Effective and scalable prevention approaches are urgently needed to address the rapidly increasing rates of e-cigarette use among adolescents. School-based eHealth interventions can be an efficient, effective, and economical approach, yet there are none targeting e-cigarettes within Australia. This paper describes the protocol of the OurFutures Vaping Trial which aims to evaluate the efficacy and cost-effectiveness of the first school-based eHealth intervention targeting e-cigarettes in Australia.OurFutures Vaping Program intervention group or an active control group . The intervention consists of four web-based cartoon lessons and accompanying activities delivered during health education over a four-week period. Whilst primarily focused on e-cigarette use, the program simultaneously addresses tobacco cigarette use. Students will complete online self-report surveys at baseline, post-intervention, 6-, 12-, 24-, and 36-months after baseline. The primary outcome is the uptake of e-cigarette use at 12-month follow-up. Secondary outcomes include the uptake of tobacco smoking, frequency/quantity of e-cigarettes use and tobacco smoking, intentions to use e-cigarettes/tobacco cigarettes, knowledge about e-cigarettes/tobacco cigarettes, motives and attitudes relating to e-cigarettes, self-efficacy to resist peer pressure and refuse e-cigarettes, mental health, quality of life, and resource utilisation. Generalized mixed effects regression will investigate whether receiving the intervention reduces the likelihood of primary and secondary outcomes. Cost-effectiveness and the effect on primary and secondary outcomes will also be examined over the longer-term.A two-arm cluster randomised controlled trial will be conducted among Year 7 and 8 students (aged 12–14 years) in 42 secondary schools across New South Wales, Western Australia and Queensland, Australia. Using stratified block randomisation, schools will be assigned to either the OurFutures platform and has the potential to make substantial health and economic impact. Without such intervention, young Australians will be the first generation to use nicotine at higher rates than previous generations, thereby undoing decades of effective tobacco control.If effective, the intervention will be readily accessible to schools via the The trial has been prospectively registered with the Australian and New Zealand Clinical Trials Registry .The online version contains supplementary material available at 10.1186/s12889-023-15609-8. Despite only emerging in recent years, e-cigarette use, particularly among adolescents who do not smoke, has become a global public health concern . The mosA major recent review found e-cigarettes can also cause a range of acute health problems, including e-cigarette or vaping use-associated lung injury (EVALI), seizures, poisoning and burns . E-cigarDrug harm prevention initiatives delivered during adolescence are an efficient and effective way to deliver long-term health and economic benefits , 17. SchDespite the demonstrated potential of school-based substance use prevention, an evidence-practice gap exists, with less than one in four teachers implementing a drug prevention program with evidence of effectiveness , 24. AmoWhilst evidence supports the effectiveness of school-based preventive eHealth interventions in addressing alcohol and other drug use among adolescents , there iOurFutures Vaping Program. OurFutures is an innovative, universal prevention model that adopts a harm minimisation and comprehensive social influence approach to drug prevention. The model was designed to maximise intervention fidelity and overcome common implementation barriers for school-based interventions. For example, the core intervention component is the cartoon storyboards which cannot be adapted by teachers. The cartoons follow the lives of a group of young people around the same age as the target students who, through their experiences, impart knowledge, skills and values related to alcohol and other drug use. In essence, this provides peer-led education, which is more effective at addressing adolescent substance use compared to adult-led education [To address these gaps, we developed the first school-based eHealth preventive intervention to target e-cigarette use among young Australians – the ducation . FurtherOurFutures programs has been established through 8 large randomised controlled trials (RCTs) across Australia . These studies demonstrated that the OurFutures programs targeting alcohol, cannabis, psychostimulants and emerging drugs, are more effective than school-based health education as usual in reducing alcohol consumption, binge drinking, cannabis use, ecstasy use, harms from substance use, intentions to use substances, and in increasing knowledge about substance use harms, up to 3 years following intervention delivery [OurFutures to be one of only two school-based alcohol and other drug education programs in Australia with a strong evidence base [OurFutures model to the prevention of e-cigarette use through the OurFutures Vaping Program. This study aims to evaluate the efficacy of the program through a multisite cluster RCT. It is hypothesised that compared to an active control group :The effectiveness of the delivery –31. Notadelivery . Moreovence base . CapitalOurFutures Vaping Program will be less likely to commence e-cigarette use at the 12-month follow-up (primary outcome).students who receive the OurFutures Vaping Program will achieve superior outcomes on secondary outcomes including: uptake of tobacco smoking, frequency/quantity of e-cigarettes use and tobacco smoking, intentions to use e-cigarettes/tobacco cigarettes, knowledge about e-cigarettes/tobacco cigarettes, motives and attitudes relating to e-cigarettes, self-efficacy to resist peer pressure and refuse e-cigarettes, mental health, quality of life, and resource utilisation.the OurFutures Vaping Program on primary and secondary outcomes will be sustained over the long-term (up to 36-months post baseline).benefits of the OurFutures Vaping Program will demonstrate cost-effectiveness (up to 36 months post baseline).the OurFutures Vaping Program intervention group or an active control . An economic evaluation will be conducted alongside the cluster RCT to determine the cost-effectiveness of the OurFutures Vaping Program. The study is sponsored by the University of Sydney and has been approved by the Human Research Ethics Committees of the University of Sydney (2022/818), University of Queensland (2023/HE000082) and Curtin University (HRE2023-0059). The trial will follow Consolidated Standards of Reporting Trials (CONSORT) guidelines for cluster RCTs and has been prospectively registered with the Australian and New Zealand Clinical Trials Registry (ACTRN12623000022662), with any modifications logged immediately. This protocol follows Standard Protocol Items: Recommendations for Interventional Trials (SPIRIT) guidelines .A two-arm cluster RCT will be conducted among Year 7 and 8 students in 42 secondary schools across New South Wales (NSW), Western Australia (WA) and Queensland (QLD), Australia, from 2023 to 2026. Cluster randomisation at the school level will be used to avoid potential contamination of the control group by the intervention group . This design allows for optimal and rigorous evaluation of the research questions and hypotheses. Schools will be randomly allocated (1:1) to either the The sample size calculations are based on a method to detect intervention by time interactions in longitudinal cluster RCTs . To deteEligible participants will be Year 7 and Year 8 students (aged approximately 12–14 years) attending participating schools in 2023. Students will be required to be fluent in English and provide informed active consent and parental consent to participate. Schools with less than 70 enrolled students per cohort and based outside of NSW, WA or QLD will be excluded.Independent, Government and Catholic secondary schools in NSW, WA and QLD will be invited to participate. Schools that have previously expressed interest in participating in research will be approached and we will simultaneously promote the study through our extensive professional networks via email and social media. Schools will also be approached using publicly available contact details. An invitation will be sent to school principals and health education staff outlining the study aims and seeking permission to implement the study. Research staff will also follow up schools via phone call and email.blockrand package in R [OurFutures Vaping Program intervention group and 21 schools to an active control group. Figure The age in R  will be Participant information statements and consent forms will be distributed to parents/guardians via hardcopy or electronically (depending on school preference). Due to differing requirements across ethics committees, some schools will use passive (opt-out) parental consent, while others will use active (opt-in) parental consent. If insufficient active written parental consent is obtained from a school, verbal parental consent will be sought from the remaining parents. A school staff member will contact parents using contact details available to the school and will either be reimbursed for their time and effort, or the school will be reimbursed the costs of employing a casual teacher for a day. Students will be required to provide active written consent prior to the baseline assessment. Active written consent will also be sought from Year 7/8 teachers at both control and intervention schools to complete online evaluations and fidelity logbooks.OurFutures Vaping Program in health education classes in 2023. The program involves four 40-minute lessons, ideally delivered one week apart. Each lesson consists of a web-based cartoon component . The primary endpoint will be the 12-month follow-up.Tobacco ever use. Assessed using a single item: “Have you ever tried smoking a cigarette, even one or two puffs?” (Yes/No). This item was based on items used in our previous trials [s trials  and the s trials .Frequency and quantity of e-cigarette and tobacco cigarette use. Assessed using a series of questions based on those used in previous research [research , 39, 41 research .Knowledge about e-cigarettes and tobacco cigarettes. Measured using a 15-item scale developed to reflect the content of the OurFutures Vaping Program intervention. The scale was derived from a larger pool of items that was piloted among adolescents to reflect items of varying degrees of difficulty. The items assess a range of topics such as the short- and long-term effects/harms of e-cigarettes and tobacco cigarettes, common myths about e-cigarettes and tobacco cigarettes, e-cigarette and tobacco cigarette laws in Australia, and the prevalence of e-cigarette and tobacco cigarette use among young people in Australia. Response options include: True/False/Don’t know.Motives to use e-cigarettes. Assessed using an adapted version of the Tobacco Motives Inventory [nventory . The scaAttitudes towards e-cigarettes. Assessed using an adapted and validated version [ version  of the S version . The scaIntentions. Two single items based on those from our previous school-based trials [d trials , 39 willE-cigarette refusal skill techniques. Assessed using items adapted from a measure developed to assess drug refusal skill techniques [chniques . ParticiSelf-efficacy to resist peer pressure. Assessed using an adapted version of the Resistive Self-Regulatory Efficacy Scale [cy Scale , with twMental health. Depressive symptoms over the past 7-days will be assessed via the Patient Health Questionnaire-8 (PHQ-8), and 8-item scale validated for use among adolescents [lescents , 