In recent decades, considerable progress in diagnosis and treatment of patients with intoxication-type inborn errors of metabolism (IT-IEM) such as urea cycle disorders (UCD), organic acidurias (OA), maple syrup urine disease (MSUD), or tyrosinemia type 1 (TYR 1) has resulted in a growing group of long-term survivors. However, IT-IEM still require intense patient and caregiver effort in terms of strict dietetic and pharmacological treatment, and the threat of metabolic crises is always present. Furthermore, crises can affect the central nervous system (CNS), leading to cognitive, behavioural and psychiatric sequelae. Consequently, the well-being of the patients warrants consideration from both a medical and a psychosocial viewpoint by assessing health-related quality of life (HrQoL), psychological adjustment, and adaptive functioning. To date, an overview of findings on these topics for IT-IEM is lacking. We therefore aimed to systematically review the research on HrQoL, psychological adjustment, and adaptive functioning in patients with IT-IEM.Relevant databases were searched with predefined keywords. Study selection was conducted in two steps based on predefined criteria. Two independent reviewers completed the selection and data extraction.Eleven articles met the inclusion criteria. Studies were of varying methodological quality and used different assessment measures. Findings on HrQoL were inconsistent, with some showing lower and others showing higher or equal HrQoL for IT-IEM patients compared to norms. Findings on psychological adjustment and adaptive functioning were more consistent, showing mostly either no difference or worse adjustment of IT-IEM patients compared to norms. Single medical risk factors for HrQoL, psychological adjustment, or adaptive functioning have been addressed, while psychosocial risk factors have not been addressed.Data on HrQoL, psychological adjustment, and adaptive functioning for IT-IEM are sparse. Studies are inconsistent in their methodological approaches, assessment instruments and norm populations. A disease-specific standard assessment procedure for HrQoL is not available. Psychosocial risk factors for HrQoL, psychological adjustment, or adaptive functioning have not been investigated. Considering psychosocial variables and their corresponding risk factors for IT-IEM would allow evaluation of outcomes and treatments as well as the planning of effective social and psychological interventions to enhance the patients’ HrQoL. Intoxication-type inborn errors of metabolism (IT-IEM) are a group of inborn errors of metabolism (IEM) which share distinct clinical features. The group encompasses urea cycle disorders (UCD), organic acidurias (OA), tyrosinemia type 1 (TYR 1), and maple syrup urine disease (MSUD). The estimated incidence is between 1:8,000 to 1:44,000 for UCD , about 1Patients with IT-IEM share two main clinical features: they have to follow a strict diet, and they live with the permanent risk of metabolic crises. These can be triggered by alterations in diet, common infections, or stress but may also occur without predictive circumstances. In cases of metabolic crises, patients immediately require intensified home care or hospitalisation. Despite such efforts, crises remain life-threatening and may cause organ and central nervous system (CNS) damage . To ensuIntense biomedical research in the field of IT-IEM has resulted in substantial advances in treatment and a growing group of surviving patients . These iWhat is the current state of knowledge about self- and proxy-reported HrQoL, psychological adjustment, and adaptive functioning in IT-IEM patients?What are the medical and psychosocial risk factors for HrQoL, psychological adjustment, and adaptive functioning in IT-IEM patients?Health-related quality of life (HrQoL), psychological adjustment, and adaptive functioning are well-established constructs to describe psychosocial consequences of chronic diseases. HrQoL has been defined as “a patient’s perception of the impact of disease and treatment on functioning in a variety of dimensions, including physical, psychological and social domains” , p.126. Pubmed, Embase, Cinahl, PsycINFO, Psyndex and the Cochrane Database of Clinical Trials and Systematic Reviews. NDLTD  and dissonline.de were searched to find eligible dissertations. We applied two groups of search terms. Firstly, we employed various disease names referring to IEM and IT-IEM. Secondly, we referred to HrQoL, psychological adjustment, and adaptive functioning by employing these terms: quality of life, life satisfaction, well being, well-being, wellbeing, adjustment, adaption, adaptation, adaptive, psycholog*, psychosocial, psychiatr*, social, emotional, mental health, mental disorder, mental disease, behavior*, behaviour*. To augment the specificity of the search, the IEM/IT-IEM group and the HrQoL/psychological adjustment/adaptive functioning group were connected to each other by the Boolean operator “AND”, whereas terms within the groups were connected by the Boolean operator “OR”. We also took advantage of other options to refine the search when the databases offered them; accordingly, search terms concerning IEM, HrQoL, psychological adjustment, and adaptive functioning were limited to titles and abstracts, and words with multiple possible endings or spellings were completed by wildcards. An additional search for studies was conducted in two ways. First, to minimise publication bias, experts in the field were contacted via e-mail and asked if they were aware of any relevant articles or unpublished data. In addition, the references of relevant articles were screened.To identify eligible studies for our review, we searched relevant databases with pre-defined search terms. The search was conducted using the following electronic bibliographic databases up to 30 April 2013: To find eligible studies, we rated all the articles and dissertations found in our systematic search according to pre-defined inclusion and exclusion criteria. Studies were included if the number of participants was N >1 and if the sample contained at least 50% IT-IEM patients or if the results of IT-IEM patients were reported separately. Outcomes had to include a self-, proxy-, or examiner’s report of patients’ HrQoL, patients’ psychological adjustment , or adaptive functioning. The assessment of these outcomes had to be completed in a standardised way and reported quantitatively. Reporting of methods and results had to be sufficient for replicability. Finally, reports were accepted if they were written in English, German, French, or Spanish. Articles not fulfilling these criteria were excluded. The selection process was conducted in two major steps. First, one reviewer (N.A.Z.) examined all titles and abstracts. Second, studies that could not be excluded in the first examination were rated in their full-text version by two reviewers (N.A.Z. and M.H.) independently. Inter-rater reliability was substantial , with CoTwo reviewers (N.A.Z. and M.A.L.) extracted the data of the articles independently. Inter-rater reliability was almost perfect , with CoThe initial search of databases revealed 1669 articles and dissertations. After the first selection, 20 articles remained. During the second selection process, we had to exclude another nine articles; three were single-case reports, one had the same sample as another article included, and seven articles lacked standardised assessments of the patients’ HrQoL, psychological adjustment, or adaptive functioning. One of these articles was a qualitative study . One addThe main characteristics and results of the articles included in our review are summarised in Table Many of the studies had methodological limitations. One main weakness is the lack of appropriate participant selection (i.e. use of convenience samples) in order to avoid selection or non-response bias –29. Two psychological and the friends domains, but higher scores for the school domain [physical domain for IT-IEM patients compared to population norms [environmental domain . The same study found HrQoL of IT-IEM patients to be similar to that of patients with phenylketonuria, who also have to follow a strict diet but who do not face the risk of sudden metabolic crises. Furthermore, IT-IEM patients had higher HrQoL in most domains compared to Morbus Fabry patients, who often have to deal with pain symptoms, and patients with metabolic diseases under pharmacological (as opposed to dietary) treatment [As shown in Table l domain . The reson norms , but lowreatment .Psychosocial and social domains were lower in IT-IEM patients than in the cancer population. In another article, the parent-rated HrQoL of IT-IEM patients was compared with the parent-rated HrQoL of patients with other metabolic diseases (aminoacid metabolic disorders and carbohydrate metabolic disorders) [school functioning, health perception (compared with both diseases) and physical functioning (only compared with aminoacid metabolic disorders).Proxy-ratings of HrQoL were all reported by parents. All results for IT-IEM patients were either not different from norms or unfavourable for IT-IEM patients Table . One stusorders) . IT-IEM physical, emotional and social HrQoL, but no difference for school functioning.One study  comparedNo risk factors regarding HrQoL were investigated in the studies.Results for self-reported psychological adjustment and adaptive functioning are shown in Tables All studies used parent proxy-reports and one additionally used teacher proxy-reports Tables  and 4. Pinternalising problems  than parents [According to one study, teachers reported more  parents .lifetime anxiety or lifetime depression disorders was higher in patients who were encephalopathic at diagnosis than patients who were non-symptomatic at diagnosis [For psychological adjustment and adaptive functioning parameters, several risk factors were investigated. The risk for iagnosis . Adaptiviagnosis . Finallyiagnosis .The first aim of our systematic review was to explore the current state of research on HrQoL, psychological adjustment, and adaptive functioning in patients with IT-IEM. We found 11 articles reporting HrQoL, psychological adjustment, or adaptive functioning for this group of patients. Results for HrQoL varied across studies from lower HrQoL to similar and better scores for IT-IEM patients compared to norms. Notably, proxy-ratings of patients’ HrQoL were consistently similar or lower than norms. Results for psychological adjustment and adaptive functioning varied less and were mostly comparable to norms or showed worse adjustment for IT-IEM patients. Fewer problems were only reported once  – howeveImpaired HrQoL, psychological adjustment, or adaptive functioning can have different causes. Firstly, this may be a result of the distress experienced in IT-IEM, such as fear of metabolic crises or social problems associated with the diet . SecondlInterestingly, HrQoL was more often reported to be impaired when rated by parents compared to self-ratings by patients. In line with this, a comparison of self- and proxy-ratings revealed better self-ratings in most domains . The facA major reason for the inconsistent findings may be attributed to methodological issues. Most of the HrQoL instruments were not specifically tailored to patients with IT-IEM. One study used an invalidated disease-specific instrument . In addiThe second aim of this review was to detect risk factors for HrQoL, psychological adjustment, and adaptive functioning for IT-IEM patients. Only a few risk factors for psychological adjustment and adaptive functioning have been investigated so far, and none have been examined for HrQoL. The risk factors examined were mainly medical ,24,27. WThis systematic review was conducted in accordance to the PRISMA guidelines  . In ordeBased on the findings of this review, several implications can be drawn. Firstly, HrQoL should be considered as an essential outcome parameter in future clinical trials. Up to now, treatment evaluations of patients with IT-IEM have predominantly focused on medical outcomes. However, because survival rates have increased considerably, improvement of HrQoL for patients with IT-IEM must be an additional major goal of new treatments.www.e-imd.com) can help to achieve this goal and to aggregate knowledge. This review has shown that a variety of assessment instruments is currently in use, thus complicating the pooling of results. Most of the studies used generic, non-disease-specific instruments. Only one of the reviewed studies used a disease-specific scale [Secondly, it is important to increase the methodological quality of psychosocial research among IT-IEM patients. Multicentre studies are necessary both to avoid convenience sampling with a high risk for biased data and to increase sample sizes. International patient registries (e.g. E-IMD, ic scale ; howeveric scale . Howeveric scale . They aric scale . To dateThirdly, knowledge of risk factors influencing HrQoL, psychological adjustment, and adaptive functioning is of great importance. Very few studies have addressed this topic at all, and where they did, research was restricted to medical or biochemical parameters or IQ. Medical parameters are weak predictors for HrQoL in most chronic diseases . In contThe small number of studies, partially inconsistent results, and the few risk factors addressed make it difficult to draw implications for clinical practice. Since HrQoL, psychological adjustment, and adaptive functioning seem to be impaired in some patients, we suggest offering psychological support for patients and their families to help them cope more effectively with the disease. Knowing more about risk factors would allow the development of targeted interventions for certain groups of patients. Overall, we consider it important to support patients and their families with a comprehensive care model, including psychological and social interventions to complement the medical ones ,21.Research data on psychosocial factors in IT-IEM patients are generally sparse. However, the growing interest in the topic is underlined by the fact that seven of the 11 articles reviewed were published in 2012 or 2013. Further research and improved methodological quality of studies are required. Multicentre studies and the use of a standardised, disease-specific assessment tools are needed to establish HrQoL as an important additional outcome parameter in patient-centred research and clinical trials.


