South Africa is experiencing a widespread drug-resistant tuberculosis epidemic, although data are limited regarding the current situation. This study finds that the extensively drug-resistant tuberculosis (XDR-TB) incidence in KwaZulu-Natal increased to 3.5 cases/100,000 (776 cases) in 2011-2012. XDR-TB cases are widely distributed geographically, with the majority of districts experiencing a rise in incidence. Extensively drug-resistant tuberculosis (XDR-TB) is a growing public health threat and has been identified from 92 countries, to date ,2. XDR-TSince the initial reports of XDR-TB, there have been notable investments in combatting the epidemic in SA. Increased political commitment and funding has resulted in a multi-sectored response among stakeholders. Community education and mobilization activities have increased awareness among patients and providers to seek early testing and referral for treatment, as well as prevent nosocomial transmission. Decentralized care for drug-resistant TB to regional and district hospitals has facilitated earlier treatment with second-line drugs. Provincial and national TB reference laboratories have improved quality assurance of diagnostic testing and strengthened surveillance systems –11. ThesEvidence from successful national TB control programs in Estonia, Latvia, Hong Kong, Singapore, and the United States have demonstrated declines in drug-resistant TB incidence, though the reversal of these epidemics was gradual even with intensive interventions . There hKwaZulu-Natal is the second most populous province in SA, with 10.3 million people. It is divided into 11 health districts with 74 provincial hospitals and 667 provincial clinics and community health centers. The provincial TB incidence is 1,156 per 100,000 and the HIV prevalence is 15.8% among those above 2 years of age .This cross-sectional study analyzed culture and drug-susceptibility testing (DST) records of the provincial TB referral laboratory in KwaZulu-Natal. All provincial TB cultures were performed at this laboratory as part of routine medical care. South African national guidelines recommend DST for TB suspects who have defaulted or failed treatment, TB patients who have repeatedly positive smear microscopy results, and people at high risk of drug-resistant TB, including MDR and XDR-TB contacts, health care personnel and prisoners.TB cultures are performed using the BACTEC Mycobacteria Growth Indicator Tube (MGIT) 960 system. MGIT-960 positive cultures undergo line probe assay (LPA), ; any LPA-resistant samples undergo DST using the 1% proportion method on Middlebrook 7H10 agar for the following drugs: isoniazid, rifampin, streptomycin, ofloxacin, and kanamycin. We included all sputum specimens with culture-confirmed XDR-TB collected between October 2010 and December 2012. Patients with multiple XDR-TB specimens were regarded as a single case with the earliest date of specimen collection selected.To describe the geographic distribution of XDR-TB, government health facilities from which an XDR-TB sputum sample was sent were grouped by district. We calculated simple frequencies to determine the proportion of cases identified by each district and incidence rate per 100,000 population. Provincial census data from 2011 was used to obtain the population for each district . PercentThe study protocol was approved by the Institutional Review Boards (IRB) at Emory University (#00060394), Albert Einstein College of Medicine, University of KwaZulu-Natal and the KwaZulu-Natal Department of Health. As these samples were collected for routine clinical care, patients were not asked to provide informed consent at the time of the clinical encounters. For the intentions of this study, there was no requirement for informed consent since all data used were previously collected during the course of routine medical care and did not pose any additional risks to the patients. Patient information was anonymized and de-identified for analysis.Between October 2010 and December 2012, a total of 776 XDR-TB cases were identified in KwaZulu-Natal province, equating to a province-wide incidence of 3.5 XDR-TB cases per 100,000 population. Women represented over half  of the cases. The median age was 33 years . Although the *incidence varied by district, nearly all districts had an incidence of greater than 1.0 XDR-TB cases per 100,000 population, with the highest incidences in Umzinyathi , Ethekwini , and uMgungundlovu  .The average number of XDR-TB cases in the province each year increased from 270 to 358 and the overall incidenc e increased by 13%, compared to 2007 . XDR-TB South Africa remains in the top 10 countries with the highest burden of drug-resistant TB worldwide . Our stuA surprising finding from this study is that investments in drug-resistant TB control have not resulted in reduced case rates in most districts. Interestingly, the most dramatic increases have been in the rural districts, suggesting improved access to health care services could be an important reason for the increase. Improved patient and healthcare provider education may have paradoxically led to increased case detection resulting in higher numbers for the current study compared with a false low baseline in 2007. In addition, use of the Hain line probe assay (LPA) since 2009, followed by introduction of GeneXpert in 2011 may have contributed to increased testing and case detection province-wide. Further analysis of the molecular epidemiology of XDR-TB may be a more sensitive indicator of the impact of control measures, namely infection control interventions to prevent nosocomial transmission, and earlier diagnosis and access to treatment to reduce the infectious period. Continued investments in prevention, care and treatment are needed to sustain progress. Initial resource allocation may be costly, but are cost-effective in maximizing health benefits . This isHIV infection has been a major driving force on the escalating burden of TB throughout sub-Saharan Africa. In KwaZulu-Natal province, 65% of incident TB cases and over 80% of drug-resistant TB cases are co-infected with HIV ,17. AntiA major strength of this study is the centralized laboratory for culture and drug-susceptibility testing (DST) of TB patients in KwaZulu-Natal at the time of this study that allowed for complete capture of all XDR-TB diagnoses in the province. A limitation, however, is variation in provider adherence to TB culture and DST guidelines, which may introduce ascertainment bias into our study. If providers were more likely to have requested culture and DST in 2011–2012 than previously, it may account for the rise in incidence observed in many districts. Data were not available to examine changes in culture-taking practices since 2007. It should also be noted that the target group for DST are high-risk patients for drug resistance; thus, the rates may be over-represented. However, the same DST policy was in place in 2007 and the validity of the trend would remain true. Patients who attended private health facilities were not included in this analysis; the role of private laboratories in diagnosing XDR-TB is very limited, and literature describing these data was not available. Lastly, district-level data for MDR-TB was not readily available for the study timeframe to allow for comparisons of changes in MDR-TB vs. XDR-TB case rates. However, MDR-TB case counts for KwaZulu-Natal province have remained relatively stable from 2005 through 2010, the latest year for which reliable data are available .KwaZulu-Natal province has the highest prevalence of XDR-TB within South Africa and has implemented multiple programmatic initiatives to combat this complex epidemic. XDR-TB rates in other provinces may differ, in part due to differing HIV prevalence, socioeconomic factors, access to MDR-TB treatment and diagnostic testing capability. The last national TB drug resistance survey was conducted in 2001–2002, but specimens were only tested for first-line drugs and data on XDR-TB were unavailable .


Patients with severe headache who undergo psychological treatment at the Danish Headache Center, a tertiary multidisciplinary treatment centre, often report positive effects on their perceived general well-being and ability to work. However there is no agreement on which quality of life (QoL) instruments are useful for monitoring outcome of psychological treatment.To assess the effect of psychological treatment in headache patients using the DOLOtest, a newer validated Health-Related QoL instrument.All patients referred to psychological assessment at the Danish Headache Center in 2012 underwent an initial interview and 129 were offered psychological treatment. Treatment was either group treatment or individual therapy. All participants were given the DOLOtest, at baseline, 1st, 5th and last therapy session and at six-month follow-up. DOLOtest-scores were compared using t-test.Of the patients offered treatment, 100 accepted, 93 completed, and 71 were reached at six-month follow-up. There was a significant improvement on the following domains at six-month follow-up compared to baseline: pain (p=.039), problems with more strenuous physical activities (p=.037), reduced energy and strength (p<.001), and low spirit (p=.007). Headache frequency was also significantly reduced from 23 to 17 days/month (p<.001).The DOLOtest may be a valuable multidimensional instrument to assess QoL in patients with severe headache, and to monitor outcome of psychological treatment in future trials.No conflict of interest.


