High-throughput, image-based screens of cellular responses to genetic or chemical perturbations generate huge numbers of cell images. Automated analysis is required to quantify and compare the effects of these perturbations. However, few of the current freely-available bioimage analysis software tools are optimized for efficient handling of these images. Even fewer of them are designed to transform the phenotypic features measured from these images into discriminative profiles that can reveal biologically meaningful associations among the tested perturbations.cellXpress" to segment cells, measure quantitative features of cellular phenotypes, construct discriminative profiles, and visualize the resulting cell masks and feature values. We have also developed a suite of library functions to load the extracted features for further customizable analysis and visualization under the R computing environment. We systematically compared the processing speed, cell segmentation accuracy, and phenotypic-profile clustering performance of cellXpress to other existing bioimage analysis software packages or algorithms. We found that cellXpress outperforms these existing tools on three different bioimage datasets. We estimate that cellXpress could finish processing a genome-wide gene knockdown image dataset in less than a day on a modern personal desktop computer.We present a fast and user-friendly software platform called "cellXpress platform is designed to make fast and efficient high-throughput phenotypic profiling more accessible to the wider biological research community. The cellXpress installation packages for 64-bit Windows and Linux, user manual, installation guide, and datasets used in this analysis can be downloaded freely from http://www.cellXpress.org.The  High-throughput, image-based phenotypic profiling enables multi-parameter measurements of cellular responses to large-scale genetic or chemical perturbations. These measurements are useful for unraveling complex changes in cellular morphology and protein subcellular localization , and hav4-105) and poses several new and different challenges to the analysis pipeline and user-interface design. First, individual cells need to be identified and quantified from these images within a reasonable time . However, most of the existing free bioimage analysis software tools are developed in high-level programming languages, such as Python or Java, which are slower than C/C++ in executing computational algorithms [However, most of these existing software tools are designed for general 2D, 3D or time-lapse image analyses, such as de-convolution, segmentation, registration, and motion tracking Figure . Few of gorithms ,13. Somegorithms , which agorithms . Very fecellXpress" for high-throughput phenotypic profiling. The platform consists of two main frameworks . These diverse types of features will allow the quantification of complex protein subcellular localization patterns at the single-cell level.Second, to extract diverse types of features, we have developed a new subcellular region detection algorithm that can automatically identify eight different subcellular regions based on the nuclear and cell masks from each segmented cell. These sub-cellular regions include whole-cell, nucleus, nuclear boundary, inner nucleus, peri-nucleus, cytoplasm, cytoplasmic boundary, and inner cytoplasm. The cellXpress data saved in HDF5 files into a R session and construct phenotypic profiles. The resulting data or profiles can then be used for supervised classification, unsupervised clustering, or other types of analysis. We also implemented phenotypic profiling algorithms to condense large numbers of raw features extracted in typical high-throughput studies into more concise and discriminative profiles, such as the support-vector-machine (SVM)-based "drug profiles" (d-profiles) [Third, to perform profile construction or other custom data analyses, we have developed a suite of library functions called "cXlibrary" under the R computing environment . Users crofiles) ,14.cellXpress make it a fast and user-friendly software platform for high-throughput image-based phenotypic profiling.Finally, to make our software user-friendly, we have developed intuitive and interactive graphical user interfaces for configuring and controlling the image processing engine, and visualizing cell segmentation and feature extraction results Figure . We havecellXpress platform. The segmentation algorithm is general and was previously used to identify individual mouse fat cells, human cancer cells, and neutrophil-like cells from fluorescence microscopy images [cellXpress platform.We have implemented and optimized a seeded-watershed-based cell segmentation algorithm  for the y images ,21,22. Iy images , Laplaciy images . Then, ay images  is used cellXpress platform has a flexible feature extraction module that can be used to measure cellular features based on different combinations of feature types, fluorescent markers, and subcellular regions. We have designed a user-friendly graphical interface to configure this feature extraction module -based phenotypic profiling algorithm called "drug profiling" (d-profiling)  in the col cells . Our impol cells .cellXpress, we considered several other alternative free biological image analysis software platforms  [To evaluate the performance of s Figure . The funpro 1.0)  to the Bpro 1.0)  because pro 1.0)  with plupro 1.0)  because cellXpress, we used two standard image benchmark datasets, namely Kc167 and HT29, which represent different cell types and numbers of image frames [Drosophila melanogaster cell line, Kc167. We used the dataset's DNA marker for detecting nuclear regions, and actin marker for detecting cellular regions. This dataset has three image frames (an image frame refers to an imaging position in a well), but we only used one of them for testing cell segmentation speed to mimic the situation when computation cannot be parallelized at the image-frame level. Each image has a resolution of 1000 × 1006 pixels, and there are ~200 cells per frame. The second dataset [To evaluate cell segmentation performance of e frames ,32. The  dataset  was coll dataset . It has  dataset , and usecellXpress, we used an image dataset from a previous high-throughput siRNA screen [To evaluate the phenotypic-profiling performance of A screen ,35 on HeA screen .We used two different segmentation accuracy criteria: the boundary and Rand error indices . The bouwhere i-th and j-th connected pixels within the respective masks. Furthermore, we denote We also used the Rand error index , which mN is the total number of pixels in the segmentation mask M.where cellXpress. Actin and tubulin were used as cell markers and DNA as a nuclear marker for the watershed algorithm. Then, we measured the morphology, intensity, intensity ratio, and pixel-level intensity correlation features for actin and tubulin in the whole cell, nuclear and non-nuclear regions; and for DNA in the nuclear region only. In total, we measured 290 features for every cell .To construct phenotypic profiles for HeLa cells, we first segmented the dataset using To evaluate the performance of these three phenotypic profiling methods, we measured the intra-group and inter-group dissimilarities for the four groups of siRNAs . All image and data files were stored in a local harddrive. For the evaluation of processing speed and segmentation accuracy, we implemented a script in Matlab version R2007b  to compute and compare both the boundary and Rand error indices. For the evaluation of phenotypic profiling, we generated multidimensional scaling (MDS) plots for all the constructed profiles using the MASS  and the cellXpress, CellProfiler [A fast and accurate bioimage analysis software platform is required to process the huge amount of microscopy images generated from high-throughput phenotypic profiling experiments. We compared the processing speed and accuracy of Profiler , and ImaProfiler  in segmeProfiler . For CelProfiler , we usedProfiler . We disaProfiler . For FijProfiler , we implProfiler  and TriaProfiler  implemencellXpress was ~2.3-17.5 times faster than CellProfiler and Fiji  on a personal desktop similar to our test system, while other software tools could take ~2-6 days. The fast processing speed of cellXpress makes it more efficient for analyzing data generated from high-throughput experiments, such as gene-knockdown or small-molecule screens, on modern desktop computers without requiring expensive computer clusters.To evaluate processing speed, we measured the processing time of the whole segmentation process, which includes image loading, processing, and saving. We repeated the measurement five times and computed the mean and standard error of the measurements , but the Rand errors of the three tested tools were not significantly different from each other . Therefore, the faster speed of cellXpress does not come at the cost of segmentation accuracy.To evaluate segmentation accuracy, we compared cell masks obtained automatically from the three software platforms to cell masks obtained from manual segmentation. For the Kc167 dataset, we manually segmented each individual cell based on the actin channel. For the HT29 dataset, we used the manual segmentation masks from the Broad Institute's website . The imar Figure . The boucellXpress to identify functional relationships from large-scale gene knockdown studies, we considered an image dataset from a siRNA screen on HeLa cells stained for DNA, tubulin and actin [n = 5, 10 and 30, and found that d-profiles had the highest average inter-group distance, irrespective of n . Both methods do not remove or penalize non-informative features that show high-variance but similar values in both siRNA-treated and control cells. However, d-profiles are based on SVM hyperplanes that optimally separate between treated and control cells, and thus will give lower weights to these non-informative features. Interestingly, we found that d-profiles could distinguish genes involved in the synthesis machineries of RNAs or proteins -based acceleration, and gene or chemical annotation analysis. The cellXpress software package can be downloaded from http://www.cellXpress.org.The s Figure . The celThe authors declare that they have no competing interests.LHL conceived the software architecture. LHL and DL designed and implemented the software packages. RZT and DL performed the performance comparisons and analyses. GWLT prepared the documentation and website. All authors participated in the writing of the manuscript, and approved the final manuscript.Plate layout for the genes in the RNA synthesis (blue), ribosomal (yellow), actin (red) and tubulin (green) groups.Click here for fileFeature list for the HeLa siRNA dataset.Click here for fileTotal processing time for cell segmentation Click here for file


