Low‐density lipoprotein (LDL) with apolipoprotein C‐III (apoC‐III) is the lipoprotein species that most strongly predicts initial and recurring coronary heart disease (CHD) events in several cohorts. Thus, a large portion of the CHD risk conferred by LDL may be attributable to LDL that contains apoC‐III. Very‐low‐density lipoprotein (VLDL) and LDL with apoC‐III have varying amounts of apoE. We hypothesized that a high content of apoE lessens the adverse influence of apoC‐III on the risk of CHD because it promotes the clearance of VLDL and LDL from plasma.We studied 2 independent cohorts, the Nurses' Health Study, composed of women, and the Health Professionals Follow‐up Study, composed of men. These cohorts contributed to this study 322 women and 418 men initially free of CVD who developed a fatal or nonfatal myocardial infarction during 10 to 14 years of follow‐up and matched controls who remained free of CHD. The apoE content of LDL with apoC‐III was inversely associated with CHD after multivariable adjustment . The apoE content of VLDL with apoC‐III had a similar inverse association with CHD. The highest risks were associated with a high apoB concentration and a low apoE content of LDL with apoC‐III or of VLDL+LDL with apoC‐III. The observed associations were in both male and female cohorts and independent of traditional CHD risk factors and of C‐reactive protein.An increased apoE content in VLDL and LDL with apoC‐III was associated with a lower risk of CHD. Strategies to enrich VLDL and LDL in apoE are worth exploring for the prevention of CHD. In addition, apoE has diverse proposed antiatherogenic properties independent of its role on lipoprotein uptake.7Apolipoprotein E (apoE) is a small apolipoprotein synthesized mostly by the liver that serves as a ligand to the low‐density lipoprotein (LDL) receptor (LDLR) and the LDL‐receptor–related protein‐1 (LRP1) and plays an essential role in metabolism by promoting cellular uptake of lipoproteins.APOE gene have been extensively studied as predictors of cardiovascular events,10 very few studies have analyzed concentrations of the apoE protein as predictors of cardiovascular outcomes or how they are affected by concentrations of apolipoprotein C‐III (apoC‐III). One study in adults older than 85 years11 found a positive association between total plasma apoE concentrations and cardiovascular mortality, and another reported a generally increased risk of stroke with higher plasma apoE in the same cohort of older individuals.12 However, plasma total apoE is distributed among all lipoprotein classes, and a considerable amount of apoE is in HDL. The apoE content of HDL is associated with recurrent coronary heart disease (CHD) events.13 Thus, the influence of apoE on atherosclerosis and CHD may depend on the lipoprotein where it is located.Even though genetic variations at the 15 apoC‐III also specifically and directly induces proatherogenic changes in monocytes and endothelial cells.16 The plasma concentration of apoC‐III in VLDL and LDL is associated with CHD in retrospective studies18 and predicts initial and recurrent CHD in prospective studies.13 Among the concentrations of the apoB lipoproteins, the plasma concentration of LDL with apoC‐III predicts most strongly the incidence of recurrent cardiovascular events in type 2 diabetes19 and first coronary event in 2 US cohorts initially free of CHD.20 The relative risk of a recurrent event in the cohort with type 2 diabetes was 6.2 for the fifth versus first quintile of LDL with apoC‐III compared with 2.2 for the fifth versus first quintile of LDL without apoC‐III. In the 2 US cohorts of men and women, the relative risk of a first coronary event was 2.4 for LDL with apoC‐III compared with 1.2 for LDL without apoC‐III,20 and the test for interaction was significant demonstrating that the prediction of CHD risk by the 2 types of LDL differed significantly. Interestingly, about 30% of LDL that has apoC‐III also has apoE.4 It could be that the balance between the apoE and apoC‐III contents of an individual's LDL affects the physiology of LDL and, subsequently, the progression of atherosclerosis and the occurrence of a coronary event. On the other hand, since nearly all of the apoE in LDL is in LDL with apoC‐III4  may be associated with an attenuated CHD risk. We prospectively studied this relationship in 2 large US cohorts of women and men, the Nurses' Health Study (NHS) and the Health Professionals Follow‐up Study (HPFS), separately and combined.24The NHS and the HPFS are prospective cohort investigations respectively involving 121 700 female US registered nurses who were 30 to 55 years old at baseline in 1976 and 51 529 US male health professionals who were 40 to 75 years old at baseline in 1986. Information about health and disease is assessed biennially.25 we randomly selected controls in a 1:1 ratio who were matched for age (±1 year), smoking status , and date of blood sampling (±2 months) from the participants who were free of CVD at the time CHD was diagnosed in the case patients. Within the NHS cohort, an additional matching criterion was fasting status at the time of blood sampling.From 1989 through 1990, a blood sample was requested from all participants in the NHS, and 32 826 women provided one. Similarly, between 1993 and 1995, a blood sample was provided by 18 225 men in the HPFS. Participants who provided blood samples were similar to those who did not. In the NHS, among women without CVD or cancer before 1990, we identified 350 women who had a nonfatal myocardial infarction or fatal CHD between the date of blood drawing and June 2004. In the HPFS, we identified 425 men initially free of CVD who had a nonfatal myocardial infarction or fatal CHD between the date of blood draw and the return of the 2004 questionnaire. Using risk‐set sampling,Study physicians who were unaware of the participant's exposure status confirmed the diagnosis of myocardial infarction on the basis of the criteria of the World Health Organization. Deaths were identified from state vital records and the National Death Index or reported by the participant's next of kin or the postal system. Fatal CHD was confirmed by an examination of hospital or autopsy records, by the listing of CHD as the cause of death on the death certificate, if CHD was the underlying and most plausible cause, and if evidence of previous CHD was available.24Medical history, lifestyle, and demographic information was derived from the questionnaire administered in 1990 to women and 1994 to men, with missing information substituted from previous questionnaires. Physical activity was expressed in terms of metabolic equivalent (MET)‐hours. The questionnaires and the validity and reproducibility of measurements have been described previously.26 The unbound lipoproteins that did not contain apoC‐III were collected by gravity flow, and the bound lipoproteins that contained apoC‐III were eluted with 3 mol/L sodium thiocyanate. The efficiency of the apoC‐III immunoaffinity separation (percentage of ligand removed from plasma by the resin) was 99%. VLDL (density below 1.006 g/mL) and LDL (density between 1.006 and 1.063 g/mL) were isolated from plasma with and without apoC‐III by ultracentrifugation.27 We used the 1.006 g/mL lower cutoff for LDL to include IDL in our analysis. A small amount of large‐size lipoprotein (a) [Lp(a)] could have been included in this density range. We note here that apoB‐containing remnants of metabolism of triglyceride‐rich VLDL are contained throughout the density interval 1.006 to 1.063 as directly determined by tracer kinetic studies.4 ApoB, apoE, and apoC‐III were measured in the lipoprotein fractions by enzyme‐linked immunosorbent assay, and cholesterol and triglycerides were measured by enzymatic methods .Blood samples from women were collected in heparin‐treated tubes and samples from men in EDTA‐treated tubes. The tubes were placed on ice packs, shipped in Styrofoam containers by overnight courier, centrifuged, divided into aliquots, and stored in liquid‐nitrogen freezers (−130°C or colder). One vial containing 0.6 mL (NHS) or 0.5 mL (HPFS) of frozen plasma was shipped to the lipoprotein laboratory at the Harvard School of Public Health for analysis of lipoprotein types. Study samples were sent to the laboratory for analysis in randomly ordered batches, and the laboratory personnel were unaware of a sample's case–control status. The entire plasma sample was thawed, filtered, and incubated overnight with affinity‐purified anti–apoC‐III antibodies  bound to Sepharose 4B resin, as previously described and validated.4 we have found the concentration of this lipoprotein type (LDL with apoE and without apoC‐III) to be negligible or undetectable in most individuals.As mentioned in the introduction, we did not measure apoE in LDL without apoC‐III because in previous studiesThe study protocol was approved by the institutional review board of the Brigham and Women's Hospital and the Human Subjects Committee Review Board of the Harvard School of Public Health. After excluding participants with missing data for apoB in one or more of the LDL and VLDL fractions, the dataset consisted of 1476 participants . The cases were identified and the controls selected in 2‐year cycles. Two men and 2 women selected as controls in one cycle later developed CHD and were selected in a subsequent cycle, this time as cases. For this reason, the study sample contains 1476 and not 1480 individuals. For these 4 participants, we used the same baseline measurements in the pair where they were cases and in the pair where they were controls. Our main exposure was the content of apoE in LDL with apoC‐III, measured as the number of apoE molecules per LDL particle (apoE:apoB molar ratio).25 We analyzed our main exposure in 3 logistic models: model 1 conditioned on matching factors only; model 2 with additional adjustment for parental history of CHD before the age of 60 years, alcohol intake, and history of hypertension at baseline; and model 3 with adjustment for all the variables in model 2 plus body mass index and history of diabetes at baseline. In additional models, we also adjusted for the plasma LDL cholesterol concentration and by plasma concentrations of C‐reactive protein (CRP). Baseline was defined as the year in which blood was drawn. To test for linear trend, we used the median levels of apolipoprotein measurements in the control quintile categories as a continuous variable. We analyzed all quintiles for all variables, but for ease of reading in Table P value for trend across quintiles. All P values are 2‐tailed, and P values <0.05 were considered to indicate statistical significance. All analyses were performed with the use of SAS software, version 9.1 (SAS Institute).Apolipoprotein measurements were divided into quintiles, from the lowest to highest levels, on the basis of the sex‐specific distributions among the controls. We analyzed the association between apolipoprotein levels and the risk of CHD using conditional logistic regression. With risk‐set sampling, the