When the new bilateral air space pacification develops, we are usually indistinguishable bilateral pulmonary infiltrates from congestive cardiac failure. Until now, for the differential diagnosis of cardiogenic edema and pneumonia, laboratory finding including white blood cell (WBC), C-reactive protein (CRP), B-type natriuretic peptide (BNP) and imaging studies such as chest computed tomography (CT) and/or echocardiography were have been used. We evaluated whether chest ultrasound  could assist in the differential diagnosis of pulmonary edema and pneumonia. So, we conducted a comparison between clinical diagnosis (C-Dx) with the result of the laboratory finding and sonographic diagnosis (US-Dx) with CUS.We performed a retrospective observational study evaluating the utility of CUS in helping to differentiate pulmonary edema and pneumonia who were admitted to the ICU from January 2013 to December 2014. The patients who admitted to the medical intensive care unit (MICU), of the patients showed new developed bilateral infiltration on chest X-ray, targeting patients who underwent CUS. CUS was performed in all patients on the first day of admission and after having obtained a clinical diagnosis of disease. We compared the US-Dx is determined based on the cardiac and lung ultrasound with C-Dx is determined on the basis of WBC, CRP, BNP. WBC > 11,000/uL, CRP > 1 mg/dL and BNP > 300 pg/mL were interpreted as a meaningful. C-Dx and US-Dx were compared to see if it matches divided into three categories of pneumonia, pulmonary edema, combined.During the 2-years study period, seventy-seven patients were enrolled. C-Dx was associated with US-Dx . US-Dx was associated with final diagnosis .In critically ill patients, diagnosis using chest ultrasound and diagnosis was inferred to be the result of laboratory test substantially coincided. Therefore, using such a point, it is useful for the differential diagnosis of the patient.


Drowning is a heavy burden on the health systems of many countries, including Pakistan. To date, no effective large-scale surveillance has been in place to estimate rates of drowning and near-drowning in Pakistan. The Pakistan National Emergency Department Surveillance (Pak-NEDS) study aimed to fill this gap.Patients who presented with a complaint of "near-drowning" were analyzed to explore patterns of true near-drowning  and intentional injuries that led to the "near-drowning" complaint. Bivariate analysis was done to establish patterns among patients treated in emergency departments, including socio-demographic information, injury-related information, accompanying injuries, and emergency department resource utilization.A total of 133 patients  with "near-drowning" as presenting complaints were recorded by the Pak-NEDS system. True near-drowning (50.0%) and intentional injuries that led to "near-drowning" complaints (50.0%) differed in nature of injuries. The highest proportion of true near-drowning incidents occurred among patients aged between 25-44 years (47.5%), and among males (77.5%). True near-drowning patients usually had other accompanying complaints, such as lower limb injury (40.0%). Very few patients were transported by ambulance (5.0%), and triage was done for 15% of patients. Eleven (27.5%) true near-drowning patients received cardiopulmonary resuscitation.There was major under-reporting of drowning and near-drowning cases in the surveillance study. The etiology of near-drowning cases should be further studied. Patients who experienced non-fatal drownings were more commonly sent for medical care due to other accompanying conditions, rather than near-drowning event itself. There is also need for recognizing true near-drowning incidents. The results of this study provide information on data source selection, site location, emergency care standardization, and multi-sector collaboration for future drowning prevention studies. Injuries are a large, yet often neglected, burden on health systems around the world . The majDrowning is defined by the World Health Organization (WHO) as "the process of experiencing respiratory impairment from submersion/immersion in liquid" . Based oPakistan is the sixth most populous country in the world with a total population of 184 million . It alsoTo date, no large-scale systematic data on drowning and near-drowning have been collected in low-resource environments, including Pakistan . All estThe Pak-NEDS study is an active pilot surveillance study that was conducted between November 2010 and March 2011 in seven urban tertiary care centers situated in five major Pakistani cities of five provinces. The seven study sites are in: 1) Sindh province - Aga Khan University and Jinnah Post-graduate Medical Center in Karachi; 2) Balochistan province - Sandeman Provincial Hospital in Quetta; 3) Punjab province - Benazir Bhutto Hospital in Rawalpindi, and Mayo Hospital in Lahore; 4) Islamabad Federal Capital Area - Shifa International Hospital in Islamabad; and 5) Khyber Pakhtunkhwa - Lady Reading Hospital in Peshawar. Figure Aga Khan University (AKU) served as the main coordinating center for the Pak-NEDS study. Ethical approval for this study was secured from a research ethics committee in each participating hospital, the AKU Ethical Review Committee and Institutional Review Board at the Johns Hopkins Bloomberg School of Public Health in the United States.The Pak-NEDS tool was based on the Centers for Disease Control and Prevention, USA ambulatory care survey tool and previous work undertaken by the investigators ,22. The ® v.12  [All patients  who presented at the participating EDs were registered in the surveillance system. The study aims to establish a standardized active surveillance system across seven sites, therefore no exclusion criteria were employed. Over the four-month data collection period, trained data collectors were responsible for collecting data 24 hours a day, seven days a week in three shifts. The main sources of data were interviews with patients or their next of kin, and ED records. Data collection did not continue beyond the EDs; rather it ended with any actions taken to move the patients out of ED . Data were entered and cleaned by the designated data entry team at AKU using EpiInfo™ v.3.3.2  . The anaas, USA) .In the current article, patients with the presenting complaint of "near-drowning" were collectively analyzed. A distinction was made between true near-drowning patients and intentional injury patients with "near-drowning" complaint: true near-drowning patients were those who incurred unintentional near-drowning incidents, whereas the rest were patients who were suicidal or assaulted, but presented to EDs with "near-drowning" complaint. Descriptive analyses were conducted to explore socio-demographic patterns for all patients with "near-drowning" presenting complaints, first collectively and then based on intention. In addition, concomitant injuries and other health conditions were explored to examine hidden reasons for patients to seek care at EDs. Injury-related information and healthcare resource utilization information were also analyzed. For questions allowing multiple responses, results were presented as a summary of outcomes (noted as "Sum" in tables). For instance, there were ten possible dispositions for ED patients: left without being seen, follow-up planned, return if required, referred to other hospital, referred to outside physician, detained for observation, admitted to ward, admitted to intensive care unit, coronary care unit or high dependency unit (ICU/CCU/HDU), expired, or left against medical advice (LAMA). Each patient can have several combinations of the dispositions, such as "detained for observation" combined with "admitted to ward." Although the combination of outcomes are intuitive, they do not directly provide information on different kinds of disposition. Therefore aggregated results were presented as "summary" information in tables. This information represents a proportion of each disposition in relation to one another. In this example, "disposition" was presented as either "discharged"  or "admitted" .Among Pak-NEDS injury patients, 133 patients  presented with near-drowning events. Among these 133 patients, intention of injury was recorded for 80, and about half suffered from the injury unintentionally . These patients were identified as true near-drowning patients.  among patients who were nearly drowned due to assault. The percentage of patients presenting with fractures was 15.8% for self-inflicted near-drowning patients and only 10.0% for true near-drowning cases. Assault cases had the highest percentage of head injury/contusions (14.3%), whereas true near-drowning cases were mostly recorded as having cuts or open wounds (52.5%) and sprain/strains or bruises (22.5%). There was no statistical significance in proportions between groups, therefore a 95% confidence interval could not be reported.Patients aged 25-44 years accounted for the highest proportion who presented with "near-drowning" complaints ; teenagers and young adults aged 15-24 years contributed to the second highest proportion .  with "near-drowning" presenting complaint. However, none of the true near-drowning patients received triage assessment. Of the 37 true near-drowning patients among whom disposition information was collected, the majority (85.0%) were discharged home from the ED, including those who had follow-up planned and those who needed to return if required by the care provider. A slightly lower proportion of intentional injury patients were discharged home (80.0%) compared with true near-drowning patients. Medical officers and nurse/midwives provided service to the majority of patients . This observation holds when it comes to true near-drowning patients, with 87.5% receiving care from a medical officer, and 80.0% receiving care from a nurse or midwife. An attending physician only provided care to five patients . Due to missing information for the intention of injury, Table The current paper analyzed ED-based information in terms of patients with "near-drowning" presenting complaints, depicting socio-demographic patterns, basic injury-related information, concomitant complaints, and preliminary results for the usage of ED resources in seven participating hospitals in Pakistan. The results show the scarcity of drowning and near-drowning data in Pakistan, even when active surveillance was carried out in major EDs across the country. It also highlighted the similarity and differences between true  near-drowning events and intentional injuries that led to near-drowning complaints. The article further pointed out potential improvements that are needed in building ED capacity and standardizing data collection systems in this nation.The results of the Pak-NEDS study have shown similar injury patterns regarding the sex of patients to studies carried out in other LMICs in the region - males were observed to be more prone to injuries compared with females ,26,27. HThe proportion of intentional injuries with "near-drowning" complaint in this study is considerably high, with half of all cases the result of either assault or self-harm . This fiThe Pak-NEDS study reveals evidence of sub-optimal utilization of emergency medical services (EMS), the most unsatisfying being the 5% utilization rate of emergency vehicles. In 2001, a Pakistan-based study explored the potential explanations for the low utilization rates of emergency vehicles, and concluded that the reasons might include inaccurate recognition of the severity of a patient's condition, unsatisfactory response time of ambulances, inability of some individuals to effectively reach out to an ambulance, as well as unaffordable charge of such services . AlthougFurther, triage was only done for 15% of patients with "near-drowning" complaints, and none for true near-drowning patients. Accurate triage is known for optimizing resource utilization and facilitating the prevention of secondary injury or even death . Only 21One positive observation was that care was generally provided by physicians, nurses, as well as paramedics, which potentially ensures comprehensive care. Interestingly, it is observed in the current study that most of the time junior staff were the first responders when a nearly drowned