We also present here, for the first time, the phylogenetic tree for archaeal LOV domains that have reached a statistically significant number but have not at all been investigated thus far.Flavin-based photoreceptor proteins of the LOV  and BLUF (Blue Light sensing Using Flavins) superfamilies are ubiquitous among the three life domains and are essential blue-light sensing systems, not only in plants and algae, but also in prokaryotes. Here we review their biological roles in the prokaryotic world and their evolution pathways. An unexpected large number of bacterial species possess flavin-based photosensors, amongst which are important human and plant pathogens. Still, few cases are reported where the activity of blue-light sensors could be correlated to infectivity and/or has been shown to be involved in the activation of specific genes, resulting in selective growth patterns. Metagenomics and bio-informatic analysis have only recently been initiated, but signatures are beginning to emerge that allow definition of a  Listeria monocytogenes  that regulates growth patterns and biofilm formation in ytogenes a 1], a , a Listeaeroides ,3 , binding a single flavin chromophore . Their photosensing and photoresponding properties, characterized by defined photochemical reactions and spectral features (vide infra) are linked to diverse effector/regulator functions in a large array of different proteins -x(4)-[GEQR]-x-C, where x is any amino acid and the terminal C is the cysteine forming the covalent bond during the photocycle. For BLUF domains we used: Y-x-[NG]-x-[LMVIFTK]-x-[FALIYCV]-x(1)-Q, where the two residues at the N- and C-terminal ends are the Tyr-Gln reactive pair. To avoid exceedingly stringent criteria, which would miss some hits, we extended in some positions the choice among amino acids similar to those super-conserved. The length of variable intervals is obtained from alignment and from structural considerations of secondary structure elements.Surveys in databases yield so-called sequence logos ,86, obta domains . It is eE. coli, Acinetobacter and K. pneumoniae). The results are summarized in a histogram , 167 archaeal LOV proteins in 86 strains (82 species), and 1705 bacterial BLUF proteins in 1282 strains  and by the large occurrence of EAL domains (34%), putatively involved in c-di-GMP metabolism, sometimes these domains are degenerated and enzymatically inactive EAL domains, as illustrated above for YcgF in E. coli   of the halobacterial protagonists carry fused HTH effector domains , whereas this motif is found in only 0.6% of all bacteria. The general architecture of these putative photo-regulated DNA-binding proteins is depicted in nPAS+kGAF+HTH, with n = 0–8, and k = 0–2, where: RR = response regulator, receiver domain; PAS = Per Arnt Sim domain (the same fold as LOV domains); GAF = domain found in cGMP-specific phosphodiesterases, cyanobacterial adenylate cyclases, and formate hydrogen lyase transcription activator FhlA -x(4)-[GEQR]-x-C for LOV domains; Y-x-[NG]-x-[LMVIFTK]-x-[FALIYCV]-x(1)-Q for BLUF domains, where x is any amino acid. With these pattern we performed a search for LOV and BLUF domains over all annotated prokaryotic genome sequences (completed or in progress), within the non-redundant protein sequence database and the SwissProt/UniProt Knowledgebase [To build the sequence logos of escribed . From thescribed  and Shanescribed   . DetailePhotophysiological studies of BL-sensing in prokaryots, as mediated by non-membrane LOV and BLUF proteins, are just now starting to accumulate. Only the demonstration of light-regulated changes in the growth behavior and the infectivity of selected animal and plant pathogens that can cause deleterious social and economic impact slowly convinces (micro)biologists of the important role of BL-sensing photoreceptors. As far as can be deduced thus far, BL seems to operate both as a stress factor and as a source of environmental information able to elicit adaptative responses in metabolism, growth patterns, and interactions with other organisms. It is still a fully open and fascinating question, if and how these Fl-Blues exert an effect in the large number of radiotolerant, extremophilic, and xenobiotic-metabolizing bacteria that are prominently represented in our lists of LOV- and BLUF-carrying prokaryots. The ever-growing information of genomic information now calls for more elaborate tools to screen new genomes (and metagenomes) for the presence of BL-photoreceptor genes and the identification of their genomic neighborhood. Though, still in its infancy, search criteria are now being developed that allow a more sophisticated search for potential photoreceptors, and also allow suggesting scenarios by which BL-photoreceptors have an impact on the gene regulation. The usefulness of such search criteria has been demonstrated here for the first time for archaea in which a manifold of BL-sensing photoreceptors could be identified. None of these archaeal species have been probed so far for their response to and lifestyle changes caused by blue light. It has now to be accepted that the generic stress response mechanisms, well studied in several bacterial species, have now to be extended by the impact elicited by blue light.