odds ratio derived from the logistic regression directly estimates the hazard ratio and, thus, the relative risk.The average content of apoE (as reflected by the apoE:apoB molar ratio) in LDL with apoC‐III was significantly lower in cases than in matched controls of both sexes . Meanwhi20 In the present study, the primary result is that a higher apoE content per each LDL with apoC‐III (apoE content per particle) predicted a markedly lower risk of CHD , which continued to be significant after multivariable adjustment  that persisted after additional multivariable adjustment in models 2 and 3 , and apoE in VLDL+LDL with apoC‐III continued to show a protective association after adjustment for major cardiovascular risk factors, body mass index, and personal history of diabetes   lipoproteins simultaneously, we analyzed the relative risks of CHD by quintiles of apoE content in VLDL+LDL. A higher content of apoE in VLDL+LDL with apoC‐III was associated with a markedly lower risk of CHD  .20 we explored whether the association between the concentration of this type of lipoproteins (expressed as the apoB concentration in these fractions) and CHD would be modulated by their content of apoE. The highest risk was associated with a high concentration of VLDL+LDL apoC‐III and a low content of apoE in this lipoprotein type or with a high concentration of LDL apoC‐III and a low content of apoE , suggesting that a high content of apoE has the potential to attenuate risk conferred by VLDL and LDL with apoC‐III or LDL with apoC‐III, even when their plasma concentration is high.Given that plasma concentrations of both VLDL and LDL with apoC‐III have been found to predict cardiovascular events, of apoE . A highe of apoE , with no7 we performed multivariable analyses that included baseline plasma CRP levels. In these models, the apoE content of LDL with apoC‐III  and the apoE content of VLDL with apoC‐III , were still inversely associated with CHD  and between apoE content of VLDL that has apoC‐III and CHD . The same pattern was observed in multivariable models adjusted for plasma HDL cholesterol or plasma triglycerides. The associations for both apoE content of LDL with apoC‐III and apoE content in VLDL with apoC‐III were only slightly attenuated. Given that apoE has been proposed to have anti‐inflammatory properties,with CHD .Finally, to explore the impact of LDL apoE content in a scenario of constant LDL concentration, we ran a logistic model that included concentrations of apoB, apoC‐III, and apoE in LDL with apoC‐III. In this model, the apoE content of LDL was still negatively associated with CHD risk .The results from this prospective study strongly suggest that the presence of apoE is associated with a lower atherogenicity of LDL that contains apoC‐III and that the abundance of apoE relative to the abundance of LDL with apoC‐III is a protective factor against CHD. The apoE content of VLDL also exhibited a negative association with CHD. The protective effect of apoE in LDL appeared to be independent of plasma LDL cholesterol levels and to persist even when apoC‐III levels in LDL are high.7 the influence of apoE in lipoproteins on hard cardiovascular end points is very scantly documented. Our results also emphasize the increasingly recognized importance of the composition and physicochemical properties of lipoproteins as more refined and often more relevant variables in the exploration of pathophysiological mechanisms than the total concentrations of plasma lipids. Even though only 1.5% to 16% of LDL contain apoC‐III,3 the idea that apoE can effectively protect against the risk provided by these particles is very appealing if one considers that LDL with apoC‐III are very strongly associated with CHD19 and that in fact much of the CHD risk ordinarily attributed to total LDL may be due to this subpopulation that contains apoC‐III.20Even though this finding makes sense given the biological antagonism between the 2 apolipoproteins and the well‐documented antiatherogenic properties of apoE,11 or the risk of stroke.12 From our results, it is apparent that the distribution of total plasma apoE across the different lipoprotein fractions can greatly affect its association with CVD. In this respect, an observational analysis of patients from the Cholesterol and Recurrent Events (CARE) trial found a positive association between apoE in HDL and the risk of coronary events.13 This might explain the positive association between plasma apoE and CVD in some studies, given that about 40% to 50% of apoE is found on HDL.5 Nevertheless, our results suggest that the relatively minor fraction of plasma apoE that is found in LDL may have a remarkable impact on the risk of CHD. One study in 2 European countries found higher plasma apoE concentrations in VLDL+LDL of myocardial infarction survivors relative to controls who did not survive a coronary event.28 In our study, when we exclude the variation in apoB levels by normalizing apoE to the apoB content per particle, apoE was clearly protective in both VLDL and LDL. Also, adjustment for CRP did not diminish the observed effect of apoE, suggesting that the anti‐inflammatory properties of apoE in LDL do not have a major repercussion on its apparent protective ability against CHD.Prior studies in older adults have found a positive association between total plasma apoE levels and CVD mortality29 Although genetic polymorphisms only partially explain variation in circulating apoE concentrations,30 future studies in which the ε2/ε3/ε4 polymorphism is available will help refine our findings. In any event, the evidence we are presenting of an overall protective role for apoE in VLDL and LDL with apoC‐III is a valuable start point for more detailed study.Finally, a limitation of our study is that we did not evaluate the influence of the apoE ε2/ε3/ε4 polymorphism on the assessed risks, and apoE isoforms have structural differences that may modulate their function in LDL.In summary, apoE in LDL with apoC‐III may mitigate its atherogenicity and association with CHD. This finding should motivate further research on mechanisms to enrich LDL in apoE as a potential intervention for the prevention of CHD.


Environ Health Perspect 122:100–106 (2014)], there was an error in Table 1. The number of women in exposure quartile 4 who had missing data for maternal smoking was given as zero instead of 3. The corrected table appears below and has also been corrected online.In the article “Exposure to Brominated Trihalomethanes in Water During Pregnancy and Micronuclei Frequency in Maternal and Cord Blood Lymphocytes” by Stayner et al. [EHP regrets the error.


The sheer amount of information about potential adverse drug events published in medical case reports pose major challenges for drug safety experts to perform timely monitoring. Efficient strategies for identification and extraction of information about potential adverse drug events from free‐text resources are needed to support pharmacovigilance research and pharmaceutical decision making. Therefore, this work focusses on the adaptation of a machine learning‐based system for the identification and extraction of potential adverse drug event relations from MEDLINE case reports. It relies on a high quality corpus that was manually annotated using an ontology‐driven methodology. Qualitative evaluation of the system showed robust results. An experiment with large scale relation extraction from MEDLINE delivered under‐identified potential adverse drug events not reported in drug monographs. Overall, this approach provides a scalable auto‐assistance platform for drug safety professionals to automatically collect potential adverse drug events communicated as free‐text data. Adverse drug effects are a very serious issue that confronts patients, healthcare providers, regulatory authorities and drug manufacturers. While stringent measures for detecting risks associated with drug usage are clinical trials, the wide field usage might show additional risks non detectable in the clinical trials due to the limited number of patients involved. After the marketing approval, undesired effect of drugs are reported to the authorities using so called Spontaneous Adverse Event Reporting Systems, that are then timely analyzed to ensure safe use of drugs . A well True relations. This represents a sparsely annotated dataset. For training a supervised classifier, it was essential to generate False relations i.e. drugs and conditions that do not fall into adverse effect relations but that are still within the same sentence. For this purpose, ProMiner, a dictionary‐based named entity recognition system [False relations. Altogether, 5968 False relations were automatically generated. The corpus enriched with machine annotated drugs, conditions, and relations between them is referred as ADE‐EXT (indicating extended ADE corpus). Figure True and False relations between drug and conditions co‐occurring within a sentence.The data set used for training and validation of the relation extraction system is the ADE corpus . The ADEn system  was empln system  and MedDn system  dictionaTrue relations were not suitable for the NLP task. Examples include overlapping inter‐related entities such as acute lithium toxicity where lithium is related to acute toxicity. After removal of nested annotations, the ADE‐EXT corpus was decomposed into a training set (ADE‐EXT‐TRAIN) and a test set (ADE‐EXT‐TEST). Counts of entities and relations in subsets of ADE‐EXT corpora are shown in Table In the ADE‐EXT corpus, 120 manually annotated True or False were transformed into the SRE format before subjecting them to relation extraction. The SRE format is a unique way of representing data within the JSRE platform where tokens appearing in sentences are enriched with their parts‐of‐speech tags, lemmas, and flags indicating if a token is a part of named entity or not. Amongst different kernels available, the shallow linguistic kernel was thoroughly used since it has been widely applied and has shown success during similar relation extraction tasks [For the identification and extraction of drug‐condition entity pairs that constitute a potential adverse event relation, the Java Simple Relation Extraction (JSRE) system  was emplon tasks . The ADEThe Clinical E‐Science Framework (CLEF) initiative  investigTrue‐labelled relations since they represent potential adverse event relations between drugs and conditions that denote a focused relation class being studied.The performance of relation extraction was evaluated by 10‐fold cross‐validation of the training data. During cross‐validation of the training data and final evaluation over the test set, classification performances were assessed using the F‐score over Niacin maculopathy (PMID:3174043) infers maculopathy as a potential adverse event of niacin that lacks contextual description to support machine classification. Distantly co‐occurring inter‐related entities constituted couple of errors. For example, in the sentenceCASE SUMMARY: A 65‐year‐old patient chronically treated with the