patient was sent to the ED. Therefore, it is important to train them in the proper management of near-drowning cases. Another relatively reassuring fact was the low hospital admission rate of near-drowning patients, which could be an indicator of high recovery rate of these patients. Nevertheless, this could be a masked result of other undesirable conditions such as limited hospital capacity, lack of in-depth diagnosis, or worse, withdrawal of patients or their families due to financial constraints.The under-reporting of near-drowning events was possible due to a few combined factors. First, while the burden of drowning is significantly higher in rural areas of Pakistan, all participating EDs in this study were affiliated with urban hospitals, which may not truthfully reflect the true burden at the national level . Second,Mortality and morbidity caused by drowning and near-drowning are largely neglected in South Asian countries . Half ofThere are a few limitations in the Pak-NEDS study, some of which have been mentioned above, including under-reporting of drowning and near-drowning in EDs; potential selection bias of ED cases; and the impact of seasonal fluctuation on data collection regarding drowning and near-drowning. One additional limitation is the lack of information on the location of near-drowning events, which can potentially guide interventions to prevent unintentional drowning incidents. Overall, it is important for researchers to note the limitations of ED-based data, which is reflected by the under-reporting of drowning-related incidents in this study. There will also be additional bias due to the higher severity of diseases seen at EDs compared with other departments in a hospital. This factor highly depends on the care-seeking pattern of patients in different countries and regions. It is also revealed that follow-up visits were notably low, which is true for the majority of ED cases reported elsewhere . The difThe Pak-NEDS study is a valuable reminder for researchers to carefully assess the information they need, and measure it against existing data collection systems. Community and household-level data are more preferable in the case of drowning events; however, these kinds of data collection activities can be extremely time consuming and resource intensive, and can hardly exceed the scale of a nationwide ED-based surveillance system. In order to control for temporality or seasonality, subsequent ED-based surveillance should cover a full seasonal cycle--especially for drowning and near-drowning events. As is made evident by many high-income countries, the negative impact of drowning on health systems can be largely reduced through collective actions across multiple sectors - a wide range of strategies can be borrowed from existing HIC preventive programs and modified to suit LMIC settings ,33,40-42The authors declare that they have no competing interests.SH and JCL developed the initial draft. Data management and analysis was done by SH. NZ, URK and KS critically reviewed the draft. AAH designed and supervised the Pak-NEDS study, and critically reviewed the draft. All authors approved the final draft.


Attention-Deficit Hyperactivity Disorder (ADHD) and Tourette Syndrome (TS) present as distinct conditions clinically; however, comorbidity and inhibitory control deficits have been proposed for both. Whilst such deficits have been studied widely within clinical populations, findings are mixed—partly due to comorbidity and/or medication effects—and studies have rarely distinguished between subtypes of the disorders. Studies in the general population are sparse. Using a continuity approach, the present study examined (i) the relationships between inattentive and hyperactive/impulsive aspects of ADHD and TS-like behaviors in the general population, and (ii) their unique associations with automatic and executive inhibitory control, as well as (iii) yawning . One hundred and thirty-eight participants completed self-report measures for ADHD and TS-like behaviors as well as yawning, and a conditioned inhibition task to assess automatic inhibition. A sub-sample of fifty-four participants completed three executive inhibition tasks. An exploratory factor analysis of the TS behavior checklist supported a distinction between phonic and motor like pure TS behaviors. Whilst hyperactive/impulsive aspects of ADHD were associated with increased pure and compulsive TS-like behaviors, inattention in isolation was related to reduced obsessive-compulsive TS-like behaviors. TS-like behaviors were associated with yawning during situations of inactivity, and specifically motor TS was related to yawning during stress. Phonic TS and inattention aspects of ADHD were associated with yawning during concentration/activity. Whilst executive interference control deficits were linked to hyperactive/impulsive ADHD-like behaviors, this was not the case for inattentive ADHD or TS-like behaviors, which instead related to increased performance on some measures. No associations were observed for automatic conditioned inhibition. Attention-Deficit/Hyperactivity Disorder (ADHD) and Tourette Syndrome (TS) present as distinct conditions clinically; however, there is evidence of comorbidity between those two disorders and inhibitory control deficits have been proposed for both  and involuntary sounds or utterances produced by moving air through the nose, mouth, or throat (phonic tics). Phonic and motor tics relate to separate diagnostic criteria as they involve discrete muscle groups, and phonic tics are generally more common  associations. The learning of stimulus-stimulus (S-S) associations follows the general laws of associative learning and may well rely on similar mechanisms, however, there are differences in the specific neural circuitries involved depending on the type of S-R  the associations between the different behavioral aspects of both conditions in the general population, and (ii) their unique roles in inhibitory control deficits, specifically in automatic inhibition. Few studies have used various tasks of response inhibition simultaneously to assess disorder and subtype specificity of deficits Nigg, , and indWhilst there are established ADHD scales for use in normal populations  based on comorbidity in clinical groups, ADHD- and TS-like behaviors were predicted to be positively associated; (ii) in line with the notion of the behavioral yawning model for TS, TS-like behaviors were predicted to be associated with excessive yawning also in contexts unrelated to fatigue or boredom; (iii) automatic attentional inhibition deficits were expected only in relation to the inattentive ADHD subscale , who completed all psychometric scales and the CI task. A subsample , recruited and tested under the same conditions, took also part in the executive behavioral inhibition response tasks. . There were also no significant sex differences for all variables  apart from Yawning-active  with females yawning more than males during activity).The full sample consisted of 138 mixed undergraduate and community participants  with a mean age of 23.54 . After complete description of the study, written consent was acquired from all participants  prior participation.ADHD-like behaviors were measured using the 18-item Adult ADHD Self-Report Scale . Items were framed to assess variation in symptomatic behaviors within the normal range, and referred to frequency occurrences of both TS-like phonic and motor symptomatology including unintended oral sounds , facial and body related motor behaviors . We also included three items referring to TS related OCBs  scale  on a standard 17” monitor computer. The Go/No-Go, Simon and Stroop tasks were administered using a standard keyboard (for one set of participants) as well as a Cedrus RB-730 response pad (for another set of participants) to examine whether use of a colored response pad would produce faster responding instead of colored keyboard buttons, and eliminating any potential keyboard lags (button pressing vs. response recording). However, no reaction time differences between responding using the keyboard or response pad were found and as such the samples were combined. The CI task used the standard computer keyboard as response input device.Conditioned inhibition task. Inhibitory learning was measured using the “Mission to Mars” task  items. Items with loadings <0.30 and /or strong cross-loadings (difference between loadings <0.10 or cross-loadings on more than 2 factors) were excluded from the subscales. Scale scores were calculated for the overall scales  and the subscales by summing the responses of the respective items. Pearson correlations were used to examine the zero-order associations between the ASRS, TS, and YWN scales. To further assess the unique contributions of the ASRS subscales on the TS subscales, and the ASRS and TS subscales on yawning behaviors, multiple regression analyses were conducted. To account for associations between ADHD and TS scales, partial correlations were computed for the relationships of ASRS and TS scales (controlling for each other) with the behavioral measures. Due to the interrelationships between variables, correlations were corrected using the false discovery rates procedure . The remaining seven items loaded onto factor two labeled TS-motor, and included questions related to unintentional physical movements . There were no cross-loading items. Four summed scale scores were calculated—one overall scale score for all TS items including the three OCB items  and three subscales scores , such that higher scores on each scale indicates greater frequency of endorsement of the respective behaviors, respectively. The two pure TS-factors were positively correlated with each other , and TS-OCB was positively correlated with both TS-phonic  and TS-motor . To test the difference between the dependent correlation coefficients, t-tests showed that the correlation between phonic and motor TS is significantly larger than the correlations of TS-OCB with phonic  and motor TS .For the pure TS items, parallel analysis indicated a two factor structure accounting for 35.85% of the variance . Seven items loaded onto factor two labeled YWN-inactive and comprised of situations involving inactivity or waiting . Five items loaded on the third factor labeled YWN-stress and consisted of stressful situations involving self-presentation or evaluation . Two cross-loading generic items were excluded (“lack of sleep” and “tired”). Four summed scales were calculated—one overall scale score including all items  and the three factor scales scores , such that higher scores reflected a greater tendency to yawn during the respective situations. YWN-inactive was significantly positively correlated with YWN-active  and YWN-stress , whereas YWN-active and YWN-stress were not significantly correlated .For the YWN scale, parallel analysis indicated a three factor structure accounting for 47.48% of the variance (MIC = 0.246). TS-OCD and YWN-stress were positively skewed and transformed as appropriate to normalize the scales. TS phonic and motor , were positively correlated with the three YWN subscales , as well as both ASRS subscales , whereas TS-OCB was positively correlated only with YWN-inactivity  and ASRS hyperactivity/impulsivity . All ASRS scales were significantly positively correlated with YWN-activity , and ASRS hyperactivity/impulsivity was also positively correlated with YWN-inactivity. The ASRS scales were not associated with YWN-stress.The means, standard deviations (SD), Cronbach's alphas or mean inter-item correlations for scales with less than 5 items ; ASRS-hyperactivity/impulsivity  was significantly associated with TS-phonic, whereas ASRS-inattention did not reach significance . For TS-motor, the overall model was significant ; again, only ASRS-hyperactivity/impulsivity  was significantly associated with TS-motor, whereas ASRS-inattention was not . For TS-OCB, the overall model was significant ; interestingly, whilst both subscales were significantly associated with TS-OCB, ASRS-hyperactivity/impulsivity  was associated with an increase whereas ASRS-inattention  with a decrease in TS-OCB.To examine the unique associations of the ASRS subscales with the TS subscales, three linear regression analyses