Low Global Self-Esteem (GSE) is a well-established risk factor for eating disorders. Whilst GSE may be defined as an overall evaluation of oneself, evidence suggests that self-esteem is a multidimensional construct involving the evaluation of specific facets of oneself. It is proposed that a Specific Self-Esteem will have stronger associations with a relevant behaviour than GSE. One example of a Specific Self-Esteem, Body-Specific Self-Esteem (BSSE), involves evaluating oneself in terms of body shape. This study investigated relationships between GSE, BSSE and dietary restraint (DR). It was hypothesised that BSSE would be more closely related to DR than GSE, and that the relationship between GSE and DR would be mediated by BSSE. Male (N=139) and female (N=133) adolescents, participants in the Prevention Across the Spectrum randomized control trial, completed the Rosenberg Self-Esteem Scale, gender-specific Body Dissatisfaction scales and the Restraint subscale of the Dutch Eating Behaviour Questionnaire at baseline. Results show that, for both genders, BSSE was more closely related than GSE to DR. In fact, among girls, there was no significant relationship between GSE and DR. Among boys, BSSE fully mediated the relationship between GSE and DR. Findings suggest that eating disorder prevention programs should prioritise targeting BSSE over GSE.Prevention stream of the 2013 ANZAED Conference.This abstract was presented in the


Attention-deficit/hyperactivity disorder (ADHD) is a common neurobehavioral psychiatric disorder that afflicts children, with a reported prevalence of 2.4% to 19.8% worldwide. Stimulants (methylphenidate [MPH] and amphetamine) are considered first-line ADHD pharmacotherapy. MPH is a catecholamine reuptake inhibitor, whereas amphetamines have additional presynaptic activity. Although MPH and amphetamine can effectively manage ADHD symptoms in most pediatric patients, many still fail to respond optimally to either. After administration, the prodrug stimulant lisdexamfetamine dimesylate (LDX) is converted to l-lysine and therapeutically active d-amphetamine in the blood. The objective of this study was to evaluate the clinical efficacy of LDX in children with ADHD who remained symptomatic  on MPH therapy prior to enrollment in a 4-week placebo-controlled LDX trial, compared with the overall population.In this post hoc analysis of data from a multicenter, randomized, double-blind, forced-dose titration study, we evaluated the clinical efficacy of LDX in children aged 6-12 years with and without prior MPH treatment at screening. ADHD symptoms were assessed using the ADHD-RS-IV scale, Conners' Parent Rating Scale-Revised short form (CPRS-R), and Clinical Global Impressions-Improvement scale, at screening, baseline, and endpoint. ADHD-RS-IV total and CPRS-R ADHD Index scores were summarized as mean (SD). Clinical response for the subgroup analysis was defined as a ≥ 30% reduction from baseline in ADHD-RS-IV score and a CGI-I score of 1 or 2. Dunnett test was used to compare change from baseline in all groups. Number needed to treat to achieve one clinical responder or one symptomatic remitter was calculated as the reciprocal of the difference in their proportions on active treatment and placebo at endpoint.Of 290 randomized participants enrolled, 28 received MPH therapy at screening, of which 26 remained symptomatic (ADHD-RS-IV > 18). ADHD-RS-IV total scores, changes from baseline, clinical responsiveness, and rates of symptomatic remission in this subgroup were comparable to the overall population. The safety and tolerability profiles for LDX were comparable to other stimulants currently available.In this analysis, children with significant clinical ADHD symptoms despite MPH treatment improved during treatment with LDX and experienced similar improvements in their symptoms as the overall study population.NCT00556296ClinicalTrials.gov:  Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) from the American Psychiatric Association ). Mean change in ADHD-RS-IV total score for the overall population was assessed using 2-way analysis of covariance. Dunnett test for multiple mean comparisons with least-squares adjustment was used to compare change from baseline in the 3 active treatment groups versus placebo. NNT to achieve 1 clinical responder or 1 symptomatic remitter was calculated as the reciprocal of the difference in proportions of clinical responders or symptomatic remitters on active treatment and placebo at treatment endpoint.In total, 297 children were enrolled at 40 study sites in the United States, of which 7 children discontinued prior to randomization, and 290 were randomized to receive LDX (n = 218) or placebo (n = 72). Of these, 285 had a postrandomization symptom assessment and were included in the efficacy population. Full demographic data for this population have been previously reported .Of the 290 randomized participants, 28 were receiving MPH treatment at screening and 26 of these were classified as nonremitters on prior MPH at the screening visit, prior to randomization Table . Median Mean (SD) screening, baseline, and endpoint ADHD-RS-IV total scores for nonremitters during prior MPH treatment, nonremitters stratified according to prior MPH dosage received, and overall efficacy population are shown in Figure P = .0063).The mean (SD) change in ADHD-RS-IV total score from baseline with LDX treatment was -24.0 (12.56)  participants receiving LDX and 1 (14.3%) receiving placebo were classified as remitters during the study  treated with LDX and 3 42.9%) treated with placebo, respectively. In the overall efficacy population, 169 (79.3%) treated with LDX and 21 (29.2%) treated with placebo achieved clinical response  morning, afternoon, and evening CPRS-R ADHD index scores at baseline and endpoint in nonremitters on prior MPH are shown in Figure Full safety analyses have been reported previously . In the In this post hoc analysis, LDX showed efficacy when given to children with significant clinical ADHD symptoms despite prior MPH treatment. Efficacy outcomes were similar to the results of the overall population assessed in the clinical trial.Among participants previously treated with MPH, more than half were receiving doses (average daily dose ≥ 1 mg/kg) considered generally effective according to the regimens administered in randomized, controlled trials ,29. ConvDifferential responses to MPH and amphetamine may explain a successful clinical response to LDX in participants who had significant ADHD symptoms despite prior MPH therapy. In 2 separate crossover studies ,32 compaClinical trial design may have contributed to the observed clinical response to LDX treatment in nonremitters on prior MPH. LDX treatment was administered in a forced-dose titration, while prior MPH therapy was provided according to community standards and included potential suboptimal dosing. Use of different definitions of therapeutic response may have altered the rates observed.This post hoc analysis has limitations. The classification of participants as nonremitters on prior MPH considers only the ADHD-RS-IV total score at screening and may not reflect the participants' overall clinical response to MPH. It should be noted that switching from MPH formulations to LDX was done as part of the study protocol and not purely as a clinical practice decision.The 4-week study duration limits the ability to extrapolate the findings to the long-term treatment generally required in managing ADHD. This study was not prospectively designed or powered to detect differences between the treatment groups. A prospective study would be required to confirm these preliminary findings.In this post hoc analysis of children who had significant clinical ADHD symptoms despite previous MPH treatment, LDX demonstrated efficacy and clinical response in the subpopulation assessed. Efficacy outcomes in this population were similar to those in the overall study population.: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision; ECG: electrocardiogram; ER: extended-release; IR: immediate-release; LDX: lisdexamfetamine dimesylate; MAS: mixed amphetamine salts; MPH: methylphenidate; NNT: number-needed-to-treat; OROS: osmotic release oral system; RCT: randomized controlled trial; SR: sustained-release; TEAE: treatment-emergent AEADHD: attention-deficit/hyperactivity disorder; ADHD-RS-IV: ADHD Rating Scale IV; AE: adverse event; BP: blood pressure; CADDRA: Canadian ADHD Resource Alliance; CD: controlled delivery; CGI-S: Clinical Global Impressions-Severity; CGI-I: Clinical Global Impressions-Improvement; CI: confidence interval; CPRS-R: Short Form: Conners' Parent Rating Scale-Revised; dMPH: dexmethylphenidate; DSM-IV-TRDr Jain or Saundra Jain receives or has received grant research support from Abbott, Addrenex, Aspect, Forest, Lilly, and Pfizer; served as a consultant for Addrenex, Impax, Lilly, and Shire; served on a speaker's bureau for Cyberonics, GlaxoSmithKline, Jazz, Pfizer, Shire, and Takeda; received honorarium from Cyberonics, Forest, Jazz, Lilly, Pfizer, Roche, Shire, and Takeda. Dr Babcock is formerly an employee of Shire and holds stock and/or stock options in Shire. Dr Burtea is an employee of Shire Canada Inc. and holds stock and/or stock options in Shire Canada Inc. Dr Dirks is an employee of Shire and holds stock and/or stock options in Johnson & Johnson and Shire. Mr Adeyi is an employee of Shire and holds stock and/or stock options in Shire. Dr Scheckner is an employee of Shire and holds stock and/or stock options in Shire. Dr Lasser is an employee of Shire and holds stock and/or stock options in Shire.RJwas an investigator on the parent study and participated in data acquisition, analysis, interpretation, and presentation. RJ was fully involved in drafting the manuscript and revising the intellectual content of this manuscript. He has given final approval of this version. TBabcockwas the associate director, Scientific Publications, Clinical Development, and Medical Affairs for this study, and made substantial contributions to the analysis and interpretation of the data. He was deeply involved in drafting the manuscript and revising the intellectual content. He has given final approval of this version. TBurteawas the medical director, Global Clinical Development and Medical Affairs for this study and made substantial contributions to the analysis, and interpretation of the data. He was deeply involved in drafting the manuscript and revising the intellectual content. He has given final approval of this version. BDwas the director, Clinical Development and Medical Affairs for this study, and made substantial contributions to the analysis and interpretation of the data. He was deeply involved in drafting the manuscript and revising the intellectual content. He has given final approval of this version. BAwas a statistician involved in all post hoc data analysis, interpretation, and presentation. Statistician BA was fully involved in drafting and revising the intellectual content of this manuscript. Statistician BA has given final approval to this version. BSwas the associate director, Scientific Publications, Clinical Development, and Medical Affairs for this study, and made substantial contributions to the analysis and interpretation of the data. He was deeply involved in drafting the manuscript and revising the intellectual content. He has given final approval of this version. RLwas the senior director, Clinical Development and Medical Affairs for this study, and made substantial contributions to the analysis and interpretation of the data. He was deeply involved in drafting the manuscript and revising the intellectual content. He has given final approval of this version.


