Although intima-media thickness (IMT) was increased in several inflammatory diseases, studies investigating whether the inflammatory processes lead to macrovascular alteration with increased IMT in complex regional pain syndrome (CRPS) lack.RA/CCA, in CRPS type I (n=17), peripheral nerve injury  and pain-free controls . Statistics: Spearman’s correlation, paired t-test, ANOVA (p<0.05).Using ultrasound (high-resolution B-mode), we compared bilaterally the IMT of the common carotid artery (CCA-IMT), the radial artery (RA-IMT), the brachial artery (BRA-IMT) and the quotient QRA/CCA , and BRA-IMT - only on the affected side in CRPS . In CRPS, QRA/CCA was significantly higher on the affected side compared to PNI (p<0.05). However, only CRPS displayed within-group side-to-side differences with a significantly increased RA-IMT and QRA/CCA on the affected side (p<0.05). The CCA-IMT was comparable between all groups and sides.Compared to PFC, RA-IMT were significantly increased in both patient groups bilaterally  and QThe increased IMT of peripheral arteries in CRPS suggests ongoing inflammatory process. Until now, only endothelial dysfunction has been reported. The presented morphological macrovascular alterations might explain the treatment resistance of some CRPS patients. Complex regional pain syndrome type I (CRPS I) occurs as a severe complication after limb trauma without evidence of a peripheral nerve lesion. At the beginning of the disease patients present signs and symptoms like pain, edema, increased skin temperature and redness . The undIncreased intima-media thickness (IMT), measured by high-resolution ultrasound, is a non-invasive marker of early arterial wall alteration. It can result from cardiovascular risk factors such as smoking, hypertension, diabetes mellitus and hypercholesterolemia. Anyway, it may not necessarily reflect pathologic changing because it is closely correlated to age . HoweverFurthermore, there is a strong link between inflammatory markers and increased internal carotid IMT . TNF-α aModern high-resolution ultrasound systems can depict the macrovascular structure (and change) of intima-media thickness. To our knowledge, there are no studies on the IMT in CRPS, although, there are several reports of microvascular alterations in this disease, e.g. endothelial swelling and changes in the vessel luminal wall detected in a bone biopsy . FurtherThe objective of the present prospective study was to investigate morphologic macrovascular alterations in patients with unilateral CRPS of the upper extremity by assessing the IMT of the radial, brachial and common carotid artery bilaterally in comparison to patients with unilateral peripheral nerve injury and matched pain-free controls using high-resolution ultrasonography.The study was approved by the local Ethics Committee of the Ruhr University Bochum, Germany (registration number: 3513–09). All subjects gave their written informed consent. 26 patients with the diagnosis CRPS type I of the upper extremity were recruited from the Pain Clinic of the University Hospital Bergmannsheil Bochum, Germany (February 2010 to September 2011). The diagnosis was made by two pain specialists (CM and EK) according to the clinical Budapest criteria (CRPS characteristics present in at least 3 of 4 symptom categories and at least 2 of 4 sign categories) . CRPS tyFor the first control group 19 patients with PNI were recruited from the Pain Clinic of the University Hospital Bergmannsheil Bochum, Germany (February 2010 to September 2011). The diagnosis of unilateral peripheral nerve injury was made by experienced neurologists by history and extensive clinical and neurophysiological examination. Clinical examination included sensory abnormalities and motor deficits referring to the skin region and muscles innervated by the affected nerve. The diagnosis was approved by nerve conduction abnormalities and the present signs and symptoms were sufficiently explained by the nerve injury (Table 22 pain-free controls (PFC) served for a second control group. They were recruited from February 2010 until January 2011 among students, hospital staff or their relatives and were matched to the CRPS patients by gender, age (± five years) and common cardiovascular risk factors . Except from the matched cardiovascular risk factors all subjects were healthy without a history of trauma, neurological, vascular or inflammatory disease. After performing the Edinburgh inventory for assessment of handedness with the PFC group, the dominant hand was defined as test side . Thus, the dominant side of the healthy subjects was compared to the affected side of both patient groups and the non-dominant side was compared to the non-affected side of both patient groups [While performing the measurements the sonographer was not blinded to the clinical information.To avoid inter-observer variability the study measurements were restricted to one examiner (ND) and were performed after a training phase with twenty other subjects with an experienced sonographer (TM). The correlation between the results obtained from TM and ND was analyzed with Spearman’s rank correlation coefficients . A Bland-Altman-analysis showed no significant differences.IMT measurements were performed on the subjects lying in supine position with the head in neutral position. The arms were in a slightly abducted, resting position with unclenched hands. A high-resolution ultrasound-system with a linear array was used . IMT-far-wall-measurements of the CCA were bilaterally performed according to the Mannheim-Consensus-protocol  using thRA/CCA as a quotient (Q) of the IMT of the radial (RA) and common carotid artery (CCA):Increased CCA-IMT is directly associated with generalized atherosclerosis. To eliminate the impact of atherosclerotic diseases, we generated the Q®-Software was used . P-values <0.05 were considered statistically significant, p-values <0.01 highly significant. Descriptive statistics were performed for all variables. Mann–Whitney-U-test was performed to compare metric variables . Shapiro-Wilks W-Test was used to test normal distribution of the parameters. After confirming normal distribution for all IMT-values using the Shapiro-Wilks W-Test, t-test for paired samples was conducted to investigate body side differences within the groups. Group comparisons of each body side were analyzed using a one-way analysis of variance (ANOVA). Levene’s test was performed to assess the equality of variance between the different samples. The post-hoc test (LSD) was performed to detect significant group differences. The correlations between mean IMT and disease duration and pain intensity were analyzed with Spearman’s rank correlation coefficients.For statistical analysis the StatisticaThe gender proportion, the mean age and the number of cardiovascular risk factors were comparable between the three groups. The proportion of patients with affection of the right or left hand as well as the reported current and maximal pain intensity were also similar in both patient groups. CRPS patients had a significantly shorter duration of disease p<0.001) compared to patients with PNI. The pain duration was less than 12 months in only one patient of the PNI group vs. ten of the CRPS patients   was significantly increased on the affected side only in CRPS patients compared to PFC  Table . There wThe mean RA-IMT was significantly increased bilaterally in both patient groups in comparison to PFC without differences between the patient groups  (Table RA/CCA was significantly higher on the affected side compared to the affected side in PNI patients (p<0.05)  (Table RA/CCA of the affected side was significantly increased compared to the non-affected side (p< 0.05)  Table . The QRACCA-IMT, BRA-IMT and RA-IMT did neither correlate with disease duration nor with pain intensity in the CRPS group and PNI group.RA/CCA were increased bilaterally compared to pain-free controls (PFC) both in CRPS and in PNI patients. The BRA-IMT of the affected side was increased only in CRPS patients compared to PFC. CRPS patients had a significantly higher QRA/CCA on the affected side compared to PNI patients. Only in CRPS the QRA/CCA and RA-IMT of the affected side were increased compared to the non-affected side. The CCA-IMT did not differ between all groups and sides.To our knowledge, this is the first study revealing morphological macrovascular alterations in CRPS patients measured by ultrasonography. The RA-IMT and the QCarotid IMT measurement by B-mode ultrasound is a common, reproducible and well accepted technique to evaluate the vascular status of patients . In contRA/CCA and matched our pain-free controls to CRPS patients on cardiovascular risk factors as well as age. Age for itself leads to an increase of 0.010 mm/y in the CCA both in males and females [To eliminate the impact of atherosclerotic diseases we generated the Q females . HoweverSeveral studies have observed functional vascular abnormalities in CRPS , e.g. imBeside the vascular changes, there is also some evidence for inflammatory alterations in CRPS patients ,4 and thRA/CCA in CRPS patients indicating disease specific alterations. Thus, our findings suggest both a systemic and local inflammatory process. According to our hypothesis that inflammation might induce increased IMT in CRPS, several studies demonstrated the association between inflammatory markers such as TNF-α or IL-6 and an increased IMT of the CCA [We hypothesize, that an increased IMT in CRPS patient is a sign of inflammatory processes. Unfortunately, we did not measure inflammatory mediators in the serum in our patients. However, we found a significantly