Malaria and dengue are the most prevalent vector-borne diseases worldwide and represent major public health problems. Both are endemic in tropical regions, propitiating co-infection. Only few co-infection cases have been reported around the world, with insufficient data so far to enhance the understanding of the effects of co-infection in the clinical presentation and severity.Plasmodium sp. detection, ELISA, PCR and NS1 tests for dengue, viral hepatitis, HIV and leptospirosis. In total, 1,578 patients were recruited. Among them, 176 (11.1%) presented P. vivax malaria mono-infection, 584 (37%) dengue fever mono-infection, and 44 (2.8%) were co-infected. Co-infected patients had a higher chance of presenting severe disease (vs. dengue mono-infected), deep bleeding (vs. P. vivax mono-infected), hepatomegaly, and jaundice (vs. dengue mono-infected).A cross-sectional study was conducted (2009 to 2011) in hospitalized patients with acute febrile syndrome in the Brazilian Amazon. All patients were submitted to thick blood smear and PCR for In endemic areas for dengue and malaria, jaundice (in dengue patients) and spontaneous bleeding  should raise the suspicion of co-infection. Besides, whenever co-infection is confirmed, we recommend careful monitoring for bleeding and hepatic complications, which may result in a higher chance of severity, despite of the fact that no increased fatality rate was seen in this group. Malaria and dengue fever are typical diseases in tropical regions of developing countries; such as the Brazilian Amazon. They become serious problems in public health as they mostly affect vulnerable populations. Both diseases are mosquito-borne. These diseases present similar signs and symptoms. Brazil registers most of the malaria cases in the Amazon. The four dengue serotypes also circulate in this region. Similar to malaria, there are records of dengue outbreaks during the first months of the year, and isolated cases in the remaining months. Official records of malaria and dengue co-infection are infrequent in Brazil; however, we believe that this event is more frequent than usually reported. Our study detected high prevalence of the co-infection in the hospitalized patients infected with malaria or dengue in a tertiary health care unit, reference in the treatment of tropical and infectious diseases in Manaus, Amazonas, Brazil. We highlight the high likelihood of co-infected patients to present clinical complications. Besides, we observed that the presence of jaundice in dengue patients, and bleeding in malaria patients, are possible indications of co-infection. Therefore, this paper is useful to physicians working in the tropics, enabling the clinical suspicion of a not so rare condition. Malaria and dengue fever are the most prevalent vector-borne diseases worldwide and represent major public health problems. Dengue epidemics have been reported in several countries; 500,000 people with severe dengue require hospitalization each year, and 2.5% of those affected die. Similarly, malaria is a life-threatening disease which was responsible for 627,000 deaths in 2012 P. vivaxThe dengue virus (DENV) is the major arbovirus responsible for human disease in Brazil. The four serotypes cause a variety of clinical presentation in humans, ranging from acute self-limited febrile illness to severe and fatal forms Malaria and dengue are endemic in similar tropical regions, and therefore, may result in the possibility of co-infection. Urban demographic expansion, deforestation and agricultural settlements in peri-urban areas, are known causes of the increase in the probability of concurrent infection of these two diseases Considering the endemicity of dengue and malaria in the Amazon Fundação de Medicina Tropical Dr. Heitor Vieira Dourado , Manaus, Brazil. All participants signed an informed consent.The study was approved by the Ethics Review Board of P. vivax infection. FMT-HVD is a tertiary health care facility and a teaching and research center, which is the reference for infectious diseases in the region. Around 30% of all malaria cases reported in Manaus are assisted in this institution. During the study period, 14,884 cases of malaria and 6,302 cases of dengue fever were diagnosed in the hospital, from which 505 and 1,127, respectively, were hospitalized. In 2011, a dengue outbreak resulted in 5,400 cases reported at the FMT-HVD .The study design was a cross-sectional study of patients hospitalized with acute febrile syndrome (history of fever in the past 10 days) from 2009 to 2011. The study was carried out in FMT-HVD, Manaus, capital of Amazonas State, Northern Brazil, where all four dengue serotypes co-circulate since 2008 and 95% of malaria cases result from During the study period, all hospitalized patients with acute febrile syndrome were considered eligible. If they signed the informed consent, they were included and submitted to malaria and dengue investigation. They were also searched for hepatitis A, B and C, HIV and leptospirosis. Abdominal ultrasound and chest X-rays were also performed when indicated. Other tests were requested at physicians' discretion.P. vivax infection with primaquine-induced hemolysis (hemoglobin <10 g/dL and reticulocytes >1.5% or increased indirect bilirubin after starting primaquine) were also excluded from the analysis.Patients with P. vivax. They were compared to two different groups: malaria mono-infection (Group A), and dengue mono-infection (Group B). Severity was classified and managed according to the World Health Organization (WHO) guidelines for dengue and malaria The diagnosis of vivax malaria was confirmed by real-time PCR. The diagnosis of dengue was made either by a positive serology (IgM) or a positive NS1 protein or a positive molecular test (RT-PCR), considering that every patient was tested by all the three methods. The Group C was defined as patients co-infected with both dengue and 3. Real time polymerase chain reaction (qPCR) was performed to confirm P. vivax mono-infection. In brief, the extraction of total DNA from whole blood was performed using the QIAamp DNA Blood Mini Kit , according to the manufacturer's protocol. The DNA was amplified in an Applied Biosystems 7500 Fast System  using primers and TaqMan fluorescence labeled probes for RT-PCR Automatized blood biochemistry and whole blood count were performed systematically in all patients. The continuous variables used for analysis were the most altered throughout hospitalization. Walker's technique was used for thick blood smear The DENV diagnosis was based on three methods: a) IgM antibodies (MAC-ELISA) detection Serological tests for leptospirosis (IgM) Demographics, clinical and laboratorial characteristics from the group of patients co-infected with dengue and malaria vivax were compared to the group of patients mono-infected with dengue and the group of patients mono-infected with malaria vivax. The association between categorical variables and the risk of co-infection (as the outcome variable) was performed by means of univariable logistic regression with the presentation of the odds ratios and 95% confidence intervals. The 95% confidence intervals (95% CI) are presented. Means and standard deviation (SD) of continuous variables with normal distributions were compared using the Student's T test; those variables with non-normal distribution (as assessed by the Kolmogorov-Smirnov test) were described using median and interquartile range (IQR) and compared using the Kruskal-Wallis test. All the analyses were performed using Stata v.11  From 2009 to 2011, 1,578 patients with acute febrile syndrome were hospitalized at the FMT-HVD. Among them, 176  had vivax malaria mono-infection (Group A), 584  had dengue fever mono-infection (Group B) and 44  were co-infected with malaria and dengue (Group C). The prevalence of co-infected patients was 20% among patients with malaria and 7% among those with dengue .As shown in P. vivax mono-infected patients, the increased odds of deep bleeding in co-infected patients  was statistically significant (p<0.001), although platelet count was not different . These serotypes were the most common among the dengue mono-infection group, 127 (49.6%) and 80 (31.2%), respectively.No patient required hospitalization in the intensive care unit, and fatality rate was zero in our casuistic.In an endemic area of dengue fever and vivax malaria, we found a high prevalence of the co-infection, mainly among those with malaria. In Brazil, a prospective study performed in 2009 on 132 patients with vivax malaria found 11 co-infected and the prevalence was 8.3% In our study, being co-infected resulted in a much higher chance of presenting deep bleeding as compared to both groups of mono-infected patients, suggesting a possible synergistic pathogenic mechanism, which could be related to both capillary fragility and coagulation disorders, but not the low platelet count. Bleeding is reported as an infrequent finding in malaria, despite common platelet depletion Hepatic injury was also a concern in the co-infected group, which, together with bleeding, resulted in a higher chance of dengue severity according to WHO criteria. Jaundice in malaria is mostly a result of cholestasis or intravascular hemolysis A warning sign commonly used to describe severe dengue is hemoconcentration  Dengue warning signs, such as vomiting, abdominal pain and hepatomegaly, were very frequent in the co-infection cases. The cautious detection of these signs is of extreme importance as they characterize potential dengue severity In addition to classical warning signs and symptoms, dyspnea was also frequent in all groups, particularly in co-infected patients. Dyspnea is an early clinical feature of plasma leakage and, in dengue, may be the evidence of fluid accumulation of in the pleural cavity P. vivax on pregnancy are scarce The pregnant women had a more complicated presentation, although we could not follow up them until the end of their pregnancy. In a case series of co-infected patients from the Amazon region, pregnant women (2 of 11) presented severe acute lung edema and anemia Co-infected patients presented similar days of fever as compared to malaria patients. That means that a patient with the diagnosis of dengue presenting with prolonged evolution should raise the suspicion of malaria co-infection. Our findings corroborate the results of a long case series in Pakistan, which presented longer disease duration on patients co-infected with vivax malaria and dengue No specific dengue serotype was associated to the co-infected patients, however the number of cases was not big enough to test that hypothesis.Our study has some limitations. It was not possible to confirm dengue infection by PCR in all patients due to the time of the disease presentation and possible non-viremic periods. On the other hand, a positive IgM in patients with malaria could also reflect recent dengue infection or recent yellow fever vaccination. In addition, our results are not extendable to other healthcare settings or to community basis, since we only included hospitalized patients.On the other hand, this study has also some strengths. This is one of few studies addressing malaria and dengue co-infection, with a considerable amount of cases diagnosed by molecular tests. Besides, this work has been conducted by the same health care team, who applied consistent selection and severity criteria throughout the duration of the study. Furthermore, the majority of the existing works are case series reports and retrospective studies, which may produce low evidence level.Plasmodium sp. on cases with acute febrile syndrome. At last, the patients with parasitological malaria diagnosis which present spontaneous bleeding must be systematically investigated for dengue, and likewise, in suspected and confirmed dengue patients presenting jaundice, Plasmodium sp. investigation must be performed. Besides, whenever co-infection is confirmed, we recommend a carefully monitoring for bleeding and hepatic complications, which may result in a higher chance of severity, regardless of WHO criteria.Malaria and dengue co-infection is a relatively common event. Being malaria the disease with easier and faster diagnosis, in areas with known endemicity, it is recommended the systematic testing for Checklist S1STROBE checklist.(DOCX)Click here for additional data file.