were conducted. For TS-phonic, the overall model was significant ; only ASRS-inattention  and TS-phonic  were significantly associated with YWN-active but not ASRS-hyperactivity/impulsivity, TS-motor or OCB (ps > 0.40). For YWN-inactive, the overall model was significant ; only the TS scales, TS-phonic , TS-motor  and TS-OCB  were significantly associated with YWN-inactive but not the ASRS scales (ps > 0.73). For YWN-stress, the overall model was non-significant ; and TS-motor was the only “predictor” that reached significance .The unique associations of the ASRS and TS subscales with the YWN subscales were examined with three linear regression analyses. For YWN-active, the overall model was significant  in automatic and effortful response inhibition deficits. For comparability, we used the same CI task used earlier in studies of clinical ADHD and TS  TS-like behaviors, and YWN-inactive was also associated with compulsive TS behaviors. The Yawning scales also showed some associations with ADHD-like behaviors, whereby YWN-activity  was significantly positively associated with all ASRS scales, and YWN-inactivity with hyperactive/impulsive  ASRS. However, YWN-stress was not linked to ASRS. The regression analyses for the unique contribution of the TS and ASRS scales (thus accounting for covariation amongst those) showed that only the three TS-like behaviors remained significantly associated with yawning during inactivity, and only motor TS-like behaviors with yawning during stressful situations involving self-presentation/awareness. The ASRS scales were not linked to these two yawning scales. In contrast, only phonic (but not motor or OCB) TS-like behaviors and inattentive (but not hyperactive/impulsive) ASRS were positively associated with yawning during activity involving concentration. In general, the findings support the notion that excessive yawning is associated with TS  add the OCBs to the scale, due to their known comorbidity with TS in clinical populations (Swerdlow, Finally, in order to examine both ADHD- and TS- like behaviors independently in a relatively large sample, as well as in relation to disorder sub-types, the present study used symptom-based measures of ADHD- and TS-like behaviors in normal participants who did not report any diagnosed condition. This could be seen as a limitation; however, given challenges posed by studies using clinical samples—due to the difficulty in recruiting participants who are medication free and without comorbidities, or samples sufficiently large to fully control for comorbid symptoms Nigg, —the studEbrahim Kantini administered the behavioral tests and questionnaire measures. Helen J. Cassaday contributed to the design and supervised data collection. Hannah L. R. Checkley conducted preliminary analyses under the supervision of Nadja Heym. Nadja Heym completed the final statistical analyses and wrote the manuscript. All authors contributed to the interpretation of the results, and the drafting and revision of the manuscript. All authors have approved the final manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


R). Both in-home SPA and in-clinic assessments demonstrated strong discriminatory power in detecting impaired motor function in PD. However, mean effect size (0.94±0.37) for in-home measures was smaller compared to in-clinic assessments (1.30±0.34) for parameters that were significantly different between PD and healthy groups. No significant correlation was observed between identical in-clinic and in-home parameters in the PD group , while the healthy showed stronger correlation in gait speed, sit-to-stand duration, and stand-to-sit duration . This suggests a better correlation between supervised and unsupervised motor function assessments in healthy controls compared to PD group. In the PD group, parameters related to velocity and range-of-motion of lower extremity within gait assessment (R = 0.58–0.84), and turning duration and velocity within iTUG test (R = 0.62–0.77) demonstrated strong correlations with PD stage (p<0.01).Advances in wearable technology allow for the objective assessment of motor performance in both in-home and in-clinic environments and were used to explore motor impairments in Parkinson’s disease (PD). The aims of this study were to: 1) assess differences between in-clinic and in-home gait speed, and sit-to-stand and stand-to-sit duration in PD patients ; and 2) determine the objective physical activity measures, including gait, postural balance, instrumented Timed-up-and-go (iTUG), and in-home spontaneous physical activity (SPA), with the highest correlation with subjective/semi-objective measures, including health survey, fall history , fear of falling, pain, Unified Parkinson's Disease Rating Scale, and PD stage (Hoehn and Yahr). Objective assessments of motor performance were made by measuring physical activities in the same sample of PD patients  and age-matched healthy controls . The association between in-clinic and in-home parameters, and between objective parameters and subjective/semi-objective evaluations in the PD group was assessed using linear regression-analysis of variance models and reported as Pearson correlations ( Parkinson’s disease (PD) is the second most common neurodegenerative disease after Alzheimer’s disease, with over 60,000 new diagnoses each year in the United States alone . Motor iCommon objective motor assessments use a gait protocol inclusive of spatio-temporal parameters such as gait speed, cadence, stride length, and gait asymmetry ,9. PostuAlthough previous studies have demonstrated motor impairments in PD patients, it is unclear whether unsupervised in-home motor function assessment is as sensitive as supervised in-clinic measures when used to identify motor impairment due to PD. Furthermore, performing several objective tests to assess longitudinal changes in motor performance could be difficult in terms of patient burden and cost; therefore, it is important to identify those physical tasks which are most sensitive to changes in the PD stage and symptom profile. The goal of the current study was to assess gait, postural balance, iTUG, and SPA in a sample of PD patients and healthy controls in order to assess correlations between in-clinic and in-home physical activity parameters . We also explored the association between the severity of PD and motor impairments using the above objective measures, correlating objective parameters and subjective  and semi-objective evaluations  and the Hoehn and Yahr (H&Y) disease stage).Fifteen aging adults over 55 years with idiopathic PD, diagnosed by movement disorder specialists based on the UK Brain Bank criteria, were recruited from the University of Arizona Neurology Clinic. Participants were excluded if they were diagnosed with any type of neurological disorder other than PD, had received previous PD surgical treatments such as deep brain stimulation, or progressed to stage five PD based on H&Y staging. A sample of 35 healthy, non-frail (measured by Fried Frailty index ) adult cObjective assessments included: 1) gait; 2) postural balance; 3) iTUG; and 4) SPA. Several sensor-based outcomes were extracted including: spatio-temporal, smoothness, and asymmetry parameters of gait; body sway and balance controlling strategy parameters for postural balance; trunk velocity and range of motion during the iTUG test; and walking, sitting, standing, and lying duration, number and speed of gait and postural transition for the SPA monitoring  under single task and dual task conditions. The dual-task condition for gait was used since previous research has demonstrated an exacerbated motor performance, specifically during gait, in PD patients while performing in a dual-task condition . The duaPostural balance: Each participant then performed four 30-second trials of balance assessment; in each trial participants stood upright with their feet as close together as possible without touching each other and with their arms crossed to minimize the effect of arm movements on center of gravity (COG) displacements. In the first two trials, participants were instructed to keep their eyes open, with no visual target specified. In the third and fourth trials participants closed their eyes .iTUG: The iTUG task was performed by asking the participants to stand up from a standard chair without using their arms, walk three meters, turn, and walk back and sit down on the same chair.Three-dimensional acceleration and angular velocity of shanks, thighs and the trunk were measured using five wearable sensors each included a triaxial accelerometer and a triaxial gyroscope  to derive gait, postural balance, and iTUG outcome measures following procedures identical to those explained in earlier studies  ,8. BriefSubjective/semi-objective measures for the PD group included the SF-12 health survey , fall stR). Cut-offs of 0.01–0.19: negligible, 0.20–0.29: weak, 0.30–0.39: moderate, 0.40–0.69: strong, and 0.70–1.00: very strong were selected for correlations . We Results suggest a relatively strong correlation between fear of falling as qualified by FES-I and gait related parameters quantified through both gait and iTUG tests . In partLimitations arise as our sample was small, and our battery of several objective assessments was challenging for individuals suffering from PD symptoms; however, we managed to recruit PD participants from all disease stages (from 1 to 4) to better associate the objective parameters with the disease severity. Additionally, the accuracy of detecting physical activity  differs when using in-clinic compared to in-home measurement tools. For example, using the available technology, it was impossible to estimate steady state walking speed using one sensor during in-home assessments. These differences may introduce additional errors in determining the correlation between in-clinic and in-home parameters. Performing in-clinic measurements in an off-medication state may have also weaken the correlations between in-home and in-clinic measurements. The reason that in-clinic measurements were performed in an off-medication state was to reduce between-subject variability due to medication effects when correlating objective outcomes and subjective/semi-objective evaluations, as well as to resemble the common physical assessment situations that occur in labs and clinics. Finally, the focus of the current study was to explore body-worn sensor parameters with the potential to objectively characterize the physiological and biomechanical symptomology of PD. Using wearable sensor technology, we were able to perform all in-clinic objective assessments in a shorter timeframe (between 30 to 45 minutes) to avoid participant exhaustion. A large number of objective parameters were considered within the current study; however, several additional parameters exist which could be explored in future studies to more accurately characterize motor impairment in those with PD.In summary, detecting motor impairments was more difficult when measuring physical activities during natural daily activity as compared to objective tests within the lab or clinic environment in those with PD, unlike in healthy controls. Furthermore, parameters related to speed and range of movement, especially during an asymmetrical task such as turning, may be more sensitive to PD stage when compared to healthy controls and could prove promising as indicators of change over time .Based on the compiled results extracted from the current study, we made the following recommendations regarding objective assessment of motor performance in Parkinson’s patients:Overall, detecting motor impairments is harder using SPA monitoring compared to in-clinic measurements, likely due to a higher between-subject variability in SPA outcome measures. Therefore, a larger sample size is required when studying SPA in PD patients in-home compared to in-clinic assessments.To better assess physical changes due to the progression of either disease or treatment, parameters related to speed and flexibility of movements  and asymmetric tasks (such as turning) are preferred.Overall, in-clinic gait and iTUG tasks that involve more rapid movements compared to balance and SPA are better options for detecting differences in motor impairments at different stages of PD.