49. Anxlescents  using thlescents  will be lescents . Internalescents . Internalescents  will be lescents . Perceptlescents –58.Health-related quality of life. Assessed using the Child Health Utility 9D instrument (CHU9D) [ (CHU9D) . This in (CHU9D) .Resource utilisation. The utilisation of healthcare and other related services will be measured using a self-report resource use questionnaire (RUQ) that has been developed for use in previous studies [ studies , 61. ParAdditional measures include demographic information comprising age, sex, gender, cultural and linguistic diversity attributes, academic performance, and truancy rates. To measure socioeconomic status, students will complete the Family Affluence Scale III  and provOurFutures Vaping Program, students and teachers in the intervention group will be asked to complete an online questionnaire to evaluate the program, and teachers will complete a logbook to assess fidelity and implementation barriers and facilitators. Using measures developed and employed in our previous school-based trials [OurFutures Vaping Program. Teacher outcomes will include adherence to the intervention, student engagement and understanding, program acceptability, ease of use, educational quality, likelihood of use in the future, and any barriers or enablers to implementation. Website analytics will provide objective data on the dose and timing of intervention delivery.After the final lesson of the d trials , the stulme4 package [Data analysis will be conducted on an intention-to-treat basis, whereby all randomised students will be analysed in the groups that they were originally assigned. Generalized mixed effects regression will investigate whether receiving the intervention reduces the likelihood of primary and secondary outcomes . Analyses will be conducted in R, using the  package . To accoOurFutures Vaping Program and active control condition. The costs that accrue across each trial arm will be calculated as the sum of: all relevant intervention delivery costs; and the cost of utilising additional healthcare and other related services. The cost of delivering the OurFutures Vaping Program and health education as usual will be estimated based on a detailed accounting of resources required to deliver each respective program. This will consider all costs associated with intervention delivery and usual education, including staff and teacher time alongside program materials. Data from the RUQ will be used to estimate the cost of utilising additional healthcare and other related services. The cost-effectiveness of the OurFutures Vaping Program – when compared to health education as usual – will be evaluated using the incremental cost-effectiveness ratio (ICER) as the main measure of cost-effectiveness. That is, the difference in mean costs divided by the difference in mean QALYs between the intervention and control arms.The base case analysis will be undertaken using a partial societal perspective, alongside an additional analysis from a health sector perspective. Area-under-the-curve methods will be applied to CHUD9D data to estimate the QALYs associated with the A cost-consequences analysis will also be done to produce a dashboard of all relevant costs and outcomes resulting in each trial arm. Additional cost-effectiveness ratios can then be estimated by adopting primary and secondary outcomes as the denominator . Standardised economic evaluation techniques, such as Fieller’s theorem and non-parametric bootstrapping, will be used to estimate confidence intervals around each cost-effectiveness ratio. Economic modelling can also be undertaken, if applicable, to estimate the long-term costs and outcomes that may accrue beyond the timeframe of the cluster RCT and to estimate the cost-effectiveness and/or budget impact of scaling up the intervention across Australian schools.A data monitoring committee consisting of researchers independent to the core trial team will meet quarterly to review trial management, progress, and oversee statistical analysis. The committee will monitor recruitment, dropouts, and any adverse events in consultation with the lead researchers in each state. All adverse events will be recorded, and serious adverse events will be immediately reported to the governing Human Research Ethics Committee/s.OurFutures Vaping Trial; the first evaluation of a school-based eHealth preventive intervention targeting e-cigarette use among young Australians. By building on effective principles of tobacco and e-cigarette prevention [OurFutures prevention model which harnesses innovative eHealth technology, this novel evidence-based program offers a highly feasible and rapidly scalable solution to a global public health priority. The simultaneous targeting of both e-cigarettes and tobacco cigarettes is another key strength of the program. However, given the study will span three Australian states and is anticipated to include > 3,300 secondary school students, it will rely on self-report measures which may be subject to reporting biases. Nevertheless, the study has the potential to improve the immediate health and wellbeing of young people, while also safeguarding them from serious health impacts and addiction caused be e-cigarettes and tobacco cigarettes. If effective, the intervention will be readily accessible via the publicly available OurFutures platform and has the potential to make substantial health and economic impact. Without such intervention, young Australians will be the first generation to use nicotine at higher rates than previous generations, thereby undoing decades of effective tobacco control.This paper describes the study design and protocol of the evention , and theBelow is the link to the electronic supplementary material.Supplementary Material 1


Background and Objectives: Polymer-free ultrathin strut sirolimus- and probucol-eluting stents (PF-SES) are recognized as safe and effective in diverse patient populations, although the implications of post-dilation during stent implantation remain underexamined. Materials and Methods: In this study, patients implanted with PF-SES at Gachon University Gil Medical Center between December 2014 and February 2018 were evaluated. Major adverse cardiovascular events (MACE), encompassing nonfatal myocardial infarction (MI), nonfatal stroke, and cardiovascular death were identified as primary outcomes, with secondary outcomes including target vessel revascularization (TVR), target lesion revascularization (TLR), and in-stent restenosis (ISR). Results: Of the 384 initial patients, 299 were considered eligible for analysis. The groups, delineated by those undergoing post-dilation (143 patients) and those not (156 patients), exhibited comparable rates of primary outcomes . The outcomes remained consistent irrespective of the post-dilation status and were similarly unaffected in multivariate analyses . Conclusions: These results suggest that the clinical outcomes of patients with post-dilation were similar to that of those without post-dilation in those with the polymer-free sirolimus- and probucol-eluting stents. Coronary artery disease poses a substantial global health challenge, significantly impacting morbidity and mortality worldwide . With thPost-dilation has been proposed as a strategy to address this problem of stent underexpansion . Post-di® ISAR, B. Braun Melsungen, Germany) [Delayed healing might transpire due to hypersensitivity reactions elicited by the stent polymer, potentially linked to an elevated risk of stent thrombosis . AlternaGermany) . ProbucoGermany) ,29,30,31Germany) ,33. PolyGermany) ,36,37,38However, like all medical advancements, PF-SES has its own limitations. Concerns have been raised about the radial strength of ultrathin strut stents, particularly in the context of lesions that demand increased radial force, such as coronary chronic total occlusions (CTOs). In such scenarios, ultrathin strut stents have been observed to demonstrate higher stent recoil, late lumen loss, and restenosis compared to traditional stents ,40. Desp® ISAR, B. Braun Melsungen, Germany) implantation at Gachon University Gil Medical Center between December 2014 and February 2018. The criteria for PCI encompassed significant de novo coronary lesions (over 70% stenosis identified through coronary angiography) as well as documented myocardial ischemia. This evidence of ischemia was derived not solely from the patient’s typical angina, indicative of ischemic heart disease, but also from positive outcomes on exercise stress or imaging tests that necessitated PCI. The range of conditions necessitating PCI extended from chronic coronary syndromes (CCS) to acute coronary syndromes (ACS), such as unstable angina and myocardial infarction. The study population was divided into two groups: those who underwent post-dilation (post-dilation group) and those who did not (no post-dilation group). The analysis excluded patients who had received different types of implanted stents, multiple PF-SESs, or a history of coronary artery bypass grafting. The current study conformed to the Declaration of Helsinki (sixth revision). The Institutional Review Board approved this study  and waived the requirement for informed consent due to the retrospective observational nature of the study.This retrospective, observational, single-center study included patients who underwent PCI with PF-SES  with a supranominal diameter.All the patients included in the study underwent stent implantation with PF-SES. In the framework of the polymer-free stent, there is a pre-assembled fine cobalt–chromium strut (50/60 µm in size). Sirolimus serves as an effective anti-proliferative agent, while probucol acts as a controlling agent for the drug’s release . Before y artery . HoweverThe baseline demographics, clinical characteristics, angiographic and procedural data, and post-procedural medications were extracted from the electronic medical records. The baseline demographics accounted for factors such as age and gender, as well as lifestyle-related information like smoking. Meanwhile, the clinical characteristics encompassed the patient’s past medical history; family history of coronary artery disease; presence or absence of risk factors for coronary artery disease such as hypertension, diabetes mellitus, dyslipidemia, or chronic kidney disease; and any previous history of myocardial infarction, heart failure, or stroke. Regarding the angiographic data, variables like the degree of coronary artery stenosis, location and length of the lesion, and presence of multi-vessel disease were meticulously recorded. The procedural data included the type of stents used, whether balloon pre-dilation or post-dilation was performed, the maximum pressure applied, and the final result of the procedure in terms of residual stenosis and thrombolysis in myocardial infarction flow grade. For the follow-up phase, the patients were asked to return for regular outpatient visits, which provided an opportunity to assess their clinical status, medication compliance, and the occurrence of any potential adverse events. Routine clinical follow-ups were scheduled at specific intervals—after 6 months, 1 year, 2 years, and 3 years—following the index PCI. Additional angiographic follow-ups were conducted as necessary, such as in the presence of ischemic symptoms, to meticulously observe stent patency and identify any cases of in-stent restenosis or other complications.This study was an in vivo investigation concentrating on clinical outcomes rather than a bench test examining the deformation of the stent platform following post-dilation. The primary outcome was MACE, a composite of nonfatal myocardial infarction, nonfatal stroke, and cardiovascular