selective serotonin reuptake inhibitor (SSRI) citalopram developed confusion, agitation, tachycardia, tremors, myoclonic jerks and unsteady gait, consistent with serotonin syndrome, following initiation of fentanyl, and all symptoms and signs resolved following discontinuation of fentanyl(PMID:17381671); the relation between confusion and the last appearing drug name fentanyl was incorrectly classified. Case reports often contain frequencies at which potential adverse events were observed. For instance, The toxic effects of methotrexate included elevated liver transaminases (3/4), nausea (2/4), abdominal pain (2/4), bone pain (2/4), mild neutropenia (1/4), and mild pruritus (1/4)(PMID:433855); this sentence shows examples of relations where the system had difficulties in identification of correct relations. Potential adverse drug events are categorized according to their severity: serious suspected adverse drug reactions require immediate action by medical professionals. Manual investigation of the predicted results showed that the system was able to capture most of the serious potential adverse events. These findings demonstrate the potential of this approach to facilitate the identification of potential signals from case reports, of great interest for drug safety experts.Baseline experiments began with training and cross‐validation of JSRE over the ADE‐EXT‐TRAIN corpus. Results of system’s performances are shown in Table In order to study the impact of size of the training data on performance of classification, the ADE‐EXT‐TRAIN was decomposed into random subsets containing 10, 20, 50, 100, 200, 500, 1000, and 2000 documents. The JSRE was trained over these subsets independently in different rounds and evaluated by 10‐fold cross‐validation. Table Condition in the ADE annotation ontology coincide with a drug adverse event in OAE; a Drug in the ADE annotation ontology coincide with a drug‐administration in OAE. The ADE ontology additionally introduce the entity dosage, not specified in OAE at the time of its development since OAE originally focused on vaccines for which dosing is not an essential medical concept. Both ADE and OAE model a causal relationship between Condition or Adverse event and Drug or Medical intervention, with the latter being the causal source. The only entity shared by the CLEF annotation ontology with OAE and ADE is the Drug‐or‐device, that coincide with a Drug or Medical intervention.As clearly shown in Figure An experiment was conducted in order to understand the real‐world use case scenarios for the extraction of potential adverse drug events from text. This was performed by applying the trained extraction tool to the whole MEDLINE and thereafter comparing them to the information present in drug leaflets present in the SIDER  databaseTrue or False where a True relation indicates potential drug‐related adverse event. As a result of relation extraction, 165680 relations were extracted between 1611 drugs and 5079 adverse effects where drugs and adverse effects were normalized to DrugBank and MedDRA respectively.MEDLINE articles published before 2009 were gathered to form a Medline‐2009 corpus. ProMiner was equipped with DrugBank and MedDRA dictionaries for tagging drugs and conditions occurring in sentences of Medline‐2009. A JSRE model trained over the ADE‐TRAIN‐EXT corpus was applied for classification of relations between drugs and conditions as Side Effect Resource (SIDER) is a database of adverse drug effects that links 888 drugs to 1450 adverse effects. It has been constructed manually from the summary of product leaflets of each drug. Drugs and their adverse effects were extracted from SIDER version 1.01 that contains drug leaflets published before 2009.In 2009, the MHRA proposed safety label updates for 26 drugs. These were of course not all the safety label updates that the MHRA identified in 2009, but those that MHRA decided to give particular visibility through their web site. These new adverse drug effects were manually extracted and they serve as a standard reference for validation of potential adverse drug events automatically extracted from Medline‐2009 using the JSRE trained method.From the MHRA label change dataset, three drugs were arbitrarily chosen for deeper investigation. They are Rituximab, Efalizumab, and Natalizumab: three anti‐neoplastic and immunomodulatory monoclonal antibodies. For the three drugs of interest, potential adverse drug events were selected from the Medline‐2009 predictions and SIDER. Potential adverse drug events extracted from Medline‐2009 that are not reported in SIDER were manually checked against the label changes of MHRA.Manual investigation of machine predicted potential adverse events showed that the system was able to capture valid potential adverse events from free‐text that were not yet reported in product leaflets Table . These aThis work reports on the adaptation of a machine learning‐based JSRE system for the identification and extraction of potential adverse events of drugs in scientific case reports. A methodology has been discussed to enrich a sparsely annotated corpus and its subsequent use to build classification models. Evaluation of the system’s performance showed promising results. A use‐case study performed on relation extraction from large scale literature showed the system’s ability to capture valid, under‐reported, and novel potential adverse events not yet present in product leaflets.The performance of the system can be improved in several ways. In the current experiments, only the default features acceptable by JSRE were used. Optimization of feature representation to include additional features for instance from syntactic sentence parse trees may further improve the results. Development of additional strategies like post‐processing to classify relations with missing contextual descriptions can help to recover more relations. Furthermore, extension of handling inter‐sentence relations needs to be considered in order to further increase coverage.The reported experimental results denote the research status on identification from text of potential adverse drug events. There are several strategies that are being followed. The authors plan to benchmark the performances of several named entity taggers against the ADE corpus for the identification of drugs and conditions mentions in text. The current experiments have been performed on the ADE corpus, since that was the only one available when this work was done, however while writing this report a new corpus has been published, namely the EU‐ADR corpus . It willSimilarly, benchmarking results of public and commercial relation extraction systems will be performed  and the The use of ontologies for driving information extraction has been reported ,25. We pThe current work has demonstrated promising results, it has the potential to reduce the manual reading time, improve the quality of the signal detection process, and therefore positively contribute to safer use of drugs to the benefit of patients and society. We speculate that this work could also pave the road to pharmacovigilance applications on social media and multimedia sources too.LT is employee of Merck KGaA. AM‐R was founded by Merck KGaA. HG has no conflicts of interests to declare.


How can we address the complexity and cost of applying science to societal challenges?Open science has been described as “a research accelerator” Open science and collaborative R&D may help open source, by analogy with open-source software such as the operating system Linux which powers Google and Amazon—collaboratively created software which is free to use and adapt, and popular for Internet infrastructure and scientific research Open science and collaborative approaches are often described as collaborative R&D, which can be defined as scalable collaboration  across organizational boundaries to solve R&D challenges It is clearer to classify open source and open science within a broader class of Many approaches to open science and collaborative R&D have been tried controlled collaboration, there are strong controls on who contributes and benefits—for example, computational platforms like Collaborative Drug Discovery or InnoCentive that support both commercial and nonprofit research Collaborative R&D approaches vary in openness Collaborative approaches can unleash innovation from unforeseen sources, as with crowdsourcing health technologies If you want to apply open science and collaborative R&D, what principles are useful? We suggest Ten Simple Rules for Cultivating Open Science and Collaborative R&D. We also offer eight conversational interviews exploring life experiences that led to these rules .Many commentators have considered challenges in translating open science and collaborative methods to biomedical research To explore such challenges and convey life experiences in biomedical open science and collaborative R&D, we offer eight conversational interviews by the first author of this article as supplementary material. The conversations were done on behalf of the Results for Development Institute and are with:Alph Bingham, cofounder of InnoCentive  project .For projects hoping to harness the power of mass collaboration, a major challenge can be attracting a large community of contributors. Many of the best mass collaborations orient around seemingly audacious goals like: “build a free encyclopedia of all the world's knowledge” (Wikipedia), “develop a review article for every human gene” (Gene Wiki), and “build a new operating system” (Linux). Establishing a driving, high-level purpose will help spread the idea of your project and motivate people to come have a look and see what they can do. Be ready to scale with success.Can you cultivate open science and collaborative R&D by helping to make them part of “standard operating procedure”? For example, can you encourage institutional data sharing As intellectual property debates illustrate, there are legitimate differences of opinion on how best to motivate innovators' investments to generate new knowledge Text S1A conversation with Alph Bingham, cofounder of InnoCentive.(PDF)Click here for additional data file.Text S2A conversation with Barry Bunin, CEO of Collaborative Drug Discovery.(PDF)Click here for additional data file.Text S3A conversation with Leslie Chan, open access pioneer and director of Bioline International.(PDF)Click here for additional data file.Text S4A conversation with Aled Edwards, director of the Structural Genomics Consortium.(PDF)Click here for additional data file.Text S5A conversation with Benjamin Good, coleader of the Gene Wiki initiative.(PDF)Click here for additional data file.Text S6A conversation with Bernard Munos, pharmaceutical innovation thought leader.(PDF)Click here for additional data file.Text S7A conversation with Zakir Thomas, director of India's Open Source Drug Discovery (OSDD) project.(PDF)Click here for additional data file.Text S8A conversation with Matt Todd, open science and drug development pioneer.(PDF)Click here for additional data file.