The efficacy of the treatment was investigated at baseline and at seven- to 10-week follow-up. TA-ICBT participants were also contacted four-weeks following treatment completion. Symptoms of postpartum depression decreased more for participants in the TA-ICBT group  compared to those participants in the waitlist control group , and these results were clinically significant and maintained at four-week follow-up. TA-ICBT participants demonstrated a reduction in postnatal anxiety, general stress, and parental distress, and an increase in psychological and environmental quality of life when compared to the waitlist control participants. Study implications, limitations, and future research directions are discussed.Postpartum depression impacts up to 15% of Canadian women following childbirth. Remarkably, many women suffering from this disorder do not receive appropriate treatment. The aim of this study was to conduct a parallel-group randomized controlled trial to determine the efficacy of Therapist-Assisted Internet-delivered Cognitive Behavior Therapy (TA-ICBT) for the treatment of postpartum depression. This study was registered with the International Standard Randomized Controlled Trials (ISRCTN: 85456371) and received funding from Canadian Institutes of Health Research (#101526) and the Saskatchewan Health Research Foundation. Fifty women who gave birth to an infant in the past year, who scored above 10 on the Edinburgh Postnatal Depression Scale (EPDS), and who resided in Saskatchewan, Canada were eligible to participate. Participants were randomly assigned to receive either TA-ICBT (ISRCTN85456371Controlled-Trials.com  Postpartum depression (PPD) impacts approximately 8 to 15% of women within the first year of childbirth . PPD mayInternet delivery systems could overcome many of these face-to-face treatment barriers. Receiving treatment from the comfort and convenience of a woman’s home would reduce mobility and childcare concerns. Relatively anonymous Internet-delivered therapy may circumvent women’s concerns of stigma . FurtherAmple empirical evidence supports the efficacy of Internet-delivered Cognitive Behavior Therapy (ICBT) in the treatment of major depression and sub-threshold depression. Particularly with therapist-assistance, ICBT is an effective method for reducing depressive symptoms when compared to treatment as usual (TAU), control groups, and treatment from a general practitioner –11. MetaPreliminary research suggests that Internet-delivered treatment is efficacious for women in the postnatal period. In one study, researchers tested the efficacy of an Internet-delivered Behavioral Activation (iBA) program compared with TAU for PPD . The 11-n = 70) with elevated levels of depression, a child under five years of age, and attending a low-income program were randomly assigned to TA-ICBT or TAU. When compared to the TAU participants, Mom-Net participants reported improvements on measures of depression, parental satisfaction and efficacy, as well as a reduction on observational indices of harsh parenting behavior [Another Internet-delivered intervention, Mom-Net, provided Therapist-Assisted ICBT (TA-ICBT) to economically disadvantaged mothers of young children . Consistbehavior . For thebehavior .While preliminary research supports the efficacy of TA-ICBT for women of young children  and Inten = 23 participants per group were required to detect a medium effect size for a mixed model ANOVA. A medium effect size is consistent with previous meta-analyses of therapist-assisted ICBT [Using the GPower program , to achited ICBT ,13.n = 2; (2) they declined to participate, n = 1; and (3) they recently had a change in their medication, n = 3.A total of 50 participants were recruited to account for participant attrition. Participant recruitment and follow-up occurred between March, 2012 and February, 2013. Recruitment efforts included notifying physicians, perinatal nurses, and the public through the use of posters, information cards, Internet advertisements, and media interviews. Participant recruitment concluded when data collection was complete. Eligibility criteria were: (a) 18 years of age or older; (b) gave birth to an infant within the past year; (c) residing in Saskatchewan; (d) self-reported access to and comfort using a computer and the Internet; (e) score of ≥ 10 on the Edinburgh Postnatal Depression Scale  in June 2013. There was a delay in registering the trial as we were made aware of the benefits of registering the trial after data collection had begun. No changes were made to the study protocol between the start of the trial and the time of registration. The authors confirm that all ongoing and related trials for this intervention are registered. The project was partially supported by funding provided by the Canadian Institutes of Health Research (#101526) and the Saskatchewan Health Research Foundation.SD = 3.89). Participants reporting sub-threshold PPD were included given that sub-clinical PPD symptoms are associated with parenting difficulties and adverse child outcome [Initial assessment included a telephone screen using the Edinburgh Postnatal Depression Scale (EPDS ) along w outcome .Following the initial assessment, participants then completed a telephone interview consisting of the administration of the MINI International Neuropsychiatric Interview (MINI ). The MIEligible and willing participants were individually randomized  to either TA-ICBT/ Maternal Depression Online or WLC conditions. Participants were allocated in equal numbers to each intervention using blocked randomization. Random allocation was conducted via an Internet computer program by a researcher who was not involved with the research study. The researchers were blind to the randomization process and were notified through e-mail regarding participant allocation following the screening process. Following the notification, the primary researcher (N.E.P.) contacted the participants over the telephone and informed them of their assigned treatment group . Due to the nature of the conditions , it was not possible for the study therapists and participants to be blind to the treatment assignment.Post intervention/delay period measures were administered to all participants over a secure Internet website . Once the T2 measures were completed by the WLC participants, they were contacted and offered TA-ICBT. Four-week follow-up measures were administered over the Internet for participants assigned to the TA-ICBT condition only .The EPDS  is a 10-The Depression Anxiety Stress Scale- Short Form  (DASS) istrongly disagree) to 5 (strongly agree). The PSI-SF has demonstrated excellent psychometric properties and is appropriate for use with parents of children as young as one month [The Parenting Stress Index-Short Form (PSI-SF ) comprisne month . In the not at all) to 5 (an extreme amount). The computerized version of the WHOQOL-BREF has demonstrated excellent psychometric properties [The World Health Organization Quality of Life Assessment BREF (WHOQOL-BREF ) is a 26operties  and the operties . In the strongly disagree) to 6 (strongly agree) with higher scores indicating the participant perceived the ICBT relationship as helpful. The HAQ-II has demonstrated acceptable psychometric properties [The Therapeutic Alliance Questionnaire (TAQ) consists of 17 items assessing the perceived helpfulness of the ICBT therapeutic relationship and has been used in multiple TA-ICBT studies . The TAQoperties , but thenot at all) to 7 (very much so) Likert scale. These questions were adapted from the Treatment Satisfaction Questionnaire-Modified . In thinot at all) to 9 (very much), while treatment expectancy was measured with two items rated using a 0 to 100% scale. Psychometric properties are strong and factor analysis has confirmed the subscales of the CEQ [The Credibility/Expectancy Questionnaire (CEQ ) assesse the CEQ .Participants randomized to the WLC condition were provided with an information pamphlet that included psycho-education on PPD and websites to access provincial mental health support services. They were requested to inform the researchers of any treatment they received during the wait period.www.onlinetherapyuser.ca [Maternal Depression Online was adapted from a TA-ICBT program for depression offered through the Online Therapy Unit for Service Education and Research (yuser.ca ), locateyuser.ca . Maternayuser.ca . Given tyuser.ca  and TA-Iyuser.ca , the depyuser.ca .n = 3) or completed seven modules in a shorter period of time (n = 6).Maternal Depression Online was designed so that each page of the program was viewed prior to proceeding to the next page. Check-in questions focusing on the module content were presented at the beginning of each module while homework exercises were assigned at the end of each module. Participants were encouraged to progress at a pace of one module per week although more time was often taken. Most TA-ICBT and WLC participants completed T2 measures at a standard 10-week follow-up time. Measures were administered earlier, however, if the participants