death. The secondary outcomes included TVR, TLR, and ISR. Myocardial infarction was defined according to the third universal definition of myocardial infarction. Stroke was defined as an acute neurological deficit lasting more than 24 h with evidence of brain infarction in imaging. TVR was defined as any repeat PCI in the target vessel. TLR was defined as repeat PCI within the index procedure stent or 5 mm edge. ISR was defined as a diameter stenosis of ≥50% within the stent or 5 mm proximal or distal to the stent, assessed either using angiography or intravascular imaging.t-test. Categorical variables were presented as frequencies and percentages and compared using a Chi-square test. Hazard ratios (HR) with 95% confidence intervals (CI) were calculated using Cox proportional hazards regression models to assess the impact of post-dilation on the primary and secondary outcomes. Multivariate analyses were performed to adjust for potential confounding factors, including hypertension, diabetes mellitus, B2 or C lesion, and calcification. Kaplan–Meier curves were used to visualize the cumulative event rates over time for the primary and secondary outcomes. A two-sided p-value < 0.05 was considered statistically significant. All the analyses were performed using SPSS software version 29 .Continuous variables were presented as means ± standard deviations and compared using a Student’s p = 0.025)  and 143 patients underwent post-dilation (post-dilation group) . The bas= 0.025) .p < 0.001; 5.1% vs. 23.8%, p < 0.001). While there was no significant difference in the stent diameter between the two groups, the stent length was longer in the post-dilation group. All the lesions were evaluated for the appropriateness of stent expansion using intravascular ultrasonography or ESV, with the majority of cases utilizing ESV. The medications prescribed at discharge were not significantly different between the two groups , indicating no statistically significant difference between the two groups  in the no post-dilation group and four patients (2.8%) in the post-dilation group. The hazard ratio for MACE was 2.17 . TVR was observed in one patient (0.6%) in the no post-dilation group and no patients (0.0%) in the post-dilation group, with a hazard ratio of 0.02 . TLR occurred in six patients (3.8%) in the no post-dilation group and three patients (2.1%) in the post-dilation group, with a hazard ratio of 0.55 . ISR was observed in five patients (3.2%) in the no post-dilation group and five patients (3.5%) in the post-dilation group, with a hazard ratio of 1.10 . All the secondary outcomes were comparable between the two groups, with no statistically significant differences detected  in the no post-dilation group and two patients (1.4%) in the post-dilation group, with a hazard ratio of 2.18 , and calcified lesions  in the post-dilation group. Also, the stent length was significantly longer in the post-dilation group . As a result, the stents used in the post-dilation group may have been longer in order to cover the long lesion. This finding strongly suggests that post-dilation was more frequently employed in complex lesion scenarios. The angiographic characteristics of type B2 and C lesions, as classified by the modified American College of Cardiology (ACC) and American Heart Association (AHA) lesion classification, were regarded as complex lesions [The most significant observation was the noticeably higher proportion of complex lesions, B2 or C lesions  in the post-dilation group . The priThe present study has several limitations. Firstly, given its retrospective, observational, single-center design, the scope of the results may be limited, potentially restricting their applicability in a broader context. Future prospective multicenter trials with larger sample sizes and randomized allocation to post-dilation are warranted to confirm these findings and elucidate the precise role of post-dilation in patients receiving PF-SES. We believe that our results can serve as a foundation for future studies that can provide more robust evidence for the effects of post-dilation. Second, the absence of a uniform evaluation method of stent expansion represents another limitation. The use of intravascular imaging was inconsistent and dependent on individual physician discretion, which may introduce selection bias. We acknowledge that intravascular imaging is the gold standard for evaluating stent expansion, but intravascular ultrasonography has the limitation that it is not covered by health insurance in Korea and is expensive. Also, optical coherence tomography is not available at our institution, so we could not apply it. We used ESV, a fluoroscopy-based evaluation method, as an alternative. ESV has been shown to be a reliable alternative to intravascular imaging in some studies ,51,52,53Furthermore, the imbalance in lesion complexity between groups is another limitation of our study. This study did not exclusively analyze calcified lesions, which is a limitation. We adjusted for this imbalance as much as possible using a multivariate Cox regression analysis. The observation of more complex lesions in the post-dilation group may be due to the fact that post-dilation is typically performed when stent under-expansion occurs, and stent under-expansion is more likely to occur in complex lesions. We believe that our findings are still clinically meaningful, as we showed that post-dilation did not lead to worse clinical outcomes in patients with more complex lesions. However, we would like to see future studies with a more balanced design to further confirm our findings. In our study, only two left main lesions were included in the post-dilation group due to the maximum available size of PF-SES being 3.5 mm at our institution. The necessity of using different stents for larger left main lesions limits our understanding of the effects of post-dilation with PF-SES in these cases, and we acknowledge this as a constraint of our study. These limitations obscure insights into the effects of post-dilatation on PF-SES in left main lesions, suggesting that further studies in left main lesions are warranted. The last limitation of this study was the relatively small number of events. This may suggest that the PCI was carried out by experienced and skilled interventionists. We anticipate that this limitation could be addressed in larger, prospective, future studies. Despite these limitations, the study provides valuable insights into the clinical outcomes of PF-SES implantation with and without post-dilation, particularly in patients with more complex lesions. These findings have important implications for clinical practice, as they suggest that post-dilation may be safely performed when indicated, which could help to optimize stent deployment and improve patient outcomes.In conclusion, this study demonstrated that the clinical outcomes were comparable between patients with and without post-dilation in PF-SES implantation, even in the presence of more complex lesions. These findings suggest that post-dilation using PF-SES may be a safe and effective method. Further research is needed to better understand the role of post-dilation and identify specific subgroups of patients who might benefit from this procedure.


The self-medication hypothesis suggests people may develop Alcohol Use Disorder (AUD) or Non-Alcohol Substance Use Disorder (NA-SUD) following PTSD as a maladaptive way of coping with PTSD symptoms. Given that an accumulation of trauma experiences and interpersonal trauma increase the likelihood and severity of PTSD, we sought to determine whether the number and type of traumas additionally predict AUD and NA-SUD following PTSD.M = 45.63 years, SD = 17.53, 56.3% female) who were administered semi-structured diagnostic interviews of trauma exposure and PTSD, AUD and NA-SUD symptoms.We analysed data from 36,309 adult participants in the National Epidemiologic Survey on Alcohol and Related Conditions-III (NESARC-III) study (Individuals with PTSD were more likely to have an AUD or NA-SUD than those without PTSD. Endorsement of a greater number of traumas was associated with greater odds of having PTSD, AUD, or NA-SUD. Experience of interpersonal trauma was related to greater odds of having PTSD and subsequent AUD or NA-SUD than not experiencing interpersonal trauma. Multiple experiences of interpersonal trauma compared to one interpersonal trauma exposure also increased the odds of having PTSD followed by AUD or NA-SUD.Interpersonal trauma and multiple experiences of interpersonal trauma may result in individuals turning to alcohol and substances as a way to alleviate intolerable PTSD symptomology, aligning with the self-medication hypothesis. Our findings highlight the importance of ensuring services and support for interpersonal trauma survivors and for those who have experienced multiple traumas given their increased for unfavourable outcomes.The online version contains supplementary material available at 10.1007/s00127-023-02472-6. Post-traumatic stress disorder (PTSD) can develop following exposure to highly distressing or life-threatening experiences, such as military combat, accidents, assaults, and natural disasters . Around The cumulative effects of multiple trauma exposures, named the dose–response effect , 12, is Differing trauma types appear to moderate the relationship between trauma exposure and the risk of PTSD. Interpersonal trauma, such as assault, torture, and combat, enhance the risk and severity of PTSD compared to non-interpersonal trauma, such as natural disasters and accidents , 22–24. Given that trauma type and dose are associated with a greater likelihood and severity of PTSD, they may also be associated with comorbidities seen in PTSD. Comorbidity in PTSD may be a proxy for greater severity and a sign that individuals have not adjusted to their trauma. Several psychiatric disorders commonly co-occur with PTSD. Almost half (46.4%) of those with PTSD also meet the criteria for Alcohol Use Disorder (AUD) or a Non-Alcohol Substance Use Disorder (NA-SUD) , 31–33. Experiencing more traumas is associated with disordered alcohol and substance use, and a wealth of evidence supports that a higher number of traumas in childhood is associated with a greater lifetime risk of developing AUD –45. CrosThe relationship between trauma type and problematic alcohol and substance use also remains unclear. Several prospective studies have found that experiencing interpersonal traumas is associated with an increased risk of alcohol and substance abuse , 49. WhiThe prevailing and most supported theory for the link between PTSD and AUD or NA-SUD is the self-medication hypothesis, which posits that substances are used to cope with and alleviate intolerable interoceptive experiences and PTSD symptomology , 61. In It is well-established that alcohol and drug disorders highly co-occur with PTSD , and eviThe present study aims to investigate whether number of lifetime trauma exposures and type of trauma are associated with the development of AUD and NA-SUD in people with PTSD. First, it was hypothesised that individuals who experience trauma and develop PTSD are more likely to be diagnosed with AUD or NA-SUD (“AUD/NA-SUD”) than individuals who do not develop PTSD following trauma. Second, we hypothesised that the greater the number of traumas experienced, the greater the likelihood of developing PTSD. Our third hypothesis predicted that the greater the number of traumas experienced, the greater likelihood of developing AUD/NA-SUD. For our fourth hypothesis, we predicted that people who have experienced interpersonal trauma would be more likely to meet the criteria for PTSD and subsequent AUD or PTSD and