It is widely held that the occupational well-being of physicians may affect the quality of their patient care. Yet, there is still no comprehensive synthesis of the evidence on this connection.This systematic review studied the effect of physicians’ occupational well-being on the quality of patient care.We systematically searched PubMed, Embase, and PsychINFO from inception until August 2014. Two authors independently reviewed the studies. Empirical studies that explored the association between physicians’ occupational well-being and patient care quality were considered eligible. Data were systematically extracted on study design, participants, measurements, and findings. The Medical Education Research Study Quality Instrument (MERSQI) was used to assess study quality.Ultimately, 18 studies were included. Most studies employed an observational design and were of average quality. Most studies reported positive associations of occupational well-being with patient satisfaction, patient adherence to treatment, and interpersonal aspects of patient care. Studies reported conflicting findings for occupational well-being in relation to technical aspects of patient care. One study found no association between occupational well-being and patient health outcomes.The association between physicians’ occupational well-being and health care’s ultimate goal—improved patient health—remains understudied. Nonetheless, research up till date indicated that physicians’ occupational well-being can contribute to better patient satisfaction and interpersonal aspects of care. These insights may help in shaping the policies on physicians’ well-being and quality of care.The online version of this article (doi:10.1007/s12529-015-9473-3) contains supplementary material, which is available to authorized users. Well-being of physicians is a growing concern , 2. CompHigh levels of work-related well-being can be conceptualized as occupational well-being, which is defined as a positive experience with or evaluation of one’s work , 13, invMost research on physicians’ well-being has so far focused on negative indicators. In line with the positive psychology approach , 22, it Before starting the review, all authors agreed upon the eligibility criteria, search strategy, study selection, data extraction, and quality assessment. The review process was reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) standards .Studies were considered to be eligible, when they examined the association between physicians’ occupational well-being and the quality of patient care. This resulted in the following eligibility criteria. First, the study included empirical data; non-empirical articles, such as letters, comments, and editorials, were excluded. Second, physicians had to comprise the entire sample or results had to be available for physicians as a subgroup. Third, in order to study our research question on the impact of occupational well-being on patient care quality, we included only articles that conceptualized occupational well-being as predictor or exposure variable and patient care quality as the outcome variable. Non-English language articles were not included.We searched the electronic databases MEDLINE, Embase, and PsycINFO from inception until August 12, 2014. A preliminary search was conducted with assistance of a clinical librarian to develop our search strategy and specify our keywords. We used both free text and MeSH (MEDLINE) or thesaurus (Embase and PsycINFO) terms on the following subjects: physicians, occupational well-being, and quality of patient care.Occupational well-being was defined as a positive experience with or evaluation of work , 13 and We used the definition for quality of care provided in a framework introduced by Donabedian (1966)  which isOne author (RS) performed the search, which was duplicated by a clinical librarian. Subsequently, one author (RS) screened both title and abstract. Clearly, irrelevant studies were excluded at this point when both title and abstract did not include physicians, occupational well-being, or quality of patient care. Non-empirical articles  were also excluded at this stage.After screening, titles and abstracts of the remaining studies were independently reviewed by two authors (RS and BB). If abstracts were unavailable, the full-text article was retrieved and reviewed by one author (RS), following the same procedure as for the abstracts. If full text was unavailable as well, two authors (RS and BB) independently reviewed each title. Two authors (RS and BB) independently reviewed the full texts of all remaining articles. When no consensus was reached, a third author (KL) reviewed the article .Data on study design, participants and setting, measures and measurements, and study findings were extracted by one author (RS) and duplicated by a second author (BB). When no consensus was reached, a third author (KL) assisted.We used the Medical Education Research Study Quality Instrument (MERSQI)  to assesWe intended to perform a meta-analysis to pool the findings of studies. However, meta-analyses can only yield valid results if the heterogeneity between studies is limited. In this review, the heterogeneity between studies was large, so no meta-analysis could be performed. We presented the findings of the individual studies descriptively in the text and tables. We categorized the different findings based on the different forms of occupational well-being as well as the different patient care quality categories of the Donabedian framework technical aspects of care  [interpersonal aspects of care  [overall processes  [patient satisfaction [patient adherence to treatment [Occupational well-being was measured with the following constructs: job satisfaction (14 studies) , 43–46,  errors) , 43–45, atients) , 32, oveof care) , 38, 41,sfaction , 40, 46,reatment   . CongrueOne study researched occupational well-being in relation to patient health outcomes. This study showed that job satisfaction of physicians was not associated with patients’ self-reported pain and depressive symptoms .This systematic review indicates that occupational well-being could positively contribute to patient satisfaction –36, 40, The findings of this review indicate that patients of physicians with high levels of occupational well-being were more satisfied with their treatment –36, 40 aAs physicians with high levels of occupational well-being experience less stress and more positive emotions , 13, 20,Ultimately, the health care system is targeted at achieving better health and well-being for patients . A vitalAlthough most research on occupational well-being in relation to aspects of patient care quality shows rather consistent results, findings for technical aspects of patient care were conflicting. Technical aspects of patient care refer to all medical or clinical behaviors that physicians undertake in their treatment for patients, i.e., prescribing medicine or performing a physical examination . Our revSome studies in this review studied specific aspects of patient care ; others reported overall patient care quality and did not specify the specific content or aspects of patient care quality , 38, 41.The majority of the included studies in this review focused on job satisfaction as a measure of occupational well-being; other forms of occupational well-being are understudied. For example, we only found one study on work engagement. Compared to job satisfaction, other forms of occupational well-being such as work engagement, have shown to induce larger effects on work performance in non-medical professions , therefoLike many systematic reviews, our review could have suffered from publication bias . Based oWe included studies from many countries and different health systems. Because of the differences between health care systems, the working conditions of physicians and, ultimately, their occupational well-being could differ between systems , 59. TheIn the last decade, research and society increasingly focused on the prevention of burnout or other negative forms of physician well-being, in order to prevent physicians from delivering suboptimal patient care . As an aAs patient care can increasingly be characterized by multidisciplinary teamwork , 63, futAlthough there is substantial research on potential consequences of physicians’ well-being, the impact on patient care’s central goal—improved patient health—remains understudied. Nonetheless, research provided clarity on the association of occupational well-being with other aspects of patient care quality. This research found that physicians’ occupational well-being could positively contribute to patient satisfaction and the quality of interpersonal aspects of care. Therefore, physicians’ occupational well-being not only is vital to a healthy physician workforce, but also may contribute to better treatment and positive experiences of patients .ESM 1(DOC 38 kb)Below is the link to the electronic supplementary material.


Inter-arm blood pressure (BP) difference has been associated with ischemic stroke. Local atherosclerosis of stroke differ among vulnerable individuals, whereas intracranial arterial stenosis (ICAS) is more frequently affected Asians, and extracranial arterial stenosis (ECAS) is more prevalent among whites. We hereby sought to explore the association of inter-arm BP difference with ICAS and ECAS in stroke-free hypertensive patients in Chinese population. All the 885 subjects were evaluated of ICAS and ECAS through computerized tomographic angiography. Both arm BP was measured simultaneously by Vascular Profiler-1000 device. In the continuous study, ICAS was significantly associated with age, male, average brachial SBP, diabetes, anti-hypertensive treatment and inter-arm DBP difference. ECAS was associated with age, inter-arm SBP and LDL. In the categorical study, subjects with the top quartile of inter-arm DBP difference (≥4 mmHg) showed significantly higher risk of ICAS . And the participants with the top quartile of inter-arm SBP difference (≥6 mmHg) showed significantly higher risk of ECAS . In conclusion, we reported a diverse association of inter-arm SBP/DBP difference with the ICAS/ECAS. Inter-arm DBP difference might be the early symbol of ICAS in Chinese population, which need further verification in long-term cohort study. Stroke is the second leading cause of death and the most common cause of adult disability worldwide26A difference in BP readings between arms can be observed in various populationsThis study was undertaken within the framework of an ongoing cross-section and prospective study in China, which was a computerized tomographic angiography (CTA) based study of intra- and extracranial asymptomatic artery stenosis and stroke outcome in stroke-free hypertension patients. Participants of current study were recruited from hypertension outpatients who were identified in Xinzhuang Community hospital between May 2012 and December 2015, and then referred to Ruijin Hospital, a general hospital in Shanghai. Patients with hypertension were invited to participate in the study if they had ≥2 cardiovascular risk factors defined according to the Chinese hypertension guidelinesThe study protocol was approved by the ethics committee of Ruijin Hospital and written informed consent was obtained from all participants. All experiments were performed in accordance with relevant guidelines and regulations of ethics committee of Ruijin Hospital.Both arm BP was measured simultaneously by the use of the Vascular Profiler-1000 device , an oscillometric cuff technique. Trained technicians placed the pressure cuffs on both arms and performed the measurement after the subject had rested for ≈10 minutes in the supine position. The device simultaneously and automatically measures the both arm BPs twice, and then discards the first measurement and only stores the second one in the database.Body weight and height were recorded with participants wearing light indoor clothing and no shoes. Clinical information was collected by interview, including smoking and drinking habits, current drug intake, personal history of diabetes, etc. Current smokers were defined as those who had smoked cigarettes on one or more days in the past 30 days. serum concentrations of total cholesterol (TC) and low-density lipoprotein cholesterol (LDL), were performed in the Central Laboratory of Ruijin Hospital  using the standard protocols.CTA was performed with a 64-section helical CT scanner  as previous describedP values were 2-tailed, and a P value of <0.05 was considered statistically significant.For