increased radial IMT in the affected side compared to the non-affected side, in line with the previously reported high local concentration of inflammatory markers only in the affected extremity . In acco the CCA -12,14. IRA/CCA of the affected side in CRPS patients compared to PNI patients.Unexpectedly, we found an increased RA-IMT also in the PNI group compared to PFC, however without significant side differences in contrast to the CRPS group. In painful peripheral neuropathies significantly higher blood levels of IL-2 mRNA and TNF-α mRNA were measured compared to healthy subjects . FurtherIt is important to notice that CRPS patients had significantly shorter mean disease duration than PNI patients. In only one patient of the PNI group vs. ten of the CRPS group the pain duration was less than 12 months. However, the disease duration in both groups was widely ranging , but neither CCA-IMT, nor BRA-IMT or RA-IMT correlated with disease duration in both patient groups. In other inflammatory diseases there was a positive correlation between disease duration and IMT . HoweverOur study was a cross-sectional analysis which served as a pilot project and which may not clarify completely the correlation of IMT-alterations and disease duration, pain intensity or clinical signs and symptoms by now. Even though the benefit of long-term measurement of carotid IMT progression to predict cardiovascular events is still under debate , longituIn conclusion, we examined macrovascular alterations in CRPS patients using high-resolution sonography demonstrating for the first time bilaterally increased radial and unilaterally increased brachial IMTs. Further longitudinal studies are required to prove whether these alterations can be used as diagnostic or prognostic markers.RA/CCA: Quotient of the IMT of the radial artery and common carotid artery; PFC: Pain-free controls; PNI: Peripheral nerve injury; TNF-α: Tumor necrosis factor alpha; IL-6: Interleukin-6; PNM: Patients with injury of the median nerve; PNRU: Patients with injury of the radial and ulnar nerve; y: Year; CMAP: Compound muscle action potential; SNAP: Sensory nerve action potential.CRPS: Complex regional pain syndrome; IMT: Intima-media thickness; RA: Radial artery; CCA: Common carotid artery; BRA: Brachial artery; QThe authors declare that they have no competing interests. This study was partly funded by the Ruhr University Bochum, FoRUM grant: F634-2008. TM has been involved in lecturing, education and training which was supported by the following companies: Sonosite , GE Healthcare , Esaote  BK Medical , Pajunk  and B. Braun . EK is a member of the IMI Europain project (see below). She is also supported by intramural fundings of the Ruhr University Bochum (FoRUM: grant number K046-10). CM is member of the IMI Europain project, including following industry members AstraZeneca, Pfizer, Esteve, UCB-Pharma, Sanofi Aventis, Grünenthal, Eli Lilly and Boehringer Ingelheim. As a member of the German Research Network on Neuropathic Pain, he has received research grants from the German Federal Ministry of Education and Research . He has received research grants from Pfizer, MSD, Mundipharma, Grünenthal, Astellas, and Lilly as well as consultant and/or speaker fees from Astellas, Sanofi Aventis, Wyeth, Pfizer, Mundipharma and Eli Lilly.ND collected, analyzed and interpreted the data and wrote the first draft of the manuscript. TM educated ND in skills in sonography and supervised her during the study, analyzed the data, designed the figures and was involved in the preparation of the final report. EK was involved in patients’ recruitment, data interpretation and in the preparation of the final report. AG revised the paper. CM contributed to the acquisition of the funding, designed the study, supervised it during the data collection and was involved in the data interpretation and the preparation of the final report. All authors read and approved the final manuscript.This work is part of the doctoral thesis of Nicola Derenthal.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2377/13/14/prepubIntima-media thickness measured by ultrasonography in mm and quotient of the IMT of the radial and carotid artery (mean ± SD).Click here for file


Patients with human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS) are at increased risk for developing Hodgkin's lymphoma (HL), a risk that has not decreased despite the success of combination antiretroviral therapy (cART) in the modern era. HIV-associated HL (HIV-HL) differs from HL in non-HIV-infected patients in that it is nearly always associated with Epstein-Barr virus (EBV) and more often presents with high-risk features of advanced disease, systemic “B” symptoms, and extranodal involvement. Before the introduction of cART, patients with HIV-HL had lower response rates and worse outcomes than non-HIV-infected HL patients treated with conventional chemotherapy. The introduction of cART, however, has allowed for the delivery of full-dose and dose-intensive chemotherapy regimens with improved outcomes that approach those seen in non-HIV infected patients. Despite these significant advances, HIV-HL patients remain at increased risk for treatment-related toxicities and drug-drug interactions which require careful attention and supportive care to insure the safe administration of therapy. This paper will address the modern diagnosis, risk stratification, and therapy of HIV-associated HL. Since the introduction of combination antiretroviral therapy (cART) in 1996, patients with human immunodeficiency virus (HIV) infection are living longer, with improved immune function and a reduced risk of developing acquired immune deficiency syndrome (AIDS) . In concμL), and disease risk is associated with cART, but it is rarely seen at severely depressed CD4 counts [There will be approximately 8800 new cases of HL diagnosed this year in the United States and 1300 deaths . HL outs4 counts , 15. WhiThe epidemiologic and pathologic pattern of HIV-associated HL is distinct from that observed in HIV-negative patients. There is an increased risk of developing HL in HIV-infected patients compared to the general population, and this risk remains increased since the advent of cART , 12, 13.Viral oncogenesis appears to play a greater role in HIV-HL than HL in the general population. Epstein-Barr virus (EBV) can be detected in approximately one-third of cases of non-HIV-associated HL, compared to nearly all cases of HIV-HL , 15. HRSμL. The most common histology is MC in approximately half of patients, followed by NS in one quarter and LD in approximately 10%. Representative pathologic images are shown in HIV-HL in the modern era presents at a median age in the mid 30s after a median time from HIV diagnosis of approximately 7 1/2 years. Approximately one quarter of patients will have a prior AIDS diagnosis at the time their cancer is diagnosed, and the majority of patients will be diagnosed while receiving cART. The median CD4 count at HL diagnosis is approximately 240 cells/μL and use of cART were independently associated with a favorable outcome. Other studies have documented the importance of cART on prognosis with improved responses to chemotherapy and survival in the cART era [Prior to the availability of cART, prognosis of HIV-HL was poor with very few patients cured of their disease. A number of adverse prognostic factors were identified, including MC subtype, extranodal involvement, presence of systemic “B” symptoms, and a high International Prognostic Score (IPS) , 25. ThecART era , 28. ImpRegardless of an underlying HIV diagnosis, all patients with newly diagnosed HL require a careful medical history including questions regarding systemic “B” symptoms, and a physical exam with attention paid to both nodal and extranodal sites. Laboratory evaluation should include a complete blood count with differential, erythrocyte sedimentation rate, and chemistry tests including a complete metabolic panel with liver function tests and albumin. Baseline HIV parameters including CD4 count and viral load should be tested, along with hepatitis B and C serologies given risk of coinfection. Patients with any HIV-associated malignancy may present with concurrent opportunistic infections or other HIV-associated malignancies, so any findings not readily ascribed to the HL should be evaluated further as clinically indicated.Initial radiographic staging is increasingly with Positron Emission Tomography/Computed Tomography (PET/CT) scans, which are associated with a higher sensitivity, specificity, and positive and negative predictive value than traditional CT scans in the initial staging of HL . They maThe most commonly used initial systemic therapy for HL worldwide is the combination of doxorubicin, bleomycin, vinblastine, and dacarbazine (ABVD). When ABVD was given to patients with HIV-HL in the pre-cART era, the objective response rate was a disappointing 62% with a median OS of only 1.5 years . Even thThe introduction of cART and its associated improved control of HIV infection, immune status, and performance status have allowed for administration of full-dose-intensive regimens with improved outcomes . In the μL. Eighty-one percent of patients achieved a CR, with a 5-year OS and DFS of 59% and 68%, respectively. An IPS <2 was associated with improved freedom from progression. The more intensive regimen of bleomycin, etoposide, doxorubicin, cyclophosphamide, vincristine, procarbazine, and prednisone (BEACOPP) similarly resulted in a high rate of CR in all 12 HIV-HL patients in a small report [μL, but there was a greater proportion of advanced-stage disease, “B” symptoms, and extranodal