subsequent NA-SUD compared to those who have not experienced interpersonal trauma. Finally, we hypothesised that people who had experienced multiple interpersonal traumas would be more likely to meet the criteria for PTSD followed by AUD/NA-SUD compared to those who had experienced one interpersonal trauma, consistent with the idea that trauma number and trauma type would have a compounding effect in predicting AUD/NA-SUD following PTSD.The present study utilised data derived from The National Epidemiologic Survey on Alcohol and Related Conditions-III . Data acThe Alcohol Use Disorder and Associated Disabilities Interview Schedule-5 (AUDADIS-5) is a structured diagnostic interview designed for use by non-clinical interviewers. The questions within this interview correspond to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition  (DSM-5) A series of binary items corresponded to each DSM-5 symptom of PTSD . A proxyParticipants were asked about 19 potentially traumatic events (PTEs) they may have been directly exposed to and 13 PTEs they may have indirectly experienced. Indirect exposure included learning about or witnessing a traumatic event. Endorsement of a stressful life experience, including kidnapping and sexual and physical abuse, was considered to reflect interpersonal trauma exposure  and anxiety diagnoses, including generalised anxiety disorder, specific phobia, social anxiety disorder, panic disorder and agoraphobia. All past-year anxiety disorders were collapsed into a singular past-year anxiety disorder variable.Sex, age, race , educational level, and marital status were evaluated.p < 0.05 (two-tailed). To test the first hypothesis, a Chi-square Test of Independence was conducted to evaluate associations between current PTSD and past-year AUD and past-year NA-SUD in those who had experienced trauma. For the interested reader, Table All analyses were conducted using the Statistical Package for the Social Sciences (SPSS) version 28. The overall significance level for all statistical tests was set at Table χ2 = 227.72, p < 0.001). Specifically, compared to those that experienced trauma and did not develop PTSD, those with PTSD following trauma were more likely to have a past-year AUD . Past-year PTSD was also related to past-year NA-SUD : individuals that experienced trauma and had PTSD were more likely to have an NA-SUD than those that experienced trauma and did not develop PTSD .A Chi-square test revealed a significant association between past-year PTSD and past-year AUD . Experiencing multiple traumas was associated with 1.61 greater odds of having PTSD compared to only having experienced one trauma (p < 0.001). Older age and post-school education was related to reduced odds of PTSD . Being female, not being partnered and presence of past year anxiety and MDD was associated with increased odds of PTSD . Compared to people identifying as White, those who were First Nations or Hispanic had greater odds of having PTSD ; however, Asians had reduced odds .A logistic regression examined the relationship between the number of traumas and the likelihood of past-year PTSD diagnosis . Those who experienced one trauma had significantly greater odds of having AUD than those with no reported trauma . Similarly, the odds of AUD were greater for those who had experienced two or more traumas in comparison with those without a trauma history . Older age and female sex were associated with reduced odds of having AUD . Post-school education, not being partnered and past year anxiety and MDD were related to increased odds of having AUD . Compared to people identifying as White, First Nations people  had increased odds of having an AUD, while people identifying as Black, Asian, and Hispanic were associated with reduced odds .Another logistic regression was used to examine the association between number of traumas and the likelihood of past-year AUD . Experiencing multiple traumatic events was associated with 2.68 times greater odds of having an NA-SUD compared to those with no trauma exposure (p < 0.001). Older age, female sex and post-school education were related to reduced odds of having an NA-SUD , whereas not being partnered and past-year anxiety or MDD was associated with greater odds of having an NA-SUD . Compared to people identifying as White, people identifying as Black  had increased odds of having an NA-SUD and the odds decreased if they identified as Asian or Hispanic .The overall regression model could differentiate between those with and without a past-year NA-SUD . Exposure to multiple traumas was not significantly associated with a greater or reduced odds of having PTSD followed by AUD (OR = 0.94), compared to those with no interpersonal trauma exposure (p = 0.58).A logistic regression was used to ascertain the influence of numbers of trauma on the likelihood of PTSD followed by AUD .The predictors reliably distinguished between those with and without PTSD followed by NA-SUD (p < 0.001).The upper part of Table p < 0.001; lower part of Table Participants who endorsed at least one interpersonal trauma had 4.72 greater odds of having PTSD followed by NA-SUD . Older age was associated with reduced odds of having AUD after PTSD . Post-school education and past-year anxiety were related to increased odds of PTSD followed by AUD . Compared to people identifying as White, people identifying as Black  had reduced odds of PTSD before AUD, whereas First Nations people had greater odds .The overall logistic regression analysis investigating the influence of trauma type and number on the likelihood of PTSD followed by AUD was significant . Compared to only experiencing one or no interpersonal traumas, those who had experienced multiple interpersonal traumas had 2.50 times greater odds of having PTSD followed by NA-SUD (p < 0.001). Older age and female sex were related to reduced odds of having PTSD before NA-SUD . Past-year anxiety was related to increased odds of PTSD and subsequent NA-SUD .The relationship between multiple interpersonal traumas and PTSD before NA-SUD is summarised in the lower section of Table The current study aimed to affirm the established literature demonstrating the relationship between trauma number and PTSD and resolve the ambiguity surrounding the relationship between trauma number and AUD/NA-SUD. Second, given the absence of literature examining these three factors in tandem, we hoped to determine whether interpersonal trauma and number of traumas were associated with PTSD followed by AUD/NA-SUD. The results strongly suggest that interpersonal trauma is a key factor in predicting PTSD and subsequent AUD/NA-SUD.In keeping with our first hypothesis, we confirmed that among individuals who have experienced trauma, those with PTSD have higher rates of AUD/NA-SUD than those without PTSD. This finding is consistent with a large body of literature showing that PTSD increases AUD/NA-SUD risk , 72, 78.The study also lends support for the second and third hypotheses: in line with past findings, number of traumas positively correlated with the likelihood of PTSD , 15, 20 multiple interpersonal traumas are more likely to develop AUD/NA-SUD following PTSD compared to individuals exposed to one or less than one interpersonal trauma. Interestingly, once controlling for interpersonal trauma, multiple traumas of any type did not significantly differ from a single trauma experience in predicting PTSD followed by AUD/NA-SUD. This finding suggests that the experience of multiple traumas is most relevant to PTSD and AUD/NA-SUD outcomes when those traumas are interpersonal. These findings are consistent with established literature that has found independent effects of multiple interpersonal traumas on increasing the likelihood and severity of PTSD, AUD, and NA-SUD [We also confirmed that interpersonal trauma increased the likelihood of a diagnosis of PTSD and later AUD/NA-SUD compared to those with no reported interpersonal trauma. In addition, our results also supported the exploratory hypothesis that those who have experienced d NA-SUD , 84, 85.Collectively, these results suggest interpersonal trauma exposure is particularly pathological for PTSD and subsequent AUD/NA-SUD development. Interpersonal trauma has been linked to a greater appraisal of threat, subjective distress and pervasive feelings of shame compared to non-interpersonal trauma, which does not typically generate these feelings , 86, 87.While interpersonal trauma and multiple interpersonal traumas were more likely in individuals with PTSD followed by AUD and NA-SUD, the odds ratios suggest this relationship is stronger for NA-SUD than AUD. This is of particular interest as alcohol is more readily and easily accessible, while illicit substances do not have the same ease of access. It could be speculated that individuals with PTSD are desperate to cope with severe PTSD symptomology that follows interpersonal trauma and multiple interpersonal trauma exposure.As outlined in the results, demographic characteristics and mental health disorders assessed in the study also predicted the likelihood of PTSD, AUD following PTSD, and NA-SUD following PTSD. These included age, sex, post-school education, marital status, ethnicity and past-year anxiety disorder and MDD, confirming findings from previous studies , 88–93. While the current secondary analysis provided critical insights into the association between trauma number and type on PTSD before AUD/NA-SUD, it also has some notable limitations. First, the study utilised a cross-sectional design and was reliant on participant recall regarding the occurrence of events, such as the date of trauma exposure and age of onset of PTSD, AUD and NA-SUD. Furthermore, the determination of PTSD preceding the onset of AUD/NA-SUD was necessarily crude. As age of onset was only reported to the nearest year in the data set, when the age of onset was the same year for both PTSD and AUD/NA-SUD, the participant was not classified as PTSD followed by AUD/NA-SUD. The number of traumas variable also had limitations, whereby participants could only report a maximum of four traumas; second, each trauma had to be a distinct specific trauma type. Thus, repeated experiences of trauma like sexual assault was only counted as one of the four traumas. Nonetheless, assessment of the number of lifetime traumas is notoriously unreliable due to participant recall error and memory distortions .The current investigation has wide-ranging implications. We have shown a temporal sequencing effect, whereby the development of PTSD increases the likelihood of developing an AUD or NA-SUD. These findings impact individuals that, due to their occupation, such as veterans, paramedics and police officers, are likely to be exposed to multiple interpersonal traumas , 99. SpeTo our knowledge, this study is the first to collectively assess the relationship between trauma number and type on PTSD followed by AUD or NA-SUD. The current investigation used a large, generalisable population to identify risk factors predictive of the progression from PTSD to AUD or NA-SUD. These risk factors included experiencing multiple experiences of interpersonal trauma. Our results are broadly consistent with the self-medication hypothesis. Namely, exposure to interpersonal trauma and multiple exposures of an interpersonal nature appeared to be particularly pathogenic for individuals with PTSD, as these risk factors may result in maladaptive attempts to self-medicate, with continued and frequent use precipitating the onset of AUD or NA-SUD. Future studies should aim to replicate these findings using prospective study designs.Supplementary file1 (DOCX 20 KB)Below is the link to the electronic supplementary material.