database management and statistical analysis, we used SPSS software . Descriptive statistics for patients with or without ICAS were compared using a Pearson Chi-square test for categorical variables and Student t test for continuous variables. In continuous analyses, stepwise logistic regression in forward conditional method was performed to test the association of inter-arm SBP/DBP (1 mmHg) difference and other risk factors with ICAS/ECAS. The variables tested in the equation included age, sex, body mass index, current smoking and drinking status, diabetes, low-density lipoprotein, average brachial SBP, heart rate, anti-hypertensive treatment, statin use, inter-arm SBP/DBP difference. In categorical analyses, we tested the association of quartiles of inter-arm SBP/DBP difference (≥6 mm Hg or ≥4 mm Hg) and increased inter-arm SBP and DBP differences (≥10 mm Hg or ≥5 mm Hg) with ICAS/ECAS by the adjustment for age, sex, body mass index, current smoking and drinking status, diabetes, low-density lipoprotein, average brachial SBP, heart rate, anti-hypertensive treatment, statin use. All Of the 885 participants, 418 had no ICAS or ECAS, 191 had ICAS only, 129 had ECAS only, and 147 had concurrent extraintracranial artery stenosis . CompariIn order to detected all the independent risk factors associated with ICAS/ECAS, we performed a stepwise logistic regression in forward conditional method, including the variables of age, sex, body mass index, current smoking and drinking status, diabetes, low-density lipoprotein, average brachial SBP, heart rate, anti-hypertensive treatment, statin use, and inter-arm SBP/DBP difference (1 mmHg). Variables potentially associated with ICAS/ECAS were shown in The categorical analyses of inter-arm SBP/DBP and ICAS/ECAS were in Then, the severity of ICAS/ECAS was compared between patients with the top quartile of inter-arm SBP/DBP and the others. Comparing with the subjects with the inter-arm DBP <4 mmHg (5.3%), the subjects in the top quartile of inter-arm DBP difference (≥4 mmHg) had more moderate to severe ICAS (7.1%) (P = 0.028) . In contMoreover, patients in the highest quartile of inter-arm DBP difference showed higher frequency of multiple ICAS (29.1%) than the rest of participants (16.6%) (P = 0.004) . The patFurthermore, the patients with inter-arm SBP difference ≥10 mmHg suffered more severe ECAS and involved ECAS vessels. While the patients with inter-arm DBP difference ≥5 mmHg suffered more severe ICAS and involved ICAS vessels .In this stroke-free Chinese hypertension population who underwent both intra- and extracranial CTA, a diverse association of inter-arm SBP/DBP difference with the ICAS/ECAS was detected. The inter-arm SBP difference was only significantly associated with the presence of ECAS and the severity of ECAS. On the contrary, the inter-arm DBP difference was only associated with the presence of ICAS and the severity of ICAS.et al. had explored the risk factors of ICAS and ECAS in 425 stroke-free Japanese patients, they found that the independent predictors of ECAS were age, hyperlipidemia and ischemic heart disease (IHD), while those for ICAS were age, hypertension, diabetes mellitus and IHDIt was a very interesting thing that the different component of BP might relate to the stenosis in different part of the arterial tree separately. Although both ICAS and ECAS were process of atherogenesis and had the similar vascular risk factors, the distribution of atherogenesis varied among different populations, whereas patients of Asian possessed more ICASet al. explained that the DBP might play more important role in the early phase of cardiovascular disease. In addition, Hu et al. had also found that inter-arm DBP difference but not SBP difference was associated with the flow-mediated dilatation of arm, which was an early index of arterial endothelium lesionBP difference between arms was a common phenomenon which could be observed in various populationset al. had found that ICAS was not independently correlated with carotid intima-media thickness and conferred that atherosclerosis might start earlier in ICAS than in ECAS in Chinese populationECAS was the main lesion in the arterial tree in whites and was considered as an important risk factor for cardiovascular diseases. Inter-arm SBP difference had long been associated with ECAS, so that it was undoubtedly that the increased SBP difference between arms might be an indicator for fatal and nonfatal events in European population. However, ICAS accounted for 30–50% of ischemic stroke and >50% of transient ischemic attack in AsiansWe acknowledge that there were several limitations of the present study. First, as a cross-sectional study, we could not infer any causal relationship between inter-arm BP and ICAS/ECAS. Second, the majority of subjects were under antihypertensive treatment, which induced that the BP differences between arms were lower than the previous findings in hypertension population. But the prevalence of BP difference was similar with the results in general populationIn conclusion, we found a diverse association of inter-arm SBP/DBP difference with the ICAS/ECAS. Inter-arm DBP difference might be the early symbol of ICAS in Chinese population. In addition, the further long-term cohort study was warranted to elucidate the concrete effect of inter-arm BP difference on the asymptomatic ICAS/ECAS.How to cite this article: Wang, Y. et al. Association of Inter-arm Blood Pressure Difference with Asymptomatic Intracranial and Extracranial Arterial Stenosis in Hypertension Patients. Sci. Rep.6, 29894; doi: 10.1038/srep29894 (2016).


Neuroplasticity in the motor system has been extensively investigated by functional MRI (fMRI) in multiple sclerosis (MS) patients; we report results obtained by both task-related and resting-state fMRI studies. Furthermore, the possibility to manipulate neuroplasticity in MS will also be addressed.The first works on fMRI and the motor system reported greater cortical activation in patients with relapsing–remitting (RR) or secondary progressive (SP) MS than in healthy subjects (HS) during a simple finger flexo-extension hand movement , 2. ThisFunctional MRI activation during a motor task should be viewed as a dynamic phenomenon that changes during the disease course. In a single-case study, Reddy and collaborators reported a progressive reduction in cortical over-activation paralleling motor improvement after a clinical relapse and NAA recovery at spectroscopy . We longNew insights come from task-related fMRI studies in different MS phenotypes. In a cross-sectional study, Rocca et al. evaluated patients with CIS, RRMS, or SPMS . They foThe MS widespread microstructural damage, as shown in combined diffusion tensor imaging (DTI) and fMRI studies, correlates with increased sensorimotor network activation , 11. A sMultiple sclerosis patients display greater cortical activation than HS even during passive movements of a limb, which, unlike active movements, are not affected by individual motor impairment , 14. In Recent years have witnessed a growing interest in the study of resting-state functional connectivity (rs-FC) in MS aimed at understanding alterations in the intrinsic functional architecture of the MS brain and their role in disease progression and clinical impairment. Resting-state fMRI (rs-fMRI) can be used to identify anatomically separate, though functionally connected, brain regions configuring specific RS networks , 17; unlSome studies have reported a reduced rs-FC in the sensorimotor network in MS. Lowe et al. demonstrated a bilaterally reduced rs-FC in the motor cortices in patients with varying degrees of MS, both in the resting state and during finger tapping, thereby showing that both these fMRI approaches differentiate patients with MS from controls . In a laIn contrast, other studies have reported increased rs-FC in the motor network in early MS  and in RSeveral factors may explain the discrepancies between studies reporting decreased or increased rs-FC in MS, including differences in the patients’ clinical characteristics , number of subjects enrolled, and methods used for both image acquisition and analysis. However, when the findings of these studies are considered together, they point to a functional reorganization of the motor network in MS patients, which is present from the earliest disease stages.More recently, some studies attempted to explore the clinical correlate of motor rs-FC alterations in MS. Indeed, although the ability of rs-fMRI to detect brain functional reorganization in MS has been proved, the role of FC alterations in the pathogenesis of MS, as well as the potential relationship between resting-state network reorganization and clinical disability, remain unclear.In a recent work, Janssen and collaborators demonstrated reduced intra-network connectivity in the motor network in RRMS patients, associated with higher levels of disease severity, thus pointing to the possibility that resting-state changes may serve as a biomarker of disease progression . On the The objectives of neuroimaging studies should be to distinguish between beneficial and non-beneficial  neuroplastic changes and to understand whether, and if so how, we can modulate brain plasticity to enhance cortical activity changes associated with a clinical improvement. Studies on the effects of drugs or motor practice on cortical activity are particularly interesting in this regard –29.In a double-blind, crossover, placebo-controlled study, we evaluated the short-term effect of a single dose of 3,4-dyaminopyridine (DAP), a K-channel blocker shown to improve motor function and fatigue, in RRMS patients with mild disability . fMRI duThe effects of a short motor training in MS patients have been reported in two task-related fMRI studies, though with discrepant results , 29. MorTomassini et al. showed that both short- and long-term (15 days) visuo-motor practice induced the same level of improvement in HS and patients . MoreoveThis conclusion is supported by our recent work on FC changes in early RRMS patients , who werFunctional MRI studies exploring the motor system in MS have demonstrated the ability of the brain to reorganize itself as a response to the disease. Functional reorganization develops in relationship with structural disconnection, making the structural substrate evaluation essential. Despite the undeniable progress in fMRI techniques, clinical interpretation is still controversial and no single technique has proved adequate to predict clinical evolution, ultimately because of the knowledge gap between brain connectivity and function.Future studies integrating rest and task fMRI  might alThe 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.


Older patients are often excluded from e-health projects on account of low IT-literacy levels. This is a barrier for their access to many current and future health care offers. The Food‘n’Go research - an innovation programme - aims to develop, test and implement information technology solutions to increase participation and empowerment of older patients and their families, in relation to frequent problems during and following hospitalisation. The present feasibility study is part of this programme.To test the feasibility and effectiveness of ICT-supported energy- and protein-enforced home-delivered main and in-between meals on older patients discharged from acute hospitalisation in medical wards.A quasi-experimental, non-randomised, controlled feasibility study. The sample consisted of older patients (n=36), 65+ years, admitted to department of internal medicine with a nutritional risk score of 3 or more, discharged to own home.Intervention: Enriched meals were delivered to patients' homes 12 weeks after discharge and a tablet computer to order meals and register intake. Primary effect measure: Muscle strength. Secondary: BMI, dietary intake, HRQoL (EQ5D), depression (GDS5); readmissions, mortality.Technology challenges were not related to participants, but to: the out-of hospital setting; organisational issues such as collaboration between kitchen, research sites and technology staff; and to IT-stability. Although weaker at baseline the intervention group increased their muscle strength in arms and legs more consistently than the control group at 6 and 12 weeks. They further improved their depression score, reported increased HRQoL, increased intake and appetite, and increased energy. Relatives reported positive impact on their level of worry and on the relationship between patient and relatives. NCT02268721.


