Noninvasive Raman imaging of non-fixed and unstained human colon tissues based on vibrational properties of noncancerous and cancerous samples can effectively enable the differentiation between noncancerous and tumor tissues. This work aimed to evaluate the biochemical characteristics of colon cancer and the clinical merits of multivariate Raman image and spectroscopy analysis. Tissue samples were collected during routine surgery. The non-fixed, fresh samples were used to prepare micrometer sections from the tumor mass and the tissue from the safety margins outside of the tumor mass. Adjacent sections were used for typical histological analysis. We have found that the chemical composition identified by Raman spectroscopy of the cancerous and the noncancerous colon samples is sufficiently different to distinguish pathologically changed tissue from noncancerous tissue. We present a detailed analysis of Raman spectra for the human noncancerous and cancerous colon tissue. The multivariate analysis of the intensities of lipids/proteins/carotenoids Raman peaks shows that these classes of compounds can statistically divide analyzed samples into noncancerous and pathological groups, reaffirming that Raman imaging is a powerful technique for the histochemical analysis of human tissues. Raman biomarkers based on ratios for lipids/proteins/carotenoids content were found to be the most useful biomarkers in spectroscopic diagnostics. Colon cancer ranks second with regard to the incidence of malignant tumors in women and men and is the third most common cause of death around the world. The mortality rate for this type of cancer is around 60% in the United States and Europe . EtiologRecently the basis of screening tests in colon cancers is a FOB test  in the stool in combination with a sigmoidoscopy examination . HoweverNowadays, optical methods, especially those based on vibrational properties of human tissue samples, have proven that the development of new spectroscopic techniques open tremendous possibilities in the detection of cancer changes even if for the early stage of carcinogenesis and that multivariate image-guided spectroscopic diagnosis can provide the objective biochemical information in real-time with entirely automated protocols of suspicious lesions ,17,18,19In this manuscript, we will discuss the applications of Raman spectroscopy and imaging in colon cancer diagnostics. The publication is a voice in the discussion about the creation of objective protocols in the real-time diagnosis of cancer changes during routine surgery based on vibrational properties of human cancerous and noncancerous tissues. Raman biomarkers of colon cancer changes are also presented. We would like to also emphasize the advantage of the analysis based on the ratios of the intensity of the biochemical component bands of the human colon tissue in comparison to the analysis based on the intensiveness of single bands.In this section we will present the results for patients suffering from colon cancer—tubular carcinoma, cancer stage G2. Before we formulate general conclusions that may be useful in medical diagnostics, we will provide data for one of the analyzed patients, patient P3, to discuss the most important research observations.−1, while for the noncancerous tissue peaks at 870, 946, 1004, 1073, 1155, 1187, 1260, 1301, 1438, 1516, 1652, 1743, 2848, 2885, 2905, 2927, 2971, 3009 cm−1 are noticed.One can see from All the frequencies mentioned above can be divided into three groups: the nonspecific observed for both types of colon tissues, the typical for the noncancerous tissue and the characteristic for the cancerous type of sample.−1—skeletal modes typical for polysaccharides; 1004 cm−1—phenylalanine; 1743 cm−1—carbonyl feature of lipids and ester groups; 2848 cm−1—CH3 symmetric stretching modes of lipids; 2885 cm−1—CH2 antisymmetric stretching modes of lipids and proteins, 2927 cm−1—symmetric CH3 stretching modes due primarily to protein, 2971 cm−1—CH3, vibrations of lipids, fatty acids, cholesterol and cholesterol esters [Raman bands observed in both the noncancerous and the cancerous tissues can be assigned as follows: 946 cml esters ,32,33,34To find reliable differentiations between the noncancerous and the cancerous tissues of human colon (data presented for patients P3), we have calculated the average spectra of both types of samples.To visualize the differences between the noncancerous and the cancerous tissues of the human colon legibly, we have calculated the differential spectrum presented in −1.One can see that −1) [−1) [−1) [−1) [−1) [−1 peak typical for structural proteins modes of tumors) [−1 and methyl groups of lipids and fatty acids, cholesterol and cholesterol esters (peak at 2967 cm−1) [−1) [−1) ,27,28,29−1) [−1) ,34,35. O−1) [−1) , collage−1) [−1) , nucleic−1) [−1) , protein−1) [−1) .To determine statistically significant differences between the noncancerous and the cancerous tissues of tubular carcinoma and to find useful medical diagnosis biomarkers, we have calculated average spectra for both types of samples based on thousands of spectra .One can see from The comparison between To confirm which individual organic components mainly contribute to the Raman spectra of the tissues, the mean Raman spectra of the noncancerous and cancerous tissues can be compared with typical Raman spectra of: DNA, unsaturated lipids (glyceryl trioleate), proteins including structural proteins , nucleoside (cytidine), and natural antioxidants (beta-carotene) in One can see from −1, and simultaneously the peak at 2848–2852 cm−1 is less intense. This observation confirms that abnormal DNA content and hyperchromatic state is typical for the cancerous tissue. When a weak interaction via electrostatic forces between the histones and DNA of the nucleosome components occurs, an alteration of chromatin structure called euchromatin can be observed and positively affects the expression of the oncogenes; the opposite effect can be obtained by the removal of the acetyl groups from the lysine residues, which makes DNA less condensed, resulting in a gene activity repression known as a gene silencing [−1, which is typical for bending modes of methyl groups, is characteristic for malignant tissue and differentiates noncancerous and cancerous samples.DNA contribution, even if taken into account for both types of tissues, is more significant for the cancerous human colon samples for which the high-frequency region is dominated by the peak at around 2930 cmilencing ,41,42. Tilencing . Table 1The dominant presence of beta-carotene in the noncancerous human colon tissue shows that carotenoids as natural antioxidants have anti-cancer benefits and can effectively decrease the influence of oxidative stress on colon tissue homeostasis. It has been proved that carotenoids have numerous biological properties