Pancreatic cancer is known to cause a hypercoagulable state and increase the risk of thrombosis. While long-term systemic anticoagulation is a treatment option to reduce this risk, its effectiveness remains ambiguous. In this retrospective study, data from the U.S. Nationwide Inpatient Sample database were extracted and compared statistically to find the solution. The results showed that pancreatic cancer patients who had received long-term systemic anticoagulant had a lower risk of sepsis, shock, acute kidney injury, and in-hospital mortality, and a shorter hospital stay. The results suggest that long-term systemic anticoagulation should be considered as a treatment option for pancreatic cancer patients.Background: Pancreatic cancer can induce a hypercoagulable state which may lead to clinically apparent thrombosis. However, the effect of anticoagulants remains ambiguous. This study aimed to investigate the potential effect of long-term systemic anticoagulant usage on hospitalization outcomes of patients with pancreatic cancer. Methods: This retrospective study extracted all data from the U.S. Nationwide Inpatient Sample (NIS) database from 2005 to 2018. We included hospitalized adults ≥18 years old with a pancreatic cancer diagnosis identified by International Classification of Diseases ninth revision (ICD-9) and tenth revision (ICD-10) codes. We utilized diagnostic codes ICD9 V58.61 and ICD10 Z79.01, i.e., ‘long-term use of anticoagulant’, to identify individuals who were on a long-term systemic anticoagulant. The study cohort were then further grouped as being with or without long-term systemic use of an anticoagulant. Propensity score matching was performed to balance the characteristics of the two groups. The risks of life-threatening events, e.g., acute myocardial infarction (AMI), acute heart failure (AHF), sepsis, shock, and acute kidney injury (AKI), in-hospital death, and prolonged length of stay (LOS) in the hospital were compared between the groups by univariable and multivariable logistic regression analyses. Results: The study population consisted of 242,903 hospitalized patients with pancreas cancer, 6.5%  of whom were on long-term systemic anticoagulants. A multivariable regression analysis showed that long-term systemic anticoagulant use was independently associated with lower odds of sepsis , shock , AKI , in-hospital mortality , and prolonged LOS . Conclusions: Long-term systemic anticoagulant use is associated with better clinical outcomes in terms of decreased risks of some life-threatening events, in-hospital death, and prolonged LOS among hospitalized patients with pancreatic cancer in the U.S. Pancreatic cancer is the eleventh most challenging malignancy to treat, with one of the highest mortality rates out of all cancers in the United States (U.S.) . It has Venous thromboembolism (VTE) occurs in approximatively 20% of patients with pancreatic cancer, resulting in increased morbidity, mortality, and high health care costs . AlthougA recent systematic review included 35 publications on VTE prophylaxis and treatment and 18 on VTE risk assessment, suggesting that hospitalized patients with cancer and an acute medical condition need anticoagulant treatment throughout hospitalization, whereas anticoagulant treatment is not routinely recommended for all outpatients with cancer . For panThis population-based, retrospective observational study extracted all data from the U.S. Nationwide Inpatient Sample (NIS) database between 2005 and 2018. The NIS database is the largest all-payer, continuous inpatient care database in the United States, showing that there are about 8 million hospital stays each year . The datHCUP-NIS is a deidentified database, and the Institutional Review Board of Johns Hopkins Medical Institutions deemed that the study, using the HCUP-NIS database, is exempt from ethical review.This study utilized the International Classification of Diseases ninth revision (ICD-9) and tenth revision(ICD-10) diagnostic codes to identify adults ≥18 years old admitted to U.S. hospitals who had pancreatic cancer  between 2005 and 2018 in the NIS database . Patients with no information on in-hospital death, length of stay (LOS), or with a history of other malignancies were excluded. Eligible patients were further divided into two groups according to whether they were treated with or without long-term anticoagulant use as documented in their medical records in the NIS database through ICD codes (ICD9-CM code V58.61 and ICD10-CM code Z79.01).The study endpoints were the incidence of (1) any life-threatening events during admission; (2) in-hospital mortality; (3) unfavorable discharge, defined as transfer to nursing homes or long-term care facilities; (4) prolonged LOS, defined as LOS being ≥75th percentile. Life-threatening events included acute myocardial infarction (AMI), acute heart failure (AHF), sepsis, shock, and acute kidney injury (AKI).The patients’ characteristics included age, gender, race, household income, insurance status (primary payer), and admission type (elective or emergent). Pancreatic resection, a history of myocardial infraction (MI), a history of valvular heart disease, prior percutaneous coronary intervention (PCI)/coronary artery bypass grafting (CABG)/valve surgery, a history of coronary heart disease (CHD), a history of atrial fibrillation (AF), history of peripheral artery disease (PAD), a history of diseases of the circulatory system, a history of cerebral artery occlusion/stenosis, and long-term aspirin use were identified using ICD-9 and ICD-10 diagnostic codes. Comorbidities were also identified through ICD codes and were further graded using the Romano adaptation of Charlson’s comorbidity index (CCI) . Hospitan) and weighted percentage (%) or mean ± standard error (S.E.). Comparisons between the study groups were performed using PROC SURVEYFREQ and SURVEYREG for categorical and continuous variables, respectively. Logistic regressions were performed using PROC SURVEYLOGISTIC to estimate the odds ratio (OR) and 95% confidence interval (CI) of the associations between study variables and outcomes of interest. In order to balance the baseline characteristics between the groups, the cohort was then matched into the case (with long-term systemic anticoagulant use) and control (without long-term systemic anticoagulant use) groups with a ratio of 1:3 by the propensity score using the SAS %OneToManyMTCH macro. The macro performs a 1:N case–control match on the propensity score; the analyst is allowed to specify the number of controls to match to each case. The macro makes “best” matches first and “next-best” matches next, in a hierarchical sequence until no more matches can be made [p-value of <0.05 in the unmatched population of the two groups. A 1:3 fixed ratio of nearest neighbor matching was performed.The descriptive statistics of the patients were presented as unweighted counts .Further, univariate and multivariate logistic regression models were used to calculate the odds ratio (OR) and 95% confidence interval (CI) of determining the association between study variables and the clinical outcomes. Variables that were significantly different between the study groups after matching were adjusted in the multivariable analysis. Since the data of NIS were the 20% samples of the total U.S. inpatient admissions, weighted samples , stratum (NIS_STRATUM), and cluster analysis (HOSPID) were utilized to produce national estimates for all the analyses as instructed by the NIS guideline. A two-sided n = 259) were excluded. Further, 15,469 patients with a history of other malignancies were also excluded. The remaining 242,903 patients were included, of which 6.5%  were on long-term systemic anticoagulants according to medical records. After propensity score matching, there were 48,353 patients left for subsequent analyses, representing 237,832 adults in the U.S. Amongst them, 12,087 (25.0%) patients were on long-term systemic anticoagulants whereas 36,266 (75.0%) were not  and those with a history of diseases of the circulatory system (p = 0.003).p-value ≤ 0.007) compared to those without anticoagulants. After P.S. matching, a lower proportion of all events was observed among the patients with long-term systemic anticoagulants than those without, except for AHF. Long-term systemic anticoagulant use had a borderline association with AMI .It has long been recognized that pancreatic cancer induces a hypercoagulable state that may lead to clinically apparent thrombosis . Using tA previous analysis found that frequent and early onsets of VTE after pancreatic cancer diagnoses are associated with significantly lower PFS and OS, suggesting that studies are needed to determine whether the primary prophylaxis for VTE pancreatic cancer will improve morbidity and mortality . The autContinuously taking an anticoagulant for more than 3 months is considered long-term use of an anticoagulant ,21,22,23With respect to the pathogenesis of VTE in cancers, chemotherapy exposure is considered a factor that leads to VTE in patients with pancreatic cancer and other cancers . AlthougAlthough a consensus has emerged on anticoagulant applications following definitive pancreatectomy, in the metastatic setting, prophylactic anticoagulation use remains controversial ,33. The The present results indicate that long-term anticoagulant use protect patients against some life-threatening events and in-hospital deaths in patients with pancreatic cancer. In clinical practice, an anticoagulant such as tinzaparin may be routinely used for patients with pancreatic cancer. A recent study demonstrated that tinzaparin enhances the antitumor effects of nab-paclitaxel and gemcitabine in mtKRAS pancreatic cancer cell lines via apoptosis in vivo. The combinatorial treatment with anticoagulant use provided extra tumor reduction by 24.3% compared to treatment with the drug only . Other rThe updated guideline recommends changes to previous recommendations and suggests that physicians offer an anticoagulant with apixaban, rivaroxaban, or low-molecular-weight heparin (LMWH) to high-risk outpatients with cancer. For long-term anticoagulation use at least 6 months of use is preferred because of the improved efficacy over vitamin K antagonists (VKAs). VKAs are inferior but may be used if LMWH or direct oral anticoagulants (DOACs) are not accessible. Although DOACs are easily applied, the efficiency and side-effects need to be noticed. Oral apixaban was found to have a similar anticoagulant effect to subcutaneous dalteparin in the Caravaggio study ,39. HoweThe present study is the first to evaluate the real-world associations between long-term systemic anticoagulation use and adverse inpatient clinical outcomes of pancreatic cancer. The strength of the present study is the use of a large sample representing a nationwide population. Also, this study conducted propensity score matching, defined as the conditional probability of a subject being assigned to the anticoagulation treatment group according to observed covariates, which minimized the bias by indication. This study was inherently limited by its retrospective and observational nature; therefore, the results should be interpreted carefully. Other limitations of this study were mainly related to the utilization of the ICD code system. Although important, the history of pancreatic cancer cannot be determined, and we cannot exclude the possibility that the difference in in-hospital outcomes was solely because of the difference in mortality between patients with a long-term and short-term history. Furthermore, the exact duration, dosage, type, purpose, or adherence to anticoagulants could not be assured due to a lack of ICD codes and data. There were, possibly, coding errors, as there were in other NIS studies that used the same ICD code systems. Specific regimens of anticoagulation such as low-molecular-weight heparin (LMWH) and direct oral anticoagulants could not be distinguished by the codes and thus were not analyzed. Chemotherapy-related parameters were not recorded, either. This study also lacked outpatient data and follow-up data after discharge.Although there are many limitations in this NIS based study, long-term systemic anticoagulant usage is shown to provide various benefits for patients with pancreatic cancer. Prospective evidence is still warranted before integrating anticoagulation into the primary prevention strategy against adverse outcomes in these patients.