Background: Greater exposures to fast-food outlets and lower levels of education are independently associated with less healthy diets and obesity. Little is known about the interplay between these environmental and individual factors.Objective: The purpose of this study was to test whether observed differences in fast-food consumption and obesity by fast-food outlet exposure are moderated by educational attainment.Design: In a population-based cohort of 5958 adults aged 29–62 y in Cambridgeshire, United Kingdom, we used educational attainment–stratified regression models to estimate the food-frequency questionnaire–derived consumption of energy-dense “fast foods” (g/d) typically sold in fast-food restaurants and measured body mass index  across geographic information system–derived home and work fast-food exposure quartiles. We used logistic regression to estimate the odds of obesity (BMI ≥30) and calculated relative excess risk due to interaction (RERI) on an additive scale. Participant data were collected during 2005–2013 and analyzed in 2015.Results: Greater fast-food consumption, BMI, and odds of obesity were associated with greater fast-food outlet exposure and a lower educational level. Fast-food consumption and BMI were significantly different across education groups at all levels of fast-food outlet exposure (P < 0.05). High fast-food outlet exposure amplified differences in fast-food consumption across levels of education. The relation between fast-food outlet exposure and obesity was only significant among those who were least educated , which suggested a positive additive interaction between education and fast-food outlet exposure.Conclusion: These findings suggest that efforts to improve diets and health through neighborhood-level fast-food outlet regulation might be effective across socioeconomic groups and may serve to reduce observed socioeconomic inequalities in diet and obesity. Obesity is a risk factor for multiple chronic diseases, including type 2 diabetes, cardiovascular disease, and some cancers. Nearly two-thirds of adults are now overweight or obese in Great Britain, with the prevalence predicted to increase further by 2050 . These tFoods consumed outside the home are typically less healthy than those consumed at home . Fast foThe consumption of fast foods appears to be influenced by both individual- and neighborhood-level factors. One individual-level factor is socioeconomic status (SES),Neighborhood food environments, including those beyond the residential neighborhood, may also be a cue for higher intakes of fast foods. Although the evidence base is mixed and methodologically heterogeneous , neighboAlthough both individual-level socioeconomic and neighborhood-level drivers of diet and weight have been recognized, limited research has examined how food environment associations with food consumption and body weight might differ by SES. Public health theories, such as deprivation amplification, have long sought to understand whether, how, and why unhealthy neighborhood environment exposures are more important for populations of low SES . Howeverwww.mrc-epid.cam.ac.uk/research/studies/fenland-study/). Cambridgeshire is a county in the east of England that comprises urban, suburban, and rural areas and the major cities of Cambridge and Peterborough. Recruitment for this study was conducted by the University of Cambridge Medical Research Council Epidemiology Unit from 2005 and is ongoing. At the time of the data request for these analyses, data were available for 10,452 participants. Participants completed a general lifestyle questionnaire, which included questions on highest educational attainment. Participants also completed a semiquantitative food-frequency questionnaire (FFQ) to assess the habitual consumption of foods; weight and height were measured by trained researchers. Eligibility criteria for this analysis were as follows: having complete demographic, anthropometric, socioeconomic, and FFQ data and information on home and work address and being employed. The analytic sample was therefore restricted to 6123 participants . The participant data used in this study were collected between 2005 and 2013 and analyzed in 2015. All of the study procedures were approved by the Health Research Authority National Research Ethics Service Committee East of England–Cambridge Central. The Fenland Study volunteers provided written informed consent.The Fenland Study is an ongoing population-based cohort study in adults aged 29–62 y (born between 1950 and 1975) enrolled in general practices in Cambridgeshire, United Kingdom  was calculated from measured height and weight. Third, those with a BMI ≥30 were classified as obese.We had 3 outcome variables. First, we estimated the consumption of energy-dense foods that can typically be obtained from a fast-food outlet —here referred to as “fast food”—using data from the FFQ. We summed the consumption in grams per day of pizza, burgers, chips (fried potatoes), fried fish, and fried chicken. Second, BMI , BMI, and odds of being obese. Educational attainment groups were as follows: lowest (≤11 y of education), middle (12–13 y of education), and highest (>13 y of education). We used general linear models to estimate adjusted marginal means with 95% CIs for fast-food consumption and BMI across quartiles of combined home and work fast-food outlet exposure. We then calculated subgroup-specific estimates of fast-food consumption and BMI across education groups.11 − OR10 − OR01 + 1, where ORs are odds ratios for being obese for those who are least educated and most exposed to fast-food outlets (OR11), those who are least educated and least exposed to fast-food outlets (OR10), and those who are most educated and most exposed to fast-food outlets (OR01)  guidelines, we used logistic regression with a single reference category  to estimate the separate and combined associations of fast-food outlet exposure and educational attainment on the odds of being obese . We tests (OR01) . RERI scs (OR01) .Supplemental Table 2). All of the analyses were conducted by using PASW Statistics 21 (SPSS Inc.).All of the models were adjusted for known confounders through the inclusion of a number of covariates: age, sex, household income , combined home and work exposure to supermarkets, total energy intake derived from FFQ data , physical activity energy expenditure (kJ/kg per day) , and smoDescriptive statistics for the analytic sample, overall and stratified by educational attainment, are presented in P < 0.001). After additional adjustment for a number of covariates including environmental exposures, those who were least educated still consumed significantly more fast food , had a significantly higher BMI , and were more than twice as likely to be obese  than those who were most educated.Greater fast-food consumption, higher BMI, and increased odds of being obese were associated with lower educational levels, with evidence of dose-response associations. Linear and logistic regression results, with adjustment for age, sex, daily energy intake (fast-food consumption model only), and smoking status (BMI and obesity models only), are shown in Greater fast-food consumption was associated with greater fast-food outlet exposure, with evidence of a dose-response association. Greater fast-food outlet exposure was associated with greater BMI, with evidence of a dose-response association. P < 0.05).Increased odds of obesity (BMI ≥30) were associated with increased fast-food outlet exposure and lower educational level, with evidence of interaction on an additive scale. In this study, with its detailed information on combined home and work environmental exposures and individual-level characteristics including measured BMI, we confirmed earlier work that showed that fast-food consumption, body weight, and the likelihood of being obese are associated with neighborhood fast-food outlet exposure , 22, 36 Our results showed that although exposure to fast-food outlets was consistently associated with fast-food consumption and body weight across all education groups, there was a clear educational gradient at every level of fast-food outlet exposure. Being more highly educated was consistently associated with lower body weight and lower intakes of energy-dense fast foods, which are associated with excess weight gain over time . FurtherTo date, there has been limited evidence of the interplay between individual SES and neighborhood exposures in relation to health and health behaviors. For example, previous research showed that in regions of the United Kingdom with greater access to green space, income-related inequalities in mortality were attenuated . With reOur results are of international significance because they contribute to an emerging evidence base that suggests that government policies to regulate neighborhood fast-food outlet exposure might succeed in improving diets and health . Such poAs detailed previously , 27, theWe used data from a semiquantitative FFQ to estimate the consumption of energy-dense fast-food and total energy intakes. The results of FFQs are representative of usual dietary intake and are commonly used in food environment research  but are We used highest educational attainment as our indicator of SES. Other commonly used indicators include income and occupation; however, these are generally imperfectly correlated . We adjuThis study contributes to the international scientific literature on neighborhood food environments, diet, and health by furthering our understanding of the differential effects of fast-food outlet exposure across education groups. For the first time to our knowledge, we showed the individual and combined effects of education and fast-food outlet exposure on the consumption of energy-dense fast foods, measured body weight, and odds of obesity in a large population-based sample of adults. Although exposure to fast-food outlets afffected all socioeconomic groups, those of a lower SES consumed consistently more fast foods, tended to have higher body weights, and were more likely to be obese. We also showed how the association between exposure to fast-food outlets and obesity was most pronounced for persons of lower SES and how the combination of low SES and high fast-food outlet exposure amplified the odds of obesity. Taken together, these findings may hold implications for health inequalities and therefore the development of public health policy.


Active learning methods have been shown to be superior to traditional lecture in terms of student achievement, and our findings on the use of Peer-Led Team Learning (PLTL) concur. Students in our introductory biology course performed significantly better if they engaged in PLTL. There was also a drastic reduction in the failure rate for underrepresented minority (URM) students with PLTL, which further resulted in closing the achievement gap between URM and non-URM students. With such compelling findings, we strongly encourage the adoption of Peer-Led Team Learning in undergraduate Science, Technology, Engineering, and Mathematics (STEM) courses. This study shows that Peer-Led Team Learning drastically reduces the failure rate for underrepresented, minority undergraduate students in an introductory biology course. Recent, extensive meta-analysis of over a decade of education research has revealed an overwhelming consensus that active learning methods are superior to traditional, passive lecture, in terms of student achievement in post-secondary Science, Technology, Engineering, and Mathematics (STEM) courses . In lighAlthough next-generation active learning classrooms are becoming more common, large instructor-focused lecture halls with fixed seating are still the norm on most campuses—including ours, for the time being. While there are certainly ways to make learning more active in an amphitheater, peer-interactive instruction is limited in such settings. Of course, laboratories accompanying lectures often provide more active learning opportunities. But in the wake of commendable efforts to increase rigorous laboratory experiences at the sophomore and junior levels at Syracuse University, a difficult decision was made for the two-semester, mixed-majors introductory biology sequence: the lecture sections of the second semester course were decoupled from the laboratory component, which was made optional. There were good reasons for this change, from both departmental and institutional perspectives. However, although STEM students not enrolling in the lab course would arguably be exposed to techniques and develop foundational process skills in the new upper division labs, we were concerned about the implications for achievement among those students who would opt out of the introductory labs. Our concerns were apparently warranted, as students who did not take the optional lab course, regardless of prior achievement, earned scores averaging a letter grade lower than those students who enrolled in the lab. However, students who opted out of the lab but engaged in Peer-Led Team Learning (PLTL) performed at levels equivalent to students who also took the lab course .Peer-Led Team Learning is a well-defined active learning model involving small group interactions between students, and it can be used along with or in place of the traditional lecture format that has become so deeply entrenched in university systems  in STEM fields are essential to sustaining America’s research and innovation capacity . AlthougWith high attrition rates of STEM majors in the United States, and even higher rates of underrepresented minorities leaving STEM disciplines at the undergraduate level, there has been a significant amount of research dedicated to interventions intended to increase the recruitment and retention of students in STEM disciplines. The literature reveals several factors that affect retention of underrepresented minorities in STEM, including mentoring , learninStudents who do not fare well in introductory STEM courses are far less likely to be recruited or retained in STEM majors, and when instruction involves only traditional lecture, there is a tendency for students to feel isolated and hopeless if they are not doing well . The PLTx2 = 7.194, n = 479, df = 1, p = 0.007).Our experiences in using PLTL alongside the lecture hall approach in our introductory biology course have yielded exciting results. Among these are that retention in the course was higher for students who enrolled in PLTL, with those who did not attend PLTL sessions being significantly more likely to withdraw from the course  and a smaller, but significant, decrease in DFWs for non-URMs as well . The pronounced achievement gap between URMs and non-URMs was closed for URMs who sufficiently participated in PLTL. That is, the DFW rate was significantly higher for URMs than it was for non-URMs among those who did not engage in PLTL , but not significantly different between URMs and non-URMs who did.Perhaps even more encouraging is how PLTL appears to have influenced student achievement in the course, particularly for URMs  Tables. (n = 479), regardless of concurrent enrollment in a lab course. There was no significant difference in prior achievement between students who opted out of PLTL or lab and those who engaged in these options  or not . Finally, we note that for URMs who did not participate in lab, half of those who did not engage in PLTL earned Ds, Fs, or withdrew from the course, while those who did engage in PLTL all completed the course and earned grades of C or higher.The results above are for all students whose URM or non-URM status could be determined Based on these data and on evidence from prior research, we are convinced that PLTL is effective in improving student achievement in introductory STEM courses, particularly for URM students. The drastic reduction in DFW rates among URM students and the closing of the achievement gap between URM and non-URM students are very compelling reasons to adopt the PLTL model, especially since significant gains were seen among non-URMs as well. The impact among students who are not concurrently enrolled in a lab course is a particularly important finding in the context of the biology program at our university, as several of the second-year courses in the biology major are not directly coupled with mandatory laboratory classes. What have we gained if we retain more diversity among life-science majors in their first year only to risk losing them as sophomores? It may be that a strong first year will help even the playing field when looking toward the second, so our future efforts will include tracking these students into upper-division courses as well as seeking to provide similar peer-interactive learning activities to students in all core courses in biology.We also encourage other post-secondary educators to consider using PLTL, and many resources exist to help facilitate implementation in introductory biology and other STEM courses. Peer-Led Team Learning: A Guidebook. Gosser D, Cracolice M, Kampmeier J, Roth V, Strozak V, & Varma-Nelson P, eds. 2001. Upper Saddle River, NJ: Prentice Hall. ISBN-10: 0130288055Peer-led Team Learning: Origins, Research, and Practice. Gosser D. Ronkonkoma, NY: Linus Publications; 2015. ISBN-10: 1607975459Peer-Led Team Learning: A Handbook for Leaders. Roth V, Goldstein E, & Marcus G. Upper Saddle River, NJ: Prentice Hall; 2001. ISBN-10: 0131876058https://sites.google.com/site/quickpltlThe Center for Peer-led Team Learning: https://sites.google.com/site/quickpltl/workshop-materialsWorkshop Problem Sets: http://pltlis.org/Peer-Led Team Learning International Society: S1 Table(PDF)Click here for additional data file.S2 Table(PDF)Click here for additional data file.S3 Table(PDF)Click here for additional data file.S4 Table(PDF)Click here for additional data file.S1 Text(PDF)Click here for additional data file.S1 Workshop Material(PDF)Click here for additional data file.