and can be considered as chemopreventive agents ,23,26. FThe protective role of oleic acid and his glycerol derivatives in cancer development was also intensively investigated. Numerous studies have reported an inhibition in cell proliferation induced by oleic acid in different tumor cell lines: prostate carcinoma, lung adenocarcinoma and myeloma cell line ,49. It hFor the cancerous tissue, one can also see an important role played in chemical composition by collagen, actin and myosin. It is well-known that cancer development increases the nuclear-to-cytoplasm ratio in cancerous tissue. The cytological features are commonly used to define the grade of cancer and histological analysis. The most important parameters for such analysis are: the estimation of the degree of anaplasia, the size and shape of cell nuclei, the volume of cytoplasm, the relative number of dividing cells (mitotic index), and the architectural features associated with skeleton proteins. The actin microfilament network is important for cell shape and many cell functions. Adhesion, motility, cellular, signaling cytokinesis and intracellular trafficking of cells depend on actin activity. Myosin belongs to motor active protein, which plays important roles in cytokinesis failure, centrosomal and chromosomal amplification, spindle formation and DNA instability. For carcinogenesis, all the above-mentioned functions of myosin prerequisite tumor formation are important, and subsequently, myosins activate various processes of tumor invasion and metastasis development, including cell migration, loss of cell polarity and suppression of apoptosis . Also, tCytidine, which is a nucleoside molecule formed when cytosine is attached to a ribose ring, plays a special role in colon cancer development and in the biomarkers defining colon cancer. Cytidine has been regarded as a potential biomarker of colon cancer by Hsu W-Y et al. . The RamBecause it would be very inconvenient to analyze the whole Raman spectrum during surgery, the intensities of single peaks can vary in a broad range depending on the patient, and because some Raman peaks are observed in spectra of both the noncancerous and the cancerous tissues of human colon, we propose to calculate some ratios for Raman peaks to find parameters that credibly differentiate between the noncancerous and the cancerous tissues.−1, are accepted as a good source of information on the ratio of proteins/lipids; proteins /Amide I, carotenoids/proteins, and lipids/proteins respectively.The ratio of Raman intensities of selected bands, such as 1667/1304, 1452/1667, 1516/1452, and 2848/2940 cmDuring the measurements, we were also focused on some technical aspects that could affect the final result and conclusions of our analysis. Because the fresh tissues cut to 16 micrometers can definitely dry relatively fast to check if the Raman spectroscopy of fresh tissue provides reliable results adequate to in vivo studies (where the tissue is hydrated) and to prove that Raman microspectroscopy is a non-destructive technique, we have performed Raman measurements controlling the humidity of sample for the same area of the colon tissue. −1. This observation confirms that for the fresh colon tissue experiments a natural water content, when analysis is performed in a short time after tissue removal, is not distorted and the methodology of human colon Raman microspectroscopy analysis presented in this paper is also a good model for in vivo studies.2 windows. Adjacent sections were used for typical histological analysis. All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration. All tissue procedures were conducted under a protocol approved by the institutional Bioethical Committee at the Medical University of Lodz, Poland . Written informed consent was obtained from patients. In the manuscript results for 20 samples: 10 cancerous—tubular carcinoma, cancer stage G2 and 10 noncancerous are presented. The selected, single sample was also analyzed using a cuvette to control the humidity. For this sample, the measurement was performed after the cuvette was connected to the tank containing clean water (for obtaining 100% humidity) and in the ambient humidity conditions about 23% after the tank was disconnected. This part of the measurements was performed to demonstrate experimentally that Raman spectroscopy and imaging are non-destructive techniques that enable rapid and objective information on the biochemical composition of analyzed tissues for properly chosen parameters of laser power and integration time. Details of the sample preparation and the research methodology have been described in detail in our previous papers [Tissue samples were collected during routine surgery. The non-fixed, fresh samples were used to prepare 16-micrometer sections. Specimens of the tissue from the tumor mass and the tissue from the safety margins outside of the tumor mass were prepared for Raman analysis by placing specimens on CaFs papers ,25,26,27All Raman images and spectra reported in this manuscript were recorded using alpha 300 RSA+ confocal microscope  using a 50 μm core diameter fiber, an Ultra High Throughput Spectrometer and a CCD Camera Andor Newton DU970NUVB- 353 operating in standard mode with 1600 × 200 pixels at −60 °C with full vertical binning. The second harmonic of the Nd:YAG laser—532 nm excitation line was focused on the sample through a 40× dry objective . The average laser excitation power was 5 mW, with an integration time of 0.5 s. Rayleigh scattered light was removed using an edge filter. A piezoelectric table was used to record Raman images. Spectra were collected at one acquisition per pixel and 1200 lines per mm diffraction grating. The cosmic rays were removed from each Raman spectrum , and the smoothing procedure, the Savitzky–Golay method, was also implemented. Data acquisition and processing including baseline removal (model: shape) were performed using WITec Project Plus ,25,26,27Deoxyribonucleic acid from human placenta (D3035), actin from rabbit muscle (A2522), myosin calcium activated from rabbit muscle (M1636), glyceryl trioleate (T7140), cytidine (C4654) were purchased in Sigma-Aldrich and used without any purification in powder form.−1 commonly accepted as a good source of information on the ratio of proteins/lipids; proteins /Amide I, carotenoids/proteins, lipids/proteins, respectively, can be treated as human colon Raman biomarkers for tubular carcinoma. Raman measurements in a function of humidity has proved that Raman microspectroscopy is a non-destructive technique to analyze the biochemical composition of human colon.Raman studies of human colon tissue samples for tubular carcinoma, cancer stage G2, show that the vibrational microspectroscopy can provide results that differentiate the noncancerous and the cancerous tissues of the human colon. The biochemical compositions of the noncancerous and the cancerous tissues are different, and the composition of the noncancerous tissue is much more diverse. The content of DNA, cytoskeleton proteins, and lipids, including unsaturated fatty acids fraction, differentiates noncancerous and cancer samples. The multivariate analysis of the intensities of lipids/proteins/carotenoids peaks shows that these classes of compounds can statistically divide the analyzed samples into noncancerous and pathological groups. Ratios of intensities of Raman peaks 1667/1304, 1452/1667, 1516/1452, 2848/2940 cm