Patients with rheumatoid arthritis (RA) are at an increased risk for cardiovascular disease (CVD). One of the earliest manifestations of CVD is endothelial dysfunction (ED), which can lead to functional and morphological vascular abnormalities. Several non-invasive assessments of vascular function and morphology can be utilised to assess vascular health, but little is known about the association between each of these assessments in patients with RA, and they tend to be used interchangeably in the literature. The objective of the present study was to examine associations between measures of vascular function and morphology in patients with RA.th to 75th percentile) age: 67 (59 to 73)) underwent assessments of microvascular endothelium-dependent and endothelium-independent function (laser Doppler imaging with iontophoresis of acetylcholine and sodium-nitroprusside respectively), macrovascular endothelium-dependent and endothelium-independent function (flow-mediated dilatation and glyceryl-trinitrate-mediated dilation respectively), and vascular morphology , and carotid plaque).A total of 201 RA patients ) after applying the Bonferroni correction for multiple comparisons. For carotid plaque, t tests showed that macrovascular endothelium-independent function was lower in patients with plaque than without .Spearman's correlations revealed that from the functional parameters, only macrovascular endothelium-independent function was inversely associated with cIMT (-0.294 (With the exception of macrovascular endothelium-independent function, all other measures of vascular function were not associated with vascular morphology. This suggests that different assessments of vascular function and morphology in patients with RA reflect quite distinct mechanisms and phases of the atherosclerotic process and should not be used interchangeably. The endothelium is the innermost layer of the vasculature and is responsible for maintaining an atheroprotective environment within the vessel. Damage to the endothelium from injurious stimuli such as oxidative stress and inflammatory mediators results in endothelial dysfunction (ED) . ED occuDuring early atherosclerosis, a reduction in NO bioavailability results in reduced vasodilatation along with the promotion of platelet aggregation and leukocyte adhesion to the vascular wall ,6. AssesIf factors that reduce NO bioavailability are not appropriately controlled then endothelial dysfunction can progress to arteriosclerosis  . ArteriaAssessment of advanced, but subclinical, atherosclerosis can be carried out by examination of carotid artery intima-media thickness (cIMT) and by determining the presence of carotid plaques . ThickenRheumatoid arthritis (RA) is a chronic systemic inflammatory musculoskeletal disease . PatientIn other populations there is conflicting evidence on whether such assessments correlate with each other  after a 12-hour overnight fast. All patients underwent a detailed clinical examination and demographic information was collected by questionnaire. The disease activity score in 28 joints (DAS28)  was alsoEndothelial function of the microvasculature was assessed non-invasively using LDI  with iontophoresis of 1% ACh  and 1% SNP  in 2.5 ml solution containing 0.5% saline by a single observer (AS). The technique was performed according to previously established guidelines  and has Assessment of macrovascular endothelium-dependent function was performed using FMD with high-resolution ultrasonography of the brachial artery  according to previously established guidelines . EndothePulse wave analysis  was used to determine AIx as previously described . In brieHigh-resolution ultrasonography of the carotid artery was performed by an experienced ultrasonographer (AS) according to previously established guidelines  using a The presence of carotid plaque was identified by scanning the right and left common carotid artery, as well as the internal and external carotid arteries. Carotid plaques were defined as a focal structure encroaching into the arterial lumen of at least 0.5 mm or 50% of surrounding IMT value, or an IMT value of >1.5 mm . The relth percentile values) or mean ± standard deviation, as applicable, with binary variables expressed as percentages. Spearman's correlation coefficients were used to assess the relationships between functional and morphological parameters of endothelial dysfunction. Associations between presence of carotid plaque (dependent variable) and other vascular parameters (independent variables) were then assessed using t tests and Mann-Whitney tests, as appropriate. A P value of 0.05 was deemed to be indicative of significance, although this was Bonferroni corrected where necessary to account for multiple comparisons. Power calculations indicated that, for the intended sample size, a correlation coefficient of 0.25 could be detected between functional and structural assessments of endothelial function at 80% power, with alpha of 0.006 . For the effect of carotid plaque, detectable differences in the functional assessments of endothelial function ranged from 33% to 50%, at 80% power with alpha of 0.006.Statistical analysis was performed using IBM SPSS version 20 . Continuous variables were tested for normality, and expressed as median (25 to 75The patient characteristics are presented in Table P = 0.002).Spearman correlations were used to examine associations between functional and morphological parameters of endothelial function. This analysis revealed only one significant correlation, after adjustment for multiple comparisons, with GTN being inversely associated with cIMT Table . For carn = 14) were recruited, which does not allow for direct comparisons to the present work. In the other study [n = 52) and macrovascular endothelium-dependent function was considerably lower than those reported in our study (5% and 11% respectively); thus, it is possible that in patients with preserved macrovascular endothelium-dependent function, an association with carotid atherosclerosis is unlikely.The findings of the present study reveal that, in RA, only macrovascular endothelium-independent function associated with carotid atherosclerosis - a marker of advanced morphological vascular alterations. To the best of our knowledge, only two studies have directly examined associations between endothelial function and carotid atherosclerosis in RA, with both studies reporting associations between macrovascular endothelium-dependent function and cIMT ,25. HoweStudies examining the longitudinal effects of anti-inflammatory medication in RA have revealed that microvascular and macrovascular endothelium-dependent function, but not vascular morphology, improved following treatment -28. Furtn = 34 to 101) [Studies in other populations have yielded mixed findings; in healthy participants, five out of the six studies included in Table  to 101) ,54, or o to 101) ,55. The  to 101) ,34,53. FThe absence of an association between functional and morphological assessments of the vasculature may be due to a time lag between endothelial dysfunction and subsequent lesion development. In the study by Hashimoto and colleagues , severalIn the present study, macrovascular endothelium-independent function associated with carotid atherosclerosis. Such an association was not surprising as both assessments (to varying degrees) reflect a reduction in smooth muscle relaxation, smooth muscle hypertrophy as well as proliferation of smooth muscle cells . NeverthThe strengths of the present work are the inclusion of a large sample of patients, which provided adequate statistical power for the analysis. Additionally, measurements of microvascular and macrovascular endothelium-dependent and -independent function, along with assessments of arteriosclerosis and carotid atherosclerosis allowed detailed characterisation of each stage of atherosclerosis. However, some limitations include the cross-sectional study design, which does not determine cause-effect relationships. Further prospective studies are required to see which measures of endothelial function and vascular morphology are able to predict the development of future cardiac events.In conclusion, the present work highlights that, with the exception of macrovascular endothelium-independent function, assessments of vascular function and morphology cannot be used interchangeably to assess vascular health. Examination of endothelial function should incorporate functional and morphological assessments to provide information on global endothelial dysfunction.ACh: acetylcholine; AIx: augmentation index; CAD: coronary artery disease; cIMT: carotid intima-media thickness; CVD: cardiovascular disease; CV: co-efficient of variation; ED: endothelial dysfunction; ET-1: endothelin-1; FMD: flow-mediated dilatation; GTN: glyceryl-trinitrate-mediated dilatation; NO: nitric oxide; PWA: pulse wave analysis; PWV: pulse wave velocity; RA: rheumatoid arthritis: SNP: sodium nitroprusside.The authors declare that they have no competing interests.AS participated in the design of the study, recruited patients, performed the vascular assessments, conducted data analysis and drafted the manuscript. JH performed the statistical analysis. KD participated in the design of the study. JPS performed laboratory analysis of blood samples. GK participated in the design of the study and helped with drafting the manuscript. All authors have read and approved the final manuscript.