Genes that increase susceptibility to age-related macular degeneration (AMD) have been identified; however, since many individuals carrying these risk alleles do not develop disease, other contributors are involved. One additional factor, long implicated in the pathogenesis of AMD, is the lipofuscin of retinal pigment epithelium (RPE). The fluorophores that constitute RPE lipofuscin also serve as a source of autofluorescence (AF) that can be imaged by confocal laser ophthalmoscopy. The AF originating from lipofuscin is excited by the delivery of short wavelength (SW) light. A second autofluorescence is emitted from the melanin of RPE (and choroid) upon near-infrared (NIR-AF) excitation. SW-AF imaging is currently used in the clinical management of retinal disorders and the advantages of NIR-AF are increasingly recognized. Here we visit the damaging properties of RPE lipofuscin that could be significant when expressed on a background of genetic susceptibility. To advance interpretations of disease-related patterns of fundus AF in AMD, we also consider the photochemical and spectrophotometric features of the lipofuscin compounds responsible for generating the fluorescence emission. Age-related macular degeneration (AMD) is a complex disorder that is influenced by genetic and environmental factors; heritability is estimated to account for 45% to 71% of cases . SeveralIn vivo imaging provides a window within which to view the natural course of retinal disease. Of the available imaging modalities, fundus autofluorescence (AF) has proven to be especially valuable, in large part because disease-related processes can alter the distribution of the AF signal. Accordingly, recognizable disease phenotypes are often produced. Advances in non-invasive fundus imaging have facilitated the diagnosis and differentiation of retinal disease. The natural autofluorescence of the fundus that is excited by SW light (488 nm excitation)  exhibitstrans-retinal having a cyclohexadiene head group  [RPE lipofuscin consists of a complex mixture of fluorophores that have been identified in by chromatography and mass spectrometry and characterized structurally; all of the known bisretinoid lipofuscin pigments have been detected in human eyes  Figure . These fl dimer) ,37 and tl dimer) . Higher l dimer) . Other ml dimer) , HNE (4-l dimer)  that arel dimer) ,43 and il dimer) . Accumull dimer) .The various bisretinoids of RPE lipofuscin have some common structural features . They prin vivo by spectrophotometry has a broad excitation spectrum that peaks between 490–510 nm. The fluorescence emission is also broad and centered at approximately 600 nm [ex vivo exhibits an excitation spectrum that peaks between 450–490 nm; the fluorescence emission is maximal at ~600 nm [In clinical settings, SW-fundus AF is excited by wavelengths ranging from 488 nm, the excitation employed with a confocal scanning laser ophthalmoscope (cSLO), to the 535–580 nm range utilized by a modified fundus camera  and the y 600 nm ,17. RPE  ~600 nm ,50,51,52 ~600 nm . The bistrans-retinal dimer and A2E have revealed that these compounds are photoinducible generators of reactive oxygen species such as singlet oxygen and superoxide anion. Singlet oxygen in turn reacts with the conjugated double bond systems comprising the arms of the bisretinoid molecules [While there exists no evidence that bisretinoids of RPE lipofuscin can undergo lysosomal degradation, loss of this material due to photodegradation has been demonstrated. Thus studies of RPE lipofuscin ,54,55 anolecules ,59,60,61olecules ,62. trans-retinal dimer has also been shown to incite complement activation [AGEs incite inflammatory processes and since they are detected in drusen ,64, theytivation ,66.rans-retinal dimer have been detected in isolated human and mouse RPE [−/− mice to retinal light damage [Photooxidation is clearly an ongoing process in the eye since photooxidized forms of A2E and all-touse RPE ,57. Thesouse RPE  and photouse RPE ,69 in Abt damage .in vivo fluorescence imaging by adaptive optics scanning laser ophthalmoscopy [cis being converted to all-trans-retinal) would likely continue unabated [The propensity for bisretinoids to undergo photooxidative and photodegradative processes may underlie the decline in RPE lipofuscin fluorescence emission (photobleaching) that has been observed in non-human primates during lmoscopy ,71, withlmoscopy  and in nlmoscopy ,74  investigators have reported that A2E is detectable in central retina of mice , but notSince the spectral features of RPE lipofuscin and fundus autofluorescence are best accounted for by the excitation and emission spectra of the bisretinoid constituents, the fluorescence originating in centrally situated RPE cells likely originates from some combination of these di-retinal adducts. Interestingly, the MALDI-MS findings could indicate that the various species of bisretinoid lipofuscin compounds exhibit spatial heterogeneity. Reduced levels of A2E in the macula could also be a consequence of greater lipofuscin photocleavage in central RPE; an explanation such as this could account for the greater susceptibility of the macula to disease. Failure to detect A2E centrally, may even be attributable to the limitations of the methodology. MALDI-MS is a surface-based technique that depends on the extraction of analyte into a matrix applied to the surface of the tissue. Factors that could cause spatial differences in extraction efficiency are regional differences in RPE height and spatial differences in the compartmentalization of lipofuscin. For instance RPE cells are taller and narrower in the human macula  with melThe healthy fundus also exhibits a near-infrared autofluorescence (NIR-AF) (>800 nm) when excited at ~787 nm ,85 Figu. The intThe more frequent use of SW-AF may be due, in part, to the introduction of the Heidelberg Spectralis having optical coherence tomography (OCT) capability (HRA + OCT) and to the subsequent decline in the popularity of the HRA2 and Spectralis HRA in retinal clinics. The OCT module in the Spectralis reduces NIR-AF signal intensity, thus compromising NIR-AF image quality as compared to cSLOs without OCT . Nevertheless, NIR-AF has advantages over SW-AF. For instance, during image acquisition, patients are not disturbed by the NIR-AF light as they are with the SW-AF exciting light. This improves patient cooperation, especially in young children and photophobic patients. In the presence of retinal disease such as AMD, patterns and intensities of fundus autofluorescence are notably altered ,91,92,93In the zone of retina immediately adjacent to geographic atrophy, there are often additional AF changes. These aberrant signals can present as intermittent foci or continuous bands of altered brightness in both SW-AF and NIR-AF images ,102,103.Since both SW-AF and NIR-AF are considered to originate in RPE cells, it is puzzling that SW-AF can be increased at positions where NIR-AF is reduced or absent. This apparent incongruity has been attributed to abnormal RPE cells that have lost melanin while accumulating excessive levels of lipofuscin due to accelerated rates of outer segment phagocytosis ,105. HowOther observations indicate that photoreceptor cells are likely to be degenerating in these junctional zones of increased SW-AF. In particular, retinal sensitivity, measured by microperimetry, is commonly reduced at positions presenting with increased SW-AF as compared to normal SW-AF ,109. In The observation that NIR-AF signals increase in parallel with increases in SW-AF at the border of GA may also not be fully understand. Hyperautofluorescence foci at the junctional zone of GA, at least in some cases, can be attributed to abnormally superimposed RPE cells ,114. ButInterest in a role for RPE lipofuscin in AMD stems from its age-related increase ,11, an aSince the products of bisretinoid photodegradation can be damaging ,60, it ien face spatial information, the spectral features of the fluorescence are not elucidated and the cellular origin of the fluorescence is not identified. Recently, however, methods have been developed for quantifying SW-AF. This approach has been shown to enable the differentiation of similar phenotypes having disparate genetic origins [versus non-diseased areas of retina are easier to distinguish in NIR-AF images as compared to SW-AF images. Indeed, in recessive Stargardt disease (STGD1), SW-AF changes are often not obvious at fundus locations where abnormalities are detectable in NIR-AF images [While fundus autofluorescence provides  origins ,118. TheF images . In addiF images . This reF images . While t


The optimal management of infants born to HIV-positive mothers who are untreated or have detectable viral load prior to delivery remains controversial. Despite the increasing use of combination antiretroviral therapy (cART) for post-exposure prophylaxis (PEP) of neonates at high risk of HIV infection, there is little safety and pharmacokinetic data to support this approach. The objective of this study was to evaluate the safety and tolerability of cART for PEP in HIV-exposed neonates.Retrospective study on 148 cART and 145 Zidovudine (ZDV) monotherapy-exposed infants identified from four Canadian centres where cART for PEP has routinely been prescribed in high-risk situations. Physician-reported adverse events and clinical outcomes were extracted by chart review. Haematological and growth parameters at birth, one and six months of age were compared between cART and ZDV-exposed infants using multivariate mixed effects modelling.p=0.01). In the multivariate model, cART recipients had lower mean haemoglobin (decrease of 2.07 g/L) over the 6-month period compared with ZDV recipients (p=0.04), but no effect was seen on absolute neutrophil count. cART recipients had lower weight and smaller head circumference at birth and one month of age compared with ZDV-exposed infants; these differences were no longer significant at six months of age.Non-specific signs and symptoms were reported in 10.2% of cART recipients versus none of the ZDV recipients. Treatment was discontinued prematurely in 9.5% of cART recipients versus 2.1% of ZDV recipients (cART administered at treatment doses for PEP in neonates was generally well tolerated, though a higher incidence of non-specific signs and symptoms and early treatment discontinuation occurred among cART recipients. While the overall risk of perinatal HIV transmission in the developed world has decreased to less than 1%, transmission still occurs, most often due to failure to diagnose HIV in pregnant women in a timely manner, or because of poor maternal drug adherence to, and/or refusal of, antiretroviral therapy . HoweverDespite the increasing use of cART for prophylaxis in neonates at high risk of HIV infection, there is