A multi-centre online survey to staff working in specialised and non-specialised acute units.To identify clinical decisions and practices made for acute cervical spinal cord injury (CSCI) patients with respiratory impairments and oropharyngeal dysphagia.All hospital intensive care units in the UK that admit acute cervical spinal cord injury patients.Online distribution of a 35-question multiple-choice survey on the clinical management of ventilation, swallowing, nutrition, oral hygiene and communication for CSCI patients, to multi-disciplinary staff based in specialised and non-specialised intensive care units across UK.Responses were received from 219 staff members based in 92 hospitals. Of the 77 units that admitted CSCI patients, 152 participants worked in non-specialised and 30 in specialised units. Non-specialised unit staff showed variations in clinical decisions for respiratory management compared to specialised units with limited use of vital capacity measures and graduated weaning programme, reliance on coughing to indicate aspiration, inconsistent manipulation of tracheostomy cuffs for speech and swallowing and limited use of instrumental assessments of swallowing. Those in specialised units employed a multi-discplinary approach to clinical management of nutritional needs.Variation in the clinical management of respiratory impairments and oropharyngeal dysphagia between specialised and non-specialised units have implications for patient outcomes and increase the risk of respiratory complications that impact mortality. The future development of clinical guidance is required to ensure best practice and consistent care across all units. Demographics of SCI have changed in western countries from young men involved in high-velocity crashes towards older people with low-velocity falls . This haIn the UK, national guidance for ventilator weaning of CSCI patients was developed through consensus by a multi-professional group called Respiratory Information for Spinal Cord Injury (RISCI) . This reThe optimal management of respiratory, nutrition and swallowing problems requires involvement from multiple clinical professionals, including doctors, nurses, physiotherapists, speech and language therapists and dietitians. The aim of this study was to explore the clinical practices of multi-disciplinary staff within specialised and non-specialised critical care units in the management of complex CSCI patients with respiratory and swallowing disorders. This information would highlight variations in care and help to contribute to future development of best practice recommendations to ensure consistent clinical management. This is the first study in a series of studies contributing to a doctoral investigation into the identification and management of oropharyngeal dysphagia in acute cervical spinal cord injury (DAISY project).Owing to the absence of any pre-existing multi-disciplinary survey on the management of CSCI patients, a new survey was developed through a process of literature review to identify topic areas followed by survey construction and piloting with a representative group for validation.Topics for inclusion were derived from a review of the literature on oropharyngeal dysphagia, respiratory function, nutrition, oral care and communication in CSCI. A Medline search was performed using the terms “dysphagia”, “deglutition”, “ventilator weaning”, “tracheostomy”, “respiratory”, “enteral nutrition”, “oral hygiene” and “communication” each of which were paired with “spinal cord injury”, “cervical” and “tetraplegia”. Searches were limited to studies with human adults, written in English.In devising the survey, multiple-choice questions were devised across five topic areas, with an option for free text comments. The topics were ventilator and tracheostomy weaning, nutritional decisions, dysphagia management, mouthcare and communication support.A total of 35 questions were created across 22 pages with two additional free-text questions . Adaptive questioning was used for two questions: grading differences between doctors, nurses and allied health professionals (AHPs) and mouthcare involvement. All professional groups were asked the same survey questions. The content and structure of the survey was evaluated by a steering group of representative multi-disciplinary professionals with expertise in acute SCI and amendments were made subject to their feedback.Multi-professional respondents were sought from all critical care units in UK that admitted spinal cord injury patients, this included major trauma centres (MTC), district general hospitals (DGH), teaching hospitals (TCH), spinal injury units (SIU) and specialist hospitals (SPH) such as neurological or cardiothoracic units. Although it was expected that SCI patients would be admitted directly to one of 22 MTC, referrals to SIUs came from a broad range of hospitals, however it was not possible to identify all these units in advance. For this reason, purposive sampling was employed through email distribution to members of each critical care network and relevant professional bodies in UK. This included the Intensive Care Society, British Association of Critical Care Nurses (BACCN), Royal College of Speech and Language Therapists (RCSLT), British Dietetic Association (BDA) and The Chartered Society of Physiotherapy (CSP) critical care groups. To increase recruitment of multi-professionals within and across units, snowball sampling was employed, whereby study participants were asked to invite other colleagues to respond to the survey.Limited personal demographic details were collected, including profession, grade and hospital name, which was used to categorise unit type. Hospitals described as MTC, DGH and TCH were sub-categorised as non-specialised units as they did not specialise in SCI care, whereas SPH and SIU were considered specialised units, where the focus was only on SCI or neurological care.The survey was launched in August 2014 and closed in January 2015. Responses were collected through an online web survey with results analysed using SPSS Statistics version 22 (IBM) to generate descriptive data. This included the total number and percentage of responses per question and responses per hospital type. To explore variations in the care