Gemcitabine/taxanes-based combination shows anti-tumor activity for the treatment of metastatic breast cancer, but there is a debate regarding the advantages of gemcitabine and taxanes regimens as a first-line or second-line treatment for metastatic breast cancer. Here we conducted a systematic review and meta-analysis to compare the efficacy and toxicity for patients receiving chemotherapy with or without GT-based regimens.The randomized controlled trials were performed by searching Pubmed, MEDLINE, EMBASE, and conference proceedings. We identified eight randomized controlled trials and then extracted and combined the data using to calculate hazard ratios (HR). The primary outcomes were progression-free survival (PFS) and time to progression (TTP). The secondary outcomes were overall survival (OS) and acute toxicity. A meta-analysis was performed using Review Manager Version 4.2.Eight eligible trails were identified. These studies involved 2234 patients with metastatic breast cancer, (1122 patients received GT-based combination regimen and 1112 patients received a regimen without the combination). A fixed-effects model meta-analysis showed that ORR and TTP are superior for GT-treated patients ORR , TTP . And GT-based combination significantly improved OS in the first-line subgroup . However, there were significant differences regarding acute hematological toxicity, particularly thrombocytopenia.Gemcitabine/taxanes-treated patients with metastatic breast cancer showed a significant improvement in the ORR, TTP and OS (first-line background) compared to patients not treated with the combination regimen. Breast cancer is a major primary malignancy affecting the health of women, and the morbidity and mortality continue to increase in developed countries  in English by entering the following terms in the searching algorithm: (gemcitabine OR gemcitabine [Mesh] AND taxanes OR taxoid [Mesh] OR paclitaxel OR docetaxel) AND (breast tumors OR cancer of breast OR breast neoplasms [Mesh]) AND (advanced OR metastatic) AND  OR randomized OR randomly OR trial). Additionally, we searched the Cochrane Central Register of Controlled Trials for randomized trials that compared gemcitabine treatment for MBC patients. The latest search was performed on September 31, 2013. We manually searched several oncology journals that publish clinical trials. The reference list of all articles was further searched for additional publications to broaden the search scope. The relevant articles and abstracts were selected and reviewed by two reviewers independently. We submitted the details of our systematic review “Gemcitabine-based chemotherapy for MBC: a systematic review and meta-analysis of randomized controlled trials” to the PROSPERO register. The registration number is CRD 42012002752.The eligible clinical trials for inclusion were all controlled randomized studies that evaluated the efficacy and safety of GT-based chemotherapy for MBC patients. The studies included gemcitabine additional roles to taxanes and gemcitabine replacement roles to other non-taxane drugs. We selected double-blinded and randomized trials in addition to non-blinded studies because of the difficulty of blinding for GT administration. The articles selected were completed trials published in full papers or abstracts. All unpublished and ongoing reports were excluded. Trials with two arms were included and one-arm articles and three-arm were excluded. We accepted trials with first-line and second-line metastatic or advanced breast cancer patients. The studies of early stage breast cancer were excluded. All cytotoxic chemotherapy regimens were considered eligible for the meta-analysis, and new targeted drugs such as bevacizumab were included. The trials that compared single agent and other cytotoxic drugs were excluded. The studies based on phase I trials and single-arm data phase II trials were excluded. The reported outcomes included time to progression (TTP), progression-free survival (PFS), overall survival (OS) and the drug toxicity. However, economic evaluations and quality-of-life (QoL) were not considered. Single gemcitabine trials were excluded from our study. Additionally, data of interim analyses were excluded only when we retrieved the complete results from the same study. When we were uncertain of the eligibility of a trial, we discussed its eligibility until a decision was reached.We recorded the following data from each report: first author’s name, publication journal name, year of publication, and number of patients. We also extracted the following individual patient characteristics: age, performance status, ER status, PR and HER-2 status and prior therapy. The following information for each randomized trial was requested: allocated treatment, number of withdraws per arm, blinding, regimen details, clinical outcomes, and study quality. All the information was extracted from each study by Hu and Jiang independently using the same recording forms. The data were then reviewed by Yao. When there was a discrepancy, we reached a consensus by discussion. The primary ends included the total response (CR + PR) using the 4-point WHO scale, time to progression (TTP), progression-free survival (PFS) and overall survival (OS). The secondary end points were acute toxicity including grade 3/4 anemia, neutropenia, febrile neutropenia, fatigue, liver function impairment, nausea/vomiting, and neuropathy graded using WHO criteria. The HRs reported with 95% CIs were extracted when possible. We could not obtain the HR and 95% CI from one of the studies. In such cases, we estimated the P-value of the log-rank statistics by examining the survival curves. The survival curves were enlarged to minimize the reading bias. All data were examined for missing values, and patient follow up was assessed to ensure it was well balanced. If we could not combine the data from the articles because of low numbers of trials and incomplete trials, we performed a systematic analysis of the data.We used the Jadad scale to assess trial quality. The following items details were extracted: blinding; method of randomization-including stratification factor-number of patients participants randomly assigned; excluded from analysis by arm; patientparticipants’ follow-up time (if possible) by arm; number of patients participants lost to follow-up by arm.http://www.cochrane.org). Using the fix random-effects model of DerSimonian and Laird  among trials as shown in Figure The ORR were reported for all trials and accounted for 2234 events. Subgroups were established for the therapy lines and the gemcitabine roles. Based on the total data, there was no evidence of heterogeneity . Heterogeneity may be caused by a few trial numbers or small samples, which were not eliminated. Therefore, a random effect model was selected. The meta-analysis result shows that PFS was not significantly improved .Only two studies were identified as shown in Figure 2 = 29%) among trials. HR for single studies ranged from 0.70 to 1.00. GT-based treatment obviously prolong TTP . However, in the subgroup study the gemcitabine additional role group shows the significant difference . Gemcitabine replacement chemotherapy subgroup contains only one study shows no significant difference . Also, the first-line subgroup study shows GT- based treatment obviously prolong TTP .TTP was reported in five articles as shown in Figure 2 = 0%). GT-based chemotherapy had no significant difference compared to other regimens . However, patients benefited from GT-based combination therapy as a first-line chemotherapy .OS data were taken from seven articles which were defined as first-line, second-line and unclear subgroups as shown in Figure Reports of hematologic toxicity were variable across the trials as shown in Figure Due to the high heterogeneity in the above analysis, we performed subgroup analysis in the meta-analysis. A sensitivity analysis was also conducted by removing one study at a time and calculating the pooled HRs for the remaining studies. We found that no article substantially influenced the pooled result in this analysis.The publication bias was evaluated by a funnel plot. The funnel plot shapes showed no obvious evidence of asymmetry. The results suggested that publication bias was not evident in this meta-analysis.Although the therapy for MBC has improved dramatically over the past decade, cancer mortality among women continues to be major concern. When the disease is incurable, prolonging the life span and relieving pain are still goals for oncologists. Gemcitabine has been shown to be active as a single agent in MBC with good tolerability Tripathy . GemcitaThe meta-analysis showed that GT-based combination chemotherapy regimens resulted in a significant benefit for ORR, TTP and OS (first-line background). Gemcitabine is an effective agent that is well tolerated with good response rates, we found the same results in non-small cell lung cancer and pancreatic cancer (Heinemann et al. Our findings clearly support the use of MBC treatment with GT-based chemotherapy and provide better data than previous single trials and three review articles. The single trials produce unclear results that include both false-negative or false-positive data. The role of GT-based combinations in MBC treatment remains controversial (Gudena et al. Additional studies similar to our review are required to better estimate the short-term and long-term efficacy conferred by the optimal chemotherapy regimen for the MBC management. Another strength of our study is a comprehensive search with two reviewers reading each article independently. The relevant articles and abstracts were selected and reviewed by Hu and Jiang. When we were uncertain about the eligibility of a trial, we would discuss the trial to reach a conclusion. Furthermore, our review includes high quality trials with GT-based-based combination regimens of MBC analyzed by meta-analysis.There are limitations of our study that deserve comment. The heterogeneity of GT-based chemotherapy regimens in the studies may have led to an underestimation of our results and led to a hazard estimate closer to the null. To avoid these defects we established subgroups in the meta-analysis to discriminate the heterogeneity. The eligible randomized controlled trials were based on different settings including first-line and second-line treatment. After carefully identifying each regimen in all eight articles, we found that there were two types of comparisons in the eligible RCTs. There were regimens that used gemcitabine as an add-on treatment and regimens that used gemcitabine as a replacement drug. Thus, we divided the studies into the additional gemcitabine group and a gemcitabine replacement group, also first-line, second-line and unclear group. In addition, we extracted the relative data not the absolute data such as the OS in the eligible studies to minimize the heterogeneity for the different settings. Second, there was heterogeneity in the length of follow up in the long-term mortality studies. Third, some of our selected studies are not blinded. As a result, high-quality randomized, multicenter, blinded, controlled trials are still required.One major limitation is the number of trials is quite small and may not represent the real situation. However, the number of patients is 2234.In conclusion, we demonstrated that GT-based combination treated patients showed a significant improvement in the ORR and TTP in patients with MBC compared with non GT-based treated patients. GT-based regimens led to more serious hematologic toxicity. The therapy line subgroup analysis demonstrated that GT-based combination chemotherapy improved ORR, TTP and OS in the first-line background; while in the second-line background GT-based combination chemotherapy showed benefit of ORR,but did not show any benefit in TTP and OS. And the gemcitabine role subgroup analysis demonstrated that GT-based combination therapy may well be superior to non GT-based in gemcitabine additional therapy group. Therefore, the results from our meta-analysis imply that GT-based chemotherapy showed benefit especially for first-line background. Additional prospective clinical trials are warranted to evaluate treatment combinations using GT-based.