involvement than that in the European Intergroup study of Stanford V. After 4 years, there had only been one relapse, but the incidence of severe neutropenia was 75%, and two patients died from opportunistic infections.As cART has evolved, treatment results in HIV-HL have further improved. A prospective phase 2 study of the Stanford V regimen with cART in 59 patients with HIV-HL found that less than one-third of patients required a dose reduction or delay . These pl report . Two-thiABVD was reexamined in conjunction with cART in a cohort of 62 high-risk HIV-HL patients, 87% of whom achieved a CR, with an encouraging 5-year OS and event-free survival (EFS) of 76% and 71%, respectively . An immuAs noted earlier, the introduction of cART has resulted in an increased number of HIV-HL patients presenting with earlier-stage disease. The optimum therapy for early-stage HL is controversial and an area of active investigation. Combined modality therapy with chemotherapy and radiation has been the standard of care, but late complications of radiotherapy including secondary malignancies and heart and lung disease have prompted consideration of chemotherapy alone in selected patients. Randomized trials in nonbulky limited-stage disease have identified no survival benefit favoring inclusion of radiotherapy, and retrospective analyses of chemotherapy alone show encouraging results, so avoiding radiotherapy is an option for limited stage patients without presenting bulk, with the caveat that HIV-HL patients have not been included in these studies –47. AlthThese data demonstrate that HIV-HL patients treated with concurrent cART in the modern era achieve similarly encouraging results as those seen in the general population when disease risk factors are matched. The improved outcomes in patients with HIV-HL demonstrate the importance of improved immunologic status and performance status, and the ability to treat on schedule and at full dose intensity in the modern era.Despite improved outcomes with initial therapy, a number of HIV-HL patients still relapse, for whom prognosis is poor. High-dose chemotherapy with autologous stem cell transplantation (HDC-ASCT) remains the standard of care in HIV-negative patients with relapsed HL based on improved PFS and EFS compared to traditional salvage chemotherapy , 49. In The data exploring the use of allogeneic stem cell transplant are retrospective or based on case reports. The Center for International Blood and Marrow Transplantation Research reported the experience of 27 HIV-associated lymphoma patients treated with allogeneic transplantation from 1986 to 2003 . Two-yeaFor patients who are not candidates for, or who have relapsed after, HDC-ASCT, traditional chemotherapy agents remain available as monotherapy or in combination. While these therapies may induce remissions, this is without significant opportunity for cure and is associated with ongoing chemotherapy toxicities and immune suppression. Novel agents are now becoming available for relapsed/refractory HL, though they have not been studied to date in the HIV-HL population. Brentuximab vedotin (SGN-35) is a monoclonal antibody against CD30 that is bound to the microtubule toxin monomethyl auristatin E (MMAE) and has recently been FDA approved for the treatment of Hodgkin lymphoma that has relapsed after HDC-ASCT, or in patients ineligible for ASCT. In non-HIV-infected HL patients, all of whom had failed prior HDC-ASCT, the overall response rate was a remarkable 75% with 34% of patients achieving a CR, many of which appeared durable . This noFollowing completion of therapy, restaging with PET/CT scans in non-HIV-infected HL patients is better at differentiating between viable and necrotic/fibrotic tumor than traditional CT scans and has a higher positive and negative predictive value . In addiPneumocystis jiroveci prophylaxis (regardless of the CD4 count prior to treatment) is recommended for all patients to minimize the extent of myelosuppression and the risk of infection in these immunosuppressed patients. Additionally, providers should pay careful attention to pulmonary symptoms during treatment, as the effect of HIV disease and associated opportunistic infections of the lungs may potentiate the pulmonary toxicity of bleomycin. Caution should also be taken in dosing of hepatically cleared chemotherapy agents such as vinca alkaloids and doxorubicin based on bilirubin levels. Certain protease inhibitors, most notably atazanavir and indinavir, cause an indirect hyperbilirubinemia due to inhibition of UGT1A1 in the liver, but this does not affect drug clearance. An indirect hyperbilirubinemia with a normal direct bilirubin and absence of other findings of hepatotoxicity should, therefore, not prompt dose reductions of chemotherapy drugs. These risks notwithstanding cART can clearly be administered safely in combination with chemotherapy, even with dose-intensive regimens, with acceptable toxicity profiles [While the use of cART in combination with full-dose chemotherapy has resulted in improved clinical outcomes, HIV-positive HL patients remain at significantly increased risk for treatment-related complications, including infections and drug toxicity. Drug interactions between antiretroviral medications and chemotherapy may lead to increased levels and toxicity of some agents, while others may become subtherapeutic . Numerouprofiles , 62, 63.Although the incidence of HIV-HL has not declined in the decades since the introduction of cART, the prognosis has significantly improved and is now analogous to their risk- and stage-matched HIV-negative counterparts when treated with full-dose chemotherapy and concurrent cART. The lack of randomized trials in this disease makes it difficult to identify an optimum regimen for the upfront treatment of these patients, but ABVD appears to be efficacious and well tolerated, even in high-risk patients. Further study is needed to compare treatment regimens and to validate the use of PET/CT scans in the staging, interim restaging, and post-treatment evaluation of HIV-HL. In addition, the promising experience of novel therapies like brentuximab vedotin and others will ideally be tested specifically in HIV-infected patients. Finally, evaluation of long-term and late-treatment-related toxicity is needed in patients with HIV-HL due to the increasing success of our therapies and the encouragingly long survivals of these patients in the modern era.


In patients with HIV and tuberculosis (TB) in resource-constrained settings, smear-negative disease has been associated with higher mortality than smear-positive disease. Higher reported mortality may be due to misdiagnosis, diagnostic delays, or because smear-negative disease indicates more advanced immune suppression.We analyzed culture-confirmed, pulmonary TB among patients with TB and HIV in the United States from 1993–2008 to calculate prevalence ratios (PRs) for smear-negative disease by demographic and clinical characteristics. Allowing two years for treatment outcome to be reported, we determined hazard ratios (HRs) for survival by smear status, adjusted for significant covariates on patients before 2006.Among 16,710 cases with sputum smear results, 6,739 (39%) were sputum smear-negative and 9,971 (58%) were sputum smear-positive. The prevalence of smear-negative disease was lower in male patients  and in those who were homeless  or used alcohol excessively , and higher in persons diagnosed while incarcerated . Patients with smear-negative disease had better survival compared to patients with smear-positive disease, both before  and after  the introduction of combination anti-retroviral therapy.In the United States, smear-negative pulmonary TB in patients with HIV was not associated with higher mortality, in contrast to what has been documented in high TB burden settings. Smear-negative TB can be routinely and definitively diagnosed in the United States, whereas high-burden countries often rely solely on AFB-smear microscopy. This difference could contribute to diagnostic and treatment delays in high-burden countries, possibly resulting in higher mortality. Sputum smear examination of acid-fast bacilli (AFB) is the cornerstone of tuberculosis (TB) diagnosis worldwide. Before the HIV epidemic, AFB smear-negative TB was diagnosed in a smaller proportion of TB patients than it is today and was regarded as earlier or less severe disease A number of explanations for the increased mortality associated with smear-negative TB in resource-limited, high HIV prevalence countries have been proposed. Some researchers suggest that smear-negative disease in HIV-infected patients may indicate more advanced immune suppression, which may be mediating the observed differences in survival Analyses of the association between sputum AFB smear result and mortality in patients with HIV and TB that assess these hypotheses would be helpful in designing interventions to improve outcomes. In the United States, TB is diagnosed by means of extensive laboratory testing, which includes microscopy, nucleic acid amplification and specimen culture Data were collected and analyzed as part of routine public health surveillance and not human subjects research, and therefore institutional review board approval was not required.In the United States since 1993, all states and affiliated jurisdictions have reported incident cases of TB to the Centers for Disease Control and Prevention (CDC) using a standardized case report form, the Report of Verified Case of Tuberculosis (RVCT) We restricted our analysis to persons with positive HIV infection status reported on the RVCT, and included all sputum culture-confirmed