delivered to CSCI patients, responses were grouped into those from specialised and non-specialised hospitals. Responses from staff working in a SIU or SPH were grouped as specialised hospitals, while those responses from MTC, DGH and TCH were grouped as non-specialised hospitals  are the staff members to manage oropharyngeal dysphagia in UK and approximately half of staff reported routine availability of SLT services. Referral to SLT was usually made after a positive nurse swallow screen test although aspiration pneumonia was a more frequent cause for referral by staff in specialised units. With some debate about patients eating with tracheostomy cuff inflated, this was reported as happening either routinely or sometimes by staff in non-specialised units whereas staff in specialised unit only allowed cuff up eating occasionally Table .Staff at specialised and non-specialised units agreed on similar criteria for determining the need for non-oral feeding Table . Having Overall, staff at both specialised and non-specialised units tended to use low-technology methods to facilitate patients’ ability to communicate, with advice given to patients and families and encouragement to use mouthing to help express themselves. High-technology aids were not used as frequently, as physical access is limited. Using cuff deflation to allow leak speech was more consistently employed by specialised unit staff along with in-line speaking valves Table .Table 6CThis is the first exploratory study to investigate the clinical care of respiratory dysfunction, oropharyngeal dysphagia and nutrition in CSCI patients within specialised and non-specialised units across the UK. Systematic reviews of the care provision in SIUs support early admissions both to prevent complications and improve outcomes , 9. DeteThe evidence for the pathophysiology of oropharyngeal dysphagia following CSCI is unclear as studies are largely observational and retrospective. Respiratory, neurological and mechanical disruption to the cervical region appear to contribute to laryngeal dysfunction. Early case series reported links to dysphagia although the causes were unclear. Pollock et al.  reportedThe loss of phrenic nerve function with injuries above C5, interrupts normal breathing patterns and paralyses the diaphragm. Swallowing function is closely coordinated with the breathing cycle and disruption leads to accidental inhalation and aspiration during the swallow, with lack of cough preventing airway clearance . RespiraCervical spinal surgery is often indicated for traumatic injuries and much of the evidence from elective surgery cohorts report both dysphagia and dysphonia as common post-operative complications often due to pharyngeal wall oedema and nerve injury due to retraction time –29, withGastrointestinal functions are often affected following CSCI due to the loss of autonomic control, leading to dysmotility and paralytic ileus, often requiring aspiration of gastric contents . This adThe combination of respiratory, swallowing and gastrointestinal impairment increases the risk of aspiration and staff need to be aware of the signs in order to prevent symptoms developing, which can be difficult to reverse. The survey results demonstrate variations in care that can have an impact on these functions and the negative consequences of dysphagia. A graduated weaning approach, utilising vital capacity as a clinical measure, has been recommended for CSCI patients through expert consensus and adopted by the Intensive Care Society , howeverAccurate evaluation of laryngeal dysfunction helps the weaning process and permits more options for verbal communication, which is important for intensive care patients . CurrentAs with many surveys, there were limitations to using this method of evaluating current practice. Recruitment of multi-professional staff in specialised and non-specialised units relied on purposive and snowball sampling, making a response rate difficult to calculate. However, responses from staff at a large number of units across UK did reveal the widespread transfer of SCI patients from trauma units to non-specialised units, which does not fulfil the national service specification for acute SCI management and this would benefit from further investigation and analysis of the national database. Sample sizes for each group varied considerably making statistical comparisons inappropriate, instead the results provide qualitative data and insight into current practices, which have not previously been identified. Some professional groups were less well represented and staff reported that they had little disease-specific training and expertise with this patient group, despite having to deliver care. This may have had an impact on the survey completion rate with a loss of just over a third (35%) of respondents. A follow-up study may consider profession specific questionnaires or interviews, to explore practices in more detail.The incidence of CSCI are increasing nationally , 41 and This paper presents independent research funded by the National Institute for Health Research (NIHR) and Health Education England. The views expressed are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health and Social Care.Respiratory Information for Spinal Cord Injury UK (RISCI) weaning guidelines for spinal cord injured patients in critical care unitsOnline survey questions


Nearly three million grandparents in the US serve as primary caregivers for their grandchildren. Little research on formal service use and grandfamilies exists for Black and Hispanic populations. To begin to address this gap we conducted exploratory analyses using nationally representative estimates of characteristics and service accessibility of noninstitutionalized children living with grandparents from the 2013 National Survey of Children in Nonparental Care. Our goal was to understand differences in service use as a function of grandfamily race/ethnicity. We specifically explored grandparents’ formal service count, financial services received, confidence in obtaining/using community services, and level of role preparation by race/ethnicity. We calculated descriptive statistics for these service variables for grandparents raising Hispanic, White, Black, and Other identified grandchildren (N = 892). On average, there was a minimal range for the number of formal services used , reported number of financial services , and confidence obtaining/using services . Most prepared to take on the caregiving role were grandparents of White children (55%) followed by Black (21.6%), Other (12.3%), and Hispanic (11.1%) indicating that although grandparents in this sample report being confident and able to access formal services, grandparents of White children report being feeling more prepared to take on caregiving than grandparents of Black, Hispanic, and Other combined.