This technique can be performed on a Bruker SolariX Fourier transform ion cyclotron resonance mass spectrometer by modifying the existing nanospray source. High-resolution paper spray spectra were obtained for both organic and biological samples to demonstrate the benefit of linking the technique with a high-resolution mass analyzer. Error values in the range 0.23 to 2.14 ppm were obtained for calf lung surfactant extract with broadband mass resolving power (m/Δm Since the first practical implementation of electrospray ionization (ESI) with mass spectrometry reported by Yamashita and Fenn in 1984, a number of different atmospheric pressure ionization (API) techniques have been developed . Many APThe use of a chromatographic medium such as paper allows for the analysis of complex mixtures since separations will occur as the analyte is being driven along the paper medium . SeparatOne limitation to PS, like many MS techniques that utilize incomplete chromatographic separations is the detector being utilized to perform the analysis. When dealing with complex samples or unknown samples, there is a need for high-quality data in order to determine what is being analyzed. Fourier transform ion cyclotron resonance (FT-ICR) mass spectrometers are powerful tools for analysis of complex mixtures due to their unsurpassed capability to obtain broadband high-resolution mass spectra with high mass accuracy. Utilizing PS with a Fourier transform ion cyclotron resonance (FT-ICR) mass spectrometer as a detector allows for rapid analysis of both unknowns and/or complex mixtures.In this present work, we show the suitability of a 12 Tesla FT-ICR MS to obtain high-resolution broadband mass spectra utilizing a coffee filter paper spray medium. High-resolution mass spectra were first obtained for polypropylene glycol (PPG) and polyethylene glycol (PEG) standards to test the source. Second, urine and calf lung surfactant extract (CLSE) were analyzed to test the PS source for analysis of complex mixtures not suitable for direct infusion.All solvents used were HPLC grade obtained from Sigma Aldrich . PPG was obtained in the form of a tuning standard from Applied Biosystems . PEG standard was made by dissolving 1 mg of PEG 2000 obtained from Sigma Aldrich  in 1 mL of HPLC grade water. Coffee filter, Wegmans brand , was cut by hand into an isosceles triangle with dimensions of approximately 5 mm (base) by 10 mm (height).μL of the standard solutions. The wet filter paper samples were allowed to dry under ambient conditions before PS analysis was performed. Mass spectra were then obtained by wetting the dried paper triangle with 10 μL of 50 : 50 methanol : water and using the method described in Samples for PPG and PEG PS analysis were prepared by wetting the coffee filter triangle with 10 μL of CLSE and allowing the sample to dry under ambient conditions before PS analysis was performed. Mass spectra were then obtained by wetting the paper with 10 μL of 50 : 50 methanol : water using the instrument method described in CLSE was obtained from ONY Inc. . Prior to analysis, the sample was stored in chloroform in the refrigerator. Samples for CLSE analysis were produced by wetting a coffee paper triangle with 2 μL was injected directly onto a triangular coffee filter and allowed to dry under ambient conditions. Once dry, the filter paper was attached to the mass spectrometer via a copper clip and rewetted using 50 : 50 methanol : water for PS analysis using the instrument method described in Urine samples were collected from two healthy adult males into sterile polypropylene centrifuge tubes (VWR Scientific) and immediately placed in the freezer. The samples were collected in accordance with the Health Sciences Institutional Review Board at the University at Buffalo (HSIRB no. CHE0050411E). Prior to analysis, the samples were thawed to room temperature and 1 mL was pipetted into 2 mL sample vials  for use. Ten 50%) was defined in accordance with the literature [High-resolution spectra were obtained on a 12T Bruker SolariX FT-ICR MS  utilizing a modified Bruker nanoelectrospray source. The positive potential was obtained by grounding the paper triangle using a copper clip and applying a negative voltage at the inlet to the mass spectrometer  such as PEG 2000 and PPG 2000 provides a detection window several hundred m/z wide for broad mass accuracy calibrations for FT-ICR MS. Signal-to-noise obtained for PEG and PPG after tuning spectra was in excess of 100/1 with absolute intensities that varied shot-to-shot by less than 20%. This allowed ample time for adjustment of the filter paper towards the inlet of the mass spectrometer so as to optimize instrument setup and analysis. Utilizing polymers of known  Calf lung surfactant extract (CLSE), which is commercially available in drug form as Infasurf, is used to treat respiratory distress syndrome . CLSE isDue to the complex nature of urine, many small molecules and metabolites were detected at varying intensities using PS with FT-ICR. PS mass spectra, showing numerous lipids and other metabolites obtained from the analyzed urine specimens of two healthy adult male subjects, are shown in We developed a PS source for Bruker FT-ICR instrumentation that can be utilized for a broad range of chemical species. The PS source was tested on a range of samples and determined the source was suitable for both polymer and biological samples. The PS source provided an API medium for the analysis of complex mixtures while mitigating the possibility of cross contamination due to the disposable nature of coffee filter paper.


Ctenocephalides felis, are one of the most common ectoparasites infesting dogs and their environments. This study evaluated the efficacy of imidacloprid + pyriproxyfen (PPF) (Advantage® II for Dogs) and spinosad (Comfortis®) against established C. felis populations in dogs’ simulated home environments.Cat fleas, Thirty Beagle dogs were randomly assigned to three groups of 10 dogs each and treated twice (Study Days 0 and 28) with imidacloprid + PPF, spinosad tablets, or a negative control (untreated). Dogs were housed individually in controlled simulated home environments capable of supporting the flea life cycle. Flea infestations were established in these environments by infesting each dog with 100 adult cat fleas on Study Days −21, -16 and 1. The impact of the treatments on fleas in the dogs’ environments were assessed by collecting floor mat samples from each simulated home environment, incubating them for 32 days, and counting the number of emerging adult fleas. On Study Days 7, 14, 21, 28, 35, 42, 49 and 56, after collection of the cocoa matting samples, each dog was infested with an additional 5 ± 1 fleas to maintain the environmental infestations. Flea comb counts on dogs were conducted on Study Days 0 (pretreatment) and 63.From Study Days 7–28, flea infestations in the imidacloprid + PPF environments were significantly lower (p < 0.03) than those in the spinosad environments. Following the second treatment, flea infestations in all the imidacloprid + PPF environments fell to zero for the remainder of the study. In contrast, flea infestations persisted in some of the spinosad environments through the study’s end.On Study Day 63 all 10 dogs treated with imidacloprid + PPF were flea free, while only one of the 10 spinosad treated dogs was flea free. Flea counts on the other 9 spinosad treated dogs ranged from 3 to 46 fleas/dog (geometric mean = 8.6). A mean of 405 adult fleas/animal were recovered from the control dogs on Study Day 63.Flea infestations in environments of dogs treated with imidacloprid + PPF declined more rapidly than in those containing dogs treated with spinosad. Flea infestations were completely eliminated by Study Day 56 in environments of dogs treated with imidacloprid + PPF, but persisted through the study’s end in some of environments of dogs treated with spinosad. Ctenocephalides felis, are one of the most common ectoparasites infesting dogs and their environments. Flea infestation is the most frequently diagnosed cause of dermatological conditions in dogs, including flea allergy dermatitis (FAD)  of emerging adult fleas were analyzed with a repeated measures analysis of covariance including terms for treatment, individual dog pen, study day, and the interaction of treatment and study day. Transformed counts of adult flea emerging from the Study Day 0 (pretreatment) cocoa mat samples were used as the covariate.SAS PROC MIXED  was used for analysis with the covariance structures ‘AR(1)’ and ‘ARH(1)’ for data collected on equal intervals, or ‘CS’ and ‘CSH’ for data collected on unequal intervals. Results from the model with the smallest Akaike’s Information Criterion were used.Because the interaction of treatment and study day was significant at the 0.05 level, the treatment groups were compared through the simple effect of treatment for each time point. These simple effect pairwise comparisons were obtained from the treatment X day interaction.Study Day 63 adult flea comb counts (transformed as noted above) were analyzed using analysis of covariance, including a term for treatment. Transformed Study Day 0 adult comb counts were used as the covariate.This simulated home environment model was successful in establishing and maintaining high numbers of fleas throughout the study. Flea infestations (measured by adult flea emergence from cocoa mat samples) were similar for all groups on Study Day 0 Table . InfestaThere were no adverse clinical findings immediately (within 24 hours) following administrations of the two IVP’s. Incidences of flea allergy dermatitis (FAD) accounted for most of the abnormal clinical observations recorded during the study. These would be expected in animals that are housed for sustained periods in simulated home environments with active flea infestations. The remainder of the clinical observations could be classified as physical abnormalities that were present in the animals at the start of the study. No animals were removed from the study as a result of any adverse clinical findings.Seven dogs in the untreated control group were diagnosed with FAD. Three of these cases were first observed between Study Days −6 and −9, while the remaining four were initially diagnosed between Study Days 13 and 57. Four of these seven cases persisted through the end of the study. Three of these persistent cases required treatment with Synulox® Ready-To-Use Suspension (35 mg/mL clavulanic acid as potassium clavulanate and 140 mg/ml amoxicillin as amoxicillin trihydrate) and/or Dexadreson® Injectable solution [2 mg/mL of dexamethasone (as the sodium phosphate)], and one was combed free of fleas on Study Day 48. Three animals in the spinosad group showed signs of FAD. This condition was first observed in two of these animals prior to treatment (Study Days −1 and −3), and on Study Day 27 for the third dog. This latter animal was combed to reduce the number of fleas on Study Day 33. No FAD was observed in any animals in this group after Study Day 33.One dog in the group treated with imidacloprid + PPF was diagnosed with mild FAD on Study Day −6. This condition persisted throughout the study but required no treatment.Imidacloprid + PPF was efficacious (≥ 90% control) in the simulated home environment model from Study Day 7 through Study Day 63, while spinosad was efficacious (≥ 90% control) from Study Day 28 through Study Day 63 Table . DiffereAfter initial administration of the IVP’s (Study Day 0), flea infestations in the imidacloprid + PPF environments declined much more rapidly than those in the spinosad simulated home environments Figure . Flea inThe insect growth regulator (IGR) PPF probably contributed to this rapid decline. This IGR mimics the action of insect juvenile hormone, preventing both flea egg hatch and development of flea larvae to the adult stage. Flea eggs