cases of pulmonary TB, including those with both pulmonary and extrapulmonary involvement, that were reported by the District of Columbia and 48 of the 50 states. California did not report HIV status directly to the NTSS; HIV status of TB patients from California was determined by matching patients on the state-level TB and AIDS registries. HIV was missing for all California TB patients not matched to the state AIDS registry prior to 2005 and for all California TB cases from 2005–2008. Given the difference in reporting and potential for bias, we excluded TB patients from California from our analyses, and conducted separate analyses of California TB/AIDS patient mortality data. Additionally, Vermont stopped reporting HIV data to the CDC in 2006; because there were fewer than five Vermont patients with TB/HIV infection over the entire study period, we excluded patients from Vermont from analyses without examining state-specific mortality results.For demographic and clinical analyses of cross-sectional data, we included all patients with a known smear status who were reported to the NTSS from January 1, 1993 until December 31, 2008. For survival analyses, we included only patients who were documented to be alive at diagnosis, initiated anti-TB therapy, and were reported to the CDC as a culture-confirmed case through December 31, 2006, to allow two years for reporting of TB treatment outcomes.In order to account for the population effect of highly active anti-retroviral therapy (HAART) on survival, we conducted separate analyses for the time periods from 1993 to 1997, before HAART became widely available, and from 1998 to 2006, when patients with TB and HIV were routinely prescribed HAART.There are no NTSS data collected about CD4 count, HIV viral load, or anti-retroviral use, so we were unable to assess the effect of these variables in our analysis.sputum smear-positive if any result of a microscopic examination of a sputum smear (expectorated or induced) was positive for acid-fast bacilli (AFB). This excludes pulmonary secretions obtained by tracheal aspirations, bronchoscopy procedures, or gastric aspiration. Sputum smear positivity grade is not available in the NTSS. A TB patient was sputum smear-negative if all results of microscopic examination of sputum smears were negative for AFB. As recommended, at least three samples of sputum are generally sent for microscopy in the United States A TB patient was To investigate features associated with AFB smear status, we compared frequency distributions of smear-negative TB with smear-positive disease across categorical demographic and clinical variables , defined in the RVCT Mycobacterium tuberculosis to the start date of TB therapy between smear-negative and smear-positive cases using a Wilcoxon two-sample test. The RVCT records the date that initial sputum was collected only for cases that had documented conversion from a positive to a negative culture. We were not able to analyze survival of patients who died before diagnosis was made because neither date of symptom onset nor reason for evaluation for TB disease are reported in the RVCT.To assess potential treatment delays by AFB smear status, we compared the median time from collection date of the first sputum that grew To investigate the relationship between AFB smear status and survival during TB treatment, we performed comparative survival analyses by smear status based on time from start of TB therapy to death (as a TB treatment outcome). To ensure uniform follow-up for treatment outcomes of all patients, we censored patients at 730 days and didn’t capture specific treatment outcomes if they were recorded more than two years after the start of therapy. Patients with outcomes other than death were censored based on either date of stopping TB therapy or last known follow-up. Overall survival distributions for both groups were estimated using the Kaplan-Meier method and compared via log-rank test statistics. We fit a Cox multivariable proportional hazards model after testing the proportional hazards assumption for each variable. We identified demographic and behavioral variables that were either epidemiologically relevant, or were significantly associated with mortality in bivariate analysis (p<0.01) and adjusted for them; these variables included age group, race, nationality, incarceration at diagnosis, previous TB, as well as reported injection drug use (IDU), excessive alcohol use, and homelessness in the past year. We assessed variables for effect modification and, given the large sample size, dropped from the model all variables that did not meet a significance level of p<0.01. All statistical analyses were performed using SAS, version 9.2 .From 1993 through 2008, there were 17,089 culture-confirmed patients with pulmonary TB and HIV infection, 16,710 of whom had a sputum smear result reported. Of those, 6,739 (40%) were sputum smear-negative and 9,971 (60%) were sputum smear-positive. The annual proportion of TB cases that were smear-negative varied from 36% to 45%; however, there was no apparent linear trend .Of the 6,739 patients with HIV infection and smear-negative TB, the majority were male , black , aged 25–44  and U.S.-born  . Smear-nM. tuberculosis to the start date of therapy was 1  for the 6,698 smear-positive patients and 12  for the 4,342 smear-negative patients, indicating a significant delay in treatment initiation (p<0.0001).Among patients who were alive at diagnosis and had available date of initial sputum collection, the median number of days between the collection of the first sputum specimen that grew Patients with HIV and smear-negative TB had significantly better survival during TB treatment than patients with HIV and smear-positive TB  . This diIn the multivariate Cox proportional hazards model, smear-negative TB/HIV patients had a 19% lower risk of death during TB treatment, even after adjusting for gender, age group, race/ethnicity, nationality, correctional institution residence at time of diagnosis, IDU, and alcohol; the hazard ratio was similar for TB/HIV patients diagnosed from 1993–1997 and for patients diagnosed from 1998–2006 . When weOur data demonstrate that, among U.S. patients with HIV, smear-negative TB patients who initiated treatment had significantly lower 2-year mortality than smear-positive patients. This was true even in the pre–HAART era, when mortality from HIV/AIDS was exceedingly high. The strengths of this study include the robustness of this population-based data, which has been estimated as >99% complete for capturing TB cases The finding of lower mortality in patients with HIV treated for smear-negative TB in the United States is different from what has been reported in resource-limited settings Many studies have demonstrated that patients with HIV infection have higher rates of smear-negative TB Smear status may correlate with degree of immune dysfunction, and it has been hypothesized that, because worsening immune suppression impairs pulmonary cavitation Pneumocystis jirovecii pneumonia, fungal diseases, etc.,) that otherwise might be misdiagnosed as TB. In countries that are unable to perform routine sputum cultures, the diagnosis of pulmonary TB in a patient with negative sputum smears is based on clinical and radiologic findings. These findings, however, are often nonspecific in persons with HIV, especially those with smear-negative disease Differences in the study populations themselves may also explain why our findings differ from those previously published from resource-limited settings with higher HIV prevalence. By including only TB cases with microbiologic confirmation of disease, we eliminated non-TB pulmonary diseases (e.g., It is probable that patients with smear-negative TB in resource-limited countries have even more considerable diagnostic and treatment delays than smear-negative TB/HIV patients in the United States. Because smear microscopy is frequently the sole diagnostic laboratory test available, sputum examinations are usually repeated multiple times for TB patients whose initial sputum smears are negative for AFB, causing significant delays in diagnosis and treatment Finally, it is also possible that differences in treatment contributed to the different findings. In some resource-limited countries, patients with smear-negative TB were not always treated with rifampicin throughout their treatment regimens This study must be interpreted with the following considerations. Fluorescent microscopy has been increasingly used in the United States over the time period studied, and it is more sensitive for detection than microscopy used in most high TB burden settings In the United States, mortality in patients with HIV infection was not higher among patients with smear-negative TB disease, as compared to those with smear-positive disease, and it is reasonable to conclude that smear-negative TB in patients who initiate treatment appears to represent an earlier or less severe form of TB disease. The difference between these findings and those from resource-limited settings is likely because diagnostics are better in this resource-rich setting. Accurate and timely TB diagnosis remains of paramount importance worldwide, especially as the global HIV epidemic confounds clinical presentation and worsens disease outcomes, and the findings of this analysis argue for the need for improved, affordable diagnostic tests in high-burden, resource-limited countries. In addition, greater efforts to identify TB cases early through active screening in high-risk groups are critical and must be combined with improved outreach to persons with limited healthcare access.