limited data on the safety of these different combination regimens, or on the appropriate dosing for the antiretroviral (ARV) medications used for this purpose. Transient haematological toxicity has been reported with the use of six-week post-natal ZDV , the recIn four Canadian centres, triple cART at treatment doses has been routinely prescribed for the post-exposure prophylaxis (PEP) of neonates deemed at high risk of HIV infection, either because of detectable maternal viral load near delivery or in the absence of viral load results, clinical factors such as poor adherence or late diagnosis. In standard-risk situations, six weeks of ZDV monotherapy is prescribed. Given the limited data to support the use of cART, the primary objective of this study was to compare the safety and tolerability of cART versus ZDV monotherapy of PEP with respect to adverse events, haematological and growth parameters in exposed neonates.2 daily for 14 days, followed by 150 mg/m2 twice daily for 14 days) or Nelfinavir (NFV) 40–50 mg/kg twice daily for six weeks) or LPV/Ritonavir (LPV/r) (300 mg/m2 twice daily) for six weeks. Combination regimens containing single or three doses of NVP were excluded.HIV-1 exposed children were eligible for this study if they were started on treatment doses of cART within 72 hours of birth because of incomplete maternal virologic suppression at delivery or, in the absence of maternal viral load results, a maternal history of incomplete adherence or non-adherence to cART, or late pregnancy initiation of cART. Neonatal cART was defined as any regimen of three or more antiretroviral agents, prescribed at treatment doses, for a minimum of six weeks. Regimens included ZDV  for six weeks, Lamivudine (3TC) (2 mg/kg twice daily) for six weeks, with the addition of either NVP (150 mg/mn=148). Approval for the study was obtained by the ethics review board of each participating institution; given the retrospective nature of the study, individual patient consent was not deemed necessary by the respective ethics review boards for the chart review.Subjects were identified for the period 1997–2013 from the clinical databases of four paediatric HIV-care institutions in Canada: The Hospital for Sick Children, Toronto; Children's Hospital of Eastern Ontario, Ottawa; Centre Hospitalier Universitaire (CHU) Sainte-Justine, Montreal; Stollery Children's Hospital, Edmonton. A control group consisting of all infants of HIV-positive mothers who were prescribed ZDV monotherapy during a three-year period (2010–2012) at the Hospital for Sick Children was selected (Baseline characteristics were reported as means with standard deviation (SD) for continuous variables and proportions for categorical variables. Comparisons between cART- and ZDV-exposed infants were performed using chi-square tests or Wilcoxon rank-sum. Haemoglobin, neutrophil count and growth parameters (head circumference (HC), weight and length) of cART- and ZDV-treated infants were compared at one, two and six months of age  and at birth, one and six months of age (growth parameters) by Student's t-test or Wilcoxon rank-sum where appropriate. For the the three-way comparison between PI based-cART, NVP based cART and ZDV groups, the Kruskal-Wallace test was used.n=13) were excluded from the analysis as all were maintained on ARV drugs. The analysis was performed using SAS statistical software, version 9.2 .Multivariate mixed models, allowing for repeated measures, were constructed to determine the overall effect of treatment category on haematological and growth parameters. For haematological parameters, effect of treatment category was adjusted for chronological age , gestational age and ethnicity (neutrophil count only). Due to a large number of missing values for haemoglobin and neutrophil count at baseline, these parameters were not included in the models. For growth parameters, effect of treatment was adjusted for chronological age, gestational age, gender and birthweight. All infants were included in the analysis of haematological toxicity and growth at one month; for all subsequent analyses infants confirmed to be HIV positive (n=8) or they did not attend the scheduled six-month visit (but were seen at 18 months of age or older) (n=12).One hundred and forty-eight infants received triple cART during the study period. NFV-based cART was the most common regimen (55%) followed by NVP-based cART (40%) and LPV/r-based cART (5%). The most common reason for prescribing cART was documented detectable maternal viral load (78.4%). Other overlapping factors included poor adherence (45%), late diagnosis (20%), no antenatal care (8%) and refusal of antenatal ARV therapy (8%). Fifteen of the cART-treated infants and five of the ZDV-treated infants had missing six-month data, either because they were lost to follow-up . None of the ZDV recipients were infected. Five of the 13 (38.5%) had HIV-1 detected by PCR within 48 hours of birth suggesting lsewhere .p<0.001). ARV treatment was discontinued prematurely in 9.5% (n=14) of cART recipients (five NVP-treated and nine PI-treated infants) compared with 2.1% (n=3) ZDV recipients (p=0.01). Reasons given for premature treatment discontinuation among cART recipients included significant anaemia , neutropenia , non-specific symptoms including rash, vomiting, and diarrhoea (n=6), and parental decision (n=4). In the six cases of non-specific symptoms, treatment discontinuation was precautionary, as the treating physician indicated that the symptoms were most likely not medication related. In four cases of parental discontinuation, parents stopped the medication without evidence of toxicity or consultation with their healthcare provider. ZDV monotherapy was stopped early in three children, all because of significant anaemia .Non-specific signs and symptoms, including vomiting, diarrhoea, rash, jitteriness or irritability, potentially attributable to medication-related adverse effects, were reported in 10.2% of cART recipients and none of the ZDV recipients (p=0.04), but not at two or six months of age . In a subgroup analysis of specific treatment type, mean haemoglobin was lower among PI-treated infants compared with NVP-treated infants at one month of age , though only statistically significant at six months of age  . In the unadjusted analysis, haemoglobin was lower in cART-treated infants compared with ZDV-treated infants at one month of age  .Supplementary Table, not shown). Overall, the mean haemoglobin was 2.07 g/L lower among cART versus ZDV-treated infants (p=0.04) over the six-month period. In the subgroup analysis looking at specific treatment type, mean haemoglobin was 3.62 g/L lower in those receiving PI-based cART compared with those receiving ZDV monotherapy (p=0.002); no such effect was observed for NVP-based cART compared with ZDV monotherapy (p=0.82). There was no difference in absolute neutrophil count between NVP-based cART, PI-based cART and ZDV monotherapy-treated infants at one, two or six months of age in the unadjusted analysis; this finding was maintained in the multivariable model adjusting for visit number, ethnicity and gestational age.To study the overall effect of treatment type on haemoglobin over time, we constructed a multivariate model adjusting for chronological age and gestational age . By six months of age, there was no difference in weight  or head circumference , although the cART-treated group remained shorter than ZDV-treated infants . In the subgroup analysis looking at specific treatment type, both NVP-and PI-treated infants were smaller than ZDV-treated infants across all growth parameters at birth; only the difference in length remained significant at six months of age.Weight, length and HC were compared between all cART-treated and ZDV-treated infants, and between PI-based cART, NVP-based cART and ZDV at birth, one and six months of age . In the p<0.001) . A similar effect was seen with respect to weight and length, with a mean weight difference of −236 g and length difference of −0.92 cm over the six-month period . In the subgroup multivariate analysis comparing PI-based cART versus ZDV and NVP-based cART versus ZDV, there was no discernable difference between the two cART treatment types and these growth parameters.To study the overall effect of treatment type on growth parameters over time, we constructed a multivariate fixed effects model adjusting for birthweight, gestational age, chronological age and gender. Overall, there was a mean HC difference of −0.63 cm among cART compared with ZDV-treated infants over the six-month period . Among the 14 cART-treated children in whom medications were prematurely discontinued, four had their medications stopped by the parents without consultation with the healthcare provider and in the absence of any side effects, and six for precautionary reasons by the clinician even though the symptoms were not thought to be medication related, highlighting a lower threshold for treatment discontinuation by both parents and physicians among cART-treated infants.With respect to haematological toxicity, the frequency and degree of anaemia observed in our cART-treated neonates was higher than that observed in the ZDV-monotherapy neonates. In the subgroup analysis of cART-treated infants, haemoglobin was lower at one month of age among PI versus NVP-treated infants, suggesting perhaps less haematological toxicity with NVP-based cART. The lower mean haemoglobin observed in cART-treated subjects compared with ZDV-monotherapy-treated subjects at one month of age was no longer evident at two and six months of age after stopping treatment, confirming the reversible nature of the anaemia. Reassuringly, compared with ZDV monotherapy, the use of cART was not associated with any discernible change in neutrophil count.in utero drug exposure, social situation, maternal health, nutritional status and education, which may be important predictors of infant growth and development.While in the multivariate mixed effects model cART-treated infants had lower mean growth measures  than ZDV-monotherapy-treated infants over time, there were no absolute differences in growth measures for head circumference or weight at six months of age, indicating good catch-up growth among the cART-treated infants. The observed lower mean growth over time in cART recipients was therefore likely due to factors associated with the indications for the use of cART. Specifically, the higher overall incidence of prematurity among cART-treated infants was likely a result of poorly controlled maternal HIV, an established risk factor for low birthweight and preterm delivery . The higBecause of the selective use of cART for infants at higher risk of perinatal transmission in our study, it is not appropriate to compare the risk of transmission among cART