The Hippo signaling acts as a tumor-suppressor pathway that negatively regulates TAZ and YAP. Increasing evidence supports the activation of TAZ and YAP in breast cancer. Moreover, the Hippo pathway is involved in the biology of non-neoplastic cells residing in the tumor microenvironment. On this basis, we herein assessed TAZ and YAP in triple-negative breast cancer and its surrounding microenvironemnt in order to investigate their impact on pathological complete response (pCR) and tumor recurrence.Sixty-one triple-negative breast cancer patients treated with neoadjuvant chemotherapy were retrospectively evaluated. TAZ and YAP were assessed by immunohistochemistry and classified as positive or negative according to the percentage of tumor-expressing cells, cellular localization, and staining intensity. TAZ and YAP expression was also evaluated in non-lymphocytic stromal cells, tumor-infiltrating lymphocytes (TILs) and endothelial cells. The Pearson’s Chi-squared test of independence was used to test the association between TAZ/YAP and clinical-molecular factors. A multivariate logistic regression model was generated to identify variables impacting pCR. The Kaplan-Meier method and the log-rank test were used for estimating and comparing survival curves. Cox proportional regression models were built to evaluate the risk of recurrence for the variables considered. Internal validation was carried out with a re-sampling without replacement method.p = 0.029). Next, the combined expression of TAZ and YAP was associated with shorter disease-free survival (DFS) in multivariate analysis . The robustness of these findings were internally validated.We did not observe any impact on pCR rate when TAZ and YAP were addressed singularly. Conversely, the combined expression of YAP in tumor cells and non-lymphocytic stromal cells was an independent predictor of reduced pCR rate in the multivariate model  contains supplementary material, which is available to authorized users. The Hippo pathway is a regulator of tissue growth that in neoplastic diseases is considered a tumor suppressor signaling . The HipIn breast cancer (BC), the activation of the TAZ/YAP-transcriptional program feeds a number of tumor-promoting functions . An impoBeyond cancer cells, the Hippo pathway is involved in the biology of other cell types residing in the tumor microenvironment. Maintenance of cancer-associated fibroblast (CAFs) properties was tied to YAP activation . MoreoveThe growing body of evidence connecting TAZ and YAP to BC biology prompted us to translate preclinical findings into clinical investigations. As a general principle, the focus was placed on the neoadjuvant setting, which is increasingly exploited for the identification of cancer biomarkers. This is rooted in the link between an intermediate endpoint, namely pathological complete response (pCR) after neoadjuvant chemotherapy (NACT), and survival outcomes . In the Herein we present results from triple-negative BC (TNBC), the most aggressive BC form. TAZ and YAP were assessed by immunohistochemistry in pretreatment biopsies related to 61 stage II-III TNBC patients who received anthracycline-taxane-based NACT. TAZ and YAP were assessed in tumor cells, and in non-neoplastic cells including endothelial cells, non-lymphocytic stromal cells, and tumor-infiltrating lymphocytes (TILs).This study was planned with the following goals: i) describing the topographic expression of TAZ/YAP in TNBC, ii) investigating the association between TAZ/YAP and pCR, iii) exploring the connection between TAZ/YAP and survival outcomes, and iv) providing clues on the role of YAP as an oncogene or an oncosuppressor in TNBC.Sixty-one TNBC patients treated with NACT were included in this retrospective analysis. Patients were considered eligible if NACT was completed, data were available on clinical-pathological features including stage, estrogen receptor (ER) status, progesterone receptor (PgR) status, tumor grade, Ki-67 and pCR, and tumors did not show HER2 overexpression/amplification according to ASCO-CAP guidelines. In this analysis, six patients with weak expression (≤10) of either ER or PgR in diagnostic biopsies were included, given that in these tumors hormone receptor status switched from weak positivity to negativity in residual cancers. For these tumors, a basal-like molecular portrait may be hypothesized in light of the fact that up to 20 % of basal-like cancers express the ER . StromalNACT consisted in anthracycline-taxane-based chemotherapy regimens, either with a concomitant or sequential schedule, as detailed elsewhere . Seven pN = 61), the impact of TAZ/YAP expression on survival outcomes was evaluated in 57 patients, considering that we were unable to retrieve this information for four patients. Disease-free survival (DFS) was defined as time from diagnosis until locoregional, invasive contralateral or distant recurrence, or death due to any cause.While the impact of TAZ/YAP on pCR rate was evaluated in the entire cohort  anti-TAZ  at the dilution of 1:400 and the MoAb anti-YAP  at the dilution of 1:200.For the evaluation of TAZ and YAP in cancer cells, their expression was reported both in terms of percentage of tumor-expressing cells and staining intensity . For tumors with both nuclear and cytoplasmic expression, staining intensity and percentage of tumor-expressing cells were independently assessed in, and reported for, the two cellular compartments.neg, YAPneg) or positive  on the basis of their cellular localization, staining intensity, and percentage of tumor-expressing cells. TAZ/YAP positivity was defined as a distinct, moderate (2+) or strong (3+) nuclear immunoreactivity in ≥10 % of neoplastic cells [Tumors were classified as negative  blinded to treatment outcomes independently evaluated immunoreactivity. Discordant cases were further reviewed by a third observer (MM).This retrospective study has been conducted in accordance with the Declaration of Helsinki and approved by the Ethic Committee of “Regina Elena” National Cancer Institute of Rome, the coordinating centre. Written informed consents were secured before chemotherapy from any single participant.Descriptive statistics were used to summarize study participants’ characteristics. Continuous data were reported as mean and standard deviation, and categorical data by frequencies and percentage values.The Pearson’s Chi-squared test of independence (2-tailed) and the Fisher Exact test, when appropriate, were used to assess the relationship between TAZ/YAP and clinical-molecular features and pCR. Survival curves were estimated with the Kaplan-Meier method, and the log-rank test was used for comparisons.To identify independent predictors of pCR, a multivariate logistic regression model was generated with variables that tested significant at the univariate assessment, and the related estimates reported as Odds Ratio (OR) and 95 % Confident Interval (CI). To identify independent predictors of DFS, multivariate Cox proportional hazard models were built with the same modality, and the related estimates reported in terms of Hazard Ratios (HR) and 95 % CI.The risk to obtain an overfitting multivariate model for DFS was controlled through a re-sampling without replacement technique, envisioning the generation of 100 less-powered datasets obtained by randomly removing ~20 % of the original sample. For each simulation, the Cox model was repeated and the replication rate was calculated.We considered statistically significant p values less than 0.05. Statistical analyses were carried out using SPSS software .Clinical-pathological features and treatment outcomes related to the 61 TNBC patients included in this study are summarized in Table As aforementioned, activation of TAZ/YAP promotes multiple oncogenic function in BC cells . TAZ/YAPThe expression of TAZ and YAP in tumor cells , non-lymphocytic stromal cells, endothelial cells, and TILs is summarized in Additional file pos and higher stage (p = 0.030) and YAPpos and higher grade (p = 0.028) .We therefore investigated whether the expression of TAZ or YAP in cancer cells, together with their expression in non-cancerous cells, was able to identify the category of patients with reduced pCR rate. As reported in Table pos/YAPpos) was associated with tumor recurrence , and it was the only significant variable at the multivariate assessment . The consistency of the TAZpos/YAPpos model was internally validated using a re-sampling without replacement method. The replication rates, defined as the percentage of Cox regression models that yielded statistically significant results upon 100 replications in less-powered datasets , were 96 and 66 % with statistical significance set at p <0.05 and p <0.01, respectively.We next investigated whether TAZ and/or YAP impacted DFS. At a median follow-up of 31 months, 19 events were recorded in the 57 evaluable patients. As previously specified in the “Study Participants and procedures” section, post-surgical follow up data were not available for four patients. The pattern of disease recurrence is shown in Additional file In the present analysis we reported on the predictive and prognostic significance of TAZ and YAP expression, assessed both at the tumor and the microenvironment level, in a moderately-sized cohort of TNBC treated with NACT. Results from this pilot study suggested that TAZ/YAP expression might impact on both pCR rate and long-term survival outcomes, and underscore the complexity of the Hippo biology, which needs to be carefully considered in the search for Hippo-related prognostic and predictive biomarkers.To our knowledge, this is the first report evaluating TAZ and YAP jointly in TNBC and its microenvironment and, more importantly, with a clear focus on pCR and recurrence –17. We aFirst, in BC great attention was put toward the identification of biomarkers related to the interactions of cancer cells with neighbor non-neoplastic cells. A number of microenvironment-related biomarkers have been proposed over the past decade, spanning from a wound-response signature denoting the transcriptional response of normal fibroblasts to serum  to the aSecond, given the exploratory nature of this study we exclusively focused on Hippo transducers. Nevertheless, a number of stimuli intersect the Hippo cascade, which either encourage or restrain TAZ/YAP nuclear localization and gene transcription. To appropriately address this issue, a study where TAZ and YAP are evaluated together with further candidate biomarkers has been planned, envisioning the concomitant assessment of i) TAZ/YAP targets (Axl and CTGF ), ii) HiAnother aspect that deserves mention relates to the biological significance of TAZ and YAP in BC. In this setting, TAZ has been defined as an oncogene promoting neoplastic transformation , chemothIntriguingly, survival data (DFS) raised the hypothesis that, in TNBC, both TAZ and YAP are involved, and possibly cooperate, in metastatic dissemination. A plausible explanation is that, albeit TAZ and YAP are closely related proteins, they elicit a partial different array of oncogenic activities. Consistently, the nature of up-regulated genes upon their forced expression in cell lines is partly different . This isNext, we have recently discussed possible strategies for assessing TAZ and YAP by IHC . In our Finally, the growing interest of our group toward the Hippo pathway in BC has fuelled a wave of studies in other BC subtypes, such as hormone receptor-positive/HER2-negative and hormone receptor-positive/HER2-positive BC, and in male BC. Results from these studies will provide a more exact picture on the clinical significance of Hippo transducers in individual BC subtypes.The combined expression of the Hippo transducer YAP in tumor cells and non-lymphocytic stromal cells seemed associated with reduced efficacy of anthracycline-taxane-based NACT in TNBC patients in terms of pCR rate. Moreover, the nuclear co-expression of TAZ and YAP may confer an increased risk of recurrence. Thus, Hippo-related biomarkers deserve larger studies in TNBC.