The common spatial pattern analysis (CSP), a frequently utilized feature extraction method in brain-computer-interface applications, is believed to be time-invariant and sensitive to noises, mainly due to an inherent shortcoming of purely relying on spatial filtering. Therefore, temporal/spectral filtering which can be very effective to counteract the unfavorable influence of noises is usually used as a supplement. This work integrates the CSP spatial filters with complex channel-specific finite impulse response (FIR) filters in a natural and intuitive manner. Each hybrid spatial-FIR filter is of high-order, data-driven and is unique to its corresponding channel. They are derived by introducing multiple time delays and regularization into conventional CSP. The general framework of the method follows that of CSP but performs better, as proven in single-trial classification tasks like event-related potential detection and motor imagery. The successfulness of common spatial pattern analysis (CSP) in the brain-computer interface applications such as motor imagery (MI) and event-related potential (ERP) detection has received considerable attentions A noticeable attempt is the introduction of common spatio-spectral pattern (CSSP) In this paper, a method namely common complex-spatio-spectral pattern (CCSSP) is proposed to accommodate the benefits of both spatial and temporal filtering. It acquires a number of filters that are data-driven and tailored for each EEG channel. These filters are the mathematical synergy of spatial filters and high-order finite impulse response (FIR) filters, whose flexibility, if being well regularized, enables a better dissociation between two distinct mental conditions and consequently outstanding classification performance.X. If a FIR filter of (2k+1) order is applied, a sample after being filtered will beSuppose CSP aims to maximize the difference between signals of two conditions after spatial filtering. Defining The optimization of It is known that conventional CSP is sensitive to both noises and overfitting Two types of datasets were collected for the assessment of the proposed method. One was acquired from publically available BCI competitions datasets for motor imagery classification, and the other was obtained from self-conducted ERP detection experiments in the scenario of rapid serial visual presentation (RSVP) http://bbci.de/competition/iv/), recorded subjects' EEG signals while imagining their limb movements. Each dataset contained training sets and testing sets. A brief summary of the experimental paradigms pertaining to this work was presented in Three publically available datasets, i.e. data set IVa, data set IIIa from BCI Competition III The experiments approved by the National University of Singapore Institutional Review Board (NUS-IRB) consisted of training sessions and testing sessions. In each session, a sequence of small-sized images (400×400 pixels) was presented to the subject, who was instructed to immediately press a button when images of interest (targets) appeared. In this work, the targets were images containing target objects and others were regarded as distractors. There were 41 targets and around 4000 distractors in each session. After providing their written consent forms which were approved by NUS-IRB, 4 subjects participated into the experiments. Scalp EEG signals were collected at 250 Hz, using a 62-channel ANT amplifier , referenced to linked ears and grounded to the forehead. For all three MI datasets, the preprocessing procedure followed the work in Whether the proposed coupling of the high-order channel-specific temporal filter with spatial filter could render better single-trial classification capability than conventional CSP which relies solely on spatial filter, can be verified based on the overall performance on MI datasets and RSVP experiments. Additionally, results of competing methods, i.e. CSSSP, BCSP, and ACSP, were also reported for comparison.Like conventional CSP, the features extracted by each method are the log-variances of the filtered signals. Only filters associated with the largest or smallest eigenvalues are used for extracting discriminative features. In the scenario of MI datasets, 3 pairs of features corresponding to the most discriminative filters were used The classifier adopted was weighted support vector machine (WSVM) based on LIBSVM −5, respectively) and applied to all data sets; 2) −4, 10−5, 10−6], respectively, using a 5-fold cross-validation procedure.As indicated in Section II, two parameters are left undetermined, i.e. order of the FIR filter t-test showed that the better performance of Pcv over CSP seemed to be marginally significant , and the improvement offered by Pfix was shown to be statistically significant, as p-value is less than 0.001. Additionally, the proposed method surpassed other methods, i.e. CSSSP, BCSP, and ACSP, according to p-value<0.001. Moreover, the general performances of CSSSP, BCSP, and ACSP were worse than that of CSP. However, this phenomenon was absent in the scenario of RSVP experiments, where BCSP obtained 5.8% higher average accuracy in comparison to CSP, and ACSP and CSSSP had slightly better performance than CSP.In Intuitively, the difference between CSP and the proposed method lies on the types of filters that are extracted. CSP filters are purely spatial filters, whilst the proposed CCSSP exploits the more complicated, spatial-FIR filters. It is worth noting that spatial-FIR filter is essentially a combination of several spatial filters, each of which takes effect on its corresponding time-delayed EEG data. Therefore, a spatial-FIR filter can be split up into a set of spatial filters. For instance, given For Subject aa in Besides being perceived as a mixture of spatial filters, a spatial-FIR filter can be interpreted as a pool of channel-specific FIR filters. The fact that these FIR filters are channel-specific can be seen in The effect of FIR filters in Furthermore, the waveform of filtered signals could shed some light on the impact of filters on the discrimination between targets and distractors. Provided these observations and the classification performance, it could be stated that unlike CSP which tries to find stationary filters, CCSSP searches for a set of filters originated from different time delays with different weighting. This voting process could grant CCSSP the desirable flexibility and dynamics, which in return rendered better performance, in comparison to conventional CSP.It is necessary to point out that Pcv underperformed Pfix in Among other competitive methods listed in In this study, CCSSP has been introduced to the CSP family. It naturally integrates and optimizes complex, specially tailored FIR filters together with spatial filters for desirable separation of two distinct conditions. The merits of such a data-driven pass-band selection for individual channels in supplemental to the broad-band CSP filtering have been attentively validated on datasets of different characteristic EEG signals. The quantitative and qualitative comparisons suggest superior discriminating capability of the proposed method over conventional CSP, e.g. 8.1% higher average accuracy in RSVP experiments.


Although deficits of attentional set-shifting have been reported in individuals with attention deficit/hyperactivity disorder (ADHD), it is rarely examined in animal models.This study compared spontaneously hypertensive rats  and Wistar-Kyoto (WKY) and Sprague-Dawley (SD) rats (normoactive control strains), on attentional set-shifting task (ASST) performance. Furthermore, the dose-effects of methylphenidate (MPH) on attentional set-shifting of SHR were investigated. In experiment 1, ASST procedures were conducted in SHR, WKY and SD rats of 8 each at the age of 5 weeks. Mean latencies at the initial phase, error types and numbers, and trials to criteria at each stage were recorded. In experiment 2, 24 SHR rats were randomly assigned to 3 groups of 8 each-- MPH-L (lower dose), MPH-H (higher dose), and SHR-vehicle groups. From 3 weeks, they were administered 2.5 mg/kg or 5 mg/kg MPH or saline respectively for 14 consecutive days. All rats were tested in the ASST at the age of 5 weeks.p < 0.001] and trials to criterion  were observed. The SHRs were found to have more perseverative and regressive errors than the control strains (p < 0.001). After MPH treatment, the two MPH treated groups exhibited significantly longer latency and fewer trials to reach criterion than the SHR-vehicle group and the MPH-L group exhibited fewer trials to reach criterion in more stages compared with the MPH-H group. Significant main effects of treatment  and error subtype  were found.The SHRs generally exhibited poorer performance on ASST than the control WKY and SD rats. Significant strain effects on mean latency [F  = 639.636, The SHR may be impaired in discrimination learning, reversal learning and attentional set-shifting. Our study provides evidence that MPH may improve the SHR's performance on attentional set-shifting and lower dose is more effective than higher dose. Attention deficit/hyperactivity disorder (ADHD), which is characterized by developmentally inappropriate symptoms of inattention, impulsivity and hyperactivity, is among the most common neuropsychiatric disorders in children. The symptoms of ADHD manifest as distractibility, difficulty in sustaining attention, and a failure to appropriately control motor responses. Some have suggested that all of these symptoms can be attributed to a primary deficit of cognition in ADHD sufferers, particularly impairment of executive functions . PreviouAttentional set-shifting is a form of executive function that represents behavioral flexibility. It requires attending to relevant stimuli while ignoring irrelevant stimuli and subsequently shifting the allocation of attention, either within "dimensions" or between "dimensions" . DeficitMethylphenidate (MPH) is one of the most commonly used psycho-stimulants for the treatment of ADHD, which has been found to improve spatial working memory, response inhibition, and other cognitive functions in children with ADHD ,17 and cThis study aimed to assess the ability of attentional set-shifting in SHRs  compared with WKY and Sprague-Dawley (SD) rats (normoactive control strains) by ASST, which applied us a tool for further investigation of the neurobiological and physiological mechanism underlying ADHD. Furthermore, in Experiment 2 dose effects of MPH on acquiring, maintaining and shifting attentional set of the SHRs were investigated in order to delineate the effects of MPH on attentional set-shifting deficits in ADHD and enhance the understanding of the effects of drug treatment on ADHD.