withdrew from the program  who were supervised by a registered psychologist and expert in TA-ICBT (co-author H.D.H.). Internet therapists completed a training workshop in the provision of TA-ICBT . TherapiAll outcome data were analyzed on an intention-to-treat basis such that the analyses included every participant who was randomized according to randomized treatment assignment. Between-group intervention effects on the EPDS from baseline (screening) to T2 (post-intervention/wait-time) were compared using longitudinal mixed effects models . The lonrecovered based on calculations of Matthey’s Reliable Change Index (RCI) for the EPDS. Those who demonstrated a decrease in their EPDS score of four or more points but still scored 10 or more after treatment were classified as improved but not recovered. Those participants who showed a four point increase in their EPDS score after treatment were classified as deteriorated. Finally, participants whose pre-post difference score was less than four points were classified as no change regardless of whether or not their post-treatment scores fell below the cut-off score of ten. The procedure and recommendations outlined by Matthey [Clinically significant change on the EDPS was calculated using procedures outlined by Matthey  in their Matthey  have bee Matthey )Multiple regression analyses were used to determine if group differences (TA-ICBT versus WLC) predicted secondary outcome measure scores  when controlling for pre-treatment scores on each respective secondary outcome measures. The effects of missing follow-up data were explored by imputing missing data using chained equations , 47 thatA within-subjects analysis for participants receiving TA-ICBT was conducted comparing four-week follow-up (T3) EPDS scores with post-treatment (T2) and baseline EPDS scores (screening). Finally, descriptive statistics are reported for program engagement, satisfaction, and therapeutic alliance reported by the TA-ICBT group .t(48) = 1.87, p = .067, d = .54. The distribution of the EPDS was normal and similar variance was revealed between the two groups. Attrition rates for TA-ICBT and WLC groups were 16% (n = 4) and 12.5% (n = 3), respectively between T1 and T2. Attrition rates for the TA-ICBT group between T2 and T3 was 28.5% (n = 5).The TA-ICBT and WLC groups did not differ with respect to demographic characteristics see . DescripWLC participants reported receiving various support/care during the waiting period. Close to 58% reported regular contact with their family physician, 32% sought psychotherapy for maternal depression, and 25% of participants reported using psychotropic medication.F = .35, p = .56, a statistically significant change in EPDS scores over time, F = 16.23, p = .001, but most importantly and consistent with our primary hypothesis, a condition by time interaction, F = 5.15, p = .02. Following the criteria outlined by Matthey [2(1) = 2.93, p = .08, Cramer’s V = .026.Results from the longitudinal mixed model analysis indicated no effect for condition on EPDS scores,  Matthey , approxiIn order to determine whether the treatment influenced participants’ stress, anxiety, depression, parental stress, and quality of life, scores on these variables at T2 were the outcome variables in a series of multiple regressions. The predictor variables were condition (TA-ICBT or WLC) and scores on the secondary outcome variables at T2. The results for these analyses are presented in t(14) = 4.13, p < .01, d = 1.10, indicating that intervention effects not only were maintained, but also that the TA-ICBT participants continued to improve.We conducted within-subjects analyses comparing follow-up scores (T3) with post-treatment scores (T2) for participants in the TA-ICBT condition. The EPDS collected at follow-up had statistically significant and large gains compared with post-treatment scores, th of 7 modules (11.8%). The website was extensively used by participants as indicated by the mean number of program visits , and the number of emails sent  and received by the participants . Over 80% of the participants reported that they liked the overall program and enjoyed communicating with their therapist (TSQ). Participants also reported a high level of therapeutic alliance, giving a rating of 86.42% (TSQ).PPD is an undertreated condition that may result in both short and long-term consequences for the infant . The resIn addition to the efficacy of TA-ICBT, our results indicated significant program adherence, with participants completing, on average, 5.92 of the seven modules (60% of completed the entire program). Participants not only completed weekly check-ins with each module, but they also messaged their therapist on average five times. Therapists, in turn, provided considerable support to participants sending, on average, eleven messages over the course of treatment. A strong therapeutic alliance and high satisfaction with the overall program was also reported. Findings are consistent with a qualitative investigation that explored participants’ perceptions of this program ; the majWe did not find any group differences for the secondary outcome measures relating to general depression, general anxiety, overall parental stress, and select domains of quality of life. Interestingly, group differences were revealed for depression when assessed with the EPDS, but not when measured with using the DASS-21. This may have been the result of the sensitivity of the DASS-21 to assess postnatal depression. Indeed, general depression measures often rely on somatic symptoms of depression, which overlap with physical symptoms associated with the postpartum period . While sGiven the dearth of literature in the area of TA-ICBT for PPD, future research directions are abundant. To begin, additional well-designed trials of TA-ICBT for PPD are required. It is suggested that these studies include a larger, more diverse sample, as well as longer-term follow-up times. Varying Internet therapeutic contact and styles could also be compared, such as weekly versus bi-weekly therapist contact or telephone versus email versus audio/video correspondence. Additionally, given the efficacy and participant satisfaction of TA-ICBT for PPD, future research exploring TA-ICBT for the treatment of other perinatal clinical disorders is warranted, such as a transdiagnostic program to concurrently address symptoms of perinatal anxiety and depression. The comparison of TA-ICBT to an active treatment condition such as face-to-face CBT as well as other Internet-delivered treatments  would also be beneficial, as not all participants responded favorably to TA-ICBT. An economic evaluation study comparing the cost-effectiveness and cost utility of TA-ICBT for PPD compared with face-to-face treatment is also warranted. Finally, future implementation research is required to determine whether different health care professionals are equally effective in delivering TA-ICBT for PPD and how this type of novel programming can be effectively implemented and utilized within community settings.There were a number of limitations that should be considered. The sample utilized was relatively small and prohibited an examination of other factors. The results, however, are promising as the sample included participants with sub-threshold PPD. An additional limitation was the absence of an active control condition, which may have exaggerated our results. However, the study demonstrates considerable feasibility and acceptability of TA-ICBT for PPD. The limited sample with respect to demographic characteristics was an additional drawback. Moreover, given that more than half of the sample reported some university education, additional research utilizing a more heterogenous sample is required. A group comparison at follow-up was not conducted, which would have been informative given that PPD is often a spontaneously remitting condition  and, theDespite some limitations to the research design, we demonstrated that TA-ICBT was an efficacious, well-utilized, and desirable intervention for women with PPD. When compared to a WLC condition, TA-ICBT appeared more efficacious at reducing symptoms of PPD, parental stress, and improved psychological and environmental quality of life. Further investigation for TA-ICBT for PPD is required, particularly comparing TA-ICBT to an active control condition, utilizing a larger and more heterogeneous sample, with longer-term follow-up. Additionally, an examination of the cost-effectiveness of TA-ICBT when delivered in community settings would also be desirable alongside the study of factors that constrain or enhance the implementation of TA-ICBT in community practice.S1 CONSORT Checklist(DOC)Click here for additional data file.S1 File(TIFF)Click here for additional data file.S2 File(SAV)Click here for additional data file.S1 Protocol(DOCX)Click here for additional data file.S1 Table(DOC)Click here for additional data file.S2 Table(DOC)Click here for additional data file.S3 Table(DOC)Click here for additional data file.S4 Table(DOC)Click here for additional data file.