The NIH Human Microbiome Project (HMP) has been carried out over ten years and two phases to provide resources, methods, and discoveries that link interactions between humans and their microbiomes to health-related outcomes. The recently completed second phase, the Integrative Human Microbiome Project, comprised studies of dynamic changes in the microbiome and host under three conditions: pregnancy and preterm birth; inflammatory bowel diseases; and stressors that affect individuals with prediabetes. The associated research begins to elucidate mechanisms of host–microbiome interactions under these conditions, provides unique data resources (at the HMP Data Coordination Center), and represents a paradigm for future multi-omic studies of the human microbiome. Over ten years, the Human Microbiome Project has provided resources for studying the microbiome and its relationship to disease; this Perspective summarizes the key achievements and findings of the project and its relationship to the broader field. Epidemiology and model systems have been used to identify associations between changes in the microbiome and conditions ranging from autism4 to cancer7, and microbial and immunological mechanisms have been identified that affect, for example, the efficacy of drugs used to treat cardiac conditions8 or survival during graft-versus-host disease9.Although the ’omics era has accelerated all aspects of biological research, its effects have been particularly apparent in studies of microbial communities and the human microbiome. In the 18 years since the publication of the first human genome, studies of the microbiome have grown from culture-based surveys of the oral cavity and gut to molecular profiles of microbial biochemistry in all ecological niches of the human body11, which are acquired early in life14, differ between environments and populations16, and can persist for years17 or undergo relatively rapid transitions18. Microbial diversity manifests differently in different ecological niches of the body; for example, greater diversity is generally expected in the gut, but can be associated with dysbiotic states and risk of adverse events in the female reproductive tract. The microbiome can be perturbed by conditions such as inflammatory bowel disease and diabetes, but a variety of microbiome-linked health states, and the underpinnings of these links, remain unexplored. How dynamic is the microbiome during processes such as pregnancy or viral infection? Which changes in the microbiome represent causes rather than effects of changes in health? Which molecular elements of a personalized microbiome might be responsible for health outcomes, and how do they integrate with and maintain physiological processes such as the immune system and metabolism? And what ecological elements dictate the success of a microbiota transplant, and why are they successful in treating some individuals and conditions, but not others?Contemporary studies of the human microbiome have also been a source of basic biological and translational surprises, exposing a compelling range of novel findings and open questions. Every human being appears to carry their own, largely individual, suite of microbial strains19  of microbial membership and enzymatic repertoires across the body, combinations of metabolic functions that were either prevalent or strain-specific, and some of the host factors (such as race or ethnicity) that determine this variation. Studies of targeted populations identified ecological states of niches such as the vagina25, skin28, and gut33, among many others . This first phase of the HMP (HMP1) thus yielded a wealth of community resources: nucleotide sequences of microorganisms and communities from a large number of isolates, individuals, and populations (http://hmpdacc.org)37; protocols to support reproducible body-wide microbiome sampling and data generation40; and computational methods for microbiome analysis and epidemiology47.The National Institutes of Health Human Microbiome Project was one of the first large-scale initiatives to address a subset of these questions21. This finding served as the foundation for the development of the second phase of the HMP, the Integrative HMP (iHMP or HMP2)48, which was designed to explore host–microbiome interplay, including immunity, metabolism, and dynamic molecular activity, to gain a more holistic view of host–microbe interactions over time. This multi-omic program sought to expand the resource base available to the microbiome research community, to begin to address the relationship between host and microbiome mechanistically, and to address the questions introduced above. Disease-targeted projects within the HMP2 were therefore encouraged to use multiple complementary approaches in order to assess the mechanisms of human and microbial activity longitudinally and to provide protocols, data, and biospecimens for future work. These projects included three studies that followed the dynamics of human health and disease during conditions with known microbiome interactions, thus addressing important health outcomes directly while also serving as models of ‘typical’ microbiome-associated conditions of broad interest to the research community. These comprised pregnancy and preterm birth (PTB); inflammatory bowel diseases (IBD); and stressors that affect individuals with prediabetes. These studies, which have now reached the first stage of completion51, together provide a wealth of information and insights about not only microbial dynamics, but also associated human host responses and microbial inter-relationships. A collection of more than 20 manuscripts to date describe some of these results at https://www.nature.com/collections/fiabfcjbfj, and together they provide a rich multi-omic data resource to be mined by future work (http://www.ihmpdcc.org).One of the main findings of the HMP1 was that the taxonomic composition of the microbiome alone was often not a good correlate with host phenotype—this tended to be better predicted by prevalent microbial molecular function or personalized strain-specific makeup52, and the incidence is even greater in lower-resource countries. Environmental factors, including the microbiome