FDG-PET/CT is part of the standard diagnostic management of a patients with a large variety of common and less common malignant tumors, based on the increased glucose metabolism within tumors.A hybrid fluorodeoxyglucose positron emission tomography and computed tomography (FDG-PET/CT) was performed in a neurofibromatosis patient to rule out relapse of malignant peripheral nerve sheet tumor. The scan revealed non-malignant neurofibromas, a testis seminoma and hypermetabolic syphilitic granulomata.This case stresses the need to rule out infectious diseases when atypical hypermetabolic lesions are present. It is useful for detecting malignant transformation of neurofibromas to MPNST, as malignant MPNST is characterized by higher FDG uptake. A cut-off maximum standardized uptake value (SUVity 95%). High FDA 32 year-old homosexual Caucasian male with neurofibromatosis type I NF1), café-au-lait patches and known superficial and deep neurofibromas consulted us for unexplained fatigue and weight loss. History and biochemistry were unremarkable. His clinical examination revealed known signs of NF1 and a nodular appearance of his right testicle.FDG-PET/CT was performed to exclude the presence of a NF1-related malignancy . It revealed multiple hypermetabolic lesions in the following sites: right scrotum, omentum, peritoneum, neuroforamen C5/C6, sternum, ribs, both lungs and mediastinum . In retrospect, the patient had no history of urogenital complaints or ulcus durum, rash or arthralgia.A broad laboratory investigation was performed to rule out some common causes of granulomata. Serologies for We thus interpreted the hypermetabolic granulomatous lesions as active syphilis (primo-infection), for which antibiotic treatment of both the patient  and his serologically-negative partner was initiated. To confirm the working hypothesis of metabolically active syphilis and to rule out distant spread of seminoma, FDG-PET/CT was repeated 21 days after end of therapy, showing complete regression of all hypermetabolic foci, except for known sites of neurofibroma.. We proposed watchful waiting, adjuvant radiotherapy or systemic chemotherapy as options for stage I seminoma, and the patient opted for adjuvant carboplatin AUC 7. He is currently in three-monthly follow-up without clinical, serological or radiological signs of relapse of testicular cancer progression of NF1-related conditions or active syphilis.max) of 3.5 discriminates neurofibroma from MPNST 1. Seminoma testis is highly FDG-avid (average SUVmean 9.2)[FDG-PET/CT is increasingly used as whole body imaging modality in oncology, with high sensitivity and specificity for a number of malignancies. It is useful for detecting malignant transformation of neurofibromas to MPNST, as malignant MPNST is characterized by higher FDG uptake. A cut-off maximum standardized uptake value (SUVean 9.2).The experience with FDG-PET/CT in syphilis is very limited but hypermetabolic syphilitic lesions in bone, lymph nodes, lung, aorta, rectum FDG-PET/CT detected an incidental seminoma testis in a NF1-patient with simultaneous hypermetabolic thoraco-abdomino-pelvic lesions, which were first attributed to the seminoma, then considered to be sarcoid-like lesions according to histology, and were ultimately diagnosed as syphilitic granulomas based on serology and functional imaging before and after antibiotic treatment. FDG-PET/CT cannot differentiate between active inflammation (infectious or not) and malignancy, so metabolic findings always have to be interpreted with caution and in the context of additional clinical information, as shown in our complex case. Infectious diseases should be ruled out in cases with aspecific pathological findings.Written informed consent was obtained from the patient for publication of this Case report and any accompanying images. A copy of the written consent is available for review by the Editor of this journal.The authors declare that they have no competing interests.SP and WEP were the responsible treating physicians of the patient. SP and CMD were responsible for the drafting of the manuscript and creation of the figure. CMD, OG and NL were responsible for the execution and interpretation of the PET scans. KS and BVC performed surgery on the patient. PM was responsible for the pathological diagnoses in the patient. All authors gave critical input to the manuscript and consented with its final version. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2342/14/19/prepub


Chromogranin-A (CgA) is a secretory protein processed into peptides that regulate angiogenesis and vascular cells activation, migration and proliferation. These processes may influence arterial inflammation and remodelling in Takayasu arteritis (TA).439), CgA fragments lacking the C-terminal region (CgA-FRs) and the N-terminal fragment, CgA1–76  were analysed in 42 patients with TA and 20 healthy age-matched controls. Vascular remodelling was longitudinally assessed by imaging. CgA peptides were related to markers of systemic and local inflammation, disease activity and vascular remodelling.Plasma levels of full-length CgA  and arterial hypertension partially accounted for CgA levels and high inter-patient variability. CgAThe plasma levels of CgA fragments are markedly increased in TA as a consequence of disease- and therapy-related variables. Anti-angiogenic forms of CgA may limit vascular remodelling. Given the effect of the various CgA peptides, it is advisable to limit the therapeutic prescriptions that might influence CgA-derived peptide levels to clearly agreed medical indications until further data become available.The online version of this article (doi:10.1186/s13075-016-1082-2) contains supplementary material, which is available to authorized users. Takayasu arteritis (TA) is a rare idiopathic chronic-relapsing large vessel vasculitis, usually affecting young women and associated with considerable morbidity and mortality –4. Typic439), large fragments cleaved after residue 436, various polypeptides spanning from the N-terminus to the central region but lacking the C-terminal region (CgA-FRs) and the N-terminal peptide CgA1–76, alias vasostatin-1 (VS-1)  were performed to evaluate vessel wall thickening. First-pass MRA dynamic sequences targeted on thoraco-abdominal aorta and supra-aortic trunks  were performed during contrast media infusion . High-resolution (HR) sequences were performed before and after contrast administration . These sequences allow the evaluation of vessel wall thickness up to 1 mm. CTA was performed with a Brilliance CT 64-channel scanner  with administration of 130 ml of Ultravist 370  at a flow rate of 5 ml/sec. US was performed with iU22 Matrix Ultrasound system . US and CTA evaluations assessed carotid, subclavian, abdominal and femoral districts, while MRA was focused on thoraco-abdominal or cervico-thoracic regions according to disease involvement. Lesions were evaluated by two radiologists with an expertise in cardio-vascular imaging, blinded to the clinical status of patients. Variables evaluated for each lesion at MRA and CTA included lesion width, length, residual lumen and contrast enhancement. Since gadofosveset trisodium was retired, the presence or absence of vessel wall enhancement was scored by two radiologist experts in cardio-vascular imaging, blinded to the clinical status of patients. Enhancement data were available for 30 patients. At US, lesions width, residual lumen, peak systolic blood flow velocity and the presence of the halo sign were assessed. Imaging follow-up occurred yearly or, in case of relapses, until disease enters the tardive phase, clinical and morphological stability for at least 3–5 years.Progression in arterial involvement was defined as appearance of novel lesions or as increase in width and/or length and/or percentage of luminal stenosis of established vasculitic lesions at follow-up. Two patients were evaluated with imaging only at a single time point, and progression over time could not be assessed. Progressive enlargement of ectasias/aneurysms may be related to biomechanical factors independent of disease activity. Therefore, it has not been included in the definition of progression of arterial involvement. Similarly, progression due to concurrent atherosclerosis was not taken into account. Confounder atherosclerotic lesions were identified and excluded on the basis of typical sites , eccentric appearance of the lesions, short and focal lesions, inhomogeneous content and irregular luminal border on US, the presence of parietal calcifications on the luminal side of the lesion and the absence of halo signs or adventitial thickenings on US.U test was used to compare biomarkers between patients with TA and controls, or between various subgroups of patients with TA stratified according to the presence or the absence of therapy with PPIs, steroids and immunosuppressive agents, arterial hypertension, wall enhancement, vascular progression and active disease. Multivariate analysis with multi-factor analysis of variance (ANOVA) was performed to verify the relationship between stratifying variables and plasma levels of CgA fragments. Plasma levels of CgA439, CgA-FRs and VS-1, their ratio to CgAtot and the anti-angiogenic CgA potential were used as dependant variables of the analysis. Five candidate factors were considered in the model on the basis of their clinical relevance and of their potential involvement: therapy with PPIs, presence of arterial hypertension, vascular progression, therapy with prednisone and therapy with immunosuppressive agents. Considering the sample size, we set the optimal number of factors in the model at four to avoid over-parameterization and loss of statistical power. Given the evidence of the impact of therapy with PPIs on plasma CgA levels [p < 0.001), the latter was excluded from the final model, resulting in a four-way ANOVA. Kruskal-Wallis test was used to compare values of biomarkers within various classes of arterial involvement [2 test and Fisher exact test.We expressed scalar variables as median values and ranges. Mann-Whitney A levels  and the olvement . Spearmap value less than 0.05 was considered to represent statistically significant differences, and p values less than 0.10 were shown in the tables. Statistical analysis was performed with IBM SPSS Statistics, version 20 .A two-tailed p = 0.017 and 3.9 ng/ml, 1.4–6.5 ng/ml, p = 0.009 respectively).Table tot) concentration by assessing all the polypeptides containing the N-terminal region, i.e. by summing the results of 436/439 + FRs ELISA and 76 ELISA [tot was higher in patients with TA than in HCs  and were more frequently treated with steroids than patients without PPIs  had significantly more active disease  and a trend toward increased VS-1  or local inflammation , and VS-1/CgAtot correlated with ESR and PTX3 values . CgA-FRs positively correlated with ESR , while VS-1/CgAtot negatively correlated with ESR and CRP  were observed in patients with active versus inactive disease, defined based on NIH criteria [439, CgA-FRs and VS-1 and their ratios to CgAtot did not correlate with the number of arterial lesions as a measure of disease extent , possibly because of the number of factors relatively to the sample size and of the association between arterial hypertension and therapy with immunosuppressive agents  at the four-way ANOVA analysis  , anti-rheumatic drugs and other supportive medications (e.g. PPIs) influence the CgA system and impact on its relationship with inflammation. CgA-derived peptides have been proved to be biologically active in vivo and to influence vascular events involved in the pathogenesis of TA and we observed a reduced anti-angiogenic CgA potential in patients undergoing vascular progression. The resulting effect of pro- and anti-angiogenic CgA forms is difficult to predict in TA patients, and further studies are needed to confirm these preliminary observations. However, our findings raise the possibility that therapies commonly used in patients with vasculitis may indirectly influence vascular events by modulating the CgA system.Vasa vasorum neongiogenesis is typical of large vessel vasculitides , 12. Infvia the CgA system. It is difficult to predict whether the final effect of PPIs would be vaso-protective or not, because different CgA-derived peptides have opposite actions with non-linear concentration-response curves [PPIs raise CgA levels by inducing gastric entherochromaffin cell hyperplasia as a consequence of hypochlorhydia. We found that patients treated with PPIs had increased levels of CgA-FRs and VS-1, even if the CgA processing is apparently conserved. PPI treatment is common in TA because of the use of steroids, anticoagulants and/or anti-platelet agents. Our data raise the possibility that PPIs