versus ZDV-treated infants as the latter group would have received better antenatal preventive management. The 8.8% overall transmission rate observed among cART recipients in our cohort was similar to that in a previous trial in which neonates of untreated mothers were randomized to different cART regimens, evidence of the high risk of transmission despite prophylaxis in these situations . Key potOur study has a number of limitations, including its retrospective nature, relatively small sample size, and potential differences in the patient population at different study sites which may have influenced biological and growth outcomes. All control group infants were selected from a single centre, and the choice of PI-based versus NVP-based cART was also site specific. Given that these were the comparison groups of interest, we could not adjust for site and treatment type in the final analysis, thereby limiting our conclusions on specific cART treatment type.In summary, our study shows that cART at treatment doses administered as prophylaxis to “high-risk” HIV-exposed neonates is generally well tolerated and should be considered for newborn infants deemed at high risk of perinatally acquired HIV infection. However, close monitoring for anaemia, neutropenia and other side effects is important if such therapy is given. Until more robust pharmacokinetic data are available, the use of cART as prophylaxis in neonates may be limited to resource-rich settings where routine therapeutic drug monitoring is possible. However, further study is urgently needed in resource-limited settings where the vast majority of high-risk HIV-exposed infants are born. The potential benefits of cART, both to avert infection and, in case of transmission, preserve future therapeutic options and potentially limit the viral reservoir, may well outweigh the risks. Finally, if this strategy is used, counselling of parents and close follow-up is necessary to avoid premature treatment discontinuation and to ensure proper monitoring of cART-exposed infants.Click here for additional data file.


Although extant meta-analyses support the notion that exercise results in cognitive performance enhancement, methodology shortcomings are noted among primary evidence. The present study examined relevant randomized controlled trials (RCTs) published in the past 20 years (1996–2015) for methodological concerns arise from Lord's paradox. Our analysis revealed that RCTs supporting the positive effect of exercise on cognition are likely to include Type I Error(s). This result can be attributed to the use of gain score analysis on pretest-posttest data as well as the presence of control group superiority over the exercise group on baseline cognitive measures. To improve accuracy of causal inferences in this area, analysis of covariance on pretest-posttest data is recommended under the assumption of group equivalence. Important experimental procedures are discussed to maintain group equivalence. First, these RCTs are considered clinical trials. According to World Health Organization , para. 3d = 0.19) compared to those from either quasi-experimental or observational designs . These results have led some authors to conclude that exercise benefits cognition in a population ranging from children to older adults. Although such message is exciting, as Rubin Analysis of Partial Variance is a parallel of this strategy , considers the gain score  as the criterion for group comparison. Forms of GSA include repeated-measures analysis of variance (RM ANOVA), gain score t-test, and ANOVA of gain score, among others. Researchers' choice between ANCOVA and GSA often leads to disparate conclusions, an inconsistency historically termed “Lord's Paradox” , investigators should choose ANCOVA in drawing causal conclusions, because ANCOVA has a higher testing power and unbiased effect estimate compared to GSA  baseline group equivalence is likely, and (b) pretest-posttest data are analyzed using ANCOVA. In practice, researchers never know with certainty that a given RCT has baseline group equivalence, but they can ascertain baseline group non-equivalence when group baseline measures show statistical differences. Assuming that baseline group equivalence is achieved by identifying no baseline group differences on any baseline measures , researchers should choose ANCOVA over GSA when comparing groups.One advantage of ANCOVA over GSA is an increased power. Originally, ANCOVA was not developed to “control” for anything but to enhance the testing power of independent variables  by having, for instance, a shorter RT than that of the exercise group on the Stroop Color task, the adoption of GSA will lead to an over-estimate of exercise's benefits on cognition. Conversely, baseline exercise group superiority (exercise-BS) will generate an under-estimated effect with the GSA method , the control group and the exercise group have an equal chance to perform better than the other descriptively on a cognitive task at baseline. The interpretation of “better” is task specific. For instance, a shorter reaction time (RT) is better in simple reaction time tasks , whereas a larger value is better in time-limited memory tasks . If the control group has baseline superiority  could raise the actual alpha level to be as high as 0.50 when comparing two groups and 0.75 when comparing three groups, depending on the power of a specific test. To make things worse, Bland and Altman's results were based on one outcome measure. When an exercise-cognition RCT assesses the effect of exercise on multiple cognitive measures (which is often the case), the practice of having a presumable false positive threshold  could turn meaningless.Baseline measures are usually negatively correlated with gain scores , to follow a binomial distribution:n represents the total number of RCTs examined and k symbolizes the expected probability (k = 0.5) of getting control-BS in a given exercise-cognition RCTX is representing the number of RCTs employing GSA.Rather than assessing the effect of exercise on cognition by considering potential moderators, a procedure common to meta-analytic studies, the focus of the present study was to determine whether exercise-cognition RCTs published in the past 20 years (1996–2015) involve false positives or false negatives due to GSA application in pretest-posttest data analysis. We provided a simple test to achieve this goal. Because group assignment was random, one would expect an equal chance for control-BS and exercise-BS on a certain cognitive measure. In other words, across all RCTs in our review, we expect half RCTs to show control-BS and the other half to have exercise-BS. In terms of a probability distribution, if we assume that X, representing the number of RCTs using GSA that showed control-BS, to continue following the binomial distribution when conditioned on statistical test result. Assuming that Y stands for the statistical test result that has two possible outcomes , we will have the following conditional binomial distribution:n is the total number of RCTs using GSA method and k still takes the value of 0.5.In order to detect possible false positive and/or negative errors among exercise-cognition RCTs using GSA, we must check for independence between baseline group imbalance  an statistical significance test result . If baseline group imbalance were independent to statistical significance test result, we would expect To summarize, we had three hypotheses in the present study. First, we hypothesized that, among all the RCTs, half of them should demonstrate control-BS and the other half should show exercise-BS due to randomization. Second, we hypothesized that researchers, as a group, selected between GSA and ANCOVA without preference, and therefore half of the RCTs should employ GSA and the other half should use ANCOVA as a group-comparison strategy. Lastly, we hypothesized that, when GSA-RCTs are counted separately based on whether they are positive  or negative , more control-BS (than exercise-BS) GSA-RCTs should be found in positive GSA-RCTs, whereas more exercise-BS (than control-BS) GSA-RCTs should be found in negative GSA-RCTs.exercise OR physical activity) AND (cognition OR cognitive performance) AND randomized controlled trial. A manual search of reference list from key studies  was also performed. The first author (S. L.) screened studies by title and abstract, then by full documentation. Trial authors were contacted when required information was missing. In total, 38 RCTs were considered for coding. However, five articles were excluded because they were missing information and corresponding authors were unable to respond to our request by July 1, 2015. The final set of studies consisted of 33 exercise-cognition RCTs.The second author (J.-C. L.) conducted a literature search in April and May 2015 using SPORTDiscus, Web of Science, and Google Scholar databases. The search strategy utilized the following key words within full documents: (2max) and a reading control group, the group exercising at 70% VO2max was selected as the treatment group and was compared to the control group. In addition, if the two exercise groups differed in exercise modality , we compared each of these exercise groups to the control group, respectively, and the results were coded under a given RCT. Furthermore, if multiple interventions were included and at least one of the groups received an intervention focusing on elements other than exercise , only the exercise group was considered as a treatment group and was compared to the control group. Finally, if multiple follow-up measurements were available after the intervention period, we chose the immediate post-intervention measurement as the post-test measure. Details of the literature search and study selection were shown in a flowchart  studies were published between January1996 and May 2015, (b) randomization is evident at the individual level, (c) the design included pre- and post-intervention measures on cognitive tasks such as perception, intelligence, academic achievement, memory, executive function, and cognitive impairment, (d) exercise intervention focused on aerobic, resistance training, or a combination of both, (e) studies included a passive control , an active control , or a combination of both  total participant number and number of groups , and (i) the presence or absence of pre-registering the trial. Table The first two authors discussed and settled coding variables to be included in the coding sheet. One author (S. L.) independently coded all the studies. The coded variables focused on the information relevant to the focus of the study, which is to check potential Type I and Type II errors in exercise-cognition RCTs. Therefore, for every cognitive task, we coded the targeted cognitive process , baseline group imbalance (control-BS vs. exercise-BS), and statistical test result (significant vs. non-significant). Other key methodological information were also coded including (a) group-comparison strategy in pretest-posttest data analysis (ANCOVA vs. GSA), (b) the form of control (passive vs. active), (c) the presence or absence of randomization procedure, (d) testing baseline group equivalence on cognitive measure(s), (e) the use of blinding procedures , (f) explicit inclusion of intention-to-treat (ITT) analysis, (g) presence of Kappa coefficient for each coding variable  were randomly selected and separately coded to produce inter-coder reliability. A research assistant blinded to the study purposes completed the coding. Inter-rater reliability was calculated using Cohen's le Table . Followile Table  recommengain scores as the criterion in comparing groups. We classified an RCT as ANCOVA-RCT if the outcome variable was the post-test score while controlling for baseline score as covariate, or if analysis of partial variance was used.We categorized and counted all the RCTs regarding their group-comparison strategy and baseline group imbalance. For group-comparison strategy, we categorized a given RCT into GSA-RCT if it used Although we coded baseline group imbalance for every cognitive task within an RCT, we later counted the number of RCT regarding their baseline group imbalance favorableness (control-BS vs. exercise-BS). This ensured an equal weight for every RCT given their varying number of cognitive measures. For example, one RCT reported 42 cognitive measures but several RCTs reported only one cognitive measure. In this case, the 42-task RCT would be over-weighted if the count were made at the task level. We applied the “dominance rule” in judging whether a given RCT favors control-BS or exercise-BS. For example, if an RCT used four cognitive measures, we coded it as favoring control-BS if three of the four measures had better performing control group at baseline. Due to within-study measurement dependence, multiple cognitive measures tended to show homogeneous results with respect to baseline group imbalance. Among 33 RCTs, we applied the dominance rule to 14 RCTs. Two RCTs showed equal number of cognitive measures between control-BS and exercise-BS, and thus were dropped from the final count on baseline group imbalance.We also made “conditional count” among GSA-RCTs. First, all the RCTs were screened for GSA employment. Then, GSA-RCTs were categorized as either positive  or negative . The “conditional count” process was very similar to the previous count except that a RCT's baseline group imbalance was decided only on those cognitive measures fitting the positive/negative category. Specifically, if a GSA-RCT had at least one significant result , its baseline group imbalance was determined on all significant cognitive measures. If a GSA-RCT had no significant results , all its cognitive measures were included to determine its baseline group imbalance. These decisions were made for two reasons. First, some positive RCTs employed only one cognitive task . Second, we could bias the negative RCT count regarding baseline group imbalance if we retained the non-significant measures from positive RCTs and recycled them in the negative RCT count.During the “conditional count,” we applied the dominance rule to only one GSA-RCT because it included one cognitive measure supporting control-BS and one cognitive measure with description-wise equal baseline between the control and exercise group; and thus it was counted as control-BS. In addition, one positive GSA-RCT reported a control-BS on one cognitive measure and exercise-BS on the other cognitive measure. This RCT was subsequently classified as neutral and was dropped from the final conditional count. We used the R version 3.2.0 , we observed that 16 RCTs resulted in a control-BS and 15 RCTs in an exercise-BS (two RCTs were dropped in the count because they showed no clear favorableness between control-BS and exercise-BS). The probability of detecting this result met our expectation, p = 0.99, with a 95% CI of . The second hypothesis assumed that the incidence of GSA and ANCOVA as a group comparison strategy are equal among RCTs. The count revealed 27 GSA-RCTs and 6 ANCOVA-RCTs. The test of such occurrence reached significance, p < 0.001, with a 95% CI of . Therefore, we rejected the second hypothesis and concluded that researchers predominantly used GSA over ANCOVA in analyzing pretest-posttest data.Table n = 17), 14 resulted in a control-BS and three in exercise-BS. This pattern reached significant level, p = 0.006, with a 95% CI of . Among the negative GSA-RCTs (n = 9), two studies had a control-BS and seven had exercise-BS. This observation was not significant, p = 0.09, with a 95% CI of . Thus, baseline group imbalance was related to statistical test in that more control-BS GSA-RCTs (which had over-estimated effect sizes) than exercise-BS GSA-RCTs resulted in significant results.Table The objective of the present study was to determine whether exercise-cognition RCTs published in the past 20 years (1996–2015) include false positives or false negatives due to the ignorance of Lord's paradox . Overall, several findings emerged from this study. First, baseline group superiority was found to be randomly determined among all the RCTs, with an equal probability of control-BS and exercise-BS. Second, GSA was the more popular group comparison strategy (27 RCTs) compared to ANCOVA (6 RCTs). Lastly, evidence suggested that positive GSA-RCTs were likely to include false positive errors because 82% (14 out of 17 studies) of them tested on over-estimated effect sizes. However, no clear evidence supported false negative errors among negative GSA-RCTs although a descriptive consistency was revealed.Given findings that GSA is prevalent and misleading, it is necessary to re-emphasize the adoption of ANCOVA in pretest-posttest data analysis. The employment of ANCOVA could eliminate the biased effect estimate due to baseline group imbalance and increase testing power, thus reducing inferential errors. However, choosing ANCOVA as group comparison strategy is only half the story because ANCOVA enhances causal inferences only when group equivalence is likely. The other half, baseline group equivalence, depends on multiple factors during the experimental process. Some important factors are discussed next.One factor influencing group equivalence is randomization procedure. According to Schulz , randomiPrior to intervention, researchers must examine group equivalence on baseline measures. To foster such an examination, the CONSORT  statement  to blind them to their respective interventions. In the present review, 18 out of the 33 RCTs reported blinding procedures and all of them were “single-blinded” . No RCTs reported blinding participants to their group assignments. This raises the concern that participants may show differential expectations due to open group assignment. Such a possibility is consistent with the idea of “unmatched task” for the control group in the literature dealing with the effect of exercise on cognition  is a widely accepted principle in analyzing clinical trials. ITT prevents group non-equivalence due to participant dropout  by including all the randomized participants in data analysis based on their intended treatment assignment  for its conclusions to appropriately address research questions.Despite that no clear evidence of false negative errors was observed in the present study, it was still important to make sure that each RCT has sufficient power so that false negative errors could be minimized. Among all the RCTs included, only eight of 33 RCTs reported performing an researcher degrees of freedom (Simmons et al., www.clinicaltrials.gov maintained by the U.S. National Institute of Health is a qualified registry, even though many other registries have become available since 2004 (Humphreys et al., Although researchers are following the best paradigm including fixed set of practices, they still make decisions on quite some circumstances. These decision-calling circumstances are regarded as the Several limitations in the present study are worth pointing out. First, we only focused on group comparison strategies in analyzing pretest-posttest data in exercise-cognition RCTs because it generates good evidence to evaluate the claim that exercise benefits cognition, and it is a design shared by all the exercise-cognition RCTs. Second, although ANCOVA should be used in analyzing pretest-posttest data in RCTs given group equivalence, it should be noted that ANCOVA was developed under several statistical assumptions, among which the assumption of homogeneity of regression slopes should receive particular attention (Miller and Chapman, Although exercise-cognition RCTs showed randomness of baseline group imbalance, RCTs adopting GSA as group comparison strategy were likely to have false positive errors and thus weakened the overall exercise-benefit-cognition claim. Future research will benefit from employing ANCOVA in analyzing pretest-posttest data while maintaining baseline group equivalence. Several suggestions have been offered to maintain baseline group equivalence in future research. It is likely that the results of current study are not limited to the effect of exercise on cognition and could potentially be extended to RCTs in other domains.Conceived and designed the study: SL, JL. Searched publications: JL. Screened publications, coded data, and analyzed results: SL. Calculated inter-rater reliability: JL. Contributed to the writing of this manuscript: SL, JL, GT.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