of the female reproductive tract, are important contributors to prematurity. Notably, these factors have a greater effect in women of African ancestry, who also bear the highest burden of PTB53. Infant mortality has been reduced in recent decades, but the incidence of PTB has not decreased54, and progress in predicting individual risk of PTB has stalled. During pregnancy, the maternal immune system maintains a delicate balance of pro- and anti-inflammatory effectors55, and contributors to PTB include breakdown in maternal–fetal tolerance, vascular disorders, stress, cervical insufficiency, premature rupture of the fetal membranes, and intra-amniotic infection56. Microbial ascension into the uterus is thought to precipitate PTB by disrupting the maternal immune balance, leading to spontaneous preterm labour, and/or by the release of microbial products  that compromise the integrity of fetal membranes and lead to premature rupture of the membranes57.Preterm birth can have devastating consequences for newborn babies, including death and long-term disability. In the United States, approximately 10% of births are premature50.The Multi-Omic Microbiome Study: Pregnancy Initiative (MOMS-PI) research group, as part of HMP2, characterized the microbiomes of pregnant women to gauge their effects on risk of PTB  also identified signatures of higher risk for PTB in women who experienced spontaneous preterm birth at less than 37 weeks of gestation50. Women who went on to experience spontaneous PTB were less likely to exhibit a vaginal microbiota dominated by Lactobacillus crispatus, as previously reported in other populations62, and were more likely to exhibit an increased proportional abundance of several taxa including Sneathia amnii, Prevotella-related clades, a Lachnospiraceae taxon known as BVAB1, and a Saccharibacteria bacterium known as TM7-H1. Notably, these taxa were also associated with low levels of vitamin D63, suggesting that the vaginal microbiome might mediate a link between PTB risk and vitamin D deficiency64. The signatures of PTB were also reflected in metagenomic and metatranscriptomic measurements, and vaginal pro-inflammatory cytokines  were positively correlated with PTB-associated taxa. Conveniently for future possible interventions, the vaginal microbiomes of mothers who experienced PTB were most distinct from those of control mothers early in pregnancy, and a preliminary model to predict risk of PTB was most sensitive and specific using vaginal microbiome profiles from samples collected before 24 weeks of gestation.These multi-omic investigations identified temporal changes in the vaginal microbiome associated with full-term pregnancies. Women who often began pregnancy with a vaginal microbiome of greater ecological complexity generally converged towards a more homogeneous 50. It is clear that PTB has a complex aetiology56. The relative contributions of fetal and maternal genetics and epigenetics, particularly as related to genetic variation of the innate immune system, should be explored. Harmonized large-scale studies would permit the development of population-specific risk assessment algorithms using vaginal microbiome profiles, features from genetic and prenatal  genetic screens, biomarkers such as cytokines and metabolites, and key clinical features from classic markers of risk including maternal age, body mass index, pregnancy history (including history of PTB), cervical length, and measures of stress and other environmental exposures. With the addition of new data from the microbiome, other environmental factors, and multi-omic inputs, new algorithms promise to improve our ability to predict risk of PTB early in pregnancy, to facilitate clinical trials by identifying high-risk patients, and ultimately to stratify patient populations into treatment groups.The MOMS-PI research group identified intriguing associations between the vaginal microbiota, host response, and pregnancy outcomes that are consistent with the involvement of microorganisms ascending from the vagina in at least some cases of spontaneous PTB. As an essential next step, the contribution of racial and demographic background to the vaginal microbiome in pregnancy with relation to pregnancy outcomes must be fully explored through harmonized, large-scale studies65. The microbiome has long been implicated in IBD, potentially as a causative or risk factor67, as an explanation for heterogeneity in treatment response 68, or as a novel point of therapeutic intervention . Although meta-omic techniques have been used to identify functionally consistent microbial responses that help to explain the gut microbiome’s role as part of a pro-inflammatory feedback loop in the gut during disease71, and a few strains of microorganisms have been shown to be IBD-specific72, no comprehensive model of specific microbial, molecular, and immune interactions yet exists to explain the disease’s onset and dynamic progression.Studies of the gut microbiome in gastrointestinal disease have a particularly long and detailed history, especially in complex chronic conditions such as the inflammatory bowel diseases (IBD). IBD, including Crohn’s disease and ulcerative colitis, affects millions of individuals worldwide, with increasing incidence over the past 50 years or more coinciding with multiple factors such as westernization, urbanization, shifts in dietary patterns, antimicrobial exposure, and many more that could influence host–microbiome homeostasis73, metaproteomes, viromes, metabolomes75, host exomes, epigenomes, transcriptomes, and serological profiles, among others, allowing concurrent changes to be observed in multiple types of host and microbial molecular and clinical activity over time. Protocols and results from the study, further information about its infrastructure, and both raw and processed77 data products are available through the IBDMDB data portal (http://ibdmdb.org), from the HMP2 Data Coordination Center , and in the accompanying manuscript49.Therefore, to better characterize mechanisms of host–microbiome dysregulation during disease, the Inflammatory Bowel Disease Multi’omics Database (IBDMDB) project followed 132 individuals from five clinical centres over the