Unit non-response occurs in sample surveys when a target subject does not respond to a survey. Potential implications are decreased power, increased standard error, and non-response bias. The objective of this study was to assess the factors associated with participation in a written survey (MSHS) of subjects who had previously participated in the Swiss Health Survey (SHS) and to evaluate to what extent non-participation could impact the estimation of various MSHS health outcomes.Multivariate logistic regression was used to assess the factors associated with MSHS participation  by eligible SHS participants . Crude participation rates and the adjusted odds ratios of participation (OR) were reported. In order to report potential bias in MSHS outcomes, the average age-standardized and sex-specific outcome values in non-participants were predicted based on several different linear regression models which had been previously fitted on MSHS participants.Adjusting for all other variables, women (OR=1.63) as compared with men, subjects with a secondary (OR=1.48) or tertiary education (OR=1.76) as compared with those with primary education, white-collar workers  as compared with unskilled manual workers, Swiss nationals (OR=1.60) as compared to non-Swiss, and subjects with very good or good self-rated health (OR=1.35) were more likely to participate in the MSHS. People who work full-time were less likely to participate than those without paid work (OR=0.76). There were no statistically significant differences in the likelihood of participation between rural and urban areas, different geographic regions of Switzerland and household income quartiles.Except for myocardial infarction, all age-standardized and sex-specific average outcomes  were significantly different between MSHS non-participants and participants.Subjects who participated in the MSHS had a higher socio-economic status, reported a better subjective health, and were more likely to be Swiss nationals. Small to moderate bias was found for most age-adjusted and sex-specific average outcomes. Consequently, these MSHS outcomes should be used and interpreted with care. Unit non-response occurs in sample surveys when a target subject does not respond to a survey. Potential implications of unit non-response are decreased power due to reduced sample size, increased standard error due to random error, and non-response bias due to systematic error because the calculation of estimates is generally based on those who responded to the survey. Consequently, the handling of unit non-response -7, the dThe study is a methodologically-focused secondary analysis of a population-based, cross-sectional health survey carried out in 2007 in Switzerland.′730) could not be contacted after numerous contact attempts, and 20.6% (n=5’825) refused to participate in the SHS. Of the latter, 445 subjects refused to participate due to language problems .The Swiss Health Survey carried out by the Swiss Federal Statistical Office (SFSO) is a nationwide survey on health status, health service utilization, and health-related behavior in Switzerland. The SHS was first conducted in 1992 and is repeated every five years. In 2007, a multistage probability sample was drawn of the entire Swiss population after stratification by geographic region. The initial sample  included subjects aged 15 years or older living in private households. The sampling frame excluded people living in institutions, i.e. hospitals, homes for the elderly, prisons, monasteries, barracks, etc. Furthermore, only subjects fluent in German, French or Italian were included. The response rate of those in the initial sample was 66.2% (n=18’760); 13.2%  were conducted for subjects aged 15–74 years . Subjects aged 75 years or older were given the choice between a CATI or a face to face interview. For those opting for face to face interviews, computer-aided personal interviews (CAPI) were conducted (n=75). Finally, CATI were conducted with proxy persons , that is close friends or relatives of the target subject were interviewed if the target subject could not be interviewed because of old-age, illness, handicap, language problems or due to absence from home for more than 4 weeks. At the end of the forty-minute interview, CATI and CAPI participants  were invited to complete and return an additional written survey (MSHS). PROXY participants were not eligible to participate in the MSHS. Of those eligible to participate, 97.7% (n=17’511) consented to return the MSHS and the questionnaires were sent out to those willing to participate in the next 2–3 days following the SHS interview. The mail-back questionnaire which included questions on mental stress, mental illness, chronic diseases, vaccination status, social support, health literacy, health insurance coverage etc., was returned by 80.3%  of the 17,931 CATI & CAPI interviewees. Subjects who did not return the questionnaire were not re-contacted.In order to prevent the loss of information and to prevent potential bias due to selective refusal to provide answers, item non-response was addressed by the statistical technique of multiple imputations (MI) and multivariate normal regression was used as the imputation method to estimate missing values -38. In c2), gender, the interaction between age and gender, socio-economic status , nationality, religious denomination, urbanity, geographic region, self-reported health and the number of contact attempts needed until the CATI or CAPI could be realized. Age was measured in years (whole-numbers), contact attempts were also represented in continuous whole-numbers. The remaining covariates comprised two or more categories: gender , educational level , occupational status , employment , income , nationality , religious denomination . Urbanity comprised two categories: rural area and urban area. Urban areas included isolated cities  and urban agglomerations ; all other areas were assigned to the category rural area. Geographic region comprised the seven greater regions of Switzerland . Self-reported health comprised two categories .Multivariate logistic regression was used to assess the factors associated with MSHS participation. Crude participation rates and the adjusted odds ratios of participation were reported. The latter were adjusted for age  were selected and the average outcome values in non-participants were predicted based on several different linear regression models which had been previously fitted on MSHS participants. From the 14 chronic diseases covered by the MSHS, 5 chronic diseases were selected based on the frequency of item non-response, i.e. outcomes with fewer missing values were preferred. The 5 disease related outcomes comprised the lifetime prevalence of arthrosis, osteoporosis, high blood pressure, myocardial infarction, and depression. Only 2 outcomes related to prevention were covered by the MSHS: contraception and influenza vaccination. The 12 month prevalence of influenza vaccination was selected because of its relevance in the contemporary Swiss public health debate, i.e. Switzerland faces a new law on mandatory vaccination. Finally, mastery and sense of coherence, the two psycho-social resources covered by the MSHS were selected because of their relevance when coping with stressful life events such as diseases . While t2). Finally, the existence of an acute major depression according to DSM-IV criteria  as a covariate. BMI calculation was based on self-reported height and weight (BMI=kg/m CIDI-SF ) was add2 (OR=0.99), age (OR=1.06), and the interaction between age and gender (OR=0.99) were all significantly associated (p<0.001) with MSHS participation. People with a secondary (OR=1.48) or tertiary education (OR=1.76) as compared with people with primary education were more likely to participate in the MSHS as were white-collar workers  as compared with unskilled manual workers. People who work full-time were less likely to participate than those without paid work (OR=0.76), and Swiss nationals were more likely to participate than were non-Swiss nationals (OR=1.60). Compared with people who had no religious affiliation, members of the Christian Catholic Church (OR=0.66), the Orthodox Church (OR=0.49), Muslim religious communities (OR=0.36) or the residual category other religious community (OR=0.52) were less likely to participate in the MSHS. Members of the remaining religious denominations, most notably members of the large Swiss State Churches (Protestant and Roman Catholic Church), did not differ from people without religious affiliation. People with better self-rated health (OR=1.35) were also more likely to complete and return the MSHS as compared with people who rated their health as moderate, bad or very bad.Overall, more than 80% of the subjects who completed the SHS CATI or SHS CAPI also completed and returned the MSHS Table . ParticiFinally, no statistically significant differences in the likelihood of participation were observed between rural and urban areas, different geographic regions of Switzerland and household income quartiles.In order to assess potential bias in MSHS outcome variables, outcomes of non-participants were estimated based on different linear regression models which had been previously fitted on MSHS participants. Table Crude predicted values for the MSHS non-participants Table  were higMore than 80% of eligible SHS participants were willing to complete and return the additional mail-back questionnaire.Subjects who participated in the mail survey had a higher socio-economic status , reported a better subjective health and were more likely to be Swiss nationals. Generally, these finding are in accordance with previous studies that investigated initial non-response ,19-28. USubjects without paid work and subjects who worked part-time were more likely to participate in the MSHS than those who worked full-time . Although this finding is not in accordance with previous evidence , one plaReligious affiliation was also found to be associated with MSHS non-response. Especially subjects who were members of relatively small religious denominations were less likely to return the mail-back questionnaire while the response rates of members of the large Swiss State Churches  and subjects with no religious affiliation did not significantly differ from each other. These finding are in partial agreement with one previous study of second-stage non-response which observed that Muslims had lower response rates than members of other religious denominations .MSHS response rates were not different between rural and urban areas and between different geographic regions. Previous evidence is mixed: some studies observed that response rates are higher in rural areas ,45,46, oFinally, numerous previous studies report that females are more likely to participate in surveys ,28,45,48In a second step, the current study attempted to quantify the magnitude of the bias due to selective non-response by estimating population average values of eight major MSHS outcome variables. Although overall non-participation rates were relatively low, non-participation was clearly associated with socio-economic status, non-Swiss nationality, and health status. Hence bias is potentially induced by the under-representation of non-Swiss nationals and lower socio-economic strata. Bias could be demonstrated for all crude average outcomes, except for the lifetime prevalence of osteoporosis and myocardial infarction. Furthermore, bias could also be shown for all age-standardized and sex-specific average outcomes, except for myocardial infarction. The predicted age-standardized average mastery and SOC scores of male and female MSHS non-respondents were below the respective values for respondents while the predicted lifetime prevalence of depression was higher in non-respondents. These results support the notion that bias is potentially induced by the under-representation of lower socio-economic strata: earlier studies find that lower mastery and SOC scores are associated with