laid on imidacloprid + PPF treated dogs will not hatch, and the close proximity of the PPF-treated dogs to the cocoa mats may have disrupted development of most flea larvae already present in the mats, preventing their metamorphosis to and emergence as adults.Following the second IVP administrations on Study Day 28, flea infestations remained relatively low for both treated groups Figure . By StudOn Study Day 0 adult flea counts were very similar for all three treatment groups, with no statistically significant differences , and counts on the imidacloprid + PPF treated dogs were significantly lower (p < 0.0001) from counts on those treated with spinosad Table .All 10 dogs treated with imidacloprid + PPF were flea free on Study Day 63 Table . This IVWhile both imidacloprid + PPF and spinosad effectively reduced adult flea infestations in the simulated home environments, imidacloprid + PPF achieved this much more rapidly than spinosad. In addition, by Study Day 56, all simulated home environments of the imidacloprid + PPF treated dogs were completely flea free and remained so through the end of the study. In contrast, all the simulated home environments of the spinosad treated dogs were never completely flea free. A pet owner, when faced with an infested home, wants rapid and complete results in the shortest amount of time. This study indicated the use of topical imidacloprid + PPF could eliminate an infestation faster and more effectively than orally administered spinosad.Additionally, this study demonstrated the use of either imidacloprid + PPF or spinosad effectively reduced adult flea infestations on dogs compared to untreated control dogs at the end of the study. At Study Day 63, the imidacloprid + PPF treated dogs were flea free, while only one of the spinosad treated dogs was flea free. This is important because a pet owner, using a flea adulticide on their pet, expects 100% efficacy from the product and often has little tolerance for the presence of even a single flea on their pet after several treatments. In this study imidacloprid + PPF was 100% effective in eliminating adult fleas on treated dogs and in their environments.The IGR activity of PPF likely contributed to the rapid decline of the environmental infestations in the imidacloprid + PPF group after the initial treatment, compared to the spinosad group. While PPF is potently ovicidal , the marPrevious studies have demonstrated the use of currently licensed veterinary insecticides and insect growth regulators can be effective in reducing or eliminating flea infestations without the use of additional premise treatments -10; howeTopically administered imidacloprid + PPF effectively reduced adult flea infestations in simulated home environments from Study Day 7 to Study Day 63 inclusive. Orally administered spinosad effectively reduced adult flea emergence from simulated home environments from Study Day 28 to Study Day 63 inclusiveAfter the initial IVP administrations, flea infestations in the environments of imidacloprid + PPF treated dogs (Group A) declined more rapidly than those in the environments of the Group B dogs treated with spinosad. Following the second IVP administrations, flea infestations in imidacloprid + PPF treated dogs’ environments were eliminated by Study Day 56 and remained at zero through the end of the study. In contrast, flea infestations were never completely eliminated from all the environments of spinosad treated dogs.C. felis) on beagle dogs based on Study Day 63 comb counts. On this day, all 10 dogs treated with imidacloprid + PPF were completely flea free; however, only one of the 10 spinosad treated dogs was flea free. Flea counts on the other 9 spinosad treated dogs ranged from 3 to 46 with a mean of 8.6. The difference in flea counts between imidacloprid + PPF and spinosad treated was significant (p < 0.0001).Imidacloprid + PPF (100%) and spinosad (98%) IVP’s both effectively controlled adult fleas (The combination of a flea adulticide (imidacloprid) plus an IGR (pyriproxyfen) applied topically to dogs was more effective in reducing and eventually eliminating flea infestations in the dogs’ environments than an adulticide (spinosad) alone. By eliminating the environmental flea infestations, the adulticide + IGR treatment provided superior flea control on the dogs, compared to the flea adulticide treatment alone.Both imidacloprid + PPF and spinosad were well tolerated.DHR, RGA and CvS are employees of Bayer Animal Health, and this work was funded by Bayer Animal Health. VD is an employee of Charles River Laboratories Preclinical Services Ireland, Ltd., where this study was conducted. MWD has served as a consultant and has been sponsored to lecture by Bayer Animal Health and ELANCO Animal Health, manufacturers of Advantage II for Dogs and Comfortis, products that were evaluated in this study.DHR was involved in the conception, design and monitoring of the study, interpretation of the data and preparation of the manuscript. RGA and CvS contributed to the study design, interpretation of the data and revision of the manuscript. VD served as the clinical Investigator and participated in the preparation and revision of the manuscript. MWD consulted with the other authors providing expertise on flea efficacy studies, and participated in the preparation and review of the manuscript. All authors read and approved the final version of the manuscript.DHR is a Manager of Clinical Development Projects, RGA is a Senior Research Fellow in Parasitology, and CvS is the Director of Veterinary Technical Services at Bayer HealthCare LLC, Animal Health. VD is a Clinical Investigator/Study Director at Charles River Laboratories, Preclinical Services Ireland, Ltd., Glenamoy, County Mayo, Ireland. MWD is a Professor of Veterinary Parasitology in the College of Veterinary Medicine at Kansas State University.


Depression has been related to mortality in coronary heart disease (CHD) patients, but few studies have evaluated the role of anxiety or the role of the co‐occurrence of depression and anxiety. We examined whether anxiety is associated with increased risk of mortality after accounting for depression in individuals with established CHD.P<0.001). Elevated scores on the HADS depression subscale (HADS‐D≥8) were also associated with increased risk of mortality . When both psychosocial factors were included in the model, each maintained an association with mortality . Estimation of the HR for patients with both anxiety and depression versus those with neither revealed a larger HR than for patients with either factor alone .The cohort was composed of 934 men and women with confirmed CHD  who completed the Hospital Anxiety and Depression scale (HADS) during hospitalization for coronary angiography. Over the 3‐year follow‐up period, there were 133 deaths. Elevated scores on the HADS anxiety subscale (HADS‐A≥8) were associated with increased risk of mortality after accounting for established risk factors including age, congestive heart failure, left ventricular ejection fraction, 3‐vessel disease, and renal disease (hazard ratio [HR], 2.27; 95% CI, 1.55 to 3.33; Anxiety is associated with increased risk of mortality in CHD patients, particularly when comorbid with depression. Future studies should focus on the co‐occurrence of these psychosocial factors as markers of increased mortality risk. Anxiety and depression were assessed using the Hospital Anxiety and Depression scale (HADS), a scale developed specifically to discriminate anxiety from depression in medically ill hospitalized patients.VAGUS (Very Anxious Group Under Scrutiny) was a prospective study designed to evaluate the relationship of anxiety with risk of adverse clinical outcomes in CHD patients. All patients were enrolled at Duke University Medical Center over a 27‐month period during an inpatient or outpatient visit for diagnostic cardiac catheterization. To be eligible for the study, patients were required to have either cardiac catheterization–confirmed significant stenosis (≥75%) of >1 major coronary artery or a documented history of prior myocardial infarction (MI) or revascularization procedure. Of the 9162 patients undergoing left heart cardiac catheterization during the enrollment period, 8028 charts were available for screening, and approximately one‐third of these patients (n=2549) were excluded because of insignificant CAD. Because one aspect of the parent study focused on heart rate variability (HRV), approximately one‐third of the available patients (n=2894) were excluded because they were not in normal sinus rhythm or had a 30‐day history of myocardial infarction and/or revascularization. Eight percent (n=627) were not approached because of medical, physical, or psychiatric complications that could impact the patient's ability to communicate . Of the 955 patients enrolled in the VAGUS study, 21 patients were unable to complete the HADS, leaving a study sample of 934 see . Of thes33 was used to estimate physical activity and habitual sleep duration during the 7‐day period prior to hospitalization. Left ventricular ejection fraction (LVEF) and degree of coronary artery stenosis were obtained from the cardiac catheterization report. Education status and smoking status were obtained through patient interview.Medical history, current diagnoses, medications, blood pressure, and coronary disease treatment plan  were extracted from patient hospital charts. A modified version of the Stanford 7‐day physical activity recall interview32 The HADS was specifically designed to avoid false‐positives when administered in hospital settings and therefore focuses on psychological and cognitive symptoms, rather than somatic symptoms or sleep and appetite disturbance. The majority of the symptoms included in the HADS‐A are indices of generalized anxiety, with only 1 item related to panic. The depression scale primarily comprises symptoms of anhedonia. Internal consistency  for the HADS‐A and HADS‐D ranged from 0.67 to 0.93 in previous studies34 and was 0.78 for each subscale in the current sample. A 2‐factor structure of the HADS has been confirmed in a number of studies,37 and a cutoff score of 8 on the HADS‐A subscale  and 8 on the HADS‐D subscale  has been found to provide the optimal balance between sensitivity and specificity for identifying cases,34 as originally recommended by Zigmond and Snaith.32 Results from 1 recent study indicated that approximately 21% of community‐dwelling individuals score ≥8 on the HADS‐A subscale and 23% score ≥8 on the HADS‐D scale.38 The HADS has moderate test‐retest reliability (r>0.8), and average sensitivities and specificities of ≥0.8.41 Among the 934 patients included, 928 had no missing items, and 6 had only 1 missing item, which was replaced using the mean score of the other items on the subscale in question.The Hospital Anxiety and Depression Scale (HADS) is a 14‐item self‐report questionnaire comprising 4‐point Likert‐scaled items covering the occurrence of symptoms of anxiety (HADS‐A) and depression (HADS‐D) over the past 2 weeks.All patients were contacted by mail at 6 months and annually thereafter up to 4 years after the initial assessment to document hospitalizations and vital status. For patients who were identified as deceased, discharge summaries, clinic notes, and supporting documentation (EKG and laboratory results) were obtained for each cardiac‐related rehospitalization during the follow‐up period. If medical records were inconclusive or not available, a telephone interview with the next of kin was used to ascertain or confirm the circumstances leading to death. An end‐point committee consisting of 2 cardiologists (M.H.S. and C.O.) blinded to HADS anxiety and depression scores reviewed medical records and telephone interviews to determine cause of death. A consensus was reached for each case. All 934 patients were included in the mortality