course of one year each as part of HMP2 . This dysbiosis was not unique to the microbial response to inflammation, however, and was associated with other host and biochemical alterations, pointing to new potential directions for management of systemic dysregulation in IBD. These included large shifts in acylcarnitine pools and bile acids, increased serum antibody levels, and alterations in transcription for several microbial species. Concurrent transcriptomics and 16S amplicon mucosal community profiling from biopsies also identified potential host factors that might be able to shape the microbial community, in particular several chemokines, highlighting these as being involved in a potentially dysregulated interaction during periods of disease activity49.This unique study design allowed the IBDMDB to identify a variety of differences in the microbiome and host immune response over time during the course of the disease. Indeed, these dynamic changes were of much greater magnitude than were cross-sectional differences among clinical phenotypes, which have been emphasized by previous studiesFaecalibacterium, Subdoligranulum, Roseburia, Alistipes, and Escherichia, some at both the metagenomic and metatranscriptomic levels, and host regulators of interleukins49. Networks of mechanistic associations such as this may provide the key to disentangling the complex system of interactions that results in chronic inflammation in IBD and in other systemic microbiome-linked immune diseases.The study’s longitudinal multi-omic profiles further allowed researchers to characterize the stability and dynamics of host–microbiome interactions during disease, in particular highlighting ways in which community state and immune responses are distinctly less stable in participants with IBD than in control, healthy individuals. In numerous cases, the microbiome of a participant with IBD changed completely over the course of only weeks , whereas such shifts were rare in individuals without IBD. The main microbial contributors to these large-scale shifts from one time point to the next largely mirrored the differences observed in dysbiosis, and the shifts frequently marked the entrance into or exit from periods of dysbiosis. Finally, the study’s long-term, complementary molecular measurements enabled the construction of a network of more than 2,900 significant host and microbial cellular and molecular interactors during IBD, ranging from specific microbial taxa to human transcripts and small molecule metabolites. This network of mechanistic associations identified several key components that are central to the alterations seen in IBD, highlighting octanoyl carnitine, several lipids and short-chain fatty acids, the taxa 80; 70% of the latter will develop diabetes in their lifetime. T2D is characterized by complex host–microbiome interactions82, but little is known about systemic alterations during prediabetes, their effects on biological processes, or the critical transition to full-blown T2D. Prediabetes and T2D are often associated with insulin resistance, and thus studies of individuals with prediabetes or insulin resistance offer unique opportunities to investigate the earliest stages of diabetes. It is essential to create a global and simultaneous profile of both host and microbial molecules in individuals with prediabetes over time, in order to fully understand the molecular pathways that are affected in people with prediabetes and/or insulin resistance and how these conditions affect both biological responses to environmental challenges  and the onset of T2D.Type 2 diabetes mellitus (T2D) affects more than 10% of the adult US population, and another 30% show early signs of the disease (referred to as prediabetes)85 followed 106 healthy and prediabetic individuals during quarterly periods of health, respiratory viral infection (RVI) and other perturbations over about four years51 s51 Fig. . In one 51. However, many analytes, such as clinical laboratory measurements, cytokine profiles, and gut microbial taxa (mostly those of low abundance) were highly variable between individuals. Participants who were ultimately insulin-resistant had distinguishable molecular and microbial patterns at baseline from those who were ultimately insulin-sensitive, and an analyte test was devised as part of the study in order to differentiate them. Notably, individuals undergoing RVI or changes in weight showed thousands of specific molecular and microbial changes during these perturbations, and insulin-resistant and insulin-sensitive individuals responded very differently to perturbations. For example, during RVI, insulin-resistant participants showed substantially decreased and delayed inflammatory responses  and altered gut microbial changes when compared with insulin-sensitive participants . Accordingly, there were fewer changes in nasal microbiota in insulin-resistant participants, and both the richness and the diversity of nasal microorganisms decreased during RVI in insulin-sensitive but not insulin-resistant participants. Furthermore, global co-association analyses among the thousands of profiled molecules revealed specific associations in insulin-resistant individuals that differ from those seen in insulin-sensitive participants and vice versa, indicating different patterns of host–microbiome interactions in the two groups51.Baseline measurements were generally stable within individuals, even for long periods of time, with only some analytes changing significantly over time87. These included early detection of T2D, which developed differently among participants and was better detectable with varied assays; for example, some individuals first exhibited measurements in the diabetic range on tests of fasting glucose, whereas others did so on tests of haemoglobin A1c, oral glucose tolerance tests, or even continuous glucose monitoring. These results, together with detailed characterization of glucose dysregulation over time, illustrate the heterogeneity of T2D development. Overall, the data led to microbially linked, clinically actionable health discoveries in a number of diseases in addition to T2D, including metabolic disease, cardiovascular disease, haematological or