lower socio-economic status ,50 and hBias was also observed for age-standardized and sex-specific average lifetime prevalence of high blood pressure, arthrosis, and osteoporosis. However, the predicted prevalence rates for female non-participants were above those for female MSHS participants while the predicted prevalence rates for male non-participants were below those for male participants. This may be due to a gender-specific self-selection mechanism: subjects with high socio-economic status  were much more common in male than in female non-participants.Although bias could be demonstrated for several MSHS outcomes, the magnitude of the bias is at most moderate, i.e. the differences between age-standardized and sex-specific average prevalence rates of MSHS respondents and predicted prevalence rates of non-respondents are below 2% and the respective differences in average mastery and SOC scores cannot be considered substantial. Yet, the SHS response rate amounted to little more than 66% which suggests that SHS participants may be a selective sample of the general population of Switzerland. Moreover, the SHS sampling frame excluded subjects living in institutions and included only subjects fluent in German, French or Italian. Were these subjects part of the SHS, their non-participation may further increase bias because they may have high MSHS non-response rates and poorer health.The current study has important limitations. Firstly, prevalence calculations for non-respondents are based on parameter estimates for respondents. This implies that the selected prevalence models for respondents also yield valid results for non-respondents. However, given the various documented differences between respondents and non-respondents, this may not necessarily be the case. That is, the use of models suited for respondents may be a potential source of bias when used to estimate the prevalence rates for non-respondents. Secondly, systematic data on initial non-response in the SHS were unavailable. Hence, the discussion on initial and MSHS second-stage non-response had to be based on previous evidence on initial HIS non-response and the available population data.Subjects who participated in the MSHS had a higher socio-economic status , reported a better subjective health and were more likely to be Swiss nationals. Small to moderate bias was found for most age-adjusted and sex-specific average outcomes, i.e. the prevalence of depression, arthrosis, osteoporosis, high blood pressure, and influenza vaccination as well as the Pearlin mastery and sense of coherence scores. Consequently, these MSHS outcomes should be used and interpreted with care. Further waves of the SHS/MSHS should especially improve participation of non-Swiss and subjects with low socio-economic status. Furthermore, the SHS should include variables that facilitate a more rigorous investigation of initial non-response and thus facilitate a better understanding of non-response bias.The author declares that he has no competing interests.TV contributed all of the writing and the analysis.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2458/13/167/prepub


There has been a great interest in application of nanoparticles as biomaterials for delivery of therapeutic molecules such as drugs and genes, and for tissue engineering. In particular, biopolymers are suitable materials as nanoparticles for clinical application due to their versatile traits, including biocompatibility, biodegradability and low immunogenicity. Biopolymers are polymers that are produced from living organisms, which are classified in three groups: polysaccharides, proteins and nucleic acids. It is important to control particle size, charge, morphology of surface and release rate of loaded molecules to use biopolymer-based nanoparticles as drug/gene delivery carriers. To obtain a nano-carrier for therapeutic purposes, a variety of materials and preparation process has been attempted. This review focuses on fabrication of biocompatible nanoparticles consisting of biopolymers such as protein , protein-mimicked polypeptides and polysaccharides . The effects of the nature of the materials and the fabrication process on the characteristics of the nanoparticles are described. In addition, their application as delivery carriers of therapeutic drugs and genes and biomaterials for tissue engineering are also reviewed. Nanotechnology has been attending much attention since 1980s and has been adapted into many engineering fields such as electronics, mechanical, biomedical and space engineering. In particular, nanotechnology has led to the significant progress in a biomedical field such as controlled drug/gene delivery , tissue The reasons that nanoparticles have been used in therapeutic application are the fact that nanoparticles exist in the same size domain as proteins. Their large surface areas can also allow for displaying a large number of surface functional groups such as ligands. Furthermore, they have a rapid absorption and release behavior provided by high abilities of their diffusion and volume change. In addition, the particle sizes and surface characteristics of nanoparticles can be tailored or controlled. Examples of surface modification of nanoparticles are covalent binding between surface and functional molecules or polymers and layer-by-layer assembly . While oGenerally, the well-defined structure of synthetic polymers exhibit well-defined and fine-tunable degradation kinetic as well as mechanical properties . In compIn recent years, a number of polymeric drug/gene-loaded nanoparticles have been developed as drug delivery carriers and their mechanism of circulation in human bodies has been extensively investigated ,22. WhenThere also needs to be toxicology on the particles since they contain various interactions of nanoparticles with fluids, cells, and tissues need to be considered, starting at the portal of entry and then via a range of possible pathways towards target organs . At the Gene therapy has been applied in many different diseases such as cancer, AIDS, and cardiovascular diseases, and is based on the concept that human disease may be treated by the transfer of genetic materials into specific cells of a patient to supply defective genes responsible for disease development . To tranNitric oxide (NO)-releasing materials has also emerged as potential therapeutics that exploit NO’s vast biological roles. Nitric oxide is known to be involved in wound healing and to have antimicrobial actions . Thus, sTissue engineering can be considered as a special case of drug delivery where the goal is to accomplish controlled delivery of cells. Controlled release of therapeutic factors enhances the efficacy of tissue engineering. The biological functions of encapsulated drugs and cells can be dramatically enhanced by designing biomaterials with controlled organizations at the nanometer scale . The incProteins are naturally-derived polymers that are advantageous in their biodegradability, low toxicity, nonantigenicity, high nutritional value, high stability and binding capacity of various drugs such as paclitaxel and ibuprofen –44. Inteetc.Preparation of nanoparticles from proteins enables to obtain precisely formed nanoparticles since the molecular sizes of proteins are determined by their secondary structures. A variety of proteins such as silk ,56, albuSilk proteins are promising materials as biomaterials due to their slow biodegradability, biocompatibility, self-assembling property, excellent mechanical property (tensile strength and Young’s modulus) and controllable structure and morphology ,61. SilkBombyx mori and tropical tasar silkworm Antheraea mylitta ,10099,10The preparation of uniformly sized albumin particles has been reported since 1970s. Coaservation , controlCore-shell nanoparticles were prepared from ovalbumin and lysozyme using thermal gelation method . Thermalin vivo fluorescent image. Paclitaxel-albumin nanoparticles carrying the homing peptides were also prepared by self-assembly. These nanoparticles were designed to target extravascular tumors, showing that nanoparticles can be effectively targeted into extravascular tumor tissue and that targeting can enhance the activity of a therapeutic nanoparticle [Self-assembly of albumin to form nanoparticles can be achieved by the addition of lipophilic drugs and diminishment of primary amino groups on protein surfaces . The disparticle .m, where Xaa is the hydrophobic domain that facilitate both self-aggregation and elastomeric functions. Thus, ELP has a unique phase behavior, which promotes recombinant expression, protein purification and self-assembly of nanostructures. Considering that polymer composition, chain length and concentration, solvent composition, and solution temperature are the driving forces for the self-assembly of ELP, the synthesis of ELP via “recursive directional ligation” (RDL) is suitable to manipulate the precise architecture of ELP [A number of protein-mimicked polypeptide-based nanoparticles has been designed and synthesized to make the most of the unique features of proteins. These molecules have a well-defined composition, monodisperse molecular weight and potential biocompatibility ,114,115.e of ELP ,118.Nanoparticles were produced by self-assembly of ELP with a sequence of VPAVG and showed a sustained release of loaded dexamethasone phosphate for about 30 days . The parl-glutamic acid)-b-poly(l-lysine) (PGA-b-PLys). This block copolymer self-assembled into schizophrenic vesicles that can reversibly be produced in moderate acidic or basic aqueous solutions. The pH-dependent vesicle formation was due to the rod-like conformation of polypeptides in the hydrophobic area of the membrane [Similarly to ELP, silk-elastin-like protein (SELP) polymeric nanoparticles have unique physical and biological properties corresponded from both silk and elastin. Thus, they have been widely used in drug delivery and tissue engineering fields. They are usually formed by two steps; (1) formation of micellar-like particles with the silk blocks as the core structure by hydrogen bonding, (2) the hydrophobic interaction between elastin blocks above a specific transition temperature, which leads to the ordered association of SELPs molecules . Other pmembrane .Polysaccharides are long carbohydrate molecules of repeated monosaccharide units joined together by glycosidic bonds. Chitosan, alginate, heparin, hyaluronic acid, pullulan and dextran are examples of polysaccharides ,123–126.N-acetyl-d-glucosamine and d-glucosamine linked by beta-(1–4)glycosidic bonds, and is obtained by the partial deacetylation of naturally derived chitin. Chitosan is hydrophilic and soluble in acidic solution by protonation of the amine groups, and is degraded by enzymes such as lysozymes, some lipases and proteases. Chitosan increases cell membrane permeability, thus, can act as an absorption enhancer across intestinal epithelia prolonging the residence time of delivery systems at absorption sites, and has the ability to open the tight junctions of cell membranes [The most commonly used polysaccharide for nanoparticle fabrication is chitosan. Chitosan is a linear cationic heteropolymer of embranes . Chitosaembranes .Chitosan nanoparticles have also been used as carriers of growth factors such as epidermal growth factor and fibroblast growth factor, which could ultimately be impregnated into engineered tissue construct. Growth factors are essential in cellular signaling for migration, proliferation, differentiation and maturation .d-mannuronic acid (M) and α-l-guluronic acid (G) residues. Alginate has some advantages in its high mucoadhesiveness, aqueous solubility, and a tendency for gelation in proper condition, biocompatibility and non-toxicity [Alginate is another example of polysaccharides that are often used for nanoparticle production. Alginate is a linear anionic polysaccharide composed of alternating blocks of 1,4-linked β-toxicity ,107,132.toxicity ,133–135.toxicity ,134,135.In vivo