Recent researches have shed light on the biological importance of microRNAs (miRNAs) in colorectal cancer (CRC) genesis, progression and response to treatments. The potential utility of miRNAs in the preclinical stage have been explored and investigated. In this review, we explored the literature and reviewed the cutting edge progress in the discovery of noninvasive plasma and faecal miRNAs for CRC early diagnosis, as well as their measurability and predictability. We also discussed the utility of miRNAs as novel prognostic and predictive markers, and their association with CRC clinical phenotypes including recurrence, metastasis and therapeutic outcomes. Finally, we summarised miRNA-related single-nucleotide polymorphisms and their potential influence on sporadic CRC susceptibility and therapeutic response. In conclusion, the use of miRNAs as biomarker for CRC is still in its infancy and need further characterisation and evaluation. MicroRNAs (miRNAs), a class of highly conserved ∼22-nucleotides single-stranded RNAs, can act as trans-acting factors that suppress translation or induce messenger RNA (mRNA) degradation of target genes . A spectApproximately 1.23 million individuals worldwide will develop CRC and 0.6 million people will die of it annually . Among tSurprisingly high concentration of miRNAs is discovered in highly stable, cell-free form in the peripheral blood , both belonging to the miR-17-92 cluster, were significantly elevated in plasma and CRC tissues, but reduced in the postoperative samples when compared with preoperative samples. These data support the idea that CRC cells can release aberrantly expressed miRNAs into the circulatory system. Furthermore, promising discriminatory power of the two miRNAs was verified in an independent larger cohort: at a cut-off value of 3.6 for miR-17-3p (relative expression in comparison with RNU6B), the sensitivity was 64% and the specificity was 70% at a cut-off value of 240 for miR-92a, the sensitivity was 89% and the specificity was 70% . In addius study . It was Tumour-derived plasma miR-29a is another potential CRC diagnostic marker. It was demonstrated that plasma miR-29a could distinguish CRC and advanced adenoma from normal group with sensitivities of 69 and 62.2%, and specificities of 89.1 and 84.7%, respectively . FurtherEmploying high-throughput transcriptomic sequencing technique, In previous studies, SYBR green-based real-time polymerase chain reaction (PCR) was generally adopted to detect the presence of miRNA. However, this method has a lower specificity and causes high false-positive and false-negative rates in diagnosis. Recently, Stool-based test is widely adopted as noninvasive screening methods for CRC diagnosis. Currently, the most commonly used stool test for CRC screening is the guaiac-based faecal occult blood test (FOBT). However, the test itself has some crucial limitations. Owing to the irregular bleeding nature of colorectal tumours, presence of red meat in digested residues, and other causes of bleeding in the gastrointestinal tract, the specificity and sensitivity of FOBT for CRC are relatively poor. Some advanced adenomas with diameter larger than 1 cm are missed by FOBT . Other sIn contrast with the fast degradation of mRNA and protein, endogenous miRNAs are packed and protected from RNase. They are therefore more likely to be detected. Nonetheless, the stool environment is much more complex and hostile than plasma, and human RNA is expected to constitute <1% of totally stool RNA. In this regard, several criteria, including measurability, reproducibility and predictability, must be met if stool miRNAs have to be developed as diagnostic markers. It is a ground-breaking attempt that A key issue of miRNA detection in stool is the selection of endogenous control. Although several small RNA species are recommended for normalising miRNA expression in tissues and cell lines  within CD86 showed a statistically significant association with increased risk of CRC in Caucasians , and that the G>C substitution would weaken the affinity of miR-337, miR-582 and miR-200a* (The whole genome is constantly evolving and generates many germ-line nucleotide changes known as single-nucleotide polymorphisms (SNPs). SNPs that fall into the protein coding sequence may have a biological effect by changing the amino acid sequence or yielding a premature stop code. Although SNPs residing in the untranslated region (UTR) do not alter the function of the protein, they may occasionally perturb the protein expression level and may have pathogenic consequences (iR-200a* . One morin vivo (uc.276 in CRC patients would putatively disturb the interaction with miR-214 and miR-887.Ultraconserved region (UCR) encodes a class of non-coding RNAs and their expression can be regulated by miRNA in vitro and in vivo  is responsible for the miRNA::miRNA duplex cytoplasm translocation. Inactivated XPO5 trapped many precursor miRNA that had potential tumour-suppressor feature in the nucleus, and promoted cancer growth Single-nucleotide polymorphisms and their mechanisms related to CRC progression remain to be investigated. Since SNPs in the miRNA-binding motifs are sometimes deleterious, natural selection keeps the SNP density in conserved seed region at lower level than expected, approximately 0.50 SNP per kb . NeverthGenome-wide searching can help identify many oncogenic and tumour-suppressing miRNAs, which are potential therapeutic targets for CRC treatment. Theoretically, the downregulated miRNAs can be replaced by chemically synthesised mimics. Overexpressed miRNAs can also be targeted by anti-miRNA oligonucleotides. Recently, In conclusion, those studies mentioned above highlight the potential value of miRNAs in CRC diagnosis, prognosis and susceptibility. Further large-scale evaluation in multiple independent cohorts is indispensable for determining their realistic expectation.


Chronic heart failure requires a complex treatment regimen on a life-long basis. Therefore, self-care/self-management is an essential part of successful treatment and comprehensive patient education is warranted. However, specific information on program features and educational strategies enhancing treatment success is lacking. This trial aims to evaluate a patient-oriented and theory-based self-management educational group program as compared to usual care education during inpatient cardiac rehabilitation in Germany.The study is a multicenter cluster randomized controlled trial in four cardiac rehabilitation clinics. Clusters are patient education groups that comprise HF patients recruited within 2 weeks after commencement of inpatient cardiac rehabilitation. Cluster randomization was chosen for pragmatic reasons, i.e. to ensure a sufficient number of eligible patients to build large-enough educational groups and to prevent contamination by interaction of patients from different treatment allocations during rehabilitation. Rehabilitants with chronic systolic heart failure (n = 540) will be consecutively recruited for the study at the beginning of inpatient rehabilitation. Data will be assessed at admission, at discharge and after 6 and 12 months using patient questionnaires. In the intervention condition, patients receive the new patient-oriented self-management educational program, whereas in the control condition, patients receive a short lecture-based educational program . The primary outcome is patients’ self-reported self-management competence. Secondary outcomes include behavioral determinants and self-management health behavior , health-related quality of life, and treatment satisfaction. Treatment effects will be evaluated separately for each follow-up time point using multilevel regression analysis, and adjusting for baseline values.This study evaluates the effectiveness of a comprehensive self-management educational program by a cluster randomized trial within inpatient cardiac rehabilitation in Germany. Furthermore, subgroup-related treatment effects will be explored. Study results will contribute to a better understanding of both the effectiveness and mechanisms of a self-management group program as part of cardiac rehabilitation.DRKS00004841; WHO International Clinical Trials: = DRKS00004841German Clinical Trials Register:  Chronic heart failure (HF) is a common, costly, disabling, and fatal medical condition encountered by a wide range of health care professionals in both primary and secondary care . It is aBarlow and colleagues  describeGenerally, management of HF should be multi-professional and comprises several health care settings . German The aim of our study is to evaluate the short-, intermediate and long-term effects of a patient-oriented self-management educational group program as compared with a usual care program for HF patients receiving inpatient medical rehabilitation.We hypothesize that the self-management education program is superior to usual care regarding self-reported self-management competence (primary outcome). In addition, we expect superior effectiveness of the new program regarding several self-management behaviors, such as symptom monitoring, physical activity, and medication adherence, as well as health-related quality of life and treatment satisfaction (secondary outcomes).Moreover, moderator effects of (1) gender, (2) age, (3) education, and (4) type of rehabilitation - cardiac rehabilitation within 14 days after an acute cardiac index event (aCR) versus cardiac rehabilitation during the chronic course of disease without recent acute index event (cCR) - will be explored.The study is a multicenter cluster randomized controlled trial in four cardiac rehabilitation clinics. Clusters are patient education groups that comprise HF patients recruited within 2 weeks after commencement of inpatient CR. Participants will be recruited consecutively. In the intervention group (IG), patients will receive the new patient-oriented self-management educational program, whereas in the control group (CG), patients will receive a short lecture program .Data will be assessed at admission t1) and three follow-ups, i.e. discharge (t2) and after 6 (t3) and 12 months (t4) using standardized patient questionnaires. Figure  and threCluster randomization was chosen for pragmatic reasons, i.e. to ensure a sufficient number of eligible patients to build large-enough educational groups, to protect the blindness of the sample and prevent contamination by interaction of patients from different treatment allocation during rehabilitation.http://www.wma.net/en/30publications/10policies/b3/17c.pdf) and was approved by the Ethics Committee of the Faculty of Medicine, University of Würzburg on 19 April 2011 (reference number: 60/11). Participation in the study is voluntary and based on written informed consent. Eligible patients will be informed about all relevant aspects of the study at the beginning of rehabilitation. Furthermore, they are informed of the right to refuse to participate or to withdraw consent to participate at any time without reprisal.The study conformed to the principles outlined in the Declaration of Helsinki (Eligibility criteria for participants are a diagnosis of chronic systolic heart failure (ICD-10: I50), left ventricular ejection fraction (LVEF) of 40 or less, and New York Heart Association functional classification (NYHA) of class II or III. Exclusion criteria are acute events of decompensation, cognitive impairment, inadequate German language ability, and severe visual or hearing impairment.All participants admitted to the rehabilitation clinic during defined time periods  will be eligible for building a cluster (education group), with a minimum of 3 participants per group as a prerequisite.German inpatient multidisciplinary CR  includesIntervention group (IG). Patients in the intervention condition will receive a self-management educational program “Curriculum Heart Failure”  and scientists with regard to previous work e.g. ,18,27. BControl group (CG). Control condition is one lecture of basic medical education given by a physician with duration of about 60 minutes. Information is mostly presented in a vertical manner. Contents include basic HF illness information on aetiology, symptoms and signs, pharmacological treatment, non-surgical device treatment, surgery, and self-management recommendations . Patients will receive three handouts which comprise main information on HF, and worksheets to list own medications as well as to monitor weight and blood pressure.We evaluate the effect of the patient education program on patient-reported self-management outcomes as well as health-related quality of life and treatment satisfaction. Therefore, all outcomes pertain to the individual level. The primary outcome is patients’ subjective self-management competence. Secondary outcomes include behavioral determinants and self-management health behavior , health-related quality of life, and treatment satisfaction. Outcomes are assessed by standardized, validated measures. To assess symptom monitoring/control, a new measure will be developed