Cutaneous melanoma carries the potential for substantial morbidity and mortality in the solid organ transplant population. We systematically reviewed the literature published from January 1995 to January 2012 to determine the overall relative risk and prognosis of melanoma in transplant recipients. Our search identified 7,512 citations. Twelve unique non-overlapping studies reported the population-based incidence of melanoma in an inception cohort of solid organ transplant recipients. Compared to the general population, there is a 2.4-fold  increased incidence of melanoma after transplantation. No population-based outcome data were identified for melanoma arising post-transplant. Data from non-population based cohort studies suggest a worse prognosis for late-stage melanoma developing after transplantation compared with the general population. For patients with a history of pre-transplant melanoma, one population-based study reported a local recurrence rate of 11% (2/19) after transplantation, although staging and survival information was lacking. There is a need for population-based data on the prognosis of melanoma arising pre- and post-transplantation. Increased incidence and potentially worse melanoma outcomes in this high-risk population have implications for clinical care in terms of prevention, screening and reduction of immunosuppression after melanoma development post-transplant, as well as transplantation decisions in patients with a history of pre-transplant melanoma. Important advances in solid organ transplantation have led to improved patient survival over recent decades. With prolonged survival, the long-term complications of immunosuppressive therapy have become increasingly important. Decreased immune surveillance after transplant leads to a three- to fourfold increased risk of malignancy compared to the general population,2.Skin cancer is the most common form of post-transplant malignancy, particularly squamous cell carcinoma (relative risk 14 to 82)-6. AlthoWith its increased incidence and significant metastatic potential, melanoma has important implications for the care of transplant recipients. We aim to systematically review the published literature to determine the overall relative risk and prognosis of melanoma in solid organ transplant recipients.On 12 January 2012, electronic literature searches were conducted in Ovid MEDLINE  and EMBASE (1980 to week 2 of 2012) to identify eligible studies using a comprehensive search strategy developed in consultation with an information specialist. The search terms consisted of the following: cancer/neoplas*/tumor/tumour/malignan*/carcin*, or melanoma (expanded), and transplant  and cohort/incidence/prevalence/prognosis.Studies were limited to those published after 1995 in English and French. We included studies that estimated the relative risk or reported clinical outcomes  of melanoma in a population-based inception cohort of solid organ transplant recipients . Studies were not excluded based on a quality assessment.We initially screened all titles and abstracts to exclude articles that were clearly ineligible. We then reviewed full-text articles for all remaining citations. Reference lists from relevant articles were also reviewed for relevant articles. When needed, we obtained additional data from the study authors by email correspondence. If there were studies with more than a 50% overlap in their patient populations , we included data from only the most recent or inclusive study.We pre-specified three main systematic review outcomes: the incidence and relative risk of melanoma diagnosed after solid organ transplantation compared to the general population; the outcomes of melanoma diagnosed after solid organ transplantation (post-transplant melanoma), including recurrence, metastasis and mortality ; and the outcomes of melanoma diagnosed prior to transplantation (pre-transplant melanoma).For articles reporting incidence data, the pooled standardized incidence ratio (SIR) and 95% confidence interval (CI) were calculated using weights from a random effects model. The variation in effect sizes attributable to heterogeneity was quantified using the I-squared statistic. To explore potential sources of heterogeneity, we used meta-regression to adjust for the graft organ type  and the most recent year of transplantation included in the study cohort (>2000 versus ≤2000). All statistical analyses were performed using Stata 12.1.The literature search identified 4,093 citations from Ovid MEDLINE and 6,311 from EMBASE. After removing duplicates, 7,512 unique citations were identified. We eliminated 7,369 citations based on title or abstract. A full-text review of the remaining 143 articles led to the further exclusion of 125 articles, most commonly because the studies were not population-based , liver (N = 2), heart (N = 1) and various solid organ transplants (N = 4) performed in North America, Europe, Australia and New Zealand. There was less than 50% overlap of populations in three included studies from Sweden. Ch. Ch30]. et al. examined the post-transplant outcomes of 59 cases of pre-transplant melanoma collected from the IPITTR, OPTN and Mayo Clinic databases.,26.20,26atabases,28, inclet al. reported data voluntarily provided by physicians in the SCOPE network database (Table Matin e Table . BreslowThis is the first systematic review of melanoma incidence and outcomes in the solid organ transplant population. Compared to the general population, there is a 2.4-fold increased incidence of melanoma in the transplant population. No population-based outcome data were identified for melanoma arising post-transplant. Data from non-population-based cohort studies suggest a worse prognosis for late-stage melanoma developing in a transplant population versus a general population. For melanoma arising prior to transplantation, one uncontrolled population-based study found an 11% local recurrence rate post-transplant, although staging and survival data were lacking.Immune function plays a prominent role in the biological response to melanoma. The incet al. proposed a consensus-based framework of waiting time prior to consideration of transplantation, based on melanoma stage[In transplant candidates with a history of melanoma, the risk of post-transplant recurrence and metastasis has important implications for the decision to pursue transplantation. The quality of data available to guide this decision is currently limited to uncontrolled, non-population-based reports that lack staging information. Otley ma stage. The risOur study has several limitations. Firstly, our review is limited by the quality of the included studies. Only one incidence study adjusted the melanoma rates for race, an important risk factor for skin cancer. This coOur systematic review found that there is a 2.4-fold increased incidence of melanoma in the transplant population compared to the general population. Non-population-based data suggest a worse prognosis for late-stage melanoma developing in the transplant population versus the general population. These findings have several implications for clinical practice and research. The significantly increased overall risk of melanoma arising post-transplant means that these patients warrant a multi-pronged approach to primary and secondary prevention, including regular full skin examinations for cancer screening, a low biopsy threshold for suspicious pigmented lesions, and continual education on the importance of sun avoidance and protection. Our study has also identified an important knowledge gap that should be addressed in future research. Population-based studies that account for melanoma stage and risk factors are needed for patients and clinicians to understand better the prognosis of pre- and post-transplant melanoma. These data would help to inform treatment decisions, as tumors known to have a poorer prognosis may require more aggressive management, including significant reduction or discontinuation of immunosuppression. Robust outcome and staging data would also help to inform the decision to pursue, avoid or delay transplantation in patients with a history of melanoma.AJCC: American Joint Committee on Cancer; ANZDATA: Australian and New Zealand Dialysis and Transplant Registry; BIDMC: Beth Israel Deaconess Medical Center; CI: confidence interval; IPITTR: Israel Penn International Tumor Transplant Registry; OPTN: Organ Procurement Transplant Network; SCOPE: Skin Care in Organ Transplant Patients, Europe network; SEER: Surveillance, Epidemiology and End Results; SIR: standardized incidence ratio.The authors of this manuscript have no conflicts of interest to disclose.All authors participated in the design of the study. ED carried out the search. AWC completed the statistical analysis. All authors were involved with analysis and presentation of collected information. ED and AWC drafted the manuscript. ED composed Figure 1. AWC and ED composed Figure 2. ED drafted the tables. CAM and JK revised the manuscript, figures and tables. All authors read and approved the final manuscript.


Phthalates might be implicated with obesity and insulin sensitivity. We evaluated the levels of primary and secondary metabolites of Di-(2-ethylhexyl) phthalate (DEHP) in urine in obese and normal-weight subjects both before and during puberty, and investigated their relationships with auxological parameters and indexes of insulin sensitivity.DEHP metabolites , were measured in urine by RP-HPLC-ESI-MS. Traditional statistical analysis and a data mining analysis using the Auto-CM analysis were able to offer an insight into the complex biological connections between the studied variables.The data showed changes in DEHP metabolites in urine related with obesity, puberty, and presence of insulin resistance. Changes in urine metabolites were related with age, height and weight, waist circumference and waist to height ratio, thus to fat distribution. In addition, clear relationships in both obese and normal-weight subjects were detected among MEHP, its products of oxidation and measurements of insulin sensitivity.per se is actually the risk factor or if the ability of the body to metabolize phthalates is actually the key point. Further studies that span from conception to elderly subjects besides further understanding of DEHP metabolism are warranted to clarify these aspects.It remains to be elucidated whether exposure to phthalates  Obesity, insulin resistance, and type 2 diabetes are interrelated metabolic disorders which prevalence has increased substantially in the past two decades . InsulinSome studies have reported an association between persistent exposure to some organic pollutants, such as phthalates, bisphenol A, heavy metals and polychlorobiphenyl, and increased body weight and diabetes , antagonHigh molecular weight phthalates, such as Di-(2-ethylhexyl) phthalate (DEHP), are primarily used as plasticizers for the manufacturing of polyvinyl chloride (PVC), which is used extensively in consumer products, flooring and wall coverings, as well as food contact applications, medical devices, toys and cosmetic containers . In the A causal role for high-molecular-weight phthalates in obesity is biologically plausible –16. PertConcentrations of urinary phthalate metabolites have been found to be associated with increased waist circumference and insulin resistance in adult males ,19.Phthalates are rapidly metabolized in the body, with elimination half-lives of less than 24 hours . SelecteUrine is the preferred matrix for phthalate determination in humans . BecauseIn recent years, systems biology approaches have developed. These methods applied to biomedical and biological data attempt to model and discover specific properties and complex interactions within biological systems. These comprise artificial adaptive systems (AAS) which use is rapidly spreading in biology and medicine  besides We hypothesized that exposure to phthalates was related with obesity and insulin resistance, and we aimed to evaluate the levels of the primary and secondary metabolites of DEHP in urine in obese and normal-weight subjects both before and during puberty, and to investigate their relationships with auxological parameters and indexes of insulin sensitivity using both traditional statistical analysis  and Auto-CM analysis.Both prepubertal and pubertal obese (N:41) and normal-weight children (N:31) were enrolled consecutively at the paediatric endocrine clinic at the University Hospital in Parma. The children were comparable for age, sex and pubertal stages. The features of these subjects are summarized in 2 (Kg/m2), and standardized according Cole’s reference data [Body mass index (BMI) was calculated as weight/heightnce data . Subjectnce data  were connce data . Waist cnce data .Based on breast development or genitalia staging subjects were classified in pubertal and prepubertal according to Tanner’s criteria ,33.All obese subjects underwent an oral glucose tolerance test (OGTT) after an overnight fast. A glucose load of 1.75 g/kg body weight (max 75 g) in 300 mL water was prepared and administered in 3 min. Blood samples were taken prior to, and 30, 60, 90 and 120 min after glucose ingestion. In all subjects insulin and glucose were assessed at all time