For the 25th time in a row the Interuniversity Cardiology Institute of the Netherlands (ICIN-Netherlands Heart Institute) and the Netherlands Society of Cardiology (NVVC) supported the competition for the best three cardiovascular PhD theses, published in the year 2013 . The dissertation prize carries the name of one of the greatest Dutchmen in the history of cardiovascular medicine, Willem Einthoven, who in 1902 for the first time recorded the human ECG, for which he received the Nobel Prize in 1924.This time the jury received a total of 33 PhD dissertations published in 2013. The jury members were very much impressed by the high scientific quality of the PhD fellows. The ultimate selection was based on a combination of several parameters: the curriculum vitae of the candidate, the scientific originality of the PhD thesis and its relevance for the cardiovascular field. In addition, several objective bibliometric parameters were used: 1) the number of articles in first-rate journals both in PubMed and the Web of Science (WOS), 2) the number of citations in WOS, 3) the Hirsch Index, and 4) the contribution as a first author (or shared first author). Based on a combination of these results, the jury finally selected three nominees: Dr. Peter Damman , Dr. Loek van Heerebeek , and Dr. Rutger-Jan Nuis .The members of the jury were: J.W. Deckers (Director CVOI), A. Mosterd (Chairman WCN), M.J. Schalij (Chairman Concilium NVVC), V.A. Umans (President NVVC), and E.E. van der Wall (Director ICIN).The three candidates presented their PhD theses at the annual Spring Congress of the NVVC at the RAI Congress Centre, in Amsterdam, on Friday 4 April 2014. The ultimate winners of the first (Loek van Heerebeek), second (Peter Damman) and third prize (Rutger-Jan Nuis) were chosen by the audience. Summaries of the three nominated PhD theses are given below.Address of correspondence:Ernst E. van der Wall, MDInteruniversity Cardiology Institute of the Netherlands (ICIN) - Netherlands Heart Institute, Catherijnesingel 52, PO Box 19258, 3501 DG Utrecht, the Netherlandsernst.van.der.wall@icin.nle-mail: Victor A.W.M. Umans, MDDepartment of Cardiology, Medical Center Alkmaar, Wilhelminalaan 12, 1815 JD Alkmaar, the Netherlandse-mail: v.a.w.m.umans@mca.nlpassive). Cardiomyocyte Fpassive is mainly determined by the elastic sarcomeric protein titin through shifts in expression of its stiff (N2B) and compliant (N2BA) isoforms and isoform phosphorylation. Whether DHF and HF with reduced EF (HFrEF) or systolic HF (SHF) represent distinct HF phenotypes is still debated.Background: Heart failure with preserved ejection fraction (HFpEF), or diastolic HF (DHF) is widely prevalent and has a poor prognosis. Its pathophysiology is incompletely understood and therapeutic strategies remain uncertain. Characteristic for DHF is high diastolic left ventricular (LV) stiffness, which is attributed to myocardial fibrosis and elevated cardiomyocyte stiffness . In addition, the importance of metabolic risk factors, such as diabetes mellitus type II (DMII), for diastolic LV dysfunction was investigated.n = 36) and SHF (n = 43) patients and perioperatively in AS patients (n = 67). Biopsies showed no evidence of infiltrative or inflammatory myocardial disease. Biopsies were analysed for structural and biochemical characteristics using histomorphometry, electron microscopy, immunohistochemistry and gel electrophoresis, respectively. Single cardiomyocytes were isolated from the biopsies, permeabilised and stretched to 2.2 μm sarcomere length for force measurements, including cardiomyocyte Fpassive.Methods: All patients were free from obstructive coronary disease. We used a translational ‘bed-to-bench’ approach, relating clinical parameters to structural, functional and biochemical characteristics of the myocardium and cardiomyocytes through procurement of LV endomyocardial biopsies, performed transvascularly in DHF  acutely lowered cardiomyocyte Fpassive, through phosphorylation of titin N2B. The larger fall in Fpassive after PKA and PKG administration in DHF implies a relative phosphorylation deficit of titin N2B in DHF. Indeed, myocardial cyclic guanosine monophosphate (cGMP) expression and PKG activity were profoundly lower in DHF than in SHF and AS, which related to higher myocardial nitrosative/oxidative stress in DHF. In DHF, downregulation of nitric oxide-cGMP-PKG signalling with subsequent hypophosphorylation of titin and increased cardiomyocyte stiffness could represent a novel mechanism contributing to elevated diastolic LV stiffness in DHF, possibly associated with the high prevalence of metabolic risk factors in DHF.Results: DHF patients had a higher prevalence of obesity and more frequently had hypertension (compared with SHF) and DMII (compared with AS). Concentric LV remodelling and hypertrophy were observed in both DHF and AS patients with similarly increased cardiomyocyte diameter, in contrast to eccentric remodelling in SHF. Cardiomyocyte filamentary density was higher in DHF than in SHF, whereas interstitial myocardial fibrosis was similar in DHF and SHF, but increased in AS. Diabetes increased diastolic LV stiffness in all groups through distinct mechanisms with increased fibrosis and advanced glycation endproduct deposition contributing relatively more in SHF and increased cardiomyocyte FConclusion: DHF and SHF are distinct HF phenotypes because of unequal myocardial structure and function.Loek van Heerebeek.Department of Physiology, VUMCE-mail: l.vanheerebeek@vumc.nlThe first part of the thesis concerns treatment strategies for acute coronary syndromes (ACS).For patients presenting with non-ST-elevation (NSTE)-ACS, two treatment strategies have been compared extensively in the past decade: a routine invasive strategy (routine angiography and revascularisation) and a selective invasive or conservative strategy .One chapter includes the long-term outcomes of the ‘Invasive versus Conservative Treatment in Unstable coronary Syndromes’ (ICTUS) trial in which these strategies were compared. At 5-year follow-up, we could not demonstrate a benefit of a routine invasive strategy in reducing death or myocardial infarction (MI) in patients with NSTE-ACS and elevated troponin T, irrespective of the patients’ baseline risk profile.These data were pooled with two other large clinical trials in which these two strategies were compared: FRISC-II and RITA-3. In the patient-pooled data of these trials (the FRISC II-ICTUS-RITA-3: FIR collaboration), we showed that a routine invasive strategy reduces long-term cardiovascular death or MI and the largest absolute effect was seen in higher-risk patients. The discrepancy between the above results is probably explained by the intensity of revascularisation in the treatment arms. A high intensity of revascularisation was observed in the selective treatment arm in ICTUS, while a relatively low intensity was observed in the selective treatment arm in FIR.After the publication of these results, the routine invasive strategy was endorsed the highest level of recommendation for high-risk patients in European and American clinical guidelines.Using the Swedish national SWEDEHEART database to assess trends in the implementation of these treatment strategies, we observed an increase in the use of a routine invasive strategy in NSTE-ACS patients over a 12-year course.An important point in the discussion on treatment strategies is the ‘early hazard’ of the routine invasive strategy, composed of procedure-related MIs. Using the FIR database and a critical appraisal of literature, we described that these procedure-related MIs probably do not have large clinical consequences, in contrast to spontaneously occurring MI.The second part of the thesis concerns risk stratification in acute coronary syndromes.In patients with NSTE-ACS, we have shown the prognostic value of qualitative assessment of the baseline electrocardiogram. Furthermore, the prognostic value of the novel biomarker growth-differentiation factor 15 (GDF-15) for long-term outcomes is described.In patients with ST-elevation MI (STEMI), we describe that the combination of different biomarkers  improves prognostication. Furthermore, the use of a simple risk score based on these biomarkers identifies a high-risk subgroup for mortality. The simple risk score was validated in an independent database from Groningen, the Netherlands. In order to further explore the association between the risk score and higher mortality risk, we assessed the association between this score and several cardiovascular mechanistic markers of outcomes. The multimarker risk score was associated with angiographic, electrocardiographic and cardiac magnetic resonance mechanistic markers of outcomes, and our data show the ability to identify patients at high-risk of sub-optimal reperfusion and cardiac magnetic resonance outcomes who might benefit most from adjuvant treatments in STEMI.P. DammanDepartment of Cardiology, Academic Medical Center - University of Amsterdam, Amsterdam, the Netherlands, e-mail:P.Damman@amc.uva.nlAortic stenosis is a common valvular heart problem of which its prevalence increases with age. Advanced age and associated comorbidities often render these patients less amenable to surgical aortic valve replacement (AVR). In the quest for development of less invasive therapies for high-risk patients with cardiac valve disease, catheter-based aortic valve implantation (TAVI) via a peripheral blood vessel was introduced in 2004 as a novel treatment modality. Despite its advantages, TAVI remains an invasive procedure used in high-risk patients which is invariably associated with substantial risks as demonstrated in this thesis.Our studies show that TAVI is associated with ≥1 (non)cardiovascular and/or permanent pacemaker implantation in 59 % of the patients while TAVI is truly uncomplicated in 41 %. Nevertheless, complication rates declined as a result of experience, and improvements in technique and technology  and, eventually the use of filters placed in the cerebral arteries that capture embolic debris that is liberated during the procedure.Acute kidney injury (AKI) occurred in 21 % of the patients following TAVI of whom 2 % needed temporary haemodialysis. Blood transfusion therapy was the strongest predictor of AKI while both transfusion and AKI predicted early and late mortality. Interestingly, patients with baseline anaemia (57 % of the cohort) had less blood loss but received more blood transfusions in comparison with patients without anaemia before TAVI, suggesting either an unconscious or better control of haemostasis during TAVI in patients with baseline anaemia and/or a lower threshold for administering transfusion during TAVI in such patients. Therefore, TAVI outcomes may be improved by a more restrictive use of transfusions, which should be directed by more strict guidelines for blood transfusion therapy in addition to optimisation of haemoglobin levels before TAVI.The ongoing cycle of iterations in design, increase in clinical experience and ongoing clinical research assessing the role of TAVI relative to AVR but also observational cohort research in large series of patients who are more close to most patients seen in clinical practice will lead to ongoing improvements in outcome. Critical assessment in accordance with clinical and scientific principles will boost the future of TAVI to the benefit of care of patients with valvular heart disease. The technique will not be restricted to the aortic valve.R-J. NuisDepartment of Cardiology, Erasmus MC, Rotterdam, the Netherlands, e-mail:r.nuis@erasmusmc.nlReferences1. van der Wall EE, Schalij MJ, Umans V, van Gilst WH. Einthoven dissertation prizes 2011. Neth Heart J. 2012;20:240–4. doi: 10.1007/s12471-012-0280-z.2. van der Wall EE, van Gilst WH, Schalij MJ, Umans V. Einthoven dissertation prizes 2012. Neth Heart J. 2013;21:256–61. doi: 10.1007/s12471-013-0404-0.