indirectly influence vascular events in TA e curves , 17. OveWe found that arterial hypertension was associated with higher levels of CgA-FR and VS-1 in TA, and that a normotensive or hypertensive status influenced the link between the CgA system and inflammation in TA. Arterial hypertension has a complex relationship with the CgA system, as hypertensive patients have higher levels of total CgA , but delThis study has limitations: first, we used imaging and pentraxin-3 rather than histology for assessing vascular inflammation, since surgery is rarely performed in TA. Second, TA is a rare disease and large cohorts are difficult to establish. This is an observational study and the relatively small number of patients and the confounding effects of disease- and treatment-associated variables might limit its statistical power. Despite these limitations, a statistically significant inverse association has been detected between the levels of anti-angiogenic CgA peptides and vascular progression in the more active TA patients on PPI. A similar inverse association has been detected in TA patients with arterial hypertension. These results might reflect a protective action of signals limiting angiogenesis associated to the arterial wall, which could as well restrict the maladaptive vascular remodelling that is the hallmark of TA. Further prospective studies on larger groups of patients are warranted to verify whether this is indeed the case.We observed marked alterations in TA of the circulating levels of CgA-derived polypeptides that might have an effect on the vascular biology. Both disease- and therapy-related variables influence the blood levels of CgA-derived peptides. Until further study clarifies the potential role of CgA-derived polypeptides in large vessel vasculitis, care should be taken with correct prescription of anti-rheumatic and supportive medications, such as PPIs.439, full-length CgA (residues 1–439); CgA-FRs, fragments of CgA spanning from the N-terminus to the central region but lacking the C-terminal region, CgAtot, total CgA; CRP, C-reactive protein; CTA, computed tomography angiography; ESR, erythrocyte sedimentation rate; GCA, giant cell arteritis; IL, interleukin; HCs, healthy controls; MRA, magnetic resonance angiography; PPI, proton-pump inhibitors; PTX3, pentraxin-3; TA, Takayasu arteritis; TNF, tumour necrosis factor; US, ultrasonography; VS-1, vasostatin-1; VSMCs, vascular smooth muscle cellsCgA, chromogranin-A; CgA


Despite the high prevalence of sedentary behaviors in childcare, little research exists on the context and/or type of activities that account for these particular behaviors. Accordingly, if the amount of screen-viewing accumulated by preschoolers in childcare is not considered, researchers may be underestimating total screen time among this population, as only a portion of their day is being captured . This systematic review provides a synthesis of research on the levels of screen-viewing among preschool-aged children (2.5-5 years) attending childcare . This review also examined the correlates of screen-viewing among preschoolers in this setting. To provide additional contextual information, Twelve electronic databases were searched to retrieve relevant articles for inclusion (dating from 2000 onwards). Additional studies were identified via manual searching techniques . Only English, published peer-reviewed articles that examined preschoolers’ screen-viewing behaviors in childcare  were included. No restrictions to study design were applied.Seventeen international studies  published between 2004 and 2014 were examined. Of those, eight studies reported rates of screen-viewing and found that preschoolers spent approximately 0.1 to 1.3 hrs/day and 1.8 to 2.4 hrs/day engaged in this behavior in center- and home-based childcare, respectively. High staff education (negative association) and type of childcare arrangement  were identified as two correlates in relation to preschoolers’ screen-viewing in childcare. Nine studies spoke to the availability of screen-viewing activities in childcare, and found the childcare environment to be conducive to this behavior.Despite some variability, preschoolers appear to engage in somewhat high levels of screen-viewing while in childcare, particularly within home-based facilities. This paper also highlighted the conduciveness of the childcare environment with regard to screen-viewing among preschoolers. Additional exploration into the correlates of screen-viewing in childcare is required. (PROSPORO registration: CRD42013005552). One of the most common sedentary activities in which preschoolers participate is screen-viewing . Often aScreen-viewing among children remains a global health concern. Recent research which aimed to solicit international consensus on research priorities concerning physical activity and sedentary behaviors among children and youth,  ranked sWhile investigations exploring screen-viewing among young children in the home environment,  as well Despite the high prevalence of sedentary behaviors among preschoolers in childcare, -33 littlThe development of a synthesized document estimating the amount of time this cohort spends in screen-viewing activities in childcare, as well as ascertaining whether this behavior is in fact problematic in an environment typically considered sedentary in nature, is warranted ,41,43. Aavailability of screen activities (a commonly used construct), was examined to supplement our understanding of preschoolers’ screen-time and behaviors while in care, and has been correlated with increased screen-time among children  th th50] thn = 6], access to screens and/or activities while in care [n = 3]), this information provides credence to the high rates of screen-viewing in childcare facilities.Nine studies reported on the availability of screen-based activities  within the childcare environment Table  48,52,5,57,59-62n = 236) were, for the most part meeting (but not exceeding) their respective standards of rarely/never showing television or videos [When analyzing the childcare environment as a whole, Trost and colleagues found that the participating home-based childcare facilities (r videos . In contr videos . Zevenber videos .n = 294 facilities) [n = 53 facilities) [n = 4), ease of access and opportunities to engage in screen-viewing activities in childcare are prevalent (n = 5). Consideration of both screen-viewing policies and accessibility is important to examine in order to understand the screen-time rates reported previously.With regard to specific policies and practices concerning screen-use in childcare, projects by Trost et al. (ilities)  and Guntilities)  reportedilities) , Natale ilities) . Over hailities)  and 45% ilities)  paper haThis systematic review aimed to report the frequency of screen-viewing among preschoolers in childcare. As a secondary objective, this review explored correlates of screen-viewing within this setting.daily screen-viewing; because this paper focused solely on screen-viewing among preschoolers in childcare, it is possible that this population could engage in additional screen-viewing outside of care. In fact, recent work by Tandon et al. [The chief finding of this review suggests preschoolers, in general, participate in somewhat high levels of daily screen-viewing while in childcare, although substantial variation exists. Of the papers that reported rates of screen-viewing, ,53,55,58n et al.  action in et al.  and Dowdn et al.  found a Levels of television viewing were assessed most often . One reason explicating this finding could be that one television can entertain many children with little input from staff, rather than other types of screens  which entertain only a few children at a time and require more monitoring  and/or assistance from staff. It is also possible that, measurement of television only is a result of the age of the studies included, as computer use, iPads, etc. might have only recently become popular and available in these facilities. However, by focusing solely on one type of screen medium , researchers may be underestimating preschoolers’ total screen-time in care, and rendering it difficult to properly address this issue. While there is research to support that young children spend the majority of their screen-time watching television  within the home environment,  it wouldBuilding on Christakis et al.’s previous work (which administered surveys to childcare staff),  this revtype of childcare arrangement, demonstrated a positive association to this behavior. Notably, children attending home-based childcare may be more prone to screen-viewing activities. In fact, all studies examining screen-viewing among preschoolers in home-based childcare [daily screen time (3.8 hours at home and 1.8. hours in childcare), in comparison to those in center-based care (3.1 hours at home and 0.1 hours in childcare) [all children can partake. Secondly, given that these types of facilities vary considerably with regard to layout and structure, [The second potential correlate to preschoolers’ screen-viewing in childcare, the hildcare ,47,50,58hildcare . While cildcare) ,71 reinfildcare) ), screenructure, . Thirdlyructure, ,74 thereThe link between access to screen sources and high screen-viewing levels has been well-established in the literature; ,28 subsetype. Lastly, it proved difficult to appropriately synthesize some of the included studies’ findings  because it was not possible in all cases to determine a proper range or upper limit value.Due to the limited available research, all study designs and quality of evidence were eligible for inclusion in this review. As a result, it was not possible to review only the highest quality of evidence; a factor that may have affected the overall strength of the current paper’s findings. Secondly, it was difficult to establish casual relationships between screen-viewing and the identified correlates as many of the included studies were cross-sectional. Thirdly, of the studies that reported rates of screen-viewing, there was a lack of consistency in the manner in which these papers presented their findings. For example, some focused solely on one medium while others provided a combined measure, thus rendering it difficult to extract findings and compare levels of screen-viewing based on screen This paper underscores the infancy of this research as only 17 studies, all published in the last decade, explored the prevalence of screen-time in childcare as well as related correlates. This is the first systematic review to identify the frequency of, and opportunities for, screen-viewing among preschoolers in this unique environment. The results of this review propose that, despite some variability, preschoolers appear to engage in somewhat high levels of screen-viewing while in childcare, particularly within home-based facilities. This paper also highlights the conduciveness of the childcare environment with regard to screen-viewing among preschoolers. The apparent association between increased staff education levels and decreased screen-viewing suggest additional training and education on screen-viewing and sedentary behaviors should be viewed as a priority. Further investigations are needed not only to establish a solid understanding of preschoolers’ habitual screen-viewing behaviors while in childcare, but to modify the childcare environment (and the policies/curriculum therein) in a way that best minimizes screen-related activities during childcare hours as well.aContact author for full search strategy details.bThese figures represent best estimates. Seven studies did not present the total number of preschooler participants, [cipants, ,57,59,60cipants,  ConsequecTwo studies provided a mean number of children included; [ncluded; ,61 howevdTwo papers did not present and upper limit to the screen-viewing levels observed in their studies  [minutes) ,55. ThisMVPA: Moderate-to-vigorous physical activity; NAP SACC: Nutrition and physical activity self-assessment for Child care.The author declares she has no competing interests.LMV was the sole author of this paper. As a result, she conceptualized the review objective; carried out all data collection, syntheses, and analyses; drafted the manuscript (and revised subsequent drafts); and, approved the final version of the paper.LMV is a PhD candidate at Western University in Health and Rehabilitation Sciences . She is currently a research coordinator at the Child Health and Physical Activity Lab at Western.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2431/14/205/prepub