based on existing instruments  and progAdditionally, sociodemographic parameters , as well as depression and anxiety , socialWe calculated the sample size based on expected effect size, power, and design effect .Sample size was powered to detect small to medium effects in the primary outcome in short-, intermediate and long-term . Therefore, 352 persons were required. Furthermore, an intraclass correlation coefficient ICC of 0.02 and an average cluster size of 10 was assumed, resulting in a design effect of 1.18. By multiplication of the design effect and sample size without cluster effect, a necessary sample size of 208 patients in each group was obtained. Overall, we want to include 540 participants, based on an estimated drop-out of about 20%.Power analyses comprise multiple uncertainties, i.e. ICC, actual cluster sizes, and effect sizes for primary and secondary outcomes. As the magnitude of the ICC varies with the venue of the trial and outcomes, no exact estimation of the ICC was possible because of the lack of data from previous studies reporting on ICC for psychological, behavioral and health outcomes for educational group clusters within inpatient medical rehabilitation. Table Clusters are randomly assigned to the two treatment conditions using a computer-generated list of random numbers. Randomization is performed by a scientific assistant of the research institute  guarantying allocation concealment until a cluster has been recruited.HF patients will be recruited at admission to inpatient CR and allocated to the next education group (cluster). Interventions will be performed every two weeks. Randomization results for the clusters will be communicated to the study assistants in each clinic per phone or e-mail only after building of a group and about two days before the intervention starts. Thus, patients will be recruited by physicians masked to later intervention allocation of the respective clusters.Patients will be blind to the allocated study arm. Educational staff cannot be blinded due to their active role in treatment. Further therapeutic staff of the rehabilitation treatment may be blind to the allocated intervention.t tests for continuous variables.All statistical analyses will be performed using SPSS for Windows. Prior to analysis, missing patterns will be explored. Missing data in accordance with missing at random (MAR) assumptions will be imputed using a multiple imputation procedure. Missing values due to drop-out will be analyzed by pair-wise deletion. Non-response-analyses and drop-out-analyses will be carried out by independent group comparisons using The analysis of the primary and secondary endpoints will be done according to the intention-to-treat principle. Treatment effects (between-group effects) will be evaluated separately for each follow-up time point using multilevel regression analysis ,40, withModerator analysis will be performed by including the moderator variable as an additional fixed factor or covariate and examining interaction effects. Significance levels for interaction effects will not be adjusted due to their exploratory nature.Patient education is recommended to foster self-management of patients with HF as several self-management interventions showed benefits on health outcomes. However, further research is needed regarding independent effects of single interventions as well as specific educational techniques and subgroups of patients who benefit most. In this cluster-RCT we will evaluate the short-, intermediate- and long-term effectiveness of a patient-oriented, self-management educational program as compared to a short lecture program  for HF patients receiving inpatient medical rehabilitation. Furthermore, subgroup-related treatment effects will be explored.Methodological challenges of our study arise from evaluating a complex intervention as part of inpatient CR. Implementation requires training of different health care professionals and coordination with further multidisciplinary rehabilitation treatment. Furthermore, cluster randomization was chosen to ensure adequate numbers of eligible patients and to prevent contamination of the intervention. However, several uncertainties arise regarding the size of the design effect.Altogether, study results will contribute to a better understanding of the effectiveness and mechanisms of a self-management group program as part of CR for a highly impaired illness population with a complex treatment regime.BMQ-D: Beliefs about medicine questionnaire, German version; CG: Control group; CR: Cardiac rehabilitation; aCR: Cardiac rehabilitation within 14 days after an acute cardiac index event; cCR: Cardiac rehabilitation during the chronic course of disease without recent acute index event; DGPR: German society for prevention and rehabilitation of cardiovascular diseases; ESSI: Enrichd social support inventory; HAPA: Health action process approach; heiQ: Health education impact questionnaire; HF: Heart failure; ICC: Intraclass correlation coefficient; IG: Intervention group; KCCQ: Kansas City cardiomyopathy questionnaire; LVEF: Left ventricular ejection fraction; MARS-D: Medication adherence report scale, German version; NYHA: New York heart association; PHQ-4: Patient health questionnaire 4-item version; RCT: Randomized controlled trial.The authors declare that they have no competing interests.KM is the principal investigator, developed the study, and is the main author of the manuscript. GM and BS undertook manualizing of the interventions, guidance of data collection and analysis and helped draft the manuscript. JG, GK, UK, EK, RS and RW are members of the patient education workgroup of the DGPR and contributed to development of the study and the intervention. They are listed as co-authors in alphabetical order. HF contributed to study development and helped draft the manuscript. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2261/13/60/prepubDescription of the “Curriculum Heart Failure”. Description of the intervention according to module, trainer, time, content, method, and material.Click here for file


Biometrics 2011).RNA sequencing (RNA-seq) has become a major tool for biomedical research. A key step in analyzing RNA-seq data is to infer the origin of short reads in the source genome, and for this purpose, many read alignment/mapping software programs have been developed. Usually, the majority of mappable reads can be mapped to one unambiguous genomic location, and these reads are called unique reads. However, a considerable proportion of mappable reads can be aligned to more than one genomic location with the same or similar fidelities, and they are called "multireads". Allocating these multireads is challenging but critical for interpreting RNA-seq data. We recently developed a Bayesian stochastic model that allocates multireads more accurately than alternative methods , the most popular read alignment format, as the standard input; then based on the Bayesian model, it calculates mapping probabilities of multireads for competing genomic loci; and BM-Map generates the output by adding mapping probabilities to the original SAM file so that users can easily perform downstream analyses. The program is available in three common operating systems, Linux, Mac and PC. Moreover, we have built a dedicated website, We have developed a stand-alone, efficient, and user-friendly software package for accurately allocating multireads, which is an important addition to our previous methodology paper. We believe that this bioinformatics tool will greatly help RNA-seq and related applications reach their full potential in life science research. In recent years RNA-seq has become a popular and powerful approach for transcriptome profiling ,2. UsingA key step in the analysis of RNA-seq data is read mapping, the goal of which is to infer the origin of short reads in the source genome. For this purpose, many software programs have been developed such as Bowtie , BFAST  and MAQ Therefore, we consider allocating multireads is a critical issue in the RNA-seq analysis, which has received relatively little attention in literature. One pioneering and influential method is "the proportional method" developed by Mortazavi et al. (2008)  in whichFigure The details about the underlying probability model and algorithm are depicted in our previous study , and herq). We assume that the observed mismatches (e for multiread and g for unique reads) come from two resources. The first one is sequencing error (α), and we estimate quality-score specific error rate by considering all the unique reads in the dataset. The second source is called hidden nucleotide variations (β), which is mainly due to that RNA-seq reads are typically mapped to a public reference genome rather than the actual sample genome. Hence, variations between the two genome versions  may cause some observed mismatches between the reads and the reference genome. Given the unique reads associated with a competing location, we model the uncertainty of hidden nucleotide variations using Markov chain Monte Carlo (MCMC) simulations. The prior distribution of reads mapping (Z) is set in proportion to the numbers of unique reads associated with competing loci, which essentially follows the main idea in Mortazavi et al. (2008) [In our model, the likelihood can be calculated based on the probability of mismatch at each nucleotide position of the multiread (. 2008) . Figure 008 . FigBecause the amount of RNA-seq data is large and our Bayesian method relies on extensive numerical computations for statistical inference, we implemented our method in a C++ programming written software package. To reduce the computer memory requirement for the calculations, we carefully examined the aligned data to minimize the size of the data structures that were held in memory simultaneously. To reduce lengthy execution times, we optimized the search algorithms used to process the reads. Finally, we achieved a further reduction in wall-clock runtime by running the calculations on multiple parallel threads of execution utilizing the capabilities typical of a modern desktop computer . Currently, for an RNA-seq dataset with 8 million post-aligned short reads, our BM-Map program takes 3~4 hours to complete allocating the multireads in a single Windows 64-bit desktop machine , which is generally comparable to the computing time of mapping short reads by other methods.http://bioinformatics.mdanderson.org/main/BM-Map. The website also contains detailed tutorials and references about the BM-Map software.We have made BM-Map a user-friendly software package. BM-Map takes SAM format (Sequence Alignment/Map) , the mosBased on a Bayesian stochastic model we previously proposed, we have developed an efficient and user-friendly software package for allocating RNA-seq multireads, which takes full advantage of the information stored in the unique reads, including sequencing error profiles, the likelihood of hidden nucleotide variations , and the expression level of competing locations. After reads are aligned by a general aligner, a mapping refinement step on multireads using our program would further improve the accuracy of gene expression quantification.Obviously, the effect of allocating multireads on gene expression is related to next-generation sequencing techniques. With the increase of read length, whether to include multireads in expression quantification would become less important. Nevertheless, through our analysis on RNA-seq datasets with different read lengths (from 36~76 nt), the effect of multireads on certain genes  appear to be non-negligible given current sequencing technologies  organisms underwent several rounds of whole-genome duplications such as plants , (ii) geWe have developed a stand-alone and user-friendly software package, BM-Map, which can accurately allocating a large amount of RNA-seq multireads in an efficient way. We expect that this useful bioinformatics tool would help RNA-seq and its related applications reach their full potential in life sciences and biomedical research.• Project name: BM-Map• Project home page: http://bioinformatics.mdanderson.org/main/BM-Map• Operating system(s): Linux, Mac and PC• Programming language: C++• Other requirements: No• License: No• Any restrictions to use by non-academics: NoCPU: central processing unit; MCMC: Markov Chain Monte Carlo; nt: nucleotide; RNA-seq: RNA sequencing; RPKM: reads per kilobase of exon model per million mapped reads; SAM: sequence alignment map; SNP: single-nucleotide polymorphism; RIP-seq: RNA immunoprecipitation sequencing; CLIP-seq: cross-linking immunoprecipitation sequencing; 3-seq: 3'-end sequencing.The authors declare that they have no competing interests.Y.J. and H.L. designed the research and drafted the manuscript. Y.Y. and C.N. wrote the programming code for the software and built the website. Y.X. and K.-W.T. optimized the algorithm for efficiency. All authors read and approved the final manuscript.Effect of multireads on the expression quantification of different gene groups.Click here for file