analyses, with 22 lost during the follow‐up period. Among these 22, 2 were lost within the first month, and the other 20 withdrew consent or were lost to follow‐up after a mean of 1.2±0.7 years from the time of their baseline assessment. The 22 patients with missing follow‐up data were comparable to the others in all other demographics and medical history variables, including scores on the HADS anxiety scale  and the HADS depression scale .32 In the originally planned model, age, congestive heart failure (CHF), presence of 3‐vessel coronary artery disease, LVEF, and renal disease were evaluated with anxiety and/or depression, both separately and together. None of the explanatory variables in the planned model had any missing data. In addition to evaluating the association with all‐cause mortality, analyses were repeated to evaluate the association between anxiety and depression and cardiovascular mortality, the most common cause of death. These analyses included all observations and treated the noncardiovascular deaths as censored observations.Cox proportional hazards models were used to examine the association between baseline characteristics and mortality during a median follow‐up period of 3 years. The primary end point was time until death. Anxiety and depression were identified using the cutoff scores shown to have optimal sensitivity and specificity for detecting anxiety disorders and clinical depression .P≤0.10). The only role of these extended analyses was to examine whether other factors modified the interpretation of anxiety and depression as explanatory because the analysis was not intended to develop a predictive model for patient outcome. For this expanded model, none of the variables had any missing data except for education, which was only missing 4 observations, and these missing variables had no influence on the findings. We repeated the analyses evaluating HADS‐A and HADS‐D scores as continuous variables, with scores on the HADS‐A or HADS‐D scale divided by 5 in order to produce more meaningful units of description for hazard ratios. In addition, we evaluated risk across quartiles of HADS‐A and HADS‐D scores to examine whether each was related to mortality risk in a graded fashion. We also evaluated how anxiety and depression work together to predict mortality risk by fitting models that included their interaction. These models not only enabled evaluation of the interaction but also provided hazard ratios for anxiety only contrasted both with patients with neither anxiety nor depression and patients with depression only. Similarly, these models provided hazard ratios for depression only contrasted both with patients with neither anxiety nor depression and patients with anxiety only. These models also enabled the evaluation of the hazard ratio for comorbid anxiety and depression versus the absence of both.To determine the robustness of the planned model, analyses considered other potentially relevant factors , which were made available for possible entry into the model by stepwise selection , and 60% of the cases classified as depressed also met criteria for elevated anxiety, and 52% of the anxiety cohort met criteria for elevated depression. When evaluated in the full cohort, both HADS‐A and HADS‐D scores were associated with younger age  and higher rates of smoking . However, only the HADS anxiety scores were associated with reduced sleep duration , female sex , greater body mass index , and hypertension history . Similarly, only the HADS depression scores were associated with congestive heart failure  and lower LVEF . When groups with anxiety only and depression only were contrasted with patients without elevated symptoms of anxiety or depression . Although dichotomization at 8 has been found to have the highest sensitivity and specificity to identify anxiety disorders and depression in primary care patients and noncancer medical patients, a cutoff of 9 on the HADS‐A subscale has been found to be optimal to identify anxiety disorders in some patient populations such as cancer patients .34 When HADS‐A scores were dichotomized at 9, anxiety continued to be associated with mortality .Elevated anxiety or depression symptoms, defined using the predetermined cutoff points of 8, recommended by Zigmond and Snaith to identify clinical cases of anxiety and depression,P<0.001), and similar findings were observed with depression . These results support the robustness of the findings for anxiety and depression from the planned model.The opportunity provided by stepwise selection of all other baseline characteristics extended the planned model by also including ICD, antidepressant use, and insulin use. No other variables were selected for the model through stepwise selection. In this extended model, anxiety scores of ≥8 continued to be associated with a 2‐fold increased risk of mortality  or the association between depression and mortality , but the association of depression with mortality was attenuated .Including both depression and anxiety status in the planned model did not eliminate the association between anxiety and mortality . Nevertheless, inclusion of the interaction term for anxiety and depression is of interest for showing the similarity of the association between anxiety and mortality when contrasted with patients with neither anxiety nor depression  and when contrasted with patients with depression only  and when contrasted with patients with anxiety only . Moreover, this model showed a 3‐fold increased risk of mortality for patients with comorbid anxiety and depression versus those with neither , with this increased risk being comparable to that produced by the product of the separate hazard ratios for anxiety and depression in the planned model without the interaction term for anxiety and depression .For both the planned and the extended models, evaluation of an interaction term for anxiety and depression showed that it was not explanatory  or continuous scores on the HADS depression subscale . Including both anxiety and depression scores/5 in the same model resulted in some attenuation of the association between anxiety and mortality  but not between depression and mortality . Evaluation of an interaction term for anxiety and depression showed that it was not explanatory (P=0.97). As shown descriptively using survival curves, an association with all‐cause mortality was observed for quartiles of anxiety and depression in the setting of no adjustment for baseline characteristics  and when included in the same model together . There were no significant interactions between anxiety and depression in these models.The majority of deaths in the current cohort were attributed to cardiovascular causes (93 of the 133). Elevated anxiety and depression (HADS scores ≥8) showed similar associations with cardiovascular deaths as observed with all‐cause mortality when evaluated separately  assessed 2 months following hospital discharge for acute coronary syndrome showed a 2.3‐fold increased risk of adverse cardiac events, and Strik et al25 reported a 2.8‐fold increased risk of adverse events in acute post‐MI patients in whom anxiety was measured 1 month following hospital discharge. Similarly, a 2‐fold increased risk of adverse events was also found in cardiac patients with stable coronary disease undergoing rehabilitation20 and in patients with consistently elevated anxiety during annual clinic visits.26 However, anxiety has not been found to be related to mortality risk in cardiac patients evaluated during hospitalization for an acute myocardial infarction.31 In addition, in a sample of 4864 patients undergoing exercise stress testing, elevated anxiety was predictive of increased risk of mortality only in those patients with left ventricular dysfunction. In the remaining patients, anxiety assessed at the time of stress testing was found to be associated with improved survival.43 These findings suggest that anxiety may convey some protective effects, possibility through increased motivation to seek and comply with health‐promoting behavior, despite its association with overall health‐damaging consequences in patient populations.The current findings that elevated anxiety symptoms were associated with a 2‐fold increased risk of mortality in CHD patients are consistent with previous reports of an approximate 2‐fold increased risk of mortality associated with anxiety in hospitalized patients undergoing CABG45 Furthermore, anxiety is often measured using self‐report questionnaires that are not designed to be used in elderly hospitalized patients. In addition to failing to differentiate anxiety from symptoms related to physical disorders, such as dizziness, insomnia, and fatigue, some of the commonly used questionnaires may be inferior to other anxiety measures in terms of discriminant and factorial validity47 and may be especially problematic when used to differentiate elderly patients with diagnosed anxiety disorder from nonanxious patients.48Methodological differences in anxiety assessment may have contributed to the apparent discrepant findings between studies. For example, in hospitalized patients following a major event such as MI, estimation of steady‐state levels of anxiety was made difficult by the substantial fluctuation of anxiety during hospitalization following MI.50 For example, 58% of the respondents in the National Comorbidity Survey and 70% of respondents in the Midlife Development in the United States Survey with generalized anxiety disorder in the previous 12 months also met criteria for major depression. Similarly, approximately two‐thirds of patients with panic disorder or agoraphobia fulfilled criteria for lifetime major depression.51The present findings that more than half the patients with elevated HADS‐A scores consistent with clinically significant anxiety (HADS‐A≥8) also met criteria for clinical depression defined as HADS‐D score ≥8 are consistent with similar estimates of high comorbidity between GAD and unipolar depression.54 Findings from recent twin studies suggest that a genetic predisposition toward a negative appraisal of life events may be present in both anxiety and depression. The presence of this genetic predisposition may lead to amplification of the perceived stressfulness of major life events. The present findings of an additive association between anxiety and depression in relation to mortality risk are consistent with greater chronicity of anxiety and depression and suggest that future research should evaluate the efficacy of stress management or cognitive behavior therapy in this patient population.Patients with comorbid anxiety and depression have been reported to show a more chronic course of psychopathology, with significantly greater functional impairment and more resistance to psychiatric treatment than patients with either condition alone.55 Similar evidence for a combined action between anxiety and depression was reported in the Olmstead County study, in which the presence of anxiety and depression conferred greater risk of rehospitalization than either factor alone56and in the PROMOTION study, a randomized clinical trial designed to evaluate the efficacy of an education intervention in decreasing patient delay in seeking treatment for CHD symptoms. Patients enrolled in PROMOTION with depression or anxiety alone were not at greater risk of mortality; however, those with persistent comorbid symptoms had significantly higher mortality.57 In addition, 1 previous study evaluating the impact of anxiety and depression reported that combining the number of psychosocial risk factors  resulted in a cumulative relationship for a composite‐outcome end point defined by rehospitalization, MI, and cardiac mortality in 222 acute post‐MI patients.22 In contrast, a combined effect of anxiety and depression was not found in a study of 804 CHD patients, in which the association between