®) was obtained from Qilu Hospital of Shandong University and was dissolved in saline. Peritoneal injection was conducted at 8 am daily at the age of 3 weeks for 14 consecutive days. Rats were tested in the ASST at the age of 5 weeks. All animal procedures were conducted in strict compliance with Protocols for Animal Use for Research and Education approved by Medicine Animal Review Committee of Shandong University.In experiment 1, male rats of the SHR (n = 8), WKY (n = 8) and SD (n = 8) strains were obtained at 3 weeks of age from the Laboratory Animal Co., Lake Hayes Division . Rats were housed individually in plastic cages, in a 12 hr light/dark cycle (lights on from 06:00 to 18:00). Food and water were provided ad libitum and the temperature was maintained at 21-23°C. Prior to training on the set-shifting task, weights were obtained and rats were then food deprived to 85% of the free-feeding standard weight. In experiment 2, 24 SHRs were randomly assigned to 3 groups of 8 each: MPH-L (lower dose of MPH), MPH-H (higher dose of MPH) and SHR-vehicle  groups. Rats in the MPH-L group were treated daily with MPH by dose of 2.5 mg/kg  was observed in the latency. Figure p < 0.001] as well as stage , and a non-significant strain by stage interaction in trials . Post-hoc tests of multiple comparisons revealed that the SHR rats needed significantly more trials to reach criterion compared with control strains (p < 0.001) at all stages including simple discrimination, reversal and shifting stages. There was no difference in trials between the WKY and SD strains: no significant main effect of strain in trials , and no significant strains by stages interaction in trials . There were no significant correlations between SD and ED on trials in SHR , WKY  and SD  rats. The SHR , WKY  and SD rats  had fewer times of trials to criterion at ID compared to CD. Both the WKY  and SD rats  had fewer times of trials to criterion at ID compared to ED. No difference of times of trials between the ED and the ID stages  were found for SHR rats. Figure p < 0.001], error subtype , and strain by error subtype interaction . Post-hoc tests of multiple comparisons revealed that the SHR rats had significantly more perseverative and regressive errors compared with control strains (p < 0.01). This indicates that the SHR has more perseverative responses and is more impaired in maintaining a new rule. No significant difference was found on never-reinforced errors between the SHR and control strains (p > 0.05). There was no difference of different types of errors between the WKY and SD strains (p > 0.05).As shown in Figure p < 0.05), CDR (p < 0.05), ID (p < 0.05) and ED (p < 0.01) compared with the SHR-vehicle group. Rats in the MPH-L group had significantly longer latency in ID (p < 0.05) and ED (p < 0.05) than animals in the SHR-vehicle group. In Figure p < 0.001] and stages in trials  and non-significant treatment by stage interaction in trials  were observed. Post-hoc tests revealed significant differences between the SHR-vehicle and MPH-L groups in their abilities to perform overall stages (p < 0.01), with the MPH-L group required significantly less trials to reach criterion compared to the SHR-vehicle group. However, only in CD (p < 0.05) and ID shift (p < 0.01) stages there were significant differences between the SHR-vehicle and the MPH-H groups. Paired-sample T test of the treated SHR showed that more trials were needed in ED than in ID for rats in the MPH-L  and the MPH-H  groups. Similarly, more trials were needed in CD than in ID for rats in the MPH-L  and the MPH-H  groups. In Figure p < 0.01], error subtype , and treatment by error subtype interaction  were observed. Post-hoc tests revealed significant difference in perseverative and regressive errors between the MPH-L and SHR-vehicle groups (p < 0.01). Significant difference in perseverative errors was found between MPH-L and MPH-H groups (p < 0.01).Figure In Experiment 1, we observed poorer performance of the SHR overall on attentional set-shifting task than the WKY and SD rats, which suggested that the SHR was impaired in discrimination learning, reversal learning and attentional set-shifting. Based on these results, we believe that impulsivity, perseverative responding and impairment in maintaining attention could all contribute to the overall impairment on attentional set-shifting tasks of the SHRs.In the ASST, the latency changes can be understood as either different in speed, accuracy trade off or simply alterations in locomotor activity . If a raOur finding appears consistent with Kantak  et al.'sAnother reason is that the SHR has more perseverative response in shifting. This study found that the SHRs made significantly more perseverative errors than the other 2 control strains, which indicates that it is difficult for the SHRs to disengage from previously relevant but currently irrelevant strategy during attentional set-shifting task. It provided an index of poor behavioural and cognitive flexibility in SHR. Increased perseverative responses resulted in more series of response at all stages. What's more, in this study, the SHRs made significantly more regressive errors than the other 2 control strains, which indicated that they might be impaired in maintaining attention. This may be the reason of poorer performance of the SHR overall on attentional set-shifting task than the WKY and SD rats.In ASST, It is important to form attentional set firstly before shifting attentional set. A rat that forms an attentional set should master the ID stage more rapidly  than the original discrimination (CD stage) and poorer performance on ED compared with ID . In our test, we observed significantly fewer trials to criterion in ID stage than in CD stage and ED stage in WKY and SD rats, which suggested that they could form attentional-set successfully. Meanwhile, it indicated that the paradigm we used here could serve as a valuable test paradigm for periadolescent rats. However, the task performance in ID stage was not improved in SHRs compared with in ED stage, which suggest that it was difficult for the SHR to acquire an attentional set by a series of successive trials. The failure of forming attentional set of the SHR may be due to their defect of maintaining attention  or dramaIn our tests, there was no significant correlation in performance between SD and ED among all the rats. The performance in SD could not be the predicted performance in the final ED shift in this test. Our result was contradictive from the study of Colacicco G  et al., In the present study, we found that the performance of the WKY strain in the ASST was similar to that of the SD strain at all stages. This finding supported the continued use of WKY as a control for SHR to investigate the ability of behavioural and cognitive flexibility in ADHD. Moreover, it suggested that SD rats may be another useful additional reference strain for SHR.From the results of Experiment 1, we observed that like individuals with ADHD, the SHRs may also have poor performance at attentional set-shifting task compared with the WKY and SD rats. Clear delineation of the effects of MPH upon attentional set-shifting deficits in ADHD would enhance understanding of the effects of drug treatment. In Experiment 2, lower dose (2.5 mg/kg) and higher dose (5.0 mg/kg) of MPH were administered to rats to investigate the dose effect of MPH on acquiring, maintaining and shifting attentional set of the SHRs. The results revealed effects of MPH of different doses on attentional set-shifting. The SHRs who received lower-dose MPH showed improved performance at all stages than the SHR-vehicle group especially at ED stage. This indicated that lower-dose MPH could improve PFC-dependent cognitive ability to shift attentional focus of the SHR. Furthermore, after treatment of lower dose MPH, the SHR could set up attentional set before set shifting . The reason maybe that lower-dose MPH could ameliorate impulse, reduce perseverative response and improve ability of maintaining attention as rats in the MPH-L group had increased latency, reduced perseverative and regressive errors than the SHR- vehicle group. These results were in consistent with previous clinical reports  which shCatecholamines in the PFC play a pivotal role in the cognition-enhancing and therapeutic actions of MPH. At higher doses, MPH may produce huge and widespread increases in extracellular levels of noradrenaline (NE) and dopamine (DA) and induce excessive catecholamine receptor stimulation throughout the brain, which can impair PFC cognitive function. In contrast, lower doses of MPH, which have behavioral-calming and cognition-enhancing functions, can exert regionally restricted actions, minimal elevated extracellular catecholamine levels and enhanced catecholamine receptor actions ,40 prefeIn conclusion, the present study revealed deficits in acquiring, sustaining and shifting attentional set and reversal learning in the SHRs, a genetic animal model of ADHD. MPH treatment of ADHD in the SHRs may ameliorate deficits in attentional set-shifting differently, and lower doses were more effective than higher doses. We provided the first evidence of the dose-dependent effect of MPH on attentional set-shifting performance in SHRs.ADHD: Attention deficit/hyperactivity disorder; SHR: Spontaneously hypertensive rat; WKY: Wistar-Kyoto; SD: Sprague-Dawley; ASST: Attentional set-shifting task; MPH: Methylphenidate; CANTAB: Cambridge Neuropsychological Test Automated Battery; TMT: Trail Making Test; WCST: Wisconsin Card Sorting Task; SD: Simple discrimination; CD: Compound discrimination; CDR: Reversal of compound discrimination; ID: Intradimensional shift; ED: Extradimensional shift; PFC: Prefrontal Cortex; SPECT: Single photon emission computerized tomography; NE: Noradrenaline; DA: Dopamine.The authors declare that they have no competing interests. The authors alone are responsible for the content and writing of the paper.Ai-hua Cao carried out the behavior study and performed the statistical analysis. Lin Yu, Yu-wei Wang, Jun-mei Wang, and Le-jin Yang participated in the behavior study and helped to draft the manuscript. Ge-fei Lei conceived of the study and drafted the manuscript. All authors read and approved the final manuscript.