studies on female albino mice demonstrated maximum uptake of the drug by mammary tissue after 24 h administration with drug loaded guar gum nanoparticles, indicating their utilization for breast cancer treatments [Preparation of polysaccharide nanoparticles by crosslinking can be achieved by either ionic crosslinking  or covalent crosslinking . Covalently crosslinked polysaccharide nanoparticles enable the network structure to be permanent since irreversible chemical links are formed unless biodegradable or stimuli-responsive crosslinkers are employed. The rigid network allows absorption of water and bioactive compounds without dissolution of the nanoparticles even when the pH drastically changes . Chemicaeatments .i.e., cornea and conjunctiva) during at least 48 h with maintaining negligible or undetectable CyA levels in inner ocular structures, blood and plasma [64−, Fe(CN)63− citrate and calcium ions as crosslinkers [Physical crosslinking of polysaccharides is based on ionic interactions between charged polysaccharides and ionic crosslinkers. This method gives nanoparticles with reversibility and is considered biocompatible due to the lack of harsh preparation condition or toxic crosslinkers. Ionically-crosslinked nanoparticles are generally pH sensitive, which is a suitable feature for stimuli-sensitive controlled release. Tripolyphosphate (TPP), a non-toxic anionic molecule, has been widely used for the preparation of crosslinked chitosan nanoparticles, and a number of drugs have been encapsulated within these nanoparticles . TPP crod plasma . Anotherslinkers . For exaslinkers .w/w) and transfection levels up to 25% GFP expressing HEK 293 cells [Polysaccharide nanoparticles are also prepared by direct electrostatic interactions of oppositely charged polysaccharides in solution. The stability of polyion-complex are determined by the degree of interaction between the polyelectrolytes, which is affected by the charge density and distribution, chemical environment such as pH of the solution, ionic strength, the temperature and the molecular weight of the polyelectrolytes and their flexibility. Chitosan is the most commonly used cationic polysaccharide for polyion-complex, whereas carboxymethyl cellulose (CMC) ,147, dex93 cells . Chitosa93 cells . Chitosa93 cells . Chitosa93 cells .4 and sodium tripolyphosphate [in vitro and in vivo studies showed that these nanoparticles could effectively infiltrate into the mucosal cell membrane and enhance hypoglycemic action by oral administration of insulin-loaded nanoparticles.Not only polysaccharides, anionic polypeptides are also used for polyelectrolyte complexation with chitosan. PH-sensitive polyion complexes (average particle size <200 nm) were formed from trimethyl chitosan and α-galactosidase A through self-assembly. These nanoparticles were able to release the enzyme at acidic pH and were efficiently internalized by human endothelial cells and mostly accumulated in lysosomal compartments . γ-Poly-block-hyaluronan were produced by self-assembly. These particles could be used as a self-targeting drug delivery cargo in over-expressed CD44 glycoprotein cells of breast cancer [Dextran-based self-assembled nanoparticles are another candidate for drug/gene delivery carriers. Dextran was chemically modified by grafting bile acids, natural product consisting of a facially amphiphilic steroid nucleus with a hydrophobic β-side and a hydrophilic α-side, or lauryl chains . Mannoset cancer .in vitro and in vivo [in vitro against HCT116 human colon carcinoma cells, and reduction of tumor growth in vivo using HCT116 human colon carcinoma-bearing mice.Nonionic pullulan is also modified by hydrophobic molecules such as cholesterol and cancer drugs. The cholesterol-bearing pullulans with different molecular weights and degree of substitution have been synthesized to form self-assembled nanoparticles . Monodis in vivo . These nStarch-based nanoparticles have also been reported by several groups. Starch is the second most abundant biomass material in nature, found in plant roots, stalks, crop seeds. It consists of two main structural components, the amylose and amylopection ,171. Prol-aspartate) (HP) amphiphilic copolymer was proposed for targeted delivery of the antineoplastic drug paclitaxel. The presence of folate not only enhanced intracellular uptake via endocytosis, but also these nanoparticles exhibited a great cytotoxicity in KB cells [Heparin, a negatively-charged polysaccharide that used as an anticoagulant, is often applied for the preparation of self-assembled nanoparticles. A self-assembled nanoparticulate system (140–190 nm) composed of a folate-conjugated heparin-poly(β-benzyl-KB cells . DeoxychKB cells .Recent progresses in synthesis of biopolymer-based nanoparticles and their application as drug/gene carriers are introduced in this review. Biopolymers possess several favorable characteristics in comparison to synthetic polymers used in drug/gene delivery, such as biocompatibility, biodegradability and abundant renewable sources. Considering that size and distribution of particles are critical parameters to target specific organs and tissues, proteins are suitable materials for drug/gene carriers due to their precise molecular sizes derived from their secondary structure. Moreover, the features of proteins that tend to form self-assembled α-helix, β-sheet or random structures enable them to easily form unique nanostructures such as nanoparticles, nanofibers and nanosheets. To produce protein-based nanoparticles with ideal size, morphology and stability, several methods have been demonstrated, including crosslinking using crosslinkers, emulsion formation, coacervation and precipitation. Polysaccharides also offer a suitable platform to produce nanoparticles due to their biodegradability, biocompatibility and ease in molecular modification both covalently and ionically. Formation of nanoparticles from polysaccharides is achieved by ionic or covalent crosslinking, ion-complex and self-assembly after grafting of hydrophobic segments to the polymer backbone. In this regard, the choice of the most suitable technique for nanoparticle production depends on the nature of the materials such as charges and polymer chain lengths. Introduction of ligands onto the surface of the nanoparticles to target specific sites will further enable biopolymer nanoparticles to be used more often in clinical application. Not only protein- or polysaccharide-based nanoparticles, but also nanoparticles based on biopolymer-synthetic polymer conjugates have been also paid much attention. Such multi-functional biopolymer-based and biopolymer-synthetic polymer conjugated nanoparticles will become candidates of the precisely targeted delivery of drugs and genes in many therapeutic fields.


Klebsiella pneumoniae (ESBL-Kp) HD access-related bacteremia remain unclear, we conducted this retrospective study to determine the clinical outcomes of patients treated with either flomoxef or a carbapenem.Hemodialysis (HD) patients are susceptible to extended spectrum beta-lactamase (ESBL)-producing bacterial infections. Because the optimal treatment and clinical significance of ESBL-producing The eligibility criterion was fistula or graft- or catheter- related ESBL-Kp bacteremia in patients on maintenance HD. The clinical characteristics and antibiotic management were analyzed. Outcome was determined by mortality resulting from bacteremia during the 14‐day period after the first positive blood culture for flomoxef-susceptible ESBL-Kp.The 57 patients studied were predominantly elderly, malnourished, with a history of severe illnesses and broad-spectrum antibiotic use before the onset of bacteremia, and with severe septicemia as determined by the Pitt bacteremia score (PBS). The study population comprised 7 fistula, 8 graft, and 42 HD catheter-related bacteremia (CRB) cases, and the mortality rate was high  in these 57 patients. Of 42 patients with CRB, those in the deceased group  had significantly lower levels of serum albumin, longer prior hospital stay and duration of catheter-dependent HD, and higher PBS than patients in the survived group. Failure to receive effective antibiotics (flomoxef or a carbapenem) within 5 days after onset of bacteremia and treatment with flomoxef both significantly contributed to higher mortality. Multivariate analyses revealed that flomoxef use, PBS, and catheter-dependent HD >30 days were independently associated with increased mortality .Considering the high mortality rate, ESBL-Kp should be recognized as a possible pathogen in patients on maintenance HD at high risk of acquiring HD access infections associated with ESBL-producing bacteria. Carbapenems rather than flomoxef should be the therapy of choice in these critically vulnerable patients. Hemodialysis (HD) access-related infections are a major cause of morbidity and mortality in HD patients; the responsible microorganisms, prevention and treatment strategies, and outcome have been assessed in earlier studies,2. Gram-Risk factors for the acquisition of ESBL infections have been well studied and include—but are not limited to—HD, old age, prolonged hospitalization, severe illness, poor nutritional status, treatment in an intensive care unit (ICU), and previous exposure to broad-spectrum antibiotics, with overuse of extended-spectrum cephalosporins in the hospital setting as one of the most important factors,4. In ad5–106 cfu/mL) and high inocula (107–108 cfu/mL) of TEM- or SHV-producing Enterobacteriaceae[The currently recommended therapy for infection caused by ESBL-producing organisms consists of carbapenems,5. CephaKlebsiella pneumoniae (K. pneumoniae) infections are associated with hospitalization, and ESBL-producing bacteria are reported to comprise a significant percentage of nosocomial K. pneumoniae strains[K. pneumoniae (ESBL-Kp) bacteremia was reported to be similarly effective[The vast majority of  strains. In a reffective. However. MHD patients admitted during the 7-year period from January 2001 to December 2007 who developed a nosocomial HD access-related infection secondary to ESBL-Kp were included. The eligibility criterion was HD access, including arteriovenous fistula or graft- or catheter-related ESBL-Kp bacteremia. Only adult patients with flomoxef-susceptible ESBL-Kp bacteremia who were treated with either flomoxef or a carbapenem (meropenem or imipenem) were included. For each included patient, the prescribed flomoxef or a carbapenem was administered for at least 2 days, starting within 5 days after receiving finalized blood culture results. The use of either flomoxef or a carbapenem was left to the discretion of the attending physician in each case. Details of the patients’ clinical course, biochemical data, sites of ESBL-Kp infection , and outcome were obtained from medical charts. Individual patient without blood culture that grew ESBL-Kp was excluded because, in the absence of concurrent blood cultures from the peripheral vein, there is a risk of enrolling patients simply representing colonization. Severely ill patients who died rapidly without receiving a carbapenem or flomoxef for at least two days were also excluded. Variables used for the assessment of severity of illness included Pitt bacteremia score (PBS), ICU stay at the time of bacteremia, and length of prior hospital stay (LOS). Mortality resulting from bacteremia within 14 days after the first positive blood culture that grew flomoxef-susceptible ESBL-Kp was used to determine the outcome.This retrospective study was conducted in a tertiary care hospital with 950 MHD patients treated in the outpatient departmentThe study was approved by the institutional review board of Kaohsiung Chang Gung Memorial Hospital with the study ID: CGMH-IRB-100-2452B.K. pneumoniae isolates were identified by standard methods, and the presence of ESBLs was evaluated using the Clinical and Laboratory Standards Institute criteria for ESBL screening and disc confirmation test[All ion test. Minimumion