Central Nervous System malignancies often require stereotactic biopsy or biopsy for differential diagnosis, and for tumor staging and grading. Furthermore, stereotactic biopsy can be non-diagnostic or underestimate grading. Hence, there is a compelling need of new diagnostic biomarkers to avoid such invasive procedures. Several biological markers have been proposed, but they can only identify specific prognostic subtype of Central Nervous System tumors, and none of them has found a standardized clinical application.The aim of the study was to identify a Cerebro-Spinal Fluid microRNA signature that could differentiate among Central Nervous System malignancies.CSF total RNA of 34 neoplastic and of 14 non-diseased patients was processed by NanoString. Comparison among groups  lead to the identification of a microRNA profile that was further confirmed by RT-PCR and in situ hybridization.Hsa-miR-451, -711, 935, -223 and -125b were significantly differentially expressed among the above mentioned groups, allowing us to draw an hypothetical diagnostic chart for Central Nervous System malignancies.This is the first study to employ the NanoString technique for Cerebro-Spinal Fluid microRNA profiling. In this article, we demonstrated that Cerebro-Spinal Fluid microRNA profiling mirrors Central Nervous System physiologic or pathologic conditions. Although more cases need to be tested, we identified a diagnostic Cerebro-Spinal Fluid microRNA signature with good perspectives for future diagnostic clinical applications. Numerous efforts have been addressed to identify diagnostic and prognostic biomarkers for Central Nervous System (CNS) neoplasms but none of them has found a standardized routine clinical application . Few tisMetastasis to the brain often arise from lung, breast, skin, kidney and gastrointestinal tract primary tumors. In 16% of cases, they represent the first evidence of malignancy requiring further clinical, radiographic, and/or histologic studies that cannot always achieve a definitive diagnosis –8.Thus, diagnosis still relays on patients’ clinical features and imaging techniques (MRI and CT). However, non-neoplastic lesions of the CNS may be radiologically and clinically mistaken as tumors: benign lesions are not always distinguished from malignant tumors, and imaging characteristics often underestimate the degree of malignancies . Hence, Therefore, it is essential to identify new biomarkers to integrate the prognostic predictivity of old tests and improve medical diagnostic and prognostic resources through non-invasive means.MicroRNAs (miRNAs) are short non-protein coding RNAs that function as key regulators of diverse biological processes through regulation of gene expression . EmerginExpression profiling has shown that microRNAs signatures differentiate normal from tumor tissues and also correlate to histopathology and prognosis , 14. ImpRecently, microRNAs have been found in almost all kind of biological fluids, including Cerebro-Spinal Fluid (CSF). Because of their high stability and easy detection by RT-PCR, microRNAs could be the ideal diagnostic and prognostic biomarkers , 21.The aim of our study was to find new biomarkers that could aid in the diagnosis of CNS malignancies in order to avoid bioptic surgical intervention. To reach our goal we analyzed 82 CFS samples by NanoString, and validated a microRNA profile that can differentiate between and among some classes of CNS tumors.CSF samples from 34 patients with CNS benign and malignant tumors  and from 14 patients without any malignant, or benign lesion, or degenerative disease, affecting the CNS, were collected at the Regina Elena Institute of Rome, Italy, and at The Ohio State University, OH, USA  as described in the material and methods paragraph.Samples were divided into 7 groups  for data analysis, and comparisons among groups were performed. As shown in Table We compared Normals to all groups, the Normal group against every single group separately, the Glioblastoma group versus the Medulloblastoma, and the Lung Metastasis group versus the Breast Metastasis group. We also compared all the malignant  groups against the Benign and Lymphoma group.We selected microRNAs that were showing a significant differential expression among groups in most comparisons  and miR-664, and -205 to differentiate between lung and breast CNS metastatic lesions.Only mir-451, -223, -125b, -711 and -935 were validated by single RT-PCR. Fold change differences among groups and significance were calculated. Table in situ hybridization with each validated miR's LNA probe on FFPE sections of Meningioma, Glioblastoma, Medulloblastoma, Breast and Lung Metastatic lesions and normal adjacent tissue. In situ hybridization experiments, although not sensitive in terms of fold change differences, reflected RT-PCR results.To further confirm our findings and, to verify that the identified CSF microRNAs were originating from cancer cells, we performed In Situ Hybridization staining , but also a 2.45 fold difference in expression. This borderline result can be due to the low number of Lymphoma cases (3 cases) with respect to the Benign cases (9 cases) .Of note is that mir-711 was up-regulated 1.8 folds in Glioblastoma compared to Medulloblastoma  overexpression in lung compared to breast metastasis.On the other hand, miR-935 showed a significant  more expressed in Glioblastomas compared to Medulloblastomas and that miR-125b was 3.9 fold higher in the Medulloblastoma respect to Glioblastoma group . Therefore, we could consider miR-223 a differentiating miR for Glioblastoma and miR-125b a differentiating miR for Medulloblastoma in those CSF samples where there is a loss of miR-935 expression.RT-PCR results revealed that miR-223 was 3 fold  that could be attributed to the low number of Lymphoma cases relative to Benign. In situ hybridization  a Normal CSF by a low expression of miR-451 and a moderate expression of both miR-711 and -935; 2) a Benign neoplasm CSF by a moderate expression of all the three screened microRNAs; 3) a Lymphoma CSF by a low expression of miR-451, the lowest expression of miR-711 , and the lack of miR-935 expression.A fourth combination of our signature expression pattern was characterized by a moderate expression of hsa-miR-451 and of hsa-miR-711 together with a total loss of hsa-miR-935. Hsa-miR-935 was not amplified by RT-PCR, nor its probe was staining Glioblastoma and Medulloblastoma samples Fig. . Therefoin vitro and in vivo proliferation and growth of glial and neuroblastoma cells [in vitro and in human samples [At this point of the chart, three microRNAs are differentiating between Glioblastoma and Medulloblastoma: hsa-miR-223, -125b and -711. Hsa-miR-223 and -711 were up-regulated in Glioblastoma relative to Medulloblastoma, while hsa-miR-125b was up-regulated in Medulloblastoma in comparison to Glioblastoma. MiR-125b is the most abundant microRNA in the brain. Its physiologic functions include neurogenesis and neural development through repression of several targets . On the ma cells –31, but ma cells –34. Recema cells . Less isma cells  where it samples . However samples .In our study, hsa-miR-125b and hsa-miR-223 expression levels were evaluated in the comparison between Glioblastoma and Medulloblastoma, independently from the tumor suppressor or oncogenic role they might play. It is also true that, due to the limited number of samples, the observed differential expression could result from the comparison of specific prognostic subgroups, or from the comparison of non-homogeneous random classes of samples.We tried to find microRNAs that could differentiate Metastasis from the rest of CNS neoplasm and/or between Lung and Breast Metastasis. As drawn in Figure Although our CSF microRNA signature needs to be tested on more samples and eventually amplified with additional pathology and prognostic classes to determine differentiating ranges of fold changes of expression among groups, our results are very promising.in situ hybridization has proven that CSF signatures mirror CNS physiologic or pathologic condition. Our study defined a CSF diagnostic microRNA profile with good prospective of future clinical application.We have been the first to employ a high-throughput microarray-like technique to identify a cancer CSF microRNA profile for CNS neoplasms. Data validation by A total of 82 CSF samples were collected from the Regina Elena Institute, Rome, Italy and from The Ohio State University, Columbus, OH. Sixty eight samples came from patients with benign and malignant brain lesions Table , while 1Two hundred and fifty μL of CSF were homogenized in 1–1, 5mL of Trizol reagent (Life Technologies Cat. 15596–018) and stored at −80°C. After thawing the samples on ice, 200 AttoMoles of spike-in RNA (Cel-miR-248) and 1 μL of RNA carrier  were added. Trizol protocol was followed up to the recovering of the aqueous phase. The aqueous phase was then loaded on the RNA clean up and concentration kit columns (Norgen Cat. 23600). We followed the kit manufacturing instructions for total RNA extraction. To check RNA quality and yield test samples were analyzed by Agilent Eukaryote total RNA pico.A total of 82 CSF samples were processed with NanoString. RNA concentration and quality were estimated by Nanodrop assay (Nanodrop Spectrophotometer 2000), and 100 ng were used as input for nCounter miRNA sample preparation reactions according to manufacturer's instructions (NanoStringTechnologies). Preparation of small RNA samples involves the ligation of a specific DNA tag onto the 3′ end of each mature miRNA. These tags are designed to normalize the melting temperatures of the miRNAs as well as to provide a unique identification for each miRNA species in the sample. The tagging is accomplished in a multiplexed ligation reaction using reverse-complementary bridge oligonucleotides to direct the ligation of each miRNA to its designated tag. Following the ligation reaction, excess tags and bridges are removed and the resulting material is hybridized with a panel of miRNA:tag-specific nCounter capture and barcoded reporter probes. Hybridization reactions were performed according to the manufacturer's instructions with 5 μL of the fivefold diluted sample preparation reaction. All hybridization reactions were incubated at 64°C for a minimum of 18 h. Hybridized probes were purified using the nCounter Prep Station (NanoString Technologies) following the manufacturer's instructions to remove excess capture and reporter probes and to immobilize transcript-specific ternary complexes on a streptavidincoated cartridge. Data collection was carried out on the nCounter Digital Analyzer (NanoString Technologies) following the manufacturer's instructions to count individual fluorescent barcodes and quantify target RNA molecules present in each sample. For each assay, a high-density scan (600 fields of view) was performed.™, a tool provided by NanoString Technologies. In particular, data was normalized by calculating the geometric mean of the top 100 miRNAs in all samples, as recommended by NanoString. P-values were calculated using the LIMMA package (Linear Models for Microarray Data) from the Bioconductor R project. The p-values were adjusted for multiple testing using the Benjamini and Hochberg method to control the False Discovery Rate (FDR). Raw data are available at NCBI GEO: GSE62381.NanoString raw data was analyzed with nSolvert-test. RT-PCR box plots are represent on Figure −ΔCt relative expression to Cel-miR-248. Means ± standard error of the mean (s.e.m.), *P < 0.05, by two-tailed Student's t test.Expression of mature single miRNAs was assessed in triplicate by the TaqMan Stem-loop miRNAassay , and normalized to Cel-miR-248 (Applied Biosystems) in all 82 samples. P-Values were calculated by one-tailed In situ hybridization was performed as described, with minor modifications [FFPE sections (Padua University) of primary central nervous system tumors  and metastatic tumors to the brain  were stained for miR-125b, miR-223, miR-451, miR-711, and miR-935. Five cases per pathologic sub-group were analyzed; further, 5 peri-lesional normal grey matter specimens were considered in the analysis. All probes were labeled with 5′-digoxigenin and synthesized by Exiqon (Denmark). ications . Negativ