A possible synergic role of serum uric acid (SUA) with thrombolytic therapies is controversial and needs further investigations. We therefore evaluated association of admission SUA with clinical improvement and clinical outcome in patients receiving rt-PA, early admitted patients not receiving rt-PA, and patients admitted after time window for rt-PA.SUA levels were obtained at admission and categorized as low, middle and high, based on 33° and 66° percentile values. Patients were categorized as patients admitted within 3 hours of symptom onset receiving rt-PA (rt-PA group), patients admitted within 3 hours of symptom onset not receiving rt-PA (non-rt-PA group), and patients admitted after time window for rt-PA (late group). Short-term clinical improvement was defined as the difference between NIHSS on admission minus NIHSS day 7. Favorable outcome was defined as mRS 0 - 3 and unfavorable outcome as mRS 4 - 6.SUA measurements were available in 1136 patients. Clinical improvement was significantly higher in patients with high SUA levels at admission. After adjustment for possible confounders, SUA level showed a positive correlation with clinical improvement  and was an independent predictor for favorable stroke outcome  only in the rt-PA group.SUA may not be neuroprotective alone, but may provide a beneficial effect in patients receiving thrombolysis. Serum uric acid (SUA) is a final enzymatic product of purine metabolism ,2. AnimaIn the present study we therefore aimed to evaluate the association of admission SUA levels with short-term clinical improvement and short-term clinical outcome in patients receiving rt-PA, patients admitted within 3 hours of symptom onset not receiving rt-PA, and patients admitted after the time window for rt-PA.This prospective study was conducted at Haukeland University Hospital, Bergen, Norway, which serves a well-defined population of 235,000 inhabitants. The study was performed from February 2006 to January 2009 as a part of a cohort study (Bergen NORSTROKE Study) in which data are collected from all consecutive ischemic stroke patients admitted to the stroke unit in the Department of Neurology. All patients were managed according to a standard protocol and received standard care as recommended by the European Stroke Organisation . EligiblSUA were categorized as low, middle and high, based on 33° and 66° percentile values.The etiology of stroke was classified as large-artery atherosclerosis, cardioembolism, small vessel occlusion, stroke of other determined etiology and stroke of undetermined etiology based on TOAST criteria .Diabetes mellitus (DM) was defined as treatment with glucose lowering medications or diet before stroke onset. Hypertension (HT) was defined as treatment with antihypertensive drugs before stroke onset. Serum creatinine levels were measured at admission and categorized as normal < 120 μmol/L or high ≥ 120 μmol/L. Previous stroke or TIA were registered. Seven days after stroke onset, functional outcome was assessed by modified Rankin scale (mRS) . AssessmChi-square test, Student's t-test, and analysis of variance (ANOVA) were used as appropriate. Age, sex, systolic blood pressure at admission, serum creatinine, pre-existing diabetes were considered as possible confounding factors of SUA level. Multiple linear regression was used to estimate the relationship between SUA and Δ-NIHSS. Age, sex, systolic blood pressure at admission, serum creatinine, pre-existing diabetes and admission NIHSS score were included as other exposure variables. Logistic regression analysis was performed to determine factors that could be considered independent predictors for stroke outcome. Significance was set at p < 0.05. The analysis was performed with the software 'STATA/SE 11.0 for Windows'.During the study period, 1224 patients with ischemic stroke were admitted to our department. SUA measurements were available in 1136 patients. Missing values were due to technical error and may be called protocol violations. Basic characteristics of the study population are shown in Table Among the three groups, the rt-PA group had the largest short-term clinical improvement Table . Within Stepwise logistic regression analysis including the same covariates as the multiple linear regression, identified SUA levels as predictor for favorable stroke outcome (mRS 0-3) only in the rt-PA group . Young age and low NIHSS score at admission were predictors for better stroke outcome in all the three groups.To be effective, neuroprotective agents should act in the acute phase of ischemic stroke, before neuronal death has occurred. We therefore focused our study on SUA levels measured within the first 3 hours after stroke onset. Antioxidant agents have so far shown to be effective only in animal models of AIS, but not in humans . PotentiThrombolysis may lead to recanalization which can salvage viable tissue in the penumbral zone, and is currently the only approved treatment for acute stroke. Dual therapy with rt-PA and neuroprotective agents has shown promising results only in model of AIS ,27. CombDuring the first hours of AIS, reactive oxygen species (ROS) produced by mitochondria play a central pathogenetic role in neuronal death. A further burst of ROS occurs during the early tissue reperfusion induced by recanalization . Serial In our study high SUA was independently associated with higher short-term clinical improvement and better short-term clinical outcome in rt-PA patients whereas no association was found in early patients not receiving rt-PA or in late patients. SUA may not achieve clinical effect alone, but may provide an additional beneficial effect in patients receiving recanalizing therapies.The authors declare that they have no competing interests.NL was involved in the conception and design of the study, acquisition, analysis and interpretation of data, and drafting the manuscript. HN was involved in the conception and design of the study, and acquisition, analysis and interpretation of data. JB was involved in the conception and design of the study, and acquisition, analysis and interpretation of data. TTI was involved in acquisition of data and drafting the manuscript. UWA was involved in the conception and design of the study, acquisition, analysis and interpretation of data and drafting the manuscript. LT was involved in the conception and design of the study, acquisition, analysis and interpretation of data, and drafting the manuscript. All authors participated in the revision of the manuscript for important intellectual content and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2377/11/114/prepub


We developed a web-based application called Cistrome, based on the Galaxy open source framework. In addition to the standard Galaxy functions, Cistrome has 29 ChIP-chip- and ChIP-seq-specific tools in three major categories, from preliminary peak calling and correlation analyses to downstream genome feature association, gene expression analyses, and motif discovery. Cistrome is available at  Cistromes were initially identified using chromatin immunoprecipitation (ChIP) combined with microarrays (ChIP-chip) [The term 'cistrome' refers to the set of IP-chip) . HoweverIP-chip)  has becoComputational analyses of cistrome data have become increasingly complex and integrative. Investigators often examine the data from many different angles by combining cistrome, epigenome, genomic sequence, and transcriptome analyses. Many algorithms and tools have been published over the years to facilitate such analyses. However, these tools require investigators to have both the hardware resources and computational expertise to install, configure, and run these different algorithms effectively. Integrated platforms such as CisGenome  and seqMTo address the above challenges, we developed the Cistrome platform to provide a flexible bioinformatics workbench with an analysis platform for ChIP-chip/seq and gene expression microarray analysis. Cistrome was built on top of Galaxy , an openBefore interpreting the biological results from ChIP-chip or ChIP-seq data using the Cistrome platform, researchers can upload raw data from their microarray or sequencing facilities and then preprocess those data using Cistrome peak-calling tools. Alternatively, researchers can also upload intermediate results from their own analysis tools. As illustrated in Figure Several methods can be used to import data into Cistrome. The 'Upload File' function can import a file from the user's computer or from an HTTP or FTP file server in the same manner as in Galaxy. In most cases, sequencing facilities will manage the low level base calling and read mapping processes. The least processed Cistrome data formats that we allow are the SAM/BAM  or BED fCaenorhabditis elegans to human. Affymetrix CEL files are required as input. For NimbleGen two-color arrays, MA2C [Cistrome contains peak-calling tools for both ChIP-chip and ChIP-seq data. We deployed the MAT tool  for Affyys, MA2C  was deplys, MA2C  tool forWith the rapid growth of ChIP-chip and ChIP-seq datasets in public repositories, it has become increasingly important to be able to integrate information from cross-platform and between-laboratory ChIP-chip or ChIP-seq datasets. We recently developed the powerful meta-analysis tool MM-ChIP   and deplt-test, ordinary least-squares, and permutation by re-sampling. Correction for false positive (type I) errors may be performed using either the Bonferroni correction or Benjamini-Hochberg false discovery rate (FDR) methods. The output from this tool is a list of differentially expressed genes, log2-transformed fold changes and FDR-corrected P-values of differential expression. The differential expression result can be processed into gene lists, such as up-regulated or down-regulated genes, using one of the public workflows as described in Table S2 in Additional file The Cistrome Expression pipeline uses R and Bioconductor  packagesSeveral downstream analysis modules are also available. A transcription factor tool allows the user to find the transcription factors with the highest level of expression. The selection is done based on an expression index cutoff value, and further filtering can be performed to restrict the resulting list to the Gene Ontology (GO) terms for transcription regulation activities. A correlation tool allows the user to detect all genes for which their expressions correlate with another given gene. This correlation result can also be filtered by applying the GO terms. The GO enrichment tool helps researchers explore the functions for a list of genes, such as the up-regulated genes after