Aging is associated with common conditions, including cancer, diabetes, cardiovascular disease, and Alzheimer's disease. The type of multi-targeted pharmacological approach necessary to address a complex multifaceteddisease such as aging might take advantage of pleiotropic natural polyphenols affecting a wide variety of biological processes. We have recently postulated that the secoiridoids oleuropein aglycone (OA) and decarboxymethyl oleuropein aglycone (DOA), two complex polyphenols present in health-promoting extra virgin olive oil (EVOO), might constitute anew family of plant-produced gerosuppressant agents. This paper describes an analysis of the biological activity spectra (BAS) of OA and DOA using PASS (Prediction of Activity Spectra for Substances) software. PASS can predict thousands of biological activities, as the BAS of a compound is an intrinsic property that is largely dependent on the compound's structure and reflects pharmacological effects, physiological and biochemical mechanisms of action, and specific toxicities. Using Pharmaexpert, a tool that analyzes the PASS-predicted BAS of substances based on thousands of “mechanism-effect” and “effect-mechanism” relationships, we illuminate hypothesis-generating pharmacological effects, mechanisms of action, and targets that might underlie the anti-aging/anti-cancer activities of the gerosuppressant EVOO oleuropeins. The inter-species hormesis, or xenohormesis, hypothesis originally proposed by Dr. David A. Sinclair , 2 statehormesis does not make sense except in the light of TOR-driven aging” [e.g., atherosclerosis, diabetes, cancer, and other diseases) can be understood as the product of synergistic interactions between our evolutionary path to sedentarism, which increases a number of gero-promoting factors  that upregulate key gerogenes , and the “defective design” of central energy metabolism sensors that function either as metabolic gerogenes  or metabolic gerosuppressors  [switched off upon its completion and therefore drives aging; and (b) the weakness of the metabolic gerosuppressors that antagonize the metabolo-gerogenic pathway. In this metabolic framework for aging-related diseases, upregulation of metabolic gerogenes limits lifespan by accelerating age-related diseases, whereas the responsiveness of metabolo-gerosuppressor signaling should decline with aging because robust and continuous activation of metabolic suppressors in response to metabolic stresses results in accelerated aging [Dr. Mikhail V. Blagosklonny has recently proposed that “n aging” . In thisof mTOR) -29. Thised aging , 31. In e.g., via non-permanent activation of metabolic gerosuppressors) should increase healthy lifespan. We have recently explored, for the first time, the putative AMPK/mTOR-related xenohormetic nature of complex polyphenols that are naturally present in extra virgin olive oil (EVOO), a pivotal component of the Mediterranean-style diet that has been repeatedly associated with a reduction in age-related morbidity and a longer life expectancy [bona fide xenohormetins that are able to activate the gerosuppressor AMPK and trigger numerous resveratrol-like anti-aging transcriptomic signatures in biologically aggressive cancer cells. As such, we postulated that EVOO secoiridoids constitute a new family of plant-produced gerosuppressant agents that molecularly “repair” the aimless (and harmful) AMPK/mTOR-driven quasi-program that leads to aging and aging-related diseases, including cancer [If the upregulation of metabolic gerogenes limits lifespan by accelerating the progression of age-related diseases, such as atherosclerosis or cancer, the behavioral and/or pharmacological suppression of metabolic gerogene-driven aging , which is hosted by the V. N. Orechovich Institute of Biomedical Chemistry (www.ibmc.msk.ru/en) under the aegis of the Russian Foundation of Basic Research. Using Pharmaexpert (www.genexplain.com/pharmaexpert), a tool developed to analyze the BAS of substances predicted by PASS, we characterized EVOO oleuropeins with different types of biological activities based on multiple mechanisms of action, analyses of activity-activity relationships, and drug-drug interactions. We now report on how a multi-targeted pharmacological approach needed for a complex multifaceted disease, such as aging, might take advantage of EVOO-derived polyphenols, pleiotropically impacting a wide variety of biological processes.As a compound's biological activity spectrum (BAS) is an intrinsic property that is representative of different pharmacological effects, physiological and biochemical mechanisms of action, and specific toxicities, and the BAS is largely dependent on the structural nature of a compound -43, we rOA and DOA are structurally related secoiridoids with identical dihydroxylated aromatic moieties that differ only due to the presence of a methoxycarbonyl group on C-5 of the dihydropyrane ring of OA Fig. . As the www.genexplain.com/pass), which predicts 1,105 types of biological activities with a mean prediction accuracy in leave-one-out cross-validation (LOOCV) of 96%. PASS prediction tools are constructed using principal compounds from the MDDR database (produced by Accelrys and Prous Science), which is continuously updated with biologically relevant compounds. The PASS training set consisted of 287,633 known biologically active substances  compiled from various sources, including publications, patents, chemical databases, and “gray” literature [Predictions were made using the PASS12 refined version of the program (terature .www.genexplain.com/pharmaexpert), a tool that was developed to analyze the biological activity spectra of substances predicted by PASS. PharmaExpert software analyzes the relationships between biological activities (“mechanism-effect(s)” and “effect-mechanism(s)”), identifies probable drug-drug interactions, and searches for compounds acting on multiple targets [Figs.  targets -43.mechanisms of action, pharmacological effects, metabolism-related actions, transporter terms, gene expression terms, and toxic/adverse effects.Different types of biological activities are divided into six classes: mechanisms of action reflect the interactions of biologically active compounds with biological entities at the macromolecular level. In addition to the expected antioxidant mechanism of action of OA (Pa = 0.872), PASS predicts some new mechanisms for the cyclic hemiacetalic form of OA, including cardiotonic (Pa = 0.826), immunomodulator (Pa = 0.598), vasodilator (Pa = 0.487), and hepatoprotectant (Pa = 0.453) activities. The cyclic hemiacetalic form of DOA is similarly predicted to exhibit an expected antioxidant mechanism of action (Pa = 0.790) while lacking all of the cardiotonic, immunomodulator, and hepatoprotectant mechanisms predicted for the cyclic hemiacetalic form of OA.The The open dialdehydic form of OA is predicted to lack all of the cardiotonic, immunomodulator, and hepatoprotectant mechanisms of action suggested for the cyclic hemiacetalic form of OA. Moreover, the expected antioxidant mechanism of OA is notably reduced when PASS predictions are used to estimate the probable mechanisms of action of the open dialdehydic form of OA (Pa = 0.247). The top predicted mechanism of action for the open dialdehydic form of OA is GABA aminotransferase inhibitor activity (Pa = 0.433). The open dialdehydic form of DOA is predicted to lack (Pa = 0.221) the highly predicted antioxidant mechanism of action of the cyclic hemiacetalic form of DOA, while gaining new mechanisms such as acting as a tyrosine 3 hydroxylase inhibitor (Pa = 0.407) and cholesterol synthesis inhibitor (Pa = 0.380).pharmacological effects reflect the pharmacological action or pharmacotherapeutic application of the compound. Some of the most likely anti-aging/anti-cancer pharmacological effects, showing higher Pa values in the predictions for the cyclic hemiacetalic form of OA, include anti-antioxidant (Pa = 0.872), anti-inflammatory (Pa = 0.809), anti-neoplastic (Pa = 0.610), apoptosis agonist (Pa = 0.419), and chemopreventive (Pa = 0.387) effects. The cyclic hemiacetalic form of DOA conserves all the anti-aging/anti-cancer pharmacological effects observed in the prediction for the cyclic hemiacetalic form OA, but displaying somewhat lower Pa values . The sole exception is the apoptosis agonist effect, which is predicted to occur with a higher probability (Pa = 0.610) for the cyclic hemiacetalic form of DOA.The Remarkably, the open dialdehydic form of OA exclusively conserves the chemopreventive effect of the cyclic hemiacetalic form of OA, and with an even higher Pa value (0.596). Similarly, the open dialdehydic form of DOA notably gains a strong anti-aging/anti-cancer-related chemopreventive effect (Pa = 0.766) compared with the weaker effect observed in the activity prediction for the cyclic hemiacetalic form of DOA (Pa = 0.372).metabolism-related actions reflect interactions of chemical compounds with metabolic enzymes. The cyclic hemiacetalic forms of OA and DOA are predicted to function as CYP1A2 inhibitors .The The open dialdehydic form of OA is predicted to function as a substrate of GST A and GST P1-1 . Similarly, the open dialdehydic form of DOA is predicted to function as a GST A and GST P1-1 substrate .transporter terms reflect the interaction of chemical compounds with transporters . The cyclic and open forms of OA as well as the cyclic form of DOA are all predicted to function as P-glycoprotein substrates, but with a low Pa (~0.220); this activity is not predicted for the open dialdehydic form of DOA.The gene expression terms reflect the influence of chemical compounds on the expression of certain genes. The cyclic hemiacetalic form of OA is predicted to negatively regulate ICAM1 gene expression with a low Pa (0.228). The cyclic hemiacetalic form of DOA is similarly predicted to inhibit the expression of ICAM1 (Pa = 0.329) and AR (Pa = 0.235) genes.The ICAM1 gene (Pa = 0.303) and AR (Pa = 0.290), as indicated for the cyclic hemiacetalic form of OA, the open dialdehydic form is predicted to inhibit the expression of the TNF (Pa = 0.392) and NOS2 (Pa = 0.253) genes. The open dialdehydic form of DOA, in addition to inhibiting the ICAM1 (Pa = 0.295) and AR (Pa = 0.310) genes, as indicated for its cyclic hemiacetalic form, is also predicted to inhibit the expression of the TNF (Pa = 0.331) and NOS2 (Pa = 0.208) genes.In addition to inhibiting the expression of the toxic/adverse effects reflect the specific toxicities or adverse reactions of the chemical compounds. No highly predicted toxic/adverse effects are indicated for the cyclic hemiacetalic form of OA beyond ulceration (Pa = 0.215). Interestingly, other indirectly related anti-aging/anti-cancer pharmacological effects with low Pa values are predicted for the cyclic hemiacetalic form of DOA, specifically embryotoxic (Pa = 0.260) and teratogen (Pa = 0.248) effects.The The open dialdehydic form of OA, in addition to showing skin irritation (Pa = 0.971) and eye irritation (Pa = 0.774) effects, is predicted to exhibit embryotoxic (Pa = 0.457) and teratogenic (Pa = 0.435) toxicities with Pa values that are somewhat higher than those predicted for its cyclic hemiacetalic form. A very similar pattern of toxic and adverse effects is predicted for the open dialdehydic form of DOA, including skin irritation (Pa = 0.954) and eye irritation (Pa = 0.823) effects as well as embryotoxic (Pa = 0.456), and teratogenic (Pa = 0.429) activities.i.e., the hemiacetalic closed forms versus dialdehydic open forms) impact some anti-aging/anti-cancer-related effects predicted with probabilities of Pa > 0.500 by PASS . Some of the pharma-cological effects assumed to be closely related to the previously reported anti-aging and anti-cancer effects of OA and DOA  are exclusively restricted to the hemiacetalic cyclic forms of OA and DOA . As green-colored atoms reflect a positive impact on a given activity while the red-colored atoms reflect a negative impact on the same activity, it should be noted that the chemopreventive mechanisms of action that are significantly predicted for the open dialdehydic forms of OA and DOA, but not for their cyclic hemiacetalic isomers mostly involve all of the atoms involved in the polyphenolic structure of DOA. Remarkably, as observed for many drugs with potential antineoplastic and chemopreventive properties, including curcumin and resveratrol [To preliminarily elucidate hypothesis-generating structural requirements of gerosuppressant oleuropeins, we assessed how the naturally occurring chemical structures of OA and DOA  and a dialdehyde isomer . Although this equilibrium could be shifted in practice, for instance, by the preferential interaction of one of the isomers with a target protein, the dialdehyde form appears to be more conformationally free and adaptable to interact with a suitable target. It should be noted that the presence of the methoxycarbonyl constituent in OA clearly favors the cyclic hemiacetalic form due to the conjugation of the ester group with the internal double bond. In sharp contrast, a much greater ratio favoring the open dialdehydic form should be expected for DOA. Accordingly, the reported 1H-NMR of DOA shows that the dialdehyde form largely predominates [in vitro studies with cultured cancer cells, but also based on their predicted toxicities. Archetypal anti-aging/anti-cancer polyphenols, such as curcumin and resveratrol, have been shown to operate as “double-edged swords”, such that in vitro experiments reveal carcinogenic and pro-oxidant effects, in addition to anticancer and antioxidant effects. Accordingly, these polyphenols have been shown to exert embryotoxic and teratogenic effects using zebrafish embryos as disease models [in vitro might also predict developmental toxicity under in vivo conditions [in vitro model of embryotoxicity and the tumor-initiation properties of cancer stem cells.Importantly, the results of our application of PASS to the EVOO oleuropeins OA and DOA, which exhibit two naturally occurring isomeric structures, strongly suggest that a different biological activity spectrum can be expected from hemiacetalic ominates -69. In tominates -72. It ie models -50. The e.g., associated with endoplasmic reticulum stress, the unfolded protein response, spermidine and polyamine metabolism, AMPK activation, suppression of crucial genes involved in the Warburg effect and the self-renewal capacity of “immortal” cancer stem cells), while the same OA- and DOA-enriched phenolic extracts significantly prevented age-related changes in cell size, morphological heterogeneity, and senescence-associated β-galactosidase staining of normal diploid human fibroblasts at the end of their proliferative lifespans [in silico techniques. The results of the present study confirm that PASS software is extremely useful for the elucidation of unknown therapeutic mechanisms in plant-based drug discovery and, more importantly, reveals hypothesis-generating pharmacological effects, mechanisms of action, and targets that likely underlie the anti-aging/anti-cancer activities of complex polyphenols that are naturally present in EVOO.We have recently postulated that the secoiridoids OA and DOA, two complex polyphenols present in health-promoting EVOO, might constitute a new family of plant-produced gerosuppressant agents , 32. We ifespans . Because


A large proportion of existing prediction algorithms are ‘disease agnostic’ but are nevertheless quite capable of predicting when a mutation is likely to be deleterious. However, most clinical and research applications of these algorithms relate to specific diseases and would therefore benefit from an approach that discriminates between functional variants specifically related to that disease from those which are not. In a whole-exome/whole-genome sequencing context, such an approach could substantially reduce the number of false positive candidate mutations. Here, we test this postulate by incorporating a disease-specific weighting scheme into the Functional Analysis through Hidden Markov Models (FATHMM) algorithm. When compared to traditional prediction algorithms, we observed an overall reduction in the number of false positives identified using a disease-specific approach to functional prediction across 17 distinct disease concepts/categories. Our results illustrate the potential benefits of making disease-specific predictions when prioritizing candidate variants in relation to specific diseases. A web-based implementation of our algorithm is available at  The average human exome harbours around 20,000 single nucleotide variants (SNVs), of which approximately half are annotated as non-synonymous single nucleotide polymorphisms (nsSNPs) . HoweverThere is a plethora of computational prediction algorithms capable of analysing the functional consequences of nsSNPs . One of gene-specific manner, e.g. predicting the effects of nsSNPs in mismatch repair proteins [disease-specific predictions have been developed is in the prediction of cancer-associated mutations [To the best of our knowledge, computational prediction algorithms have been explored exclusively in a proteins ,7. The sutations -11. In outations . We haveIn order to assess the potential benefits of making disease-specific predictions, we compared the performance of our disease-specific weighting scheme with the performance of our original algorithm (weighted for inherited disease mutations) and two (generic) computational prediction algorithms: SIFT  and PolyIn the above, tp, fp, tn and fn refer to the number of true positives, false positives, true negatives and false negatives observed, respectively. Accuracy, precision, specificity, sensitivity, negative predictive value (NPV) and Matthew's correlation coefficient (MCC) were calculated using normalized numbers. Italic font corresponds to the best performing method for a given statistic.disease, and those with a higher proportion of other disease-causing mutations/neutral polymorphisms would predict all variants as neutral. Overall, we observed a similar performance to that of our algorithm , we recognize the potential for bias. Therefore, we also performed a 20-fold cross-validation analysis (see Table http://fathmm.biocompute.org.uk). Using this dataset to train and test our algorithm, we observed similar performances to those reported above  with the disease concepts used in our analysis and make this resource publically available at our website . In order to alleviate the potential for bias in our results, we performed a 20-fold cross-validation procedure across our 17 disease concepts. From this analysis, we observed no significant deviations in the reported performance measures and therefore conclude that the performances observed were not an artefact of our disease-specific weighting scheme.One of the major limitations of our disease-specific approach is that, in extreme cases, there is potential for dominating pathogenicity weights which could bias or exaggerate the effects of variants, e.g. when prioritizing variants in proteins and/or domains which have very strong associations with the disease concept under investigation. Here, the pathogenicity weights used could dominate the underlying amino acid probabilities (used to measure sequence conservation) and therefore bias the prediction. For example, when these weights are biased towards the disease concept, neutral polymorphisms falling within diverse regions of a protein/domain would be classified as ‘damaging’ as opposed to being classified as ‘benign’. As a consequence, our disease-specific models are best suited as a whole-genome/whole-exome prioritization method (hypothesis-free) and should be used with caution when prioritizing variants in a gene-specific manner. In an attempt to alleviate the potential effects of dominating pathogenicity weights, measures of sequence conservation are presented alongside our rankings so that spurious predictions can be assessed and ignored.http://fathmm.biocompute.org.uk.An alternative approach to our disease-specific weighting scheme is to filter putative disease-causing nsSNPs using the Gene Ontology . Howeverab initio hidden Markov model (HMM), representing the multiple sequence alignment of homologous  sequences within the SwissProt/TrEMBL [ab initio model. Next, our algorithm combines sequence conservation, within the most informative model  in the Human Gene Mutation Database  are typically considered ‘neutral/benign’. However, our weighting scheme assesses the tolerance of the corresponding model (representing a protein or domain) to mutation and then adjusts a conservation-based prediction accordingly. For example, nsSNPs falling within P53 (a well-established cancer gene) are penalized according to the gene's intolerance to mutation whereas nsSNPs falling within MHC (known to contain hypervariable regions) are not penalized given the gene's apparent tolerance to mutation.In Equation 1, Pro 12.4 ) and putPro 12.4   in the Human Gene Mutation Database (HGMD Pro 12.4 ) were anIn accordance with published guidelines , the folIn the aforementioned data, tp and fp refer to the number of true positives and false positives reported, respectively, whereas tn and fn refer to the number of true negatives and false negatives reported, respectively. Receiver operating characteristic (ROC) and area under the curve (AUC) analyses were performed using the ROCR software suite .The authors declare that they have no competing interests.HAS participated in the design of the study and performed the analysis. TRG, JG and INMD participated in the design and coordination of the study. DNC and MM provided the training data and corresponding disease annotations. All authors read and approved the final manuscript.Performance of computational prediction algorithms. This file reports the performance of computational prediction algorithms when tasked with discriminating between inherited disease-causing mutations, disease-specific mutations and neutral polymorphisms.Click here for filePerformance of computational prediction algorithms using SwissProt/TrEMBL. This file reports the performance of our disease-specific algorithm and two generic computational prediction algorithms: SIFT and PolyPhen-2, when tasked with discriminating between disease-specific mutations and other disease-causing mutations/neutral polymorphisms in SwissProt/TrEMBL.Click here for file