test,12.ESBL-Kp bacteremia was defined by the isolation of ESBL-Kp from blood cultures. Nosocomial bacteremia was defined as bacteremia occurring >48 h after admission to the hospital. HD access infections were defined as local signs (pus or redness) at the vascular access site with or without a positive culture of catheter tip, pus, or a positive blood culture with no known source other than the vascular access. Empiric antibiotic was defined as antibiotic therapy started at the time blood cultures were drawn. Effective antibiotics for flomoxef-susceptible ESBL-Kp bacteremia included carbapenems and flomoxef. Significant underlying disease was defined as a medical history of diabetes mellitus, liver cirrhosis, malignancy, and congestive heart failure.t test. The statistical difference in the frequency of occurrence of the variants in patients with HD catheter-related bacteremia between survived and deceased subgroups was assessed by the chi-square test or Fisher’s exact test. A logistic regression model was used to estimate the effects of multiple factors associated with mortality in the univariate analyses. Variables with P ≤ 0.1 in univariate analysis between patients of deceased and survived groups were entered for further assessment. Estimated ORs and 95% CI were obtained from this model. For all analyses, two-sided tests of significance were used with P < 0.05 considered significant.All statistical analyses were performed using the Statistical Package for Social Science program . Continuous variables were each expressed as the mean ± SD and were analyzed using the Student A total of 57 MHD patients with HD access-related bacteremia who met the criteria were identified during the study period. The clinical courses and characteristics of these patients are summarized in TableIn addition to antibiotic treatment, surgical interventions  were performed in 7 of 15 patients with fistula or graft infection. All HD catheters related to ESBL-Kp bacteremia in 42 patients were removed after the onset of bacteremia. The extent and perioperative risk of surgery may affect survival of patients with fistula or graft infection but their effects were difficult to estimate. We believe bias and confounding factors could be reduced if we only analyzed 42 patients, all with catheter-related bacteremia.Most of the 42 patients with HD CRB were elderly, exhibited low levels of serum albumin and hemoglobin at the onset of bacteremia, and had a history of prolonged hospitalization. Patient demographics are summarized in TableVariables that were determined to be significantly associated with mortality at 14 days after the first positive blood culture result by univariate analysis were subjected to multivariate analysis. Flomoxef use, higher PBS, and catheter-dependent HD > 30 days were independently associated with increased mortality .There is limited information regarding the clinical characteristics associated with HD access-related ESBL-Kp bacteremia in MHD patients. Most of the patients with bacteremia in the present study were elderly, malnourished, and had a history of severe illness and prolonged hospitalization. These patients were also critically ill, as determined by PBS, and had high prevalence rates of significant underlying diseases and ICU stay at the time of the onset of bacteremia; therefore, they had a high mortality rate. Although broad-spectrum antibiotic treatment prior to the onset of bacteremia was also highly prevalent, its contribution to the acquisition of ESBL infection and effect on patient outcome were not analyzed; this might contribute to an epidemiological bias. Only 36.8% of these critically ill patients received empiric effective antibiotics within 5 days after the first positive blood culture for ESBL-Kp, which may have contributed to the high mortality rate.Previous studies have demonstrated vascular access accounts for 48–73% of bacteremia in HD patients. In the For ESBL infections, there are both a higher clinical failure rate and mortAcinetobacter baumanii[Pseudomonas aeruginosa[Stenotrophomonas maltophilia[5 or 107 cfu/mL[Although carbapenems have been recommended for the treatment of infections caused by ESBL-producing organisms, extensive use of these antibiotics may result in the outbreak of infections related to carbapenem-resistant strains such as  baumanii, Pseudomeruginosa, and Steltophilia, and it ltophilia,21. Flom7 cfu/mL. AlthougThe use of effective antibiotics such as carbapenems during the 5-day period after the onset of bacteremia due to an ESBL-producing organism has been reported to be associated with lower mortality. In the This is the first study to report the clinical implications of nosocomial HD access-related ESBL-Kp bacteremia. We stress that ESBL-Kp should be considered as a possible pathogen in HD access-related infections. Because of the high antimicrobial resistance and high mortality rate in these more vulnerable and critically ill patients, we suggest carbapenems rather than flomoxef as the first choice for empiric or directed therapy in HD patients at high risk for HD access-related ESBL-Kp infections. Shortening the duration of catheter-dependent HD also improved the outcome.The authors declare that they have no competing interests.CCY was responsible for the literature search, study design, data collection, data analysis, data interpretation, and writing the manuscript. SHL contributed to the literature search, data collection, statistical analysis and data interpretation. FRC contributed to the literature search and data collection. CHC contributed to the literature search and data collection. CHL contributed to the literature search and data collection. JBC contributed to the literature search and data collection. CHW was responsible for the literature search, study design, data collection, data analysis, data interpretation, and article revision. CTL was responsible for the literature search, study design, data collection, data analysis, data interpretation, and article revision. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2334/12/206/prepub


To evaluate the influence of food habits, specifically adherence to the Mediterranean diet, on carotid intima-media thickness (CIMT) and the presence of plaques in HIV-infected patients taking antiretroviral therapy (ART) and non-HIV-infected participants and to determine if HIV infection contributes independently to subclinical atherosclerosis.We conducted a cross-sectional study of 110 HIV-infected patients on ART and 131 non-HIV-infected participants at the University Hospital for Infectious Diseases in Zagreb, Croatia, from 2009-2011. CIMT measurement and determination of carotid plaque presence was detected by ultrasound. Adherence to the Mediterranean diet was assessed by a 14-point food-item questionnaire. Subclinical atherosclerosis was defined by CIMT≥0.9 mm or ≥1 carotid plaque.P < 0.001; Mann-Whitney test), higher body mass index , hypertension , and a lower Mediterranean diet score , and in non-HIV-infected participants with older age  and hypertension . Multivariate analysis showed that decreased adherence to the Mediterranean diet was associated with higher odds of subclinical atherosclerosis  as was current smoking , hypertension , and male sex . There was a significant interaction of age and HIV status, suggesting that older HIV-infected patients had higher odds of subclinical atherosclerosis than controls .In HIV-infected patients, subclinical atherosclerosis was associated with older age (We confirmed the association between lower adherence to the Mediterranean diet and increased risk of subclinical atherosclerosis and found that treated HIV infection was a risk factor for subclinical atherosclerosis in older individuals. The advent of antiretroviral therapy (ART) for treatment of human immunodeficiency virus (HIV) infection has improved the quality of life and life expectancy of HIV-infected patients ,2. HowevThe impact of HIV infection and exposure to ART on development of subclinical atherosclerosis is incompletely understood ,5. SeverAn early marker of atherosclerosis is an increase in carotid intima-media thickness (CIMT), which enables the risk assessment of coronary and cerebral-artery disease . CarotidThe Mediterranean diet  has beenThe aims of the present study are to evaluate the influence of food habits, specifically adherence to the Mediterranean diet, on CIMT and the presence of plaques in HIV-infected patients taking ART and non-HIV-infected participants and to assess if HIV-infection contributes independently to subclinical atherosclerosis.We conducted a cross-sectional study comparing CIMT and the presence of carotid plaques as surrogate markers of atherosclerosis in HIV-infected patients and non HIV-infected participants.We selected participants from a consecutive sample of HIV-infected patients who had been on ART for ≥12 months at the University Hospital for Infectious Diseases (UHID) in Zagreb, Croatia. Non HIV-infected participants were healthy volunteers who were UHID employees or individuals who came to the Department of Radiology and Ultrasound at UHID for routine preventive ultrasound check-ups. They were not tested for HIV before the study. Participants were consecutively recruited and enrolled over a 20-month period beginning in July 2009. Inclusion criteria for HIV-infected patients were age of over 18 years with documented HIV infection (enzyme immunoassay and Western-blot positive) and at least 12 months of ART, and for controls the age of 18 years or older. Exclusion criteria were dementia, current acute illness, current use of drugs that modify lipid and glucose metabolism , as well as diuretics and corticosteroids. We also excluded participants with a history of cardiovascular disease or stroke, documented hepatitis C infection, diabetes mellitus, and allergy or intolerance to olive oil, fish, or nuts. All participants provided written informed consent prior to enrolment. The study protocol was reviewed and approved by the Ethics Committee of UHID and the Committee on Human Research at the University of California, San Francisco.Participants were enrolled and underwent ultrasound measures at the same visit. Measurements of CIMT and assessment of the plaque presence was performed by a single radiologist, who was blinded to the participants’ HIV status and Mediterranean diet score, using a linear array probe (10 MHz and 42 mm) in the supine position. We examined the left and right common carotid arteries in anterolateral, posterolateral, and mediolateral directions and obtained longitudinal images of the distal common carotid arteries in which the interfaces were most clear. CIMT was measured in the far wall of the common carotid artery, 1 cm proximal to the carotid bulb in the region free of plaques with the optimum angle for measuring at the proximal and distal wall .We defined plaque as a focal wall thickening 50% greater than the surrounding wall thickness, confirmed during scanning by electronic calipers . We examPrior to the ultrasound, each participant was asked to fill out a 14-point food-item questionnaire to assess the adherence to the traditional Mediterranean diet. The questionnaire was originally developed and validated by Babio et al ,30 and wWe abstracted additional data for HIV-infected patients, including medication history, from medical records using a standardized abstraction form. Patients were considered as having been treated with a particular drug or drug class if the drug combination had been administered for more than 12 months. We measured the patients’ weight with a standard physician’s office balance scale and rounded the weight to the nearest 0.1 kg, and the height using a wall-mounted stadiometer and rounded the height to the nearest 0.1 cm. Blood pressure measurements were obtained in a seated position (at the right upper arm), using a standard mercury sphygmomanometer, expressed in terms of the systolic pressure over diastolic pressure in millimeters of mercury (mmHg). Hypertension was defined according to the guidelines of the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure, that is, systolic blood pressure ≥140mmHg or diastolic blood pressure ≥90mmHg and/or concomitant use of antihypertensive medications .We categorized the cigarette smoking status as current or non-current smoker. Previous cardiovascular diseases (as an exclusion criterion) included history of angina, myocardial infarction, coronary artery disease, atrial fibrillation, congestive heart failure, and valvular heart disease . Stroke We determined plasma HIV viral load using COBAS Amplicor HIV-1 Monitor Test, version 1.5  with a lower limit detection of 50 copies per milliliter (ultrasensitive method). Absolute CD4 T-cell counts (in cells/µL) were measured using Flow Count Fluorospheres  and four-color flow cytometry was performed using Cytomics FC500 flow cytometer .2 test for categorical variables, separately for HIV-infected participants and non HIV-infected participants. The odds of having subclinical atherosclerosis were calculated in crude logistic regression models, which included one independent variable  and age and their interaction for the whole study population (N = 241). In multivariate logistic regression model analysis, we included all the above mentioned variables except BMI  and the interaction of age with HIV status. Statistical analyses were performed with SAS software, version 9.1.3. . The level of statistical significance was set at P < 0.05.. Categorical variables are presented as proportions and non-normally distributed continuous variables as medians and interquartile ranges (IQR). The normality of distribution was assessed graphically and by the Shapiro-Wilk test. To compare different characteristics of participants with and without subclinical atherosclerosis, we used the Whitney-Mann test for continuous variables and Fisher exact test or χWe enrolled 110 HIV-infected patients and 131 non-HIV-infected participants. All the participants were Caucasian. HIV-infected patients were more frequently male, younger, had a lower BMI, and a higher Mediterranean diet score .P = 0.819, P = 0.791, and P = 0.904, respectively).More than 50% of the 110 HIV-infected patients were on non-nucleoside reverse transcriptase inhibitors-containing antiretroviral regimens . Of 110 P = 0.08 and P = 0.632, respectively). In HIV-infected patients, subclinical atherosclerosis was associated with older age , higher BMI , and hypertension . In non HIV-infected participants, subclinical atherosclerosis was associated with older age  and hypertension . Patients with subclinical atherosclerosis had lower median Mediterranean diet scores. In non HIV-infected participants, 24 of 42 (57%) with subclinical atherosclerosis and 42 of 89 (47%) without subclinical atherosclerosis had a Mediterranean diet score <4 . In HIV-infected participants, 17 of 37 (46%) with subclinical atherosclerosis and 18 of 73 (25%) without subclinical atherosclerosis had a Mediterranean diet score <4 . Among participants >45 years old, more HIV-infected patients than non-HIV-infected participants had subclinical atherosclerosis .Subclinical atherosclerosis was found in 79 (32.6%) of 241 participants : 37 (33.P = 0.027) (P = 0.028) and multivariate analysis (P = 0.029), suggesting that the probability of having subclinical atherosclerosis increased in HIV-infected patients after the age of 45 years more rapidly than in non-HIV-infected individuals  . There wividuals .We found that subclinical atherosclerosis was common both among HIV-infected and non-HIV-infected participants and was associated with older age, male sex, current smoking, and hypertension. Lower Mediterranean diet scores were associated with higher odds of subclinical atherosclerosis. Older HIV-infected patients treated with ART were more likely to have subclinical atherosclerosis than non HIV-infected individuals.Croatians living near the Adriatic Sea have a relatively lower occurrence of chronic diseases such as cancer, diabetes, obesity, and cardiovascular diseases than Croatians living in the continental area, which has been linked to adherence to the Mediterranean diet . AlthougThe questionnaire used in our study was a slightly modified questionnaire previously validated in Spain, which is suitable to assess the nutritional habits of the Croatian population living in the Mediterranean region ,34,35. TIn a previous observational study conducted in Croatia, no association was found between plasma lipid changes during the first year of ART and adherence to the Mediterranean diet . This asTo determine cardiovascular risk among HIV-infected persons, we used surrogate markers of subclinical atherosclerosis: ultrasound-measured CIMT and the presence of ≥1 plaque. Higher levels of CIMT have been found to predict serious adverse cardiovascular events . GreaterThe SMART trial found a higher risk of cardiovascular events among patients with discontinuation of ART than in patients with uninterrupted ART . This suIt is quite possible that traditional cardiovascular risk factors are more important predictors of atherosclerosis than measurable HIV-related factors. In our HIV-infected participants, the factors significantly associated with subclinical atherosclerosis were smoking and hypertension. Smoking is common in HIV-infected patients and the Data Collection on Adverse events of Anti-HIV Drugs study found that smoking was the most powerful predictor of cardiovascular diseases .Previous studies have suggested that there may be an association between the use of PI and increased CIMT ,41. One Our study has some important limitations. First, we utilized a cross-sectional design to determine the risk factors, CIMT, and plaque levels. Given the fact that the effects of HIV and ART on cardiovascular risk factors, such as cholesterol, high-density lipoproteins, and blood pressure are dynamic and cumulative, a longitudinal follow up would be better suited. Second, we did not measure biochemical correlates of atherosclerosis, such as total cholesterol, high-density lipoproteins and low-density lipoproteins, which could potentially have provided additional evidence of the protective effect of the Mediterranean diet. Finally, non HIV-infected participants should ideally have been identical to infected patients except for the presence of HIV-infection, but given the highly specialized nature of our institution, it was not possible to precisely match infected and non-infected patients.Our study demonstrated an association of subclinical atherosclerosis with specific and traditional dietary habits, which had been associated with decreased all-cause mortality and improvement in cardiovascular risk factors in prior studies in the general population. We also provided evidence that HIV infection treated with ART was associated with accelerated atherosclerosis in older individuals. These results should be considered in clinical assessment of cardiovascular risk in HIV-infected patients.


Sleep is one of the essential function for normal physiologic development. During sleep, so many hormonal changes occur. Aim of this study is to determine differences in hormones and neurotransmitters are regarding with onset of puberty during sleep, and sleep pattern, among girls with precocious puberty (PP), premature telarche (PT), and non-pubertal girls.Thirty nine girls with breast development were underwent full anthropometric and, hormonal assessments. Depending on the results of Gonadotropin-Releasing Hormone (GnRH) test 22 patient, as premature telarche, and the rests, as precocious puberty, were evaluated. Nineteen age-matched, non-pubertal girls, were included as control group. Polysomnography was carried out to all patients. Levels of hormones and neurotransmitters were assessed during REM period.Weight Standart Deviation Score (SDS) in girls with PP was significantly higher than those in girls with PT and non-pubertal (p<0.05). Nocturnal kisspeptin, leptin, gamma-amino butyric acid (GABA), and glutamate levels during sleep revealed no statistically significant difference among three groups (p>0.05). First sleep interval of Stage N1 in polysomnography was shorter, whereas total sleep time was longer in girls with premature telarche compared to other groups .There were negative correlation between total sleep time (TST) and kisspeptin levels and positive correlation between TST and glutamate levels in girls with PT .Interval of transition to sleep is shortened, whereas total sleep time is prolonged in girls with premature telarche. Sleep pattern of girls with precocious puberty is similar to those of non-pubertal girls. No change was found serum levels of hormones and neurotransmitters related with pubertal activation during deep sleep periods in girls with precocious puberty compared to girls with PP and non-pubertal.


While type 1 is characterized by complete loss of beta-cells due to autoimmune attack on them, type 2 is characterized by a relative deficiency of beta-cells due to a decreased compensation for insulin resistance [In the second approach, transplantation of isolated islets from cadaveric donor pancreas has proved to be an immediate and effective method for replacing depleted beta-cells in type 1 diabetic patients, allowing them to achieve independence from exogenous insulin administration , 4. To pIn this special issue, substantial developments made in different research areas aimed at overcoming current limitations of islet regeneration and transplantation are presented. Of the numerous papers received from this open submission format, selected papers have been recommended for publication after peer reviews. This special edition presents a collection of exciting papers that describe strategies to improve availability of beta-cells and islets for transplantation, and also to improve their posttransplant survival. It is clear that one of the major hurdles challenging further success in islet transplantation is the lack of suitable donor pancreases. This issue is compounded by poor long-term survival of allotransplanted islets. The review article by F.-C. Chou et al. summarizes many strategies developed to modulate immune response to transplanted islets. Gene therapy offers a powerful tool to engineer islet grafts to become resistant to apoptosis induced by inflammation and produce immunosuppressive molecules to attenuate T-cell response. In addition, the potential to develop patient-specific, autologous beta-cell replacement therapy by using iPSC-derived pancreatic beta-like cells is discussed. Key issues in this field which are presented in this paper include (i) duration and expression levels of targeted genes in islets, (ii) use of viral vectors for direct gene therapy that could lead to insertional mutagenesis and host immunogenicity, and (iii) poor efficiency of differentiation of insulin-secreting cells from stem cells.Other recent studies have shown that long-term function of allogeneic islet transplants could be improved by effective induction immunosuppression and control of inflammation . FurtherMajor causes of development of type 2 diabetes include excessive intake of food and lack of physical activity. Reduction in food intake which increases insulin sensitivity and improves glucose homeostasis is recommended to treat this metabolic disorder. The study by L. Belkacemi et al. investigated the effects of intermittent overnight fasting in streptozotocin-induced diabetic rats on glucose tolerance, plasma insulin, and homeostasis model assessment index. The study, which included an intermittent overnight fasting design (inspired by the daily fasting period during the Islamic Ramadan holiday), was recently reported to prevent the progressive deterioration of glucose tolerance otherwise taking place in sand rats exposed to a hypercaloric diet. The authors observed that the beta-cell mass, as well as individual beta-cell and islet area, was higher in intermittently fasting than in nonfasting STZ rats, and the percentage of apoptotic beta-cells was lower in the fasting STZ rats. Based on this study result, the authors proposed that intermittent fasting could represent a possible approach to prevent or minimize disturbances of glucose homeostasis in human subjects. The paper by S.