Historically, the treatment algorithm applied to non-small cell lung cancer (NSCLC) was the same for all histologic subtypes. However, recent advances in our understanding of the molecular profiles of squamous and non-squamous NSCLC have changed this perspective. Histologic subtype and the presence of specific molecular abnormalities have predictive value for response to and toxicity from therapy, as well as overall survival. For patients with squamous NSCLC, a platinum agent plus gemcitabine, or paclitaxel is recommended as first-line therapy. The role of epidermal growth factor receptor monoclonal antibodies is uncertain. Maintenance therapy is not widely recommended, although data exist for the use of erlotinib. The standard recommendation for second-line therapy is docetaxel and erlotinib should be considered as second or third-line therapy. There is ongoing research identifying molecular targets in squamous NSCLC and many agents are in early phase clinical trials. Immunotherapeutic approaches targeting programed death-1 receptor and its ligand (PD-L1) appear promising. Historically, one simplified management algorithm was applied to all patients with non-small cell lung cancer (NSCLC). A platinum agent combined with paclitaxel, docetaxel, vinorelbine, or gemcitabine was recommended for first-line chemotherapy , 2. SecoEpidermal Growth Factor Receptor (EGFR), or Kirsten Rat Sarcoma (K-RAS) genes are rare in squamous cancers  than patients with adenocarcinoma . Additio cancers . However cancers . Higher Randomized trials in the 1980s demonstrated that chemotherapy improved OS as well as quality of life . These ip = 0.0011). OS was significantly improved for patients with non-squamous histology randomized to cisplatin and pemetrexed, versus cisplatin and gemcitabine . However, in patients with squamous cancer, OS was significantly worse for patients randomized to cisplatin and pemetrexed .More recent data demonstrate that histologic subtype is predictive of a differential response rate, OS, or toxicity profile from certain systemic therapies , 14, 15.p = 0.036). Similarly the observed improvement in OS was limited to patients with non-squamous histology . A second large randomized trial of maintenance therapy following first-line platinum-based chemotherapy evaluated erlotinib  randomized to chemotherapy plus sorafenib had worse OS than patients randomized to chemotherapy alone , as well as lower PFS .Additional trials evaluating other targeted agents have also shown worse outcomes for patients with squamous NSCLC. The ESCAPE trial randomized 926 patients with advanced NSCLC  to carboplatin, paclitaxel with or without sorafenib . The stup = 0.007), there was no difference in PFS, or OS. There was a trend to greater benefit from the addition of cetuximab to chemotherapy, in patients with squamous NSCLC  compared to patients with adenocarcinoma . A second phase III trial, the FLEX trial, evaluated the addition of cetuximab to cisplatin and vinorelbine chemotherapy in patients with advanced NSCLC demonstrating EGFR expression on immunohistochemistry (IHC)  . There wry (IHC) .There does appear to be a differential effect of treatment according to histology for necitumumab, a second EGFR monoclonal antibody. The INSPIRE trial evaluating the addition of necitumumab to cisplatin and pemetrexed in non-squamous NSCLC patients, was stopped early because of an increased risk of thromboembolic complications in the necitumumab arm . HoweverThe available data support adopting a different algorithm for first-line therapy of patients with squamous NSCLC compared with non-squamous histology. While cisplatin and pemetrexed appears to be the preferred chemotherapy in patients with non-squamous NSCLC, pemetrexed appears to be an ineffective drug in patients with squamous cancers. The JMBD trial did show that cisplatin and gemcitabine was superior chemotherapy in patients with squamous cancers . HoweverSecond-line chemotherapy for NSCLC has been widely adopted since publication of two randomized trials in 2000 , 4. The p = 0.04). On the other hand, patients with squamous histology who received pemetrexed had inferior survival . This analysis primarily showed that patients with squamous NSCLC treated with pemetrexed had an inferior outcome.A retrospective analysis was subsequently undertaken of the JMEI trial to look for an interaction between treatment effect and histology , 9. SimiThese data support a differential approach to second-line chemotherapy according to histology. Docetaxel is recommended as second-line chemotherapy in patients with squamous type NSCLC, whereas pemetrexed is recommended for patients with non-squamous NSCLC. However, due to the adoption of pemetrexed in the first-line setting, docetaxel remains an option for second-line chemotherapy, in patients with non-squamous histology.Many patients with advanced NSCLC are still candidates for further systemic therapy, at the time of progression on second-line chemotherapy. There is little evidence though, to support the use of a third-line of chemotherapy. However, the results of the BR21 trial of erlotinib vs. best supportive care support the use of erlotinib as second or third-line therapy . This trEGFR gene are strongly predictive of benefit from an EGFR tyrosine kinase inhibitor (TKI)  and patients with adenocarcinoma . Therefore, erlotinib should be considered as a second or third-line option for treatment in patients with squamous NSCLC. To date no other agents have be shown to improve survival in this setting.Since publication of the BR21 trial, there has been a considerable body of evidence demonstrating that the presence of activating mutations of the or (TKI) . It has rlotinib , demonstK-RAS, EGFR, as well as translocations of the Anaplastic Lymphoma Kinase (ALK) gene. However, there has been less research characterizing molecular abnormalities in lung cancer patients with squamous tumors. The cancer genome atlas (TCGA) network published data on genomic and epigenetic analysis of 178 squamous NSCLC patients from across the world (fibroblast growth factor receptor gene (FGFR), mutations of phosphatidylinositol 3-kinase, catalytic subunit alpha gene (PIK3CA), phosphatase and tensin homolog gene (PTEN), discoid domain receptor 2 gene (DDR2), BRAF, as well as EGFR amplification (The molecular profile of adenocarcinomas of the lung has been well described . Common he world . The datfication . This wop = 0.05). These data require confirmation in phase III trials. The data suggest patients with squamous cancers may have more benefit from the addition of ipilimumab  than patients with non-squamous cancers .Immune based therapies also appear to be gaining momentum in NSCLC. There is considerable interest in immune checkpoint regulation in NSCLC. In particular, therapy directed toward the programed death-1 receptor (PD-1), or its ligand PD-L1 has shown considerable promise in early phase clinical trials. Phase I trials of several PD-1 receptor monoclonal antibodies, including nivolumab , MK-3475It is clear that a different treatment algorithm has emerged for patients with squamous NSCLC. In the first-line setting platinum doublets involving gemcitabine, or potentially paclitaxel should be considered. The role of EGFR monoclonal antibodies such as cetuximab and necitumumab, require further clarification. Treatment options beyond progression of first-line therapy include docetaxel and erlotinib. Multiple trials are currently examining new therapies targeting the common molecular abnormalities observed in squamous lung cancers.Peter Michael Ellis has received honoraria from Eli Lilly and Roche for advisory board meetings. The other co-author reports no conflicts of interest.


Summary: The ms-data-core-api is a free, open-source library for developing computational proteomics tools and pipelines. The Application Programming Interface, written in Java, enables rapid tool creation by providing a robust, pluggable programming interface and common data model. The data model is based on controlled vocabularies/ontologies and captures the whole range of data types included in common proteomics experimental workflows, going from spectra to peptide/protein identifications to quantitative results. The library contains readers for three of the most used Proteomics Standards Initiative standard file formats: mzML, mzIdentML, and mzTab. In addition to mzML, it also supports other common mass spectra data formats: dta, ms2, mgf, pkl, apl (text-based), mzXML and mzData (XML-based). Also, it can be used to read PRIDE XML, the original format used by the PRIDE database, one of the world-leading proteomics resources. Finally, we present a set of algorithms and tools whose implementation illustrates the simplicity of developing applications using the library.Availability and implementation: The software is freely available at https://github.com/PRIDE-Utilities/ms-data-core-api.Supplementary information:Supplementary data are available at Bioinformatics onlineContact:juan@ebi.ac.uk The Proteomics Standards Initiative (PSI) has developed and actively promotes the use of open standard data formats to represent the data produced in mass spectrometry (MS) based proteomics experiments . Three of the most broadly used formats are: mzML  to efficiently handle the main data types in MS proteomics workflows, ranging from spectra to peptide/protein identifications to quantitative results. The current version supports three major PSI data standards  and the majority of mass spectra file formats . This makes ms-data-core-api the first open-source API supporting both identification and quantitation PSI file formats. In addition, as a key feature, it fully supports access to data stored in the PRIDE database . The biggest advantage of using the library is that any application based on it is largely file format agnostic. Following a modular design, many independent libraries were grouped at the same dependency level . The developed data model provides adapters that can translate the input data from the different source files into the core data structures, enabling the support of widely used formats . Crucially, the output from some of the most used analysis software in the field supports or can be converted to these highly popular formats, and then supported by the library ; (ii) the transformers between the native file data representation and the data model; (iii) the cache system warranting fast and efficient access to the data ; and (iv) the data access controllers that can interface with external tools and libraries.The API is composed of four functional components: (i) the data models incorporating all data structures  or an ontology (e.g. the PSI-MS CV), and userParams, which are user-defined parameters to represent information not yet included in CVs and ontologies. The API also contains general metadata on the experimental set-up. For example, metadata on the protein identification protocol such as software, enzyme and search database are part of the ProteinDetectionProtocol class.metadata . The proCache design and PRIDE utilities: The design of the ms-data-core-api aims to achieve an optimal balance between memory consumption and access performance to the data by using a custom caching implementation . Most of the data structures in the API are cached as key-value entries depending on access patterns. Data objects are cached as a whole if they are requested frequently, whereas objects requested less often are cached as mappings to their locations within the source file for fast random access. Also, new refinements were introduced in the file format native readers . The independent PRIDE Utilities module . As shown in the code snippet below, the calculation of these properties for all the supported formats takes minimum effort:MzIdentMLControllerImpl controller = new MzIdentMLControllerImpl(new File(“file.mzid”));Collection<Comparable> proteins = controller.getProteinIds;for(Comparable id: proteins) for(Comparable pepId: controller.getPeptideIds(id))  double pI=                    IsoelectricPointUtils.calculate));s module  providesExporting to mzTab: The library includes a range of options to export the core data models and the processed results to mzTab files. The current version enables the conversion from mzIdentML and PRIDE XML to mzTab files including a set of filters to select only the high-quality peptide and protein identifications . As shown in the code snippet below, the conversion of mzIdentML to mzTab takes minimum effort:MzIdentMLControllerImpl controller = new MzIdentMLControllerImpl(new File(“input.mzid”));AbstractMzTabConverter mzTabconverter = new MzIdentMLMzTabConverter(controller);MZTabFile mzTabFile = mzTabconverter.getMZTabFile;MZTabFileConverter checker = new MZTabFileConverter;checker.check(mzTabFile);mzTabFile.printMZTab(new FileOutputStream(“output.mztab”));Supplementary information, Section S3). The widespread use of the library ensures its stability, continued development, and community support. The ms-data-core-api library is freely available, and is released under the Apache 2.0 license at https://github.com/PRIDE-Utilities/ms-data-core-api.Various algorithms, tools and pipelines have already been developed using the ms-data-core-api including PRIDE Inspector, the PRIDE internal submission pipeline, HI-bone and the PIA protein inference algorithm, among others , a project of North Rhine-Westphalia, Germany.Y.P-R. is supported by the Conflict of Interest: none declared.