generalized anxiety disorder (GAD) and clinical depression on a composite index of risk was evaluated.23 Although reduced power may explain the lack of a combined effect of anxiety and depression in this study, because only 11 patients were diagnosed with both GAD and depression in this study, there was also no apparent combined effect when anxiety and depressive symptoms were measured using the HADS anxiety scale to assess anxiety and the Beck Depression Inventory to measure depression.Despite the extensive comorbidity between anxiety and depression, few studies have accounted for the impact of the alternate psychosocial factor when evaluating the prognostic significance of anxiety or depression in CHD patients. The findings of an approximately 3‐fold increased risk of mortality in patients with comorbid anxiety and depression are consistent with previous findings of a combined action between anxiety and depression in the Vietnam Experience Study, in which veterans with comorbid major depressive disorder (MDD) and GAD were at substantially greater risk of mortality than the veterans who reported only MDD or GAD.58 Second, the circumstances associated with the hospitalization or catheterization procedure may have influenced the assessment of anxiety or depression in some individuals. In addition, although the HADS was developed specifically to classify cases of anxiety and depression in a medical setting, it may offer some disadvantages to the use of a diagnostic interview to define clinically significant anxiety and depression. Evaluation of the association between psychosocial factors and risk of mortality may also have been compromised in this sample by the higher number of deaths occurring as a direct consequence of a medical procedure. Exclusion of the procedural deaths, however, did not alter the strength of the association between elevated anxiety or elevated depression and mortality risk when these factors were evaluated separately. When evaluated together, the association between anxiety and mortality was maintained , but depression had an attenuated association with increased risk of mortality when the analysis was limited to nonprocedural deaths . The findings were also limited in that substance abuse was not considered a potential confounding variable. A number of studies have found high rates of substance use and abuse in clinically depressed patients and in some types of anxiety disorders such as posttraumatic stress disorder.61 However, we did examine smoking and alcohol use in the current cohort and observed an association between current smoking and depressive symptoms. In contrast, anxiety was unrelated to smoking and was related to significantly lower alcohol use. It therefore seems plausible that substance abuse would not explain the association between anxiety and mortality in the current cohort but could have contributed to the excess mortality observed in the patients with depression.Caution must be taken in generalizing the current findings to all CHD patients for a number of reasons. First, patients who undergo diagnostic tests such as cardiac catheterization to explain physical symptoms may be more likely to include individuals with elevated anxiety and depression.Anxiety and depression are common in CHD patients during hospitalization for coronary angiography, and each was independently associated with an approximate 2‐fold increased risk of all‐cause mortality. The association of these factors was additive, with a 3‐fold increased risk in anxious patients with comorbid depression. These findings suggest that clinicians assess patients for both anxiety and depression and continue to monitor these symptoms on a regular basis. Patients with elevated anxiety, particularly when found in the context of comorbid depression, may benefit from treatment of anxiety and from more intensive monitoring.


There are well established national and local policies championing the need to provide dignity in care for older people. We have evidence as to what older people and their relatives understand by the term ‘dignified care’ but less insight into the perspectives of staff regarding their understanding of this key policy objective.A survey of health and social care professionals across four NHS Trusts in England to investigate how dignified care for older people is understood and delivered. We received 192 questionnaires of the 650 distributed.Health and social care professionals described the meaning of dignified care in terms of their relationships with patients: ‘respect’ (47%), ‘being treated as an individual’ (40%), ‘being involved in decision making’ (26%) and ‘privacy’ (24%). ‘Being treated as an individual’ and ‘maintaining privacy’ were ranked as the most important components of dignified care. Physical caring tasks such as ‘helping with washing, dressing and feeding’ were rarely described as being part of dignified care and attributed much less importance than the relational components.Dignity in care is a concept with multiple meanings. Older people and their relatives focus upon the importance of providing physical care when describing what this means to them. Our participants focussed upon the relational aspects of care delivery rather than care itself. Proactive measures are therefore required to ensure that the physical aspects of care are met for all older people receiving care in NHS trusts.


As waiting lists for lung transplantation are ever increasing, the number of organ donors is not able to keep pace with it. Living donor lobar lung transplantation is a source of organs which could be lifesaving in end-stage lung disease patients who cannot wait for cadaveric organs due to deteriorating lung function and clinical condition. Two young women with end stage cystic fibrosis received lobes from their relatives and an altruistic friend. They are surviving for more than 12 and 14 years with good lung functions. Living donor lobar lung transplantation (LDLLT) is performed as a life-saving procedure for critically ill patients who are unlikely to survive the long wait for cadaveric lungs. It has been proved life saving for various lung diseases and appears to provide similar or better survival than cadaveric lung transplantation. We are reporting two LDLLT recipients surviving for more than a decade with good lung functions.1 25%) and she became bed ridden. As it became apparent that her clinical condition was falling so fast that she will not survive a waiting for suitable cadaveric donor lungs, her family was given a choice of live related lobar lung transplantation, for which it agreed. The donors were her biological father, aged 60 years  and real sister, aged 24 years . The recipient height and weight were 164 cm and 53 Kg. The recipient, the right lobar donor (father) and the left lobar donor (sister) were taken to the different theatres with gap of half to one hour each, in that order. The recipient had clamshell incision and both the lungs were dissected. She was put on cardiopulmonary bypass (CPB) and right pneumonectomy was performed. The right lower lobectomy was performed in father through right postero-lateral thoracotomy at the same time and the lobe was brought to recipient theatre. The bronchial anastomosis  was followed by pulmonary artery  and pulmonary venous  anastomoses. The left pneumonectomy was performed in the recipient and the left lower lobe was obtained from the sister and anastomosed in similar fashion. The ischemic time for right side was 2 hours while for left side it was 1 hour and 5 minutes. The recipient was weaned off CPB with modest inotropic support and nitric oxide and blood gases were suggestive of good gas exchange. Immunosuppression protocol in LDLLT was similar to cadaveric donor lung transplantation, consisting of tacrolimus, mycophenolate mofetil and prednisolone and was started in the patient on the day of transplantation. Recipient was weaned off ventilator in 48 hours, but had slow recovery and long intensive care unit stay due to infection with Pseudomonas, persistent pleural effusions, renal failure needing intermittent hemofiltration for a month and early rejection requiring re-intubation and methyl prednisolone pulse. She was discharged home 3 months after surgery and over another 6 moths her lung functions and exercise tolerance kept improving steadily. Over the last 12 years her respiratory function tests have fallen twice but bronchial biopsy never showed rejection. Her latest lung function showed predicted FVC of 65% and predicted FEV1 of 66%. Figure th day.A 25 years old university graduate student diagnosed of cystic fibrosis with pancreatic insufficiency in childhood was started deteriorating clinically due to uncontrolled infection in chest, not responding to multiple courses of various intravenous antibiotics over 6 months. Her main complaints were cough with copious green expectorations and shortness of breath with which she could barely manage her household work. After detailed clinical examination and investigations, she was accepted on the waiting list for lung transplantation. Following repeated respiratory infections, her lung function deteriorated rapidly  received a right lower lobe from a 24 years old altruistic friend  and a left lower lobe from her biological mother, aged 54 years  through a clamshell incision in a way mentioned in case 1. The ischemic time for right side was 2 and half hours while for left side it was 1 hour and 20 minutes. The patient was weaned off ventilator on third day; however her post-operative course was complicated by fungal endophthalmitis requiring right side evisceration. She was discharged after 2 months. At the end of one year, she developed collapse of the right lung due to stenosis of right bronchial anastomosis which required endobronchial stenting. Her latest lung function showed predicted FVC of 78.6% and predicted FEVLung transplantation is now established as a treatment option for end-stage pulmonary disease . The demThe ethical dilemma in LDLLT is whether family members should be risked in order to save a relative . Two lunIn case of lung transplantation, the breathing capacity and exercise tolerance increases initially after surgery, then plateau and after 5–7 years and then starts decreasing as transplanted lungs inevitably develop bronchiolitis obliterans. Interestingly, in both our LDLLT recipients lung function has improved over time and recipients feel that the breathing and exercise capacity has increased over the years and it was always better than before. These two cases do not represent our institute’s experience of LDLLT, but embodies good outcome and long term survival in patients undergoing LDLLT.LDLLT is a source of organs which could be life saving in end-stage lung disease patients who are likely to die on list waiting for cadaveric organs. As the procedure involves risk to healthy donors, proper assessment of family members as a donor, appropriate recipient-donor size matching and superlative timing of recipient-donor surgeries is a key to success. Although cadaveric donors remain the main source of organs, LDLLT should continue to be used under properly selected circumstances, to maintain the viability of this potentially life-saving procedure.Written informed consent was obtained from the patients for publication of this Case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.LDLLT: Living donor lobar lung transplantation; FVC: Forced vital capacity; FEV1: Forced expiratory volume in 1 second; CPB: Cardiopulmonary bypassThe authors declare that they have no competing interests.PNM drafted the manuscript, AFP analyzed and interpreted the patient data, YM performed the surgery and was a major contributor in writing the manuscript, ARS conceptualize the manuscript and was involved in the crucial revisions of manuscript. All authors read and approved the final manuscript.