-T. Chen et al. investigated the complementary role of hyperglycemia and p27kip1 suppression on islet beta-cell regeneration in a syngeneic mouse model. Glucose has been postulated to regulate cyclin D2 in pancreatic islet beta-cells and play a dominant role in beta-cell compensation; however, it is not yet clear how glucose controls the cell cycle of islet beta-cells. It has been reported that the suppression of both cdk-inhibitors p27kip1 and p18INK4c, but not p27Kip1 alone, promotes endocrine tumor formation in rodents. In this study, they used shRNAs to silence p27Kip1 and used hyperglycemia as a complementary factor to examine the synergistic effect of glucose and p27Kip1 on the adaptation of adult mice islets. They transduced adult islets with lentivirus-carrying shRNA to silence 80% of p27Kip1 protein, and the resultant suppression of p27Kip1 expression lasted for over 96 hours after infection. The study results suggested that adult mouse islet beta-cells can replicate when the metabolic demands increase, and there is a synergistic effect of hyperglycemia and concurrent suppression of p27Kip1 on islet beta-cell replication.in vivo or alternatively provide methods for ex vivo expansion of beta-cell numbers before transplantation. In the review article by A. Amedeo Vetere and B. Bridget K. Wagner, the authors present an overview of the current trends involving small-molecule approaches to induce beta-cell regeneration. For further understanding about the physiological proliferative behavior of human beta-cells, we can start to identify the molecular switches that could be used to foster the proliferation of beta-cells in humans.Beta-cell mass is maintained at optimal levels in the body through a slow turn-over rate. In humans, it has been shown that beta-cell mass expands several folds from birth and through the first three years of childhood, but thereafter this initial period, beta-cell replication potential declines markedly until adulthood. A critical barrier to progress in the treatment of diabetes is the lack of small-molecule drugs to induce beta-cell regeneration. Small molecule-induced beta-cell proliferation in humans could be an important way to achieve this goal; such compounds could be used to restore beta-cell mass In another interesting investigation into beta-cell mass equilibrium, the review article by E. Tarabra et al. describes the cellular counter-forces of beta-cell proliferation, neogenesis, and hypertrophy to increase beta-cell mass, while apoptosis and atrophy (reduced cell size) decrease beta-cell mass. They proposed that postnatal beta-cell mass responds to changing metabolic demands, carried out by an interaction of beta-cell replication (proliferation and/or neogenesis) and apoptosis, and this process is regulated by different growth factors/nutrients. Specifically, this review elaborated on principal hormones and nutrients, as well as downstream signaling pathways regulating beta-cell mass in the adult. They also reviewed the role of miRNAs in beta-cell mass regulation. The most studied miRNA in this contest was miR-375 overexpression, which was reported to attenuate proliferation of beta-cells and glucose-induced insulin secretion. In ob/ob mice in which miR-375 was deleted, a marked decrease in beta-cell mass resulted in severe insulin-deficient diabetes not found in ob/ob miR-375+ mice. Therefore, it is becoming clear that miR-375 targets a suit of genes that negatively regulate cell growth and proliferation and that aberrant loss of this miRNA leads to dramatic reduction of beta-cell mass.Interestingly, generation of patient-specific beta-cells could also provide for a revolutionary type of treatment for patients with diabetes. The review article by X. Wang et al. focused on the significant applications of patient-specific therapy which include the engineering of new beta-cells from a patient's own cells, and thus, the elimination of the life-long usage of immunosuppressants, bioincompatibility, and disease transmission inherent with donor cells. Of course, transcription factors for pancreatic stem cell development and differentiation of beta-cells play a critical role in this process for they are essential for tailoring the transplantable beta-cells to function optimally. They concluded that the success of generating islet-like insulin-producing cell is largely achieved by building upon knowledge of the major steps in the differentiation of beta-cells during embryonic development of the pancreas. By applying multiple transcription factors, the available cells are coerced to differentiate into desired types in a unique delineation pathway, including across lineages, such as from fibroblasts into iPSs, or from one fully functional lineage to another, such as from fibroblasts into insulin-positive cells.In conclusion, islet cell transplantation offers a potential cure for type 1 diabetes, but it is challenged by insufficient donor tissue and side effects of current immunosuppressive drugs , 6. TherA. N. BalamuruganA. N. BalamuruganVelayutham KumaravelVelayutham KumaravelSubbiah PugazhenthiSubbiah PugazhenthiBashoo NaziruddinBashoo Naziruddin


Nelumbo nucifera, contains high levels of polyphenolic compounds, and several health-promoting properties of lotus root have been reported. In this study, we tested whether feeding a polyphenolic extract of lotus root to db/db mice protects them from hepatic steatosis.Nonalcoholic fatty liver disease (NAFLD) is emerging as the most common liver disease of industrialized countries. Thus, discovering food components that can ameliorate NAFLD is of interest. Lotus root, the edible rhizome of db/db mice relative to the control mice. Although the lipolytic enzyme activity was not changed, the activities of lipogenic enzymes, such as fatty acid synthase and malic enzyme, were significantly lower in the lotus polyphenol diet-fed db/db mice. Additionally, the ESI-IT/MS and MALDI-TOF MS spectra revealed the presence of B-type proanthocyanidin polymers with polymerization degree up to 9 in the polyphenolic lotus root extract.After 3 weeks of feeding, the hepatomegaly and hepatic triglyceride accumulation were markedly alleviated in the lotus polyphenol-diet-fed db/db mice.We speculate that the condensed tannins contained in lotus root can alleviate hepatic steatosis by suppressing the lipogenic enzyme activity in the livers of  They develop a syndrome that involves multiple metabolic and hormonal disorders, including NAFLD, and shares many features with human metabolic syndrome [Nonalcoholic fatty liver disease (NAFLD) is often associated with features of the metabolic syndrome and is emerging as the most common liver disease worldwide -4. NAFLDsyndrome -7.Nelumbo nucifera is a plant in the monogeneric family Nelumbonaceae. Its rhizome (lotus root) is recognized in eastern countries as one of the most delicious and nutritional vegetables, and it has also been used in traditional Asian herbal medicine. There are several studies showing that lotus root contains high levels of polyphenolic compounds and possesses several beneficial health properties, such as hypoglycemic, anti-inflammatory and antioxidant activities [db/db mice (submitted data). In the present study, we evaluated the effect of a diet supplemented with a polyphenolic extract of lotus root on the development of NAFLD in db/db mice. Additionally, the structures of the polyphenolic lotus root extract were characterized through analyses combining a butanolic-HCl assay, electrospray-ionization mass spectrometry (ESI/MS), and matrix-assisted laser-desorption ionization time-of-flight mass spectrometry (MALDI-TOF MS).Diet has been recognized as factor that contributes to the development and prevention of NAFLD -11, and tivities -18. Our db/db mice (C57BLKS/J Iar-db/+Leprdb+Lepr) were purchased from Japan SLC . The mice were housed individually in plastic cages in a temperature-controlled room (24°C) under a 12-h light/dark cycle. The basal semisynthetic diets were prepared according to the recommendations of the AIN-76 [db/db mice were assigned to two groups (of six mice each) that were fed one of two diets . The serum glutamic pyruvic transaminase (GPT) and alkaline phosphatase (ALP) activities were measured using commercial enzyme assay kits .The enzyme activities of fatty acid synthase (FAS)  and maliFirst, a colorimetric butanolic-HCl assay for procyanidins was employed to assess the polyphenolic lotus root extracts; it used procyanidinB2 as the positive standard and (+)-catechin as the negative standard . Second,t-test. Differences were considered to be significant at p < 0.05.All of the values are expressed as the means ± standard error. The significance of the differences between the means of the two groups was determined by the Student's NAFLD is common in type 2 diabetic and obese patients. Although the mechanisms responsible for the development of NAFLD are unclear, it has been suggested that hepatic steatosis results from increased lipogenesis and/or decreased lipolysis, in addition to the accelerated mobilization of the expanded visceral WAT fat to the liver .db/db mice did not differ in their initial body weight, nor did they differ in their final body weight, food intake, or total WAT weight during and after the 3-week feeding period  triglyceride accumulation in the liver (Figure The relative liver weight was 15% less in the lotus polyphenol diet-fed ly less 6% triglycdb/db mice than in the sera of the control diet-fed db/db mice (Table db/db mice.The serum cholesterol levels and triglyceride levels were not different between the two groups Table . Consistce Table . These rdb/db mice. Previous studies have demonstrated that dietary polyphenols suppress lipogenesis. Previous reports have indicated that polyphenols from plants have FAS inhibitory activity in vitro [in db/db mice is partly attributable to the suppression of hepatic lipogenic enzyme activity by the lotus root polyphenols.To further examine the effect of the lotus polyphenol diet on the liver, the hepatic enzymes related to triglyceride metabolism were analyzed Figure . Althougin vitro , and we in vitro . Given tin vivo physiological properties, such as antioxidant, anti-carcinogenesis, and anti-inflammatory activities [et al. have shown that proanothocyanidin dimmers and trimmers have similar permeability coefficients in Caco-2 cells [in vivo physiological properties.The colorimetric butanoic-HCl assay showed that the polyphenolic lotus root extract contained proanthocyanidins Figure . The lottivities -33. Additivities -36. Depr-2 cells , and abs-2 cells -40. Furtdb/db mice is attributable to the suppression of hepatic lipogenesis by the lotus root polyphenols.Although further qualitative and quantitative analyses of lotus root polyphenols are necessary, the present results suggest that the ameliorative effect of dietary lotus root on hepatic steatosis in ALP: alkaline phosphatase; CPT: carnitine palmitoyltransferase; ESI/MS: electrospray-ionization mass spectrometry; FAS: fatty acid synthase; GPT: glutamic pyruvic transaminase; MALDI-TOF MS: matix-assisted laser-desorption ionization time-of-flight mass spectrometry; ME: malic enzyme; WAT: white adipose tissue; NAFLD: nonalcoholic fatty liver disease.The authors declare that they have no competing interests.YT and KN made substantial contributions to the conception and design of the study, to performing the experiment, to the assembly, analysis and interpretation of the data and to drafting the manuscript. SK, KT, and TY participated in the experimental work and in the collection, assembly, analysis of the data. KK and TY contributed to planning the experiment and discussing the results. All authors read and approved the final manuscript.