points.The insulinogenic index was calculated as Δ insulin (0–30 min) divided by Δ glucose (0–30 min) where the values were calculated at baseline and at 30 min during OGTT, and was used as an index of pancreatic β-cell function .0) divided by fasting plasma insulin (I0) levels [0 was in milligrams per deciliter and I0 in microunits per milliliter.The fasting glucose-to-insulin ratio (FGIR) was calculated as the ratio of fasting plasma glucose (G) levels  where G00 and I0 were basal fasting glucose and insulin, respectively. Glucose was expressed in mmol/L and insulin in mIU/mL. HOMA-IR indexes were classified according to criteria for age and Tanner stage of puberty [Homeostasis model assessment estimate of insulin resistance (HOMA-IR) was calculated, according to the following formula : G0×I022 puberty .The whole body insulin sensitivity index (WBISI) was calculated based on insulin (IU/mL) and glucose (mg/dl) concentrations obtained during the OGTT and the corresponding fasting values, as originally described by Matsuda and DeFronzo . Areas uThe presence of metabolic syndrome was established based on the International Diabetes Federation criteria .Insulin sensitivity parameters of obese and normal-weight subjects are reported in Plasma glucose concentrations were assayed using a polarographic method (Synchron CX systems).Insulin concentrations were measured using a chemiluminescence method by Diagnostic Products Corporation  for reading by Immulite2000. The intra-assay CV was 6.5, the inter-assay CV 7.1%.First morning urine specimens were collected in all subjects, and stored at -20°C until assayed.The following metabolites were measured as previously described : MEHP m. Each siDEHP metabolite concentrations in each single specimen were normalized according to urinary creatinine concentration. All children had urine creatinine within the normal reference range for age. Urine creatinine measurements were assesed using a Synchron AS/ASTRA clinical analyser (Beckman Instruments). We used values (μg/L) for creatinine and (g/L) for dilution correction in the analyses, therefore the concentration of each metabolite in urine was expressed as μg/g.2) greater than 0.998 were generated .Human urine samples (1 mL) were defrosted, sonicated, mixed and dispensed in glass tubes prior to assaying. Then ammonium acetate buffer  was added. Incubation with β glucuronidase  was performed at 37°C for 90 min, resulting in quantitative glucuronide hydrolysis of phthalates and metabolites. After deconjugation, samples were treated with two steps of SPE,  to remove any contamination of biological matrix, following the procedure described by Blount et al. . AnalyteInformed consent was obtained from the parents of subjects and controls as appropriate. The study was approved by the local Ethics Committee in Parma.Statistical analysis was carried out using the SPSS package 18.0. Any normal distribution of data was assessed by the Kolmogorov-Smirnov test. As no significant difference was detected in this series between males and females, subjects of both sexes were analyzed together.To analyze differences between obese and normal-weight subjects, and differences between subgroups of obese subjects we used Student’s T test for unpaired data or Mann-Whitney test, and Kruskall-Wallis ANOVA followed by Bonferroni’s correction as appropriate. Non-parametric Spearman correlation test was used to measure associations between variables and DEHP metabolites. A multiple linear regression analysis was performed to establish which were the major determinants of MEHP urinary concentration.th-75th percentiles as appropriate. Only significant correlations are reported in the text.Data are expressed as mean±SEM, and as median and 25Auto-CM is a new data mining tool based on an Artificial Neural Network that is effective at highlighting any kind of consistent pattern and/or systematic relationships, and hidden trends and associations among variables. The architecture and mathematics of Auto-CM were described elsewhere . BrieflyThe input variables for each model were: MEHP, 6-OH-MEHP, 5-oxo-MEHP, 5-OH-MEHP, 5-Cx-MEHP, FGIR, HOMA index, insulinogenic index, HtSDS, BMISDS, and birth weight SDS. Quite uncommonly, the weights determined by Auto-CM after the training phase, admit a direct interpretation. Specifically, they are proportional to the strength of many-to-many associations across all variables. Subsequently, association strengths are visualized by transforming weights into physical distances: i.e. couples of variables which connection weights are higher get relatively nearer and viceversa if connection weights are lower, they get further apart. By applying a simple mathematical filter such as the minimum spanning tree to the matrix of distances, a graph is generated ,43, termUrinary DEHP metabolites in obese children and controls. The percentages of detectable DEHP metabolites in urine samples from obese and normal-weight (control subjects) are reported in Both obese and control subjects were subsequently subdivided according to presence or absence of puberty .In childhood, MEHP urine concentrations were higher in pre-puberty than in puberty both in control and obese subjects. Prepubertal controls had lower concentrations of 6-OH-MEHP than prepubertal obese subjects, and had less 5-OH-MEHP, 5-oxo-MEHP and 6-OH-MEHP concentrations than pubertal obese subjects.Urinary DEHP metabolites in obese children, based on the HOMA index. 9/39 obese (23%) subjects had an increased HOMA index compatible with insulin resistance.Obese children with normal HOMA index had significantly higher 5-oxo-MEHP concentrations than obese subjects with insulin resistance . 6-OH-MEHP showed a trend to be lower in insulin resistance.Urinary DEHP metabolites in obese children, based on the presence or absence of the metabolic syndrome. 18/39 obese subjects (46%) had the metabolic syndrome. No statistical significant difference was observed between the two groups, however, obese children with metabolic syndrome showed a trend to have lower 5-OH-MEHP, 5-oxo-MEHP, and 6-OH-MEHP urinary concentrations (data not shown).Correlation of DEHP metabolites with auxological parameters. In controls, MEHP was negatively correlated with chronological age  and with the presence of puberty , whereas in pubertal controls 5-Cx-MEHP was negatively correlated with birth weight , and 5-oxo-MEHP was positively correlated with BMISDS .In obese subjects, MEHP was negatively correlated with chronological age, as in controls , and with waist circumference . Interestingly, MEHP was correlated also negatively with the age at onset of obesity  and with the waist to height ratio , and with the waist circumference , as in the entire group.In the children who had started puberty only a relationship of 5-Cx-MEHP with the HtSDS ratio  was found.Correlation of DEHP metabolites with measurements of insulin sensitivity. In the entire group of controls, 6-OH-MEHP was positively correlated with insulin  and negatively correlated with FGIR, as would be expected  and with the insulinogenic index .In obese subjects relationships of MEHP and 6-OH-MEHP were found with all calculated measurements of insulin sensitivity .In obese prepubertal subjects a positive relationship between MEHP and WBISI was confirmed .No correlation among any metabolite and measurements of insulin sensitivity was detected in puberty.A multiple regression analysis was performed using MEHP as dependent variable, and HtSDS, BMISDS, gender, puberty, waist circumference, waist to height ratio, CA age at onset of obesity, HOMA, WBISI, AUCG, AUCI, and the insulinogenic index as independent variables in obese children. This showed a significant effect of puberty (p: 0.020), a near significant effect of CA age at onset of puberty (p:0.055), and of waist circumference (p: 0.059). In controls, HtSDS, BMISDS, gender, puberty, birth weight, HOMA and insulinogenic index were the available independent variables and a significant relationship was found for puberty (P: 0.001) and a near significant effect for gender (p: 0.051).The main relationships among the variables emerging from the AutoCM are shown is The condition of obesity and normal-weight were clearly distinct and on opposite sides of the graph.Vice versa low 5-oxo-MEHP urine concentrations were associated with a low FGIR and a low insulinogenic index with a very high link strength. A high concentration of 5-Cx-MEHP was associated with a low HtSDS. Birth weight showed no relationship with the metabolites analyzed.High MEHP and high 6-OH-MEHP concentrations were associated with a high BMISDS with a moderate-high link strength. The data of this study showed changes in DEHP metabolites related with obesity, onset of puberty, and presence of insulin resistance. Changes in urine metabolites were related also with waist circumference and waist to height ratio, thus to fat distribution.The main limitation of this study stands in the small number of subjects analysed, however, large population studies have addressed issues related to exposure but have not taken into account aspects specifically related with metabolism and very few studies have considered restricted age-groups . We seleFrom a metabolic point of view hydrolysis of DEHP, oxidative metabolism of MEHP and organ-specific metabolites of DEHP have been previously examined in laboratory animals –54. HoweWe detected differences between obese and normal-weight children in the concentration of DEHP metabolites in urine. In particular, 5-Cx-MEHP and 6-OH-MEHP were higher in concentration in obese than in normal-weight children. This could be generically ascribed to a different exposure and/or metabolism in the groups investigated. Omega 1 oxidation and transformation of MEHP to 5-Cx-MEHP was reduced in normal-weight subjects, whereas both ω and ω-1 oxidation end-products  were incThe negative relationship between MEHP and chronological age suggested an increase in MEHP metabolism with age, and onset of puberty. The negative relationship of MEHP with age at onset of obesity could suggest that a reduced capacity to metabolize MEHP might be a cause or consequence of obesity. Furthermore, we detected a negative relationship of MEHP with waist circumference, and with abdominal fat distribution (waist to height ratio) supporting a relationship between MEHP metabolism and fat distribution. The multiple regression analysis confirmed in the obese group a major effect of puberty, and an effect of chronological age at onset of obesity, and of fat distribution (waist circumference).Moreover, when Auto-CM analysis was used, a high MEHP concentration was directly related with a high BMISDS as well as with high 6-OH-MEHP concentrations in urine. This latter finding was in accordance with other author’s findings. Wang et al. also reported this relationship in an 8–11 age-group which would have included both pre-and pubertal subjects , and othAmong the downstream metabolites, in obese children, 5-Cx-MEHP was correlated with increased adipose tissue in prepuberty, whereas in puberty most relationships were lost suggesting that puberty in itself played a major role in regulating DEHP metabolism, as confirmed in the multiple regression analysis in both the normal-weight and obese children. A gender effect was seen in the normal-weight subjects but statistical significance was not attained likely due to the limited number of subjects included in this pilot study.The positive correlation, in controls, of 6-OH-MEHP with insulin, and the HOMA index, and the negative correlation with the FGIR suggested that this metabolic pathway favoured insulin resistance. This was further confirmed by the negative relationship of 6-OH-MEHP with the amount of insulin released (AUCI) in the obese children.In summary, these findings showed that the more MEHP was metabolised to 6-OH-MEHP, the greater the state of insulin resistance in a given subject, whereas the lesser MEHP was metabolised, the lesser insulin was required, the better the FGIR, the lower the HOMA index, and the higher the WBISI .At variance with our study, previous studies in white elderly subjects, evaluating MEHP in serum, failed to detected any relationship with the HOMA-IR index, however, this could be due both to the age-group considered and to the substrate used to determine its concentration , 58. IntFinally, in prepubertal controls, 5-Cx-MEHP was found to be negatively correlated with birth weight. Birth weight was normal in all the children enrolled in the study, however, this might suggest a possible programming of MEHP metabolism in utero which extends at least to prepubertal years. However, the AutoCM analysis failed to find a link of birth weight with any of the metabolites studied in this study. Other authors have described relationships of other phthalates with birth weight , therefoPossible limitations of this study stand in the sample size, in the lack of details related with food, and daily calorie intake. Furthermore, it is unknown whether the shorter stature in the controls could have affected the results.In conclusion, metabolism changed with age, height, weight, and mostly puberty. Fat distribution and measurements of insulin sensitivity showed relationships with specific DEHP metabolites.