The aim of the present study was to compare the frequencies of mtDNA haplogroups as well as control region (CR) polymorphisms of obese juveniles (n = 248) and obese adults (n = 1003) versus normal weight controls  1.71 (1.2–2.4), adjusted for sex and age]. The frequencies of the T haplogroup-linked CR polymorphisms C16294T and the C16296T were found to be elevated in both the juvenile and the adult obese cohort compared to the controls. Nevertheless, no mtDNA haplogroup or CR polymorphism was robustly associated with any of several investigated metabolic and cardiovascular parameters  in all obese subjects.By investigation of this large ethnically and geographically homogenous cohort of Middle European Caucasians, only mtDNA haplogroup T was identified as an obesity risk factor. The heritability of obesity has long been appreciated. Early studies focused on monogenic and syndromal forms of extreme obesity, while subsequent genome-wide association studies (GWAS) of common genetic variants have identified novel loci. However, the common variants uncovered in the latter studies were found to have modest effects , and the proportion of variability explained by the GWAS-identified loci to date remains relatively small (<10%) . The respective level of significance for analysis of CR polymorphisms was <0.0003 for the STYJOBS/EDECTA juvenile obese group [number of comparisons = 192] and <0.0002 for the SAPHIR adult obese group [number of comparisons = 333]. Additionally, logistic regression analysis was applied to adjust for possible confounders (sex and age).The following clinical and biochemical variables were analyzed in the juvenile obese group for association with specific mtDNA haplogroups or CR polymorphisms: BMI, BMI standard deviation score (BMI sds), diastolic blood pressure, systolic blood pressure, blood glucose concentration, insulin resistance (HOMA-Homeostasis Model Assessment), triglycerides (TGs), low-density lipoprotein-cholesterol (LDL), high-density lipoprotein-cholesterol (HDL), waist-to-hip ratio (WHR), body fat percentage, birthweight, BMI of mother, fasting insulin, ultra-sensitive C-reactive protein (CRP), adiponectin, intima-media thickness (IMT), family history of diabetes mellitus type 2, family history of hypertension, family history of myocardial infarction (MI) and family history of stroke.For the SAPHIR study group the following variables were available: BMI, blood glucose concentration, fasting insulin, insulin resistance (HOMA-Homeostasis Model Assessment), waist circumference (WC), hip circumference (HC), visceral adipose tissue (VAT), subcutaneous adipose tissue (SAT), body fat percentage, lean body mass (LBM), ultra-sensitive C-reactive protein (CRP) and adiponectin.ANOVA was used to compare metabolic parameters in the different mtDNA haplogroups. To test for an association between clinical and biochemical parameters and presence of a specific mtDNA haplogroup or CR polymorphism, an independent sample t-test  or a non-parametric Mann-Whitney U-test was performed. The Kolmogorov-Smirnov test was used to check for normality.All analyses were performed using PASW 18.0 .The clinical characteristics of all study groups are shown in The frequency of the T haplogroup was higher in the obese group compared to the URSPRUNG age-matched control group  , howeverIn the overweight and obese adult subjects, haplogroup T was again found at a higher frequency than in the normal weight group  .mtDNA D-loop variants of all 514 juvenile samples were investigated by direct sequencing of a 1066-bp fragment between np 16024 and 526. In 1598 adult samples, sequences were analyzed between np 16145 and 509. Only CR polymorphisms with a frequency ≥5% in either controls or cases were deemed to be relevant and analyzed further.www.ncbi.nlm.nih.gov/genbank), Phylotree (www.phylotree.org) or MITOMAP (www.mitomap.org/MITOMAP) .The presented data are in agreement with the results of Nardelli et al. , who anaPreviously, haplotype T was reported to be a risk factor for multifactorial disorders such as coronary artery disease and diabetic retinopathy . FurtherAlthough most mitochondrial polymorphisms are believed to be neutral, population-specific mtDNAs may be functionally different and exert varying influences on the outcome of a disease . DiffereKnoll et al. reported a higher frequency of the polymorphism T16189C among extremely obese cases (17% vs. 9%) . The polWe further looked for potential correlations of certain mtDNA haplogroups or CR polymorphisms with obesity-relevant metabolic and cardiovascular parameters. However, no mtDNA variant was robustly associated with any of the investigated metabolic and cardiovascular parameters in both the obese juvenile cohort and the adult obese cohort. Nor could we confirm the results of Yang et al., who reported an association of haplogroup X with lower BMI and body fat mass in a sample of unrelated Northern European Caucasians . Saxena There are study limitations that need to be acknowledged. Firstly, since the data of the adult study group were taken from a previous study, our study design was post-hoc. However, analyzing both the juvenile and the adult subjects together had the advantage to increase the number of samples as it is widely recognized that small sample sizes do have limited study power . HoweverIn summary, our study found the frequencies of mitochondrial haplogroup T and a linked D-loop variant (C16294T) to be elevated in a juvenile obese cohort and an adult obese cohort of Middle European ancestry. However, the frequency of the subhaplogroup T2 marker C16296T was elevated only in the juvenile cohort, but not in the adult group. No association of certain mtDNA haplogroups or CR polymorphisms with relevant metabolic and cardiovascular parameters could be detected. In conclusion, our data suggest that there is a population-specific association of mtDNA haplogroup T with obesity in Middle European Caucasians.S1 File(DOCX)Click here for additional data file.


Motivation: The vast majority of the many thousands of disease-associated single nucleotide polymorphisms (SNPs) lie in the non-coding part of the genome. They are likely to affect regulatory elements, such as enhancers and promoters, rather than the function of a protein. To understand the molecular mechanisms underlying genetic diseases, it is therefore increasingly important to study the effect of a SNP on nearby molecular traits such as chromatin or transcription factor binding.Results: We developed SNPhood, a user-friendly Bioconductor R package to investigate, quantify and visualise the local epigenetic neighbourhood of a set of SNPs in terms of chromatin marks or TF binding sites using data from NGS experiments.Availability and implementation: SNPhood is publicly available and maintained as an R Bioconductor package at http://bioconductor.org/packages/SNPhood/.Contact:judith.zaugg@embl.deSupplementary information:Supplementary data are available at Bioinformatics online. The vast majority of these disease- or trait-associated SNPs lie in the non-coding part of the genome and are likely to affect regulatory elements (i.e. enhancers and promoters) rather than the function of a protein. Thus, to understand the molecular mechanisms underlying complex genetic traits and diseases, it is increasingly important to study the effect of SNPs on nearby molecular traits such as chromatin or transcription factor (TF) binding. Current workflows for analysing ChIP-Seq data typically involve peak calling, which summarises the signal of each binding event into two numbers: enrichment and peak size, and usually neglects additional factors like binding shape. However, when a set of regions of interest (ROI) is already at hand—e.g. GWAS SNPs, quantitative trait loci (QTLs), etc.—a comprehensive and unbiased analysis of the molecular neighbourhood of these regions, potentially in combination with genetic or allele-specific binding (ASB) analyses will be more suited to investigate the underlying (epi-)genomic regulatory mechanisms than simply comparing peak sizes. Currently, such analyses are often carried out ‘by hand’ using basic NGS tools and genome-browser like interfaces to visualise molecular phenotype data independently for each ROI. A tool for systematic analysis of the local molecular neighbourhood of ROI is currently lacking. To fill this gap, we developed SNPhood, an R/Bioconductor package to investigate, quantify and visualise the local epigenetic neighbourhood of ROI using chromatin or TF binding data from NGS experiments. It provides a set of tools that are largely complimentary to currently existing software for analysing ChIP-Seq data. Many functionalities of SNPhood have been used in our recent study to investigate the chromatin environment of H3K27ac QTLs, which has led to the conclusion that H3K27ac QTLs lie in the nucleosome free regions and show the same effect across multiple histone marks and TF binding  have been identified in genome-wide association studies (GWAS) to be associated with complex traits and diseases  across multiple samples . It's functionalities are largely complementary to and extend current tools used for ChIP-Seq data analysis  detection of allelic bias across ROI, for which we implemented a procedure that identifies the most significant bin within each region controlled by an empirically determined FDR, (ii) exploration and visualisation of genotype-dependent binding patterns including generation of publication-quality figures, or unsupervised clustering-based, and (iii), optionally, genotype-dependent comparisons and grouping of the binding pattern across ROI and samples. Methodological details and all functionalities can be found in the SNPhood Vignette (http://bioconductor.org/packages/release/bioc/vignettes/SNPhood/inst/doc/IntroductionToSNPhood.html).SNPhood also allows background normalisation (e.g. input DNA) as employed by ChIP-Seq peak callers such as MACS2  a set of BAM files (e.g. from ChIP-Seq), (ii) a list of genomic positions/ROI (e.g. GWAS-SNPs), and, optionally, (iii) corresponding genotype data. If available, SNPhood with a typical workflow example. For a comprehensive documentation of all functionalities, we refer the reader to the SNPhood workflow vignette: http://bioconductor.org/packages/release/bioc/vignettes/SNPhood/inst/doc/workflow.html. We start with a set of ROIs, in our case SNPs that have been identified as histone quantitative trait loci (hQTLs) within the Yoruba (YRI) population (SNPhood for H3K27ac ChIP-Seq data from two CEU individuals (plotAllelicBiasResultsOverview for a high-level overview of the allelic bias across a chromosomal region. To visualise the binding pattern for specific ROI we employed the function plotAllelicBiasResults (Here, we briefly illustrate some functionalities of sResults . This reSNPhood is flexible and can be applied to any ROI. We believe that it will be a helpful tool to generate new biological hypotheses by integrating molecular-phenotype data in an unbiased and position-specific manner.Despite the name,


