine or clinical subgroups . After a601 (14%) patients died . Nine devs 556 [76%] of 728; p=0·0020) and with CMF than capecitabine . 18 months after randomisation, the proportions of patients with permanently discontinued periods did not differ between the epirubicin groups . Between the CMF and capecitabine groups, however, the proportions of patients with permanently discontinued periods at 18 months remained significantly different , as did those for patients receiving adjuvant ovarian suppression .Of the 1399 premenopausal women with data available on ovarian function, disruption or discontinuation of periods during chemotherapy was significantly higher with accelerated epirubicin than standard epirubicin  of whom received at least one cycle of allocated chemotherapy . The proAmong the toxicity and quality-of-life substudy patients, 2074 (98%) of 2121 patients received at least one cycle of allocated CMF or capecitabine chemotherapy . During vs 59·4, 57·8–61·2, respectively). These differences did not persist over time . Longitudinal analysis with generalised estimating equations models showed no differences in quality of life over time  than standard epirubicin. By contrast, patients receiving standard epirubicin reported more weight gain . These d p=0·96, .Figure 4vs 62·4, 60·6–64·3) and at 12 and 24 months ; analysis of change from baseline showed a similar pattern  and at 12 months . Longitudinal analysis with generalised estimating equations models confirmed that patients receiving CMF had a significantly worse quality of life over time .The proportions of patients with grade 3 or worse late adverse events 12 months or later after randomisation did not differ significantly between the standard and accelerated epirubicin groups, irrespective of whether or not events were prespecified . LikewisIn the TACT2 trial, despite achieving the intended 50% increase in epirubicin dose density, our findings did not support the hypothesis that this would lead to significant improvements in breast cancer outcomes. The two treatment groups were well balanced for standard clinicopathological factors likely to influence outcomes, and we found no evidence of heterogeneity of effect by breast cancer subtype or nodal status. By contrast, our results support the second hypothesis, that capecitabine can be safely substituted for CMF, when given after single-agent epirubicin, without loss of efficacy and with improvements in toxicity profile and overall quality of life. We found no evidence in any subgroup of significantly inferior efficacy. Patients randomly assigned to capecitabine had fewer adverse events in most categories, with more adverse events seen than with CMF in only three: diarrhoea, hand–foot syndrome, and neuropathy. For diarrhoea, which is a known side-effect of capecitabine, patients' self-reported severity did not differ significantly between the CMF and capecitabine treatment groups.Patients in all groups had 5-year overall survival of around 90% with no unexpected adverse events. Fatal adverse events were rare and occurred at similar frequencies in all groups, although numerically more deaths due to infection were seen among patients receiving CMF and more vascular deaths were seen among patients receiving capecitabine. These deaths serve as a reminder that adjuvant chemotherapy is toxic. Thus, although even with an improved toxicity profile, use of capecitabine did not prevent all treatment-related deaths.The results of our analysis of accelerated versus standard epirubicin might seem to be at odds with those from other studies. However, a meta-analysis of 3418 patients in four trials that included the CALGB 9741 study showed an overall significant benefit in terms of survival free from invasive disease for accelerated chemotherapy ,The TACT2 population differs from the populations in other trials in several ways. 54% of TACT2 patients had involved axillary nodes, whereas CALGB 9741In TACT2, patients with HER2-positive tumours had access to routine treatment with trastuzumab upon completion of their chemotherapy, which was given to 761 (92%) of 831 atients with known HER2-positive disease. Of the other studies, GIM2 was the only one to be done in the trastuzumab era, but only 130 (27%) of 480 patients with HER2-positive disease received this drug, which constituted 6% of the overall trial population (compared with 17% in our study), and in this small group no benefit was associated with accelerated chemotherapy.We had anticipated that epirubicin given every 2 weeks in our accelerated regimen would be associated with reduced risk of toxicity because of the use of primary prophylactic granulocyte-colony-stimulating factor. Apart from the expected significant reduction in neutropenia and febrile neutropenia, patients in the accelerated epirubicin group had more adverse events, particularly low-grade events, than those in the standard epirubicin group. The overall quality of life was worse during accelerated epirubicin treatment than during standard epirubicin treatment, although this difference did not persist after this treatment ended.2 per day. The study was stopped early due to inferiority of capecitabine when just over 600 patients had been enrolled, of whom less than half of the standard chemotherapy group had opted for CMF. The delivery of the chemotherapy seems to have been challenging in both groups. The overall poorer result for the capecitabine group was based on an early analysis (18 vs 24 distant recurrence events). An updated analysis suggested that the difference in efficacy between the two groups had reduced, and might only be significant in patients with hormone-receptor-negative tumours.Although other studies have tested the efficacy of additional capecitabine in early breast cancer .An important difference in the toxicity profiles of capecitabine and CMF was the recovery of menstrual function in women who were premenopausal at enrolment. Evidence suggests that recovery of function could have resulted in a slightly less active endocrine regimen,There is no one universal standard regimen for adjuvant chemotherapy in breast cancer. In the TACT2 study, we used a UK regimen of epirubicin followed by CMF that was standard care at the time. This regimen, along with fluorouracil, epirubicin, and cyclophosphamide chemotherapy, was compared in the TACT trial