Prostate cancer (PCa) is the most common cancer in men and the second most common cause of cancer-related death in men. In recent years, novel therapeutic options for PCa have been developed and studied extensively in clinical trials. Sipuleucel-T is the first cell-based immunotherapeutic vaccine for treatment of cancer. This vaccine consists of autologous mononuclear cells stimulated and loaded with an immunostimulatory fusion protein containing the prostate tumor antigen prostate acid posphatase. The choice of antigen might be key for the efficiency of cell-based immunotherapy. Depending on the treatment strategy, target antigens should be immunogenic, abundantly expressed by tumor cells, and preferably functionally important for the tumor to prevent loss of antigen expression. Autoimmune responses have been reported against several antigens expressed in the prostate, indicating that PCa is a suitable target for immunotherapy. In this review, we will discuss PCa antigens that exhibit immunogenic features and/or have been targeted in immunotherapeutic settings with promising results, and we highlight the hurdles and opportunities for cancer immunotherapy. Prostate cancer (PCa) is the most commonly diagnosed non-cutaneous cancer among men in the United States and is the second leading cause of death from cancer in men . In EuroIn 2010, the first cellular immunotherapy was approved as a treatment for mCRPC by the US Food and Drug Administration (FDA). More recently, cancer immunotherapy hit a new peak, Science Magazine elected cancer immunotherapy the breakthrough of 2013 . EspeciaInflammation is an innate response to harmful stimuli, such as infections, tissue damage, or tissue malfunction , 9. The Cancer has been described as a wound that refuses to heal , and todInflammatory response inducers in prostate vary from infections to life style factors, such as diet or smoking . SymptomSeveral studies have reported autoimmune responses against both seminal proteins , 24 and The increased knowledge of how specific immune responses are evoked and the development of tools to manipulate the immune system have enabled implementation of novel immune-based cancer therapies. The rationale of these immunotherapies is to induce anti-tumor immune responses, decrease tumor-load, and change the course of the disease. Recognition of target antigens by the immune system is crucial. Several types of immunotherapeutics have been developed, such as peptide vaccines, DNA/RNA vaccines, cell-based vaccines, and T-cell modulators. Although improving overall survival is the primary endpoint of most clinical studies, a better understanding of induced T-cell responses, boosting pre-existing immune responses, and the effect of the tumor microenvironment on the T cells is needed to further improve PCa immunotherapy.Tumor-associated antigens in PCa can be proteins that are present on prostate cells and on their malignant counterparts. Examples are prostate-specific antigen (PSA), prostate-specific membrane antigen (PSMA), and the cancer/testis antigens (CTAs). In a steady state, these antigens are not provoking strong immune responses. Immunosuppressive mechanisms in the prostate microenvironment, such as transforming growth factor (TGF)-β, regulatory T cells (Tregs), or myeloid-derived suppressor cells, will maintain prostate infiltrating lymphocytes in an inactive state –32. In aProstate-specific antigen is a serine protease produced primarily in the epithelial cells lining the acini and ducts of the prostate gland –53. PhysCellular autoimmune responses against PSA have been detected in both healthy men and patients suffering from chronic prostatitis , 27, 58,Other PSA-expressing vectors have been tested in phase I trials in patients with PCa with rising PSA levels. Vaccinations with vaccinia-based vectors expressing PSA resulted in stabilization of serum PSA levels and PSA-specific T-cell responses were observed . PSA-spein vitro and in vivo, untreated patients with PCa often fail to induce a potent immune response against this antigen (Despite the fact that PSA-based immunotherapeutic approaches can stimulate cytotoxic T lymphocytes (CTLs) both  antigen –64. Seve antigen , 66;  is a secreted glycoprotein enzyme synthesized in the prostate epithelium . Only a in vitro  can be found in blood of healthy donors and in patients with chronic prostatitis , 78, 79.in vitro . Moreovein vitro , 83. Alsin vitro , 85. Natin vitro , 83, 84.In a PAP-based DNA vaccine, patients with CRPC received six vaccinations with granulocyte-macrophage colony-stimulating factor (GM-CSF) biweekly. Both humoral and cellular immune responses were detected in 3 of the 22 patients, with an at least threefold increase in PAP-specific IFN-gamma secreting CD8+ T cells. Nine of 22 patients showed PAP-specific CD4+ and/or CD8+ T-cell responses, but no antibody responses were detected. Also, an increase in the PSA doubling time was observed . The resex vivo activation of APCs and as tumor-associated antigen, respectively. The proposed mechanism of sipuleucel-T is inducing antigen-specific immune responses and thereby destroys PCa cells . Increased antibody levels against PAP were noticed in 28.5% of the sipuleucel-T treated patients and in 1.4% of the placebo-treated patients, not correlating with survival  or PAP did not show a survival difference. Increased antibody levels against PA2024 were observed in 66.2% of the sipuleucel-T treated patients and in 2.9% of the placebo-treated patients coinciding with a slight, although not significant, survival benefit  is a glycosylphosphatidylinositol (GPI)-anchored protein expressed on the cell surface of both basal and luminal cells in the normal prostate, but overexpressed by PCa cells , 96. It Its distinct expression pattern and possible function in tumor-progression makes PSCA an interesting target for immunotherapy. It has already been exploited in several studies, with promising results , 103–105To conclude, PSCA has been used as a target for antigen-based immunotherapy in several clinical studies due to its role in tumor growth and metastases. Unfortunately, the study results were less impressive than expected. This might be the reason that to date there is no ongoing clinical trial with PSCA registered.in vitro with MUC-1 peptide displayed a decreased expression of both co-stimulatory molecules and antigen presenting molecules upon activation  to MUC-21 . MUC-1 itivation . Similartivation . The inh vaccine . In a re vaccine . Richman vaccine  . The vaccine consisted of four peptides based on each patient’s immunoreactivity profile. Peptides of a variety of tumor-associated antigens were tested, including PSA, PAP, PSMA, multidrug resistance protein, and a choice of different epithelial tumor antigens. The peptides included in the vaccine were selected on their capacity to induce CTL responses. In the first phase II trial, patients with CRPC were randomized to PPV combined with chemotherapy or chemotherapy only . AntibodThe results of the PPV vaccinations are promising. A randomized trial with an appropriate control group before and after chemotherapeutic treatment is needed to fully identify a clinical benefit of PPV treatment. Currently, a vaccine consisting of 20 peptides is applied to patients with CRPC in an exploratory, randomized, open-label study  with GVAX . More thAn alternative approach for PCa cell lines is the use of PCa cell line-derived RNA or tumor antigen encoding mRNA. Kyte et al. transfected monocyte-derived DCs with mRNA derived from the PCa cell lines LnCAP, DU-145, and PC-3. Although the generation of mRNA-transfected DC is challenging, DC vaccination appeared feasible and safe , 150. Fuper se, and pre-existing immune responses directed against this antigen are common in treatment-naive patients  and the specificity of the antigen facilitates a precise selection of target antigens with the intention of optimizing the translation of immunotherapeutic treatments to the clinic. However, despite significant T-cell responses, tumor progression is seen most frequently in patients treated with cancer immunotherapy. This is due to the complexity of human beings and the complexity of tumors and metastases . The comA correlation of immune parameters with clinical outcome after immunotherapy is not established in patients with PCa. This can be attributed to (i) a limited number of patients per immunotherapeutic approach; (ii) a variation in clinical features of patients with PCa before treatment; and (iii) the difference in clinical signs of tumor control between conventional toxic treatments and immunotherapeutic treatments. This last argument is also one of the hurdles identified by the SITC. Effective immunotherapy does not always display initial shrinkage of the tumor, but rather a pattern of tumor growth and progression followed by shrinkage when the tumor is recognized and destroyed by the immune system –158. ThiNovel monoclonal antibodies targeted against inhibitory receptors on T cells (anti-CTLA-4 and anti-PD-1) are able to prolong their effector functions and prevent immune inhibition. These treatment strategies are tested in combination with other immunotherapeutic approaches and showed promising results in a subset of patients , 160. ThUntil recently, patients with mCRPC had limited treatment options and a poor prognosis. With new sequential hormonal therapies, second-line chemotherapy, and new immunotherapeutic strategies, a new era has started. To date, PCa is one of the few tumor types in which immunotherapy is part of the current standard of care. Augmenting immune responses to PCa antigens is a valid therapeutic approach, and clinical responses with minimal toxic effects are observed.In this review, we focused on commonly expressed tumor-associated antigens. Recently, patient-specific epitopes are identified as highly important to improve T-cell reactivity. Targeting these patient- and cancer-specific mutated epitopes holds promise for even better results and possibly cure of patients. By complete genome and transcriptome, sequencing and mass spectrometry-mutated HLA-binding peptides, so-called neoantigens, might be identified . VaccinaHarm Westdorp, Annette E. Sköld, Berit A. Snijer, Sebastian Franik, Sasja F. Mulder, Pierre P. Major, Ronan Foley, and I. Jolanda M. de Vries declare no disclosures of potential conflicts of interest. Winald R. Gerritsen is a consult for Aglaia Biomedical Ventures, is on the supervisory board for PsytoBe, has received speakers fee from J&J and BMS, and is on the advisory boards for Amgen, BMS, Janssen-Cilag, Sanofi, Astellas, Bayer, and Merck.