Sevelamer hydrochloride is used widely, but its impact upon cardiovascular calcification, cardiovascular mortality, all-cause mortality and hospitalization is not known.Primary outcome was cardiovascular calcification  and aortic calcification scores (ACS)). Secondary outcomes were serum characteristics, hospitalization, cardiovascular mortality and all-cause mortality. Risk ratio (RR), mean differences and standard mean difference with 95% confidence intervals (CIs) were pooled using random- or fixed-effects models.We identified 31 studies . An analysis pooling showed a significant decrease in serum levels of phosphate with calcium-based phosphate binders (CBPBs) by 0.17 mg/dL  than sevelamer. A significant difference in the change of CACS by –102.66  and ACS by –1008.73  between sevelamer and CBPBs was observed. Prevalence of hypercalcemia  was significantly smaller for sevelamer . No significant difference was found in hospitalization, all-cause mortality or cardiovascular mortality.This meta-analysis suggests that sevelamer benefits dialysis patients in terms of CACS, ACS and hypercalcemia. Chronic kidney disease (CKD) is a major public-health problem . As a maHigher levels of phosphate in serum are associated with worse outcomes in dialysis patients, so different types of therapies have been employed to deal with this problem. Phosphate binders taken with meals, which bind dietary phosphate, play an important part in the treatment of hyperphosphatemia . DietaryNew non-calcium, non-magnesium, and aluminum-free phosphate-binding means agents such as sevelamer have been reported to reduce the Medicare costs of inpatients compared with calcium binders  without Several reviews –13 have We undertook a systematic meta-analysis of RCTs according to Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines  16]. We. We16]. We also searched  the abstracts of conference proceedings of the American Society of Nephrology from 1998 to 2013. However, we did not have access to RCTs that were not reported.Restrictions on language or dates were not imposed in our searches. Finally, we found 2961 studies for the analysis. After screening, 31 studies  were included  in the aAll RCTs that studied dialysis ESRD adults (age ≥18 years) and compared sevelamer to any calcium-based phosphate binder (CBPB) were included. Included studies are assumed to have analyzed the effect of phosphate binders on serum levels of phosphate or calcification of coronary arteries. Studies comparing sevelamer to any other types of phosphate binders or no phosphate binders were excluded. Titles and abstracts were reviewed by two reviewers independently, as well as the full-text articles.Cochrane Handbook for Systematic Reviews of Interventions  according to the ventions  17]. Le. LeCochrventions  [17]. A 2≤25%) and a random-effects model (used if I2≥50%) was used to analyze data.We undertook meta-analyses using Review Manager 5.2 and meta-regression by comprehensive meta-analysis (CMA). Mean difference (MD) and standard mean difference (SMD) were used to pool results for continuous outcomes , and we also computed pooled risk ratios (RRs) for dichotomous outcomes . We used change-from-baseline results rather than final values in the analysis of CACS and aortic calcification scores (ACS) to evaluate the effect of phosphate binders upon vascular calcification. Pooling methods that account for the with-inpatient-correlation from crossover trials were used to combine data from crossover and parallel continuous trials . A fixed2 index  and P values were also used. Publication bias was assessed using Funnel plots.Ninety-five percent confidence intervals (95% CIs) were provided for all pooled estimates. Heterogeneity was assessed using the Cochrane Q test. IA total of 2961 potentially relevant citations were identified and screened. Eighty-six articles were retrieved for detailed evaluation, of which 31  fulfilled the eligibility criteria . DetaileA total of 31 studies, including an abstract  and fiveIn an analysis of 18 studies with 3327 participants reporting on serum levels of phosphate (duration of follow-up ranged from 8 weeks to 45 months), a significant decrease in serum levels of phosphate with CBPBs by 0.17 mg/dL  was observed . All RCTCompared with CBPBs, the MD in serum levels of calcium  and in calcium-phosphate product  were significantly lower in patients administered sevelamer by –0.24  and by –0.14  separately.Level of hypercalcemia  reported in ten trials with 957 participants was smaller for sevelamer  compared with CBPBs . When hySeven studies with 731 participants, one of which had a sample size of only 52 participants, reported on the change of CACS. Considering the quality of the RCTs, we only included the six trials with 679 patients. The duration of follow-up varied from 26 weeks to 104 weeks. MD was significant, and was lower with sevelamer therapy by –102.66  . All RCTConsidering that the use of statins , showing that sevelamer benefited patients with regard to hospitalization. Only one trial [Nine trials with 3000 participants reported all-cause mortality, and the duration of follow-up ranged from 20 weeks to 45 months. Three RCTs analyzed all-cause mortality as the primary outcome. The RR was 0.91  between sevelamer and CBPBs. Three RCTs with 2102 participants reported on cardiovascular mortality, and the RR was also non-significant by 0.94 . As a result, no significant difference was found in all-cause mortality and cardiovascular mortality.2≤50%) and random-effects (I2>50%) models. Between-study heterogeneity ranged from 0% to 75%. Among all the data analyzed, no between-study heterogeneity (0%) was observed in the analysis of cardiovascular mortality, all-cause mortality, change in ACS, hospitalization, and hypercalcemia. Between-study heterogeneity was low (I2≤25%) in the analysis of change in CACS, and was moderate (25%<I2≤50%) in the analysis of serum calcium-phosphate product. Between-study heterogeneity of the data analyzed was high (>50%) for serum levels of phosphate and calcium. We could not undertake a subgroup analysis, so we used the random-effect model to analyze the data: serum levels of phosphorus had an I2 = 58% and serum levels of calcium had an I2 = 75%.All data  in the analysis of phosphorous, we undertook a meta-regression using CMA and analyzed three factors: mean duration of dialysis; designed duration of the trial; and sample size of the trial. However, we did not find a significant factor (P>0.1) that contributed to heterogeneity , we did not find a significant factor that contributed to the heterogeneity .We carried out a meta-analysis to estimate the impact of sevelamer upon cardiovascular calcification, cardiovascular mortality, all-cause mortality, and hospitalization in patients on dialysis, and identified 31 studies . Compared with CBPBs, sevelamer therapy resulted in smaller decreases in serum levels of phosphorus and a lower prevalence of hypercalcemia. A significant difference in the CACS and ACS was observed between sevelamer and CBPBs. Evidence that sevelamer reduced all-cause mortality or cardiovascular mortality was lacking. Also, there was a slight reduction in the duration of hospitalization with sevelamer therapy according to three RCTs.Our review updates and complements the findings of earlier systematic reviews. It also includes >3000 additional participants, including a Dialysis Clinical Outcomes Revisited (DCOR) study  with 210Different to former meta-analyses, this meta-analysis found a significant difference in CACS and ACS. This phenomenon may be due to a better search strategy, as well as the inclusion of more trials and different types of patients. In the analysis of CACS, compared with eight RCTs on dialysis patients, a meta-analysis by Zhang 2010  includedIn this meta-analysis, we found a significant difference in CACS. Compared with CBPBs, sevelamer does not contain calcium, and is a type of non-calcium, non-magnesium, aluminum-free agent. As a result, sevelamer therapy can result in a smaller increase in serum levels of calcium and calcium-phosphate product. Also, the prevalence of hypercalcemia  was also smaller. Serum levels of calcium are independent risk factors for vascular calcification, so less calcium in blood leads to a smaller increase in CACS for sevelamer therapy. However, our analysis showed no significant differences between sevelamer therapy and CBPB therapy in terms of cardiovascular mortality. A long time is required from vascular calcification to a cardiovascular event. Hence, sevelamer may reduce cardiovascular mortality in the long-term, and the fact that no significant evidence was observed for cardiovascular mortality may be due to short-term follow up.Though sevelamer has less impact in controlling hyperphosphatemia, its use can result in a significant reduction in hospitalization. Moreover, a study showed that sevelamer-treated patients over 65 years old had a significant reduction hospitalization (P = 0.03) with a trend toward fewer hospital days (P = 0.08). In this respect, sevelamer can enhance the quality of life of patients.Previous reviews showed no evidence to recommend use of sevelamer because there was no evidence to show that sevelamer has clinically meaningful benefits. However, our meta-analysis showed favorable use of sevelamer, especially for patients with hypercalcemia or high CACS. Also, compared with calcium-phosphate binders, the available trials mostly showed a clinically relevant beneficial effect of sevelamer.The strengths of this meta-analysis were the number of participants and studies that we evaluated. Indeed, this is the largest systematic review of RCTs on dialysis patients to examine the effect of sevelamer compared with CBPB therapy on kidney-related serum measurements, CACS, ACS, hospitalization, and other endpoints of clinical safety.However, several limitations must be considered. Unpublished reports could not be identified, which might have biased our results. Also, we could not assess the dosing schedules of sevelamer therapy and CBPB therapy , which may have contributed to the heterogeneity of our analysis . Patients undergoing hemodialysis or peritoneal dialysis were studied in the populations. With only four studies focusing on adequate allocation concealment, the quality of trials was not very high. Also, the duration of follow-up was short except for four Dialysis Clinical Outcomes Revisited trials. Intention-to-treat analysis was not used in some trials. In addition, some trials did not describe the number of dropouts.In summary, compared with CBPBs, sevelamer has virtually no advantage in terms of the control of serum levels of phosphate, but it can decrease in the prevalence of hypercalcemia, and benefits vascular calcification in the long-term. We can conclude that sevelamer improves clinically relevant outcomes in ESRD patients on dialysis. Therefore, routine use of sevelamer in dialysis patients is recommended in patients that already have control of serum levels of phosphate, and if patients may suffer, or already are suffering, from hypercalcemia or cardiovascular disease. Those with severe hyperphosphatemia are recommended to choose CBPB therapy (at least in the short-term).S1 Fig(PDF)Click here for additional data file.S2 Fig(TIF)Click here for additional data file.S3 Fig(TIF)Click here for additional data file.S4 Fig(TIF)Click here for additional data file.S5 Fig(TIF)Click here for additional data file.S6 Fig(TIF)Click here for additional data file.S7 Fig(TIF)Click here for additional data file.S8 Fig(TIF)Click here for additional data file.