Executive functions (EFs) in childhood predict important life outcomes. Thus, there is great interest in attempts to improve EFs early in life. Many interventions are led by trained adults, including structured training activities in the lab, and less-structured activities implemented in schools. Such programs have yielded gains in children's externally-driven executive functioning, where they are instructed on what goal-directed actions to carry out and when. However, it is less clear how children's experiences relate to their development of self-directed executive functioning, where they must determine on their own what goal-directed actions to carry out and when. We hypothesized that time spent in less-structured activities would give children opportunities to practice self-directed executive functioning, and lead to benefits. To investigate this possibility, we collected information from parents about their 6–7 year-old children's daily, annual, and typical schedules. We categorized children's activities as “structured” or “less-structured” based on categorization schemes from prior studies on child leisure time use. We assessed children's self-directed executive functioning using a well-established verbal fluency task, in which children generate members of a category and can decide on their own when to switch from one subcategory to another. The more time that children spent in less-structured activities, the better their self-directed executive functioning. The opposite was true of structured activities, which predicted poorer self-directed executive functioning. These relationships were robust (holding across increasingly strict classifications of structured and less-structured time) and specific . We discuss implications, caveats, and ways in which potential interpretations can be distinguished in future work, to advance an understanding of this fundamental aspect of growing up. Why do young children often forget (or outright refuse) to put on a coat before leaving the house on a snowy day? The choice to put on a jacket may seem frustratingly obvious to parents and older siblings, but this simple decision arises from a surprisingly complex interplay of behaviors. Children must keep in mind a goal (staying warm and dry) that is not yet relevant in the comfort of a warm house. They must inhibit the urge to proceed with a regular sequence of tasks (put on socks and shoes and head out the door), and instead modify their routine to include something new (pulling a coat from the closet). Unless someone intervenes, this change in the status quo must be accomplished without any external reminders .To accomplish each of these tasks, children must engage executive functions (EFs), the cognitive control processes that regulate thought and action in support of goal-directed behavior. EFs develop dramatically during childhood , and when . In the real world, children who have developed externally-driven EF might behave in a goal-directed way when given reminders. For example, a child might successfully put on a coat in the morning after a reminder from a caregiver. However, it is less clear how children's experiences relate to their development of more self-directed executive functioning, where they must determine on their own what goal-directed actions to carry out and when. A self-directed child, for example, might put a coat on just before going outside without being told what to do.The development of self-directed EF is a critical part of growing up. Self-directed EFs develop later than externally-driven forms of executive control  or during a visit to a museum . These types of self-directed choice and planning are central to the Tools of the Mind and Montessori classrooms, although the exact form they take and the types of activities emphasized differ across these programs ; males = 37]. All participants were recruited from a database of families who had volunteered to participate in research. During subject recruitment, parents were informed that they would be asked to document child activities during the week prior to the study visit. Three participants were excluded from analyses because detailed information on their weekly activities was unavailable, either because parents did not wish to provide this information (2), or because data were lost due to a technical error at the time of parent submission (1). Of the remaining participants, one child did not complete the Flanker task, one child did not complete the digit span task, and two children did not complete the verbal fluency task; each of these children was excluded from the analysis of only that task. All other participants completed all study tasks. Prior to their participation, parents gave informed consent, and children gave verbal assent. Children received small gifts  throughout the project for their participation, and parents received $5 as compensation for travel.Seventy children participated in the study . In subsequent tests for interactions, we found an unexpected interaction between less-structured time and age . Post-hoc tests indicated that additional time in less-structured activities predicted better self-directed control in most but not all children; specifically, this finding held in both the youngest sample quartile  and at the median , but not in the oldest quartile . When the interaction between less-structured time and age was included in the model, children from higher-income households demonstrated marginally better verbal fluency performance {Income: η2p = 0.05; }. Age, vocabulary, and time in less-structured activities also continued to predict self-directed EF .As predicted, children who spent more time in less-structured activities demonstrated better self-directed EF, as indexed by verbal fluency performance  and social events  significantly predicted self-directed EF, and play with others was marginally predictive . Interactions with age were not significant in these models, and were therefore excluded (p's > 0.2). No other classes of less-structured activities predicted verbal fluency performance.media and screen time ;activities within the less-structured time classification that may have included more structure than other such activities; andper se).enrichment activities that may have yielded benefits specific to verbal fluency performance  = 5.23; p < 0.03]. This finding persisted when we also excluded less-structured activities that may have included more structure than other such activities  = 6.17; p < 0.02]. As a final step, we also excluded visits to museums, aquariums, and zoos, which may have benefitted organization of semantic clusters on the verbal fluency task . Using this fully-restricted measure of less-structured time, child time in less-structured activities continued to predict better self-directed EF . Interactions with age were significant and were included in each of these restricted analyses .When media and screen time were excluded, less-structured time continued to demonstrate a positive relationship with self-directed EF . Time spent in other categories of less-structured activities did not vary with age (p's > 0.2).We also explored whether participation in types of less-structured activities changed with age, and whether such changing patterns of time use could speak to the diminished link between less-structured time and self-directed control in the oldest quartile of children in our sample. Media and screen time use was more prevalent in older children , and vocabulary , and marginally predicted by household income Additional time in structured activities predicted marginally worse self-directed control .p > 0.2; AX-CPT proactive control score: p > 0.8). Similarly, time in structured activities was unrelated to externally-driven EF 2p = 0.10; F = 4.64; p < 0.04]. No other variables predicted externally-directed EFNo measure of child time predicted any aspect of externally-driven EF Figures . SpecifiOur findings offer support for a relationship between the time children spend in less-structured and structured activities and the development of self-directed executive function. When considering our entire participant sample, children who spent more time in less-structured activities displayed better self-directed control, even after controlling for age, verbal ability, and household income. By contrast, children who spent more time in structured activities exhibited poorer self-directed EF, controlling for the same factors. The observed relationships between time use and EF ability were specific to self-directed EF, as neither structured nor less-structured time related to performance on externally-driven EF measures. These findings represent the first demonstration that time spent in a broad range of less-structured activities outside of formal schooling predicts goal-directed behaviors not explicitly specified by an adult, and that more time spent in structured activities predicts poorer such goal-directed behavior. Consistent with Vygotskian developmental theory and programs that build on that theory, such as Tools of the Mind, less-structured time may uniquely support the development of self-directed control by affording children with additional practice in carrying out goal-directed actions using internal cues and reminders. That is, less-structured activities may give children more self-directed opportunities. From this perspective, structured time could slow the development of self-directed control, since adults in such scenarios can provide external cues and reminders about what should happen, and when.Surprisingly, the relationship between less-structured time and self-directed control changed with age in our participant sample, such that less-structured time predicted self-directed control in all but the oldest quartile of participants. This interaction between less-structured time and age was reliably observed across increasingly restrictive measures of less-structured time. One interpretation is that most but not all age groups within our sample spent their less-structured time in activities that encourage the development of self-directed control. Indeed, despite a relatively limited age range, our sample demonstrated differences in the content of less-structured time across 6–7 years of age, with older children spending more time engaged in media and screen activities. However, time spent in unguided practice, enrichment outings, and some forms of play was the main driver of the relationship between less-structured time and self-directed control in our data, and time spent in such activities did not change as a function of age. Another possibility is that children who have less developed self-directed control are more likely to benefit from less-structured time . To generate a more precise estimate of the amount of time children spend pursuing activities in a self-directed way, one would ideally assess child time directly, possibly by supplementing parent-reported child time use data with direct observation. One possibility along these lines could be to employ experience sampling techniques Miller, , where pF = 6.10; p < 0.02], but typical experiences do not (p > 0.6). This finding could reflect the greater importance of recent experiences, or it could reflect the greater precision of the time-diary measure, which indexes recent experiences but is also representative of more distal/typical experiencesp's > 0.2). This finding could reflect the importance of the combination of recent and distal experiences, or simply the greater robustness of using a composite measure. Therefore, while we have posited that less-structured experiences allow children to practice self-directed, goal-oriented behavior, producing benefits over time, we cannot discount the possibility that observed linkages may have been driven by recent experiences which increased self-directed behavior. In either scenario, regular participation in less-structured activities would yield benefits.In addition, although we have identified links between child time use and self-directed EF, we are unable to draw firm conclusions about whether the observed relationships were driven by activities occurring in the week preceding the test session ; however, a broader range of measures could provide a more robust and generalizable assessment of self-directed EF.The findings of the current study are consistent with previous research in showing a link between children's experiences and EF  less-structured activities more often. Likewise, children with poorer self-directed control may be more likely to engage in structured activities. Alternatively, the observed relationship between less-structured time and self-directed control may be driven by a third, unmeasured variable. Although we have attempted to control for some characteristics that might influence both time spent in less-structured activities and verbal fluency, such as household income, we have not controlled for other possibilities, such as parent EF and child's fluid intelligence (which we did not assess). However, we did control for child vocabulary , which may serve as a proxy for fluid intelligence in testing relationships with EF, given that EF fully mediates the correlation between crystallized and fluid intelligence in 7-years-old . While such longitudinal studies could thus provide important information about temporal precedence, this information is not sufficient evidence of causality . Thus, future research using experimental manipulations of time spent in less-structured activities is necessary to definitively test causality. One approach would be to attempt to randomly assign children to more structured or less structured environments, such as summer camps, where child activities could be carefully monitored via regular sampling of staff and/or on-site observation. Although this kind of work is ambitious, and poses challenges, it could be used to inform more targeted laboratory-based training studies.Finally, we hope that future explorations of the relationship between child time use and developing self-directed EFs will inform a wider question: specifically, whether societal shifts in child time use over the past 50 years have influenced development. Hours formerly devoted to less-structured, social play have been replaced by media time (Vandewater et al., Jane E. Barker, Andrei D. Semenov, and Yuko Munakata contributed to the development of the study hypothesis. All authors contributed to study design. Jane E. Barker performed the data analysis and drafted the manuscript with input from Yuko Munakata. Critical revisions were contributed by Hannah R. Snyder, Laura Michaelson, and Yuko Munakata. All authors discussed the results, implications, and literature, and approved the final version of the manuscript for submission.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.