NCD) in India is increasing. Diet and body composition ‘track’ from childhood into adult life and contribute to the development of risk factors for NCD. Little is known about the diet patterns of Indian children. We aimed to identify diet patterns and study associations with body composition and socio‐demographic factors in the Mysore Parthenon Study cohort. We collected anthropometric and demographic data from children aged 9.5 years (n = 538). We also administered a food frequency questionnaire and measured fasting blood concentrations of folate and vitamin B12. Using principal component analysis, we identified two diet patterns. The ‘snack and fruit’ pattern was characterised by frequent intakes of snacks, fruit, sweetened drinks, rice and meat dishes and leavened breads. The ‘lacto‐vegetarian’ pattern was characterised by frequent intakes of finger millet, vegetarian rice dishes, yoghurt, vegetable dishes and infrequent meat consumption. Adherence to the ‘snack and fruit’ pattern was associated with season, being Muslim and urban dwelling. Adherence to the lacto‐vegetarian pattern was associated with being Hindu, rural dwelling and a lower maternal body mass index. The ‘snack and fruit’ pattern was negatively associated with the child's adiposity. The lacto‐vegetarian pattern was positively associated with blood folate concentration and negatively with vitamin B12 concentration. This study provides new information on correlates of diet patterns in Indian children and how diet relates to nutritional status. Follow‐up of these children will be important to determine the role of these differences in diet in the development of risk factors for NCD including body composition.The burden of non‐communicable chronic disease ( The World Health Organisation (WHO) has estimated that 53% of all deaths in India in 2008 were attributable to non‐communicable conditions such as cardiovascular disease and type 2 diabetes  to describe diet patterns of children living in and around the city of Mysore, located in central South India, using a principal component analysis (PCA) of food frequency data; (2) to examine demographic variables as correlates of diet patterns; and (3) to examine diet patterns as correlates of body composition and micronutrient status (folate and vitamin B12).There are few data on the dietary patterns of Indian children. Given that diet in childhood may affect chronic disease risk, we investigated the diet patterns of 9.5 year old South Indian children.Two diet patterns were identified: ‘snack and fruit’ and ‘lacto‐vegetarian’. Both patterns were associated with markers of nutritional status.Knowledge of these patterns may be useful for designing targeted interventions to improve nutritional status and for developing food based dietary guidelines in this population.et al. Children were recruited from the Mysore Parthenon study, a birth cohort set up to investigate the long‐term cardiovascular risk outcomes associated with maternal gestational diabetes and body composition of the infant at birth. Details of the cohort have been published elsewhere ; 10 years education (secondary level); or more than 10 years education (above secondary level). Occupations were classified as follows: professional, e.g. university teacher, chemist, lawyer; skilled, e.g. goldsmith, carpenter, police constable; unskilled, e.g. labourer, vegetable seller. Socio‐economic status data were collected using the Standard of Living questionnaire from the Indian National Family Health Survey  et al. et al. et al. et al. et al. We chose to measure plasma folate and vitamin B12 concentrations in the children as there has recently been significant interest in the status of these nutrients and later risk of chronic disease (Yajnik http://onlinelibrary.wiley.com/doi/10.1111/mcn.12046/suppinfo) was developed based on responses to 24 h recalls administered to children in the cohort at 8 years. All food and drinks reported were listed and local nutritionists added any foods that had not been reported during the recalls but were thought to be consumed by the study population. In order to help respondents to conceptualise the child's diet .A trained nutritionist interviewed the child and a parent or guardian  in order to collect dietary data; both child and adult provided information. A 136‐item FFQ (see −2). Weight and BMI were compared with WHO international child growth standards . Weight was measured to the nearest 100 g using an electronic digital weighing scale . Body mass index (BMI) was calculated as weight divided by the square of height . Impedance (Ω) at 50 kHz and percentage body fat, based on the pre‐programmed Bodystat equation for children, were recorded. The CV for impedance measurements was <1%.z‐scores were then calculated with a mean (SD) of 0 (1). The number of diet patterns described in the results section was based on the identification of a break in the scree plot, the component eigenvalue being >2 and interpretability of the pattern for this population. Food groups with coefficients >|0.2| were considered to be discriminatory.The 136 foods on the FFQ were condensed to 52 food groups based on nutrient content and typical use, for example puffed rice and rice flakes were grouped as ‘processed rice foods’ and cabbage palya (cooked vegetable preparation served dry), green leafy vegetable palya and green leafy vegetable curry were grouped as ‘green leafy vegetable dishes’. PCA without rotation was used to identify the children's diet patterns. PCA is a statistical technique that has been widely used in diet patterns research Hu . It ident‐tests. Analyses of variance (ANOVAs) and correlation coefficients were used to assess univariate associations between predictor variables and pattern scores. Correlate variables were season of the year that the FFQ was administered, socio‐demographic characteristics and maternal BMI. All variables significantly associated with pattern score in the univariate analyses were entered into multivariate regression models to identify independent correlates of pattern scores. Based on the findings, post hoc two‐factor ANOVAs were used to test for interaction. The associations between pattern scores and nutritional status of the child including height, BMI, folate and vitamin B12 concentrations, and body composition were assessed using the Wilcoxon rank‐sum test for trend across all four quarters of pattern score.Variables that were not normally distributed were transformed by taking natural logarithms. Differences in mean pattern scores between boys and girls were examined using All data were analysed using Stata version 11 .−2. The proportion of families that were Muslim was considerably greater than the Indian national survey figure of 12.5%  and Macro Interntional Table We carried out separate PCA for girls and boys and found minimal differences in the patterns (data not shown) therefore, the data presented relate to the sexes combined. Based on the scree plot and eigenvalues, we examined the first three components to assess interpretability. The first component, which explained 9.1% of the variance, was named ‘snack and fruit’ and was characterised by high intakes of snacks, fresh fruit, sweetened drinks, rice and meat dishes (biryani), noodles and leavened breads. The second component explained 7.5% of the variance and was named the ‘lacto‐vegetarian’ diet as it was characterised by high intakes of finger millet (ragi), traditional rice dishes, yoghurt (curd), vegetable dishes, sugar added to foods and a low frequency of meat consumption. The third component explained less variance (4.1%). Its key characteristics were high intakes of malt‐based hot drinks and low intakes of tea and coffee but there was no clear pattern in the remaining food groups (data not shown). It was not considered to provide a meaningful or interpretable pattern of foods in the context of chronic disease risk and was not included in any further analyses. Table Univariate analyses showed that the snack and fruit pattern was predicted by season of interview with the pre‐monsoon and monsoon seasons being associated with higher scores Table . Muslim Season of FFQ administration was associated with the lacto‐vegetarian pattern, with those interviewed during the pre‐monsoon season having higher scores Table . MaternaP = 0.002) and no effect in the rural group . Results of a post hoc test for interaction showed that there was a significant interaction between standard of living and urban/rural dwelling (P = 0.033).There was an apparent paradox whereby the children with higher scores on the lacto‐vegetarian pattern were more likely to live in rural areas but the occupation of the head of the household was more likely to be professional. We therefore explored the associations between standard of living and pattern scores in the urban and rural children separately and found that there was a positive association between standard of living and pattern score within the urban group of children although the effect size was small  was associated with being better educated  indicated that the children were relatively inactive and there was little variability in activity between children (Kehoe The absence of an obviously ‘healthy’ or ‘prudent’ pattern in our analysis is of interest and is in contrast to many analyses conducted in the United States and Europe (Newby & Tucker In conclusion, we have shown that meaningful diet patterns can be identified in this population and these patterns are associated with demographic and body composition variables in Indian children. These findings may be helpful in developing food‐based dietary guidelines in this population and also in designing interventions aimed at prevention of overweight and other risk factors for chronic disease. As we follow this cohort, we will use these patterns to study associations between diet and risk factors for chronic disease in childhood and later life.This work was funded by the Parthenon Trust, Wellcome Trust and the Medical Research Council.The authors declare that they have no conflicts of interest.CHDF designed the study, SMR and BMM provided significant advice, GVK and SRV supervised the data collection, AMG conducted the statistical analysis, SHK wrote the manuscript. All authors contributed to the interpretation of the results and were involved in preparing the final manuscript.Appendix S1: Mysore Cohort Food Frequency Questionnaire.Click here for additional data file.