a transcription factor knockdown or the genes with transcription factor bound in promoter regions. Enrichment can be compared to the background of all genes or a subset of genes on the array. This tool uses Bioconductor GO and GOstats  packagesDownstream analyses for a cistrome study require specific or integrative tools. The value of Cistrome is that it enables biologists to use a broad range of bioinformatics tools to easily generate report-quality figures and tables, and to simplify routine analysis using reproducible pipelines. In Cistrome, we provide tools for correlation studies, genome feature association studies and motif analysis together with public workflows to link these tools together.Usually, researchers require at least two biological replicates to show the consistency of an experiment. An intuitive way to show consistency is to ask if the replicates can be correlated in some meaningful measurement. Correlation can also answer the question of whether or not two transcription factors are co-localized. For instance, two biological replicates with low correlation might suggest poor data quality, or highly overlapping cistromes between two factors might suggest interactions between the factors. For these reasons, we deployed two levels of tools in Cistrome to calculate correlations: one to compare protein-DNA binding signals and the other to investigate the overlap of the predicted binding sites. First, Cistrome can calculate Pearson correlation coefficients for multiple signal profiles on a whole-genome scale or by restricting the calculation to a set of genomic regions defined by the user. A Pearson correlation coefficient close to 1 implies that the replicates are consistent or two factors are correlated. To save computation time, these tools use window-smoothing methods to calculate the mean or median values within non-overlapping fixed-size windows. This approach decreases the number of data points involved in the calculation. The results are represented as scatter plots or heatmap images in either PDF or PNG format as illustrated in Figure Functional DNA regions in genomes are often evolutionarily conserved between different species -19. TherAnother useful task is to find the genomic features or genes associated with transcription factor binding or histone modification sites. For instance, H3K4me3 is enriched in the promoter regions of active genes , and H3KIn addition to the average signal profiles at a given set of genomic locations, as shown in CEAS, the visualization and clustering of signal profiles from different factors at specific locations provides another angle of insight. Through the observation of patterns, we can also find the co-factors (co-activators or co-repressors) that tend to work together on their regulated genes. The Cistrome 'Heatmap' tool can extract the signals centered at every given genomic location, perform either a k-means clustering or a sorting by maximum, mean, or median values within each region, and then draw a heatmap. For example, the group of TSSs for active genes should have H3K4me3 enriched at the TSS and a gradual H3K36me3 enrichment downstream of the TSS, whereas the group of TSSs for inactive genes would have low signals of both H3K4me3 and H3K36me3. Additional detailed clustering will be revealed when signal profiles of multiple factors are used , to Cistrome to target histone modification data . When ChMany new features and tools for cistrome analysis are included in our future plans. Basic file manipulation tools - for example, the BedTools  suite - Because Cistrome was built on Galaxy, we will continue updating the Galaxy framework codes for new features, such as Galaxy Pages for the reproducible and interactive supplementary material or Galaxy Visualization to show data tracks in a genome browser view. We also plan to follow in the steps of Galaxy and provide a cloud computing solution for future scalability. We welcome feedback from users regarding new features and better representations to make Cistrome a better resource for the community.bp: base pair; ChIP: chromatin immunoprecipitation; DC: Data Collection; GO: Gene Ontology; NGS: next-generation sequencing; TSS: transcription start site; TTS: transcription termination site.The authors declare that they have no competing interests.TL, MB, and XSL designed the project. TL, JAO, and XSL wrote the manuscript. TL, JAO, MP, MB, YT, and XSL revised the manuscript. TL, JAO, LT, CAM, BL, YZ, HGS, SSW, JM, UJP, YC, and KY implemented the system. TL, LT, and JM maintain the public server instance hosted in Dana-Farber Cancer Institute. All authors read and approved the final manuscript.Supplementary Tables S1, S2 and S3. File formats and restrictions on the Cistrome server; public workflows; and detailed comparison between Cistrome and CisGenome or seqMINER. Online demonstration of a general ChIP-seq analysis can be found at the public Cistrome site [ome site .Click here for file


A recent study investigated the therapeutic response of dogs afflicted by hip osteoarthritis when evaluating therapeutic modalities compared to a negative (placebo) control group. Authors suggested a placebo effect based on peak vertical force measurement. In addition, small effect size for each of the tested therapeutics as well as the extremely large sample size needed (>450) to discern therapeutic efficacy using force platform gait analysis were reported. We wish to express our concerns regarding the eligibility criteria used to select the studied cohort, the small effect size, and the placebo effect reported in force platform gait analysis. We would like to provide some comments on the recently published article on the clinical outcome measures in a randomized controlled trial (RCT) of canine osteoarthritis (OA) from the perspective of clinical investigators. The article investigated the therapeutic response of dogs afflicted by hip OA to three therapeutic modalities compared to a negative (placebo) control group . The maiet al.  but also observer-centred [doctor global opinion]), but ineffective for almost all objective outcomes ; the ES of placebo was twice as high in hand OA (0.80) compared to hip OA (0.37).As indicated in their Introduction, in a recent meta-analysis of RCTs in human OA, Zhang et al.  reportedet al. . With an et al. [1et al.  days. Th [et al.  and a co [et al. ,21. It i [et al. .et al. [We are in agreement with the clinical relevance of reporting ES and the paramount importance of statistical power and sample size estimates to design fruitful RCTs. However, we encourage a thorough presentation of the method used for single group ES calculation  from whiet al.  derived ResponseBy Peter Muirmuirp@vetmed.wisc.eduE-mail: et al. For example, there are at least 10 different published velocity ranges used for force-plate analysis-of-gait in dogs, including a recent paper published in the Journal of Veterinary Medical Association that used a velocity range of 1.3-2.1 m/s [Address: Comparative Orthopaedic Research Laboratory, University of Wisconsin-Madison, School of Veterinary Medicine, 2015 Linden Drive, Madison, WI 53706, USA. Force-plate analysis-of-gait is one of several different outcome measures used in clinical trials studying client-owned dogs with osteoarthritis. Approaches to experimental design and statistical analysis of data in force-plate analysis-of-gait studies vary widely in the veterinary literature and often vary from the perspective of Moreau -2.1 m/s .The main objective of our study was to develop a screening assay in client-owned dogs for analgesic activity of new compounds for the treatment of human and veterinary osteoarthritis. As such, the number of animals and the duration of the study were kept to a minimum. Other studies have often used larger group sizes and longer durations of treatment. In our study, effect size determinations were used to establish which of the measured variables could best detect differences among treatment groups. In undertaking a treatment experiment, trial design may be restrictive or model-based, such that a test article may show a treatment effect that is subsequently less evident in clinical practice. Trials that more closely model clinical practice represent a greater treatment challenge for a test article to overcome. Whilst homogenous cohorts are often used in experimental osteoarthritis studies, client-owned dogs represent a more heterogeneous, but more clinically relevant, population for longitudinal veterinary treatment studies. For example, lumbosacral abnormalities in dogs are very common and may not always have been identified in past osteoarthritis studies in client-owned dogs. Lumbosacral spondylosis is often an incidental finding in clinically normal dogs, but may also be associated with clinical signs. Neuropathic pain as a clinical syndrome is poorly recognized in dogs  and its Our study highlights the value of examining a combination of clinical outcome measures in clinically relevant longitudinal studies of client-owned dogs with osteoarthritis. Our study also highlights the need for better analgesic treatments for canine osteoarthritis in veterinary medicine. In this short-term study, habitual diet was maintained to minimize change in body weight over time. Whilst improvement in some gait analysis parameters was identified with placebo treatment in our study, these effects were not statistically significant. Some individual dogs showed an improvement in measured parameters with carprofen treatment, similar to a previous report, in which 19 of 34 dogs showed improvement in ground reaction forces with placebo treatment .et al. contributes to discussion of force-plate analysis-of-gait as an outcome measure in longitudinal studies in client-owned dogs with osteoarthritis. Their commentary does not affect our conclusions regarding its importance in small screening studies.To summarize, the article by Moreau RCT: Randomized controlled trial; OA: Osteoarthritis; ES: Effect size; NSAIDS: Non-steroidal anti-inflammatory drugs; SD: Standard deviation.The authors declare that they have no competing interests.MM drafted the manuscript. BL, JPP and ET reviewed, commented and complemented the manuscript. All authors have read and approved the final manuscript.MM is experienced in force platform gait analysis in canine and feline naturally-occurring and canine experimentally induced osteoarthritis.BL, JPP and ET are full professors at the Université de Montréal, and present several decades of expertise in canine and feline osteoarthritis.JPP and ET are heads of the Osteoarthritis Research Unit and GREPAQ, respectively.