Concurrent validity and intra-rater reliability using a customized Android phone application to measure cervical-spine range-of-motion (ROM) has not been previously validated against a gold-standard three-dimensional motion analysis (3DMA) system.Twenty-one healthy individuals  participated, with 16 re-examined for intra-rater reliability 1–7 days later. An Android phone was fixed on a helmet, which was then securely fastened on the participant’s head. Cervical-spine ROM in flexion, extension, lateral flexion and rotation were performed in sitting with concurrent measurements obtained from both a 3DMA system and the phone.The phone demonstrated moderate to excellent  concurrent validity for ROM measurements in cervical flexion, extension, lateral-flexion and rotation. However, cervical rotation demonstrated both proportional and fixed bias. Excellent intra-rater reliability was demonstrated for cervical flexion, extension and lateral flexion (ICC = 0.82-0.90), but poor for right- and left-rotation (ICC = 0.05-0.33) using the phone. Possible reasons for the outcome are that flexion, extension and lateral-flexion measurements are detected by gravity-dependent accelerometers while rotation measurements are detected by the magnetometer which can be adversely affected by surrounding magnetic fields.The results of this study demonstrate that the tested Android phone application is valid and reliable to measure ROM of the cervical-spine in flexion, extension and lateral-flexion but not in rotation likely due to magnetic interference. The clinical implication of this study is that therapists should be mindful of the plane of measurement when using the Android phone to measure ROM of the cervical-spine. Cervical range-of-motion (ROM) assessment forms an integral part of physiotherapy evaluation in people with neck-pain by quantifying an important physical impairment  and provAdvances in smart phone sensor technology have resulted in inexpensive ROM measurement tools with clinical and research potential. Specifically, the smart phone uses an embedded-accelerometer and a magnetometer to detect motion using gravity and the earth’s magnetic field respectively. To our knowledge, only one published study  has examTwenty-one healthy individuals  with no reported neck-pain participated. Sixteen participants returned 1–7 days later to assess intra-rater reliability. All participants provided informed consent as outlined by the institution’s Human Research Ethics Committee and all procedures were conducted according to the Declaration of Helsinki.Three reflective markers were located on the following anatomical landmarks: anterior to the tragus bilaterally and on the glabella Figure  for 3DMAAll measures were performed with the subject seated in the same high-back padded chair. To ensure minimal contribution from the thoracic spine, the participant was securely strapped across the shoulders to the chair using an inelastic belt Figure , and theThe following cervical-spine ROM limit measurements were obtained in the same order in all subjects: (i)flexion, (ii)extension, (iii)right-lateral-flexion, (iv)left-lateral-flexion, (v)right-rotation and (vi)left-rotation. The flexion/extension, lateral flexion/extension and rotation axes were measured using the pitch, roll and azimuth angles respectively. Given that cervical rotation values are based on the magnetometer within the phone and the outcome may be influenced by the surrounding magnetic fields, a magnetic yoke was placed around the subject’s neck in an attempt to address this problem. This replicates the use of the CROM, which also uses magnetic fields to determine angles and requires the use of a magnetic yoke.The patient was instructed to perform each test actively, with manual guidance provided by the examiner to ensure that the movement was along the pure axis of alignment if necessary. Specifically, the examiner determined the end of ROM when a firm resistance was felt. No pain was reported by any subject during the procedure. Three consecutive trials using concurrent measurements from the VICON and the phone were obtained for each movement. The mean value of the three measurements for the first testing day was used to calculate validity, and an inter-day comparison of these mean values was performed to determine intra-rater reliability.All subjects were assessed by the same examiner (JQ) who has 12 years of clinical musculoskeletal physiotherapy experience. Noteworthy, because it is difficult for the examiner to visually detect when the subject deviates away from the pure movement plane, one of the advantages of this phone application over previous applications  was thatValidity was determined from Spearman’s correlation and intra-class correlation coefficient (ICC) in combination with assessment of systematic bias. Bland and Altman plots were constructed to determine the 95% limits of agreement (LoA) between the 3DMA and phone measures ,11. OrdiIntra-rater reliability was determined using intra-class coefficients , and OLP regression to quantify the relationship between sequential measurements for both instruments. ICC was calculated in a 2-way analysis of variance based on absolute agreement. Point estimates of the ICC values >0.75 were considered excellent, 0.4-0.75 modest or <0.4 poor . To estiThe phone demonstrated excellent concurrent validity for flexion, extension, and lateral flexion ROM based on Spearman’s ρ-values >0.84 and ICC values >0.90, but only modest validity results for left-rotation  and right-rotation (ICC =0.53) Table . FurtherIntra-rater reliability is presented in Tables This study demonstrates that an Android phone can be a valid and reliable tool to measure ROM of cervical flexion, extension and lateral-flexion but not cervical rotation, consistent with previous results . CervicaPotential reasons for the greater ICC values in the present study compared to previous work  are the This study has several other limitations. (i) We did not assess inter-rater reliability and this may potentially limit the applicability of our findings in clinical settings between observers. (ii) We did not include a rigorous warm-up regime to ensure consistent inter-day readiness to perform the movements. While this is unlikely to affect the concurrent validity data (i.e. an increase in range of motion intra-session would be detected by both devices if they are comparable), it may have negatively affected our reliability results. (iii) As a preliminary step to assess the validity and reliability of the Android phone application, all participants were healthy, therefore the results need to be replicated in populations of interest, such as those with neck-pain. (iv) The reliability data of the 3DMA system for the rotation axis was not particularly good, and it is not possible to determine whether this is due to intra-day subject variation (which would provide justification for the poor phone reliability results) or equipment-related measurement error .In summary, this study aimed to establish the validity and intra-rater reliability of an Android phone application to measure cervical-spine ROM and found that cervical flexion, extension and lateral-flexion measurements are both valid and reliable in sitting and may be used in the clinical setting. In contrast, cervical rotation measurements in sitting are neither valid nor reliable likely due to magnetic field interference. We suggest further study to determine whether the phone is valid to measure cervical-rotation in supine, which would use the accelerometer derived angles and is therefore likely to provide more consistent results.The authors declare that they have no conflict of interest.JQ was involved in the study design, coordination, data collection, statistical analysis and manuscript drafting. SB was involved in the study design, coordination, manuscript drafting and general supervision of the study. JT was involved in the study design, coordination, manuscript drafting and general supervision of the study. PYH was involved in statistical analysis and manuscript drafting. BM was involved in data collection. RC was involved in the study design, application creation, data collection, coordination, manuscript drafting and general supervision of the study. All authors read and approved the final manuscript.Appendix A. Validity assessment using OLP plots for measurements with proportional bias. Appendix B. Reliability (phone). Normal Bland Altman plots. Appendix C. Reliability (3DMA). Normal Bland Altman Plots.Click here for file