oncological conditions, and other areas; these signs were often present before symptom onset, demonstrating the power of using big data, including the microbiome, to better manage human health.Another important goal of the study was to assess how host–microbiome multi-omics and related emerging technologies can be used to better manage patients’ health. We found that taking millions of measurements per individual over time enabled the early detection of potential disease stateshttp://ihmpdcc.org and in public and/or controlled-access repositories such as the Sequence Read Archive , the Database of Genotypes and Phenotypes , Metabolomics Workbench (https://www.metabolomicsworkbench.org/), and others ; other US government agencies including the National Science Foundation, Environmental Protection Agency, Department of Energy, National Institute of Standards and Technology, Department of Agriculture, National Oceanographic and Atmospheric Administration, National Aeronautics and Space Administration, and Department of Defense (https://commonfund.nih.gov/hmp/programhighlights); philanthropic organizations including the Bill and Melinda Gates Foundation, the March of Dimes, the Burroughs Wellcome Fund, the Sloan Foundation, the Keck Foundation, the Juvenile Diabetes Research Foundation, the Crohn’s and Colitis Foundation, and others; and industry and public–private partnerships. Moreover, as complex global projects are launched to tackle aspects of personalized medicine, it is now obvious that it is informative to include components focused on the effect of the human microbiome.The collective results of the NIH HMP projects, alongside many other studies, show that the microbiome is an integral component of human biology, with a major role in health and well-being. Inter-individual variability and highly diverse host–microbiome responses over time have driven the development of new methods for population microbiome studies using multiple, complementary longitudinal measurements, as well as highlighting the need to follow such studies up with mechanistic models in order to validate causative associations. The successful close of the HMP program itself has left an enduring legacy of multiple scientific generations of trained human microbiome investigators; provided the resulting community with a wealth of data, analytical, and biospecimen resources; and positioned the NIH and other funding agencies to continue work in a broad range of microbiome-linked conditionsAs with any large study, the HMP2 has raised more new questions than it has answered. The aetiologies of baseline inter-individual differences in the microbiome, and of its dynamic changes over time, were not apparent even from the wide range of measurement types incorporated into these three studies and populations. Many immune and biochemical responses appear to be associated with specific strains that are unique to one or a few individual hosts, but it is not clear whether such strains are sufficient or necessary for their associated disease phenotypes. A few mechanisms were identified by which signals in the gut can be transmitted to systemic conditions such as diabetes, but not the specific small molecules or immune cell subsets by which they are likely to be transmitted—particularly in other health conditions that have not yet been studied in such detail. Finally, each HMP2 study was necessarily carried out within a geographically and genetically constrained population, and global differences in early life events, infectious disease exposure, or diet may change how microbiome dynamics contribute to human disease. Human-associated microbiology now clearly extends beyond infectious and gastrointestinal diseases to areas barely imaginable a few decades ago, including metabolism, neoplasia, maternal and child health, and central nervous system function. As the NIH HMP comes to an end, it is clear that its results have revealed a multitude of new avenues of research and technologies for future investigation, and we look forward to new discoveries based on resources from the program and exciting findings yet to come.


Intakes of the Australian Dietary Guidelines (ADG) food groups were calculated, as well as the major, sub-major, and minor food groups from the Australian Food Composition Database. Each of these food groups provide a progressively greater level of detail. Associations with ADG food groups and major food groups were determined, and the leading sub-major and minor food group sources of fibre for low (Quartile 1) and high (Quartile 4) fibre consumers were profiled. Energy-adjusted intakes of wholegrain and/or high fibre but not refined grain  foods, vegetables, and fruit were positively associated, and discretionary foods negatively associated, with quartile of fibre intake (p < 0.001). The top three sub-major food group sources of fibre were regular breads, cereal mixed dishes, and ready-to-eat breakfast cereals in high fibre consumers and regular breads, cereal mixed dishes, and potatoes in low fibre consumers. White breads was the leading minor food group contributor in low fibre consumers, and apples and lower sugar wheat based breakfast cereal were the leading fibre contributors in high fibre consumers in children and adults, respectively. Higher intakes of wholegrain, fruits, and vegetables, and a lower discretionary intake were associated with higher fibre intake. Encouraging these foods as part of any public health intervention is likely to be effective for increasing dietary fibre intakes.Intakes of dietary fibre in Australia are lower than recommended. An understanding of food choices associated with fibre intake can help to inform locally relevant dietary interventions that aim to increase its consumption. This study aimed to profile the relationship between dietary choices and fibre intake of Australians. Using Day 1 data from the 2011–2012 National Nutrition and Physical Activity Survey ( The benefits of dietary fibre are well established. Increased fibre consumption may support regular laxation  and reduA recent review of studies worldwide, which included the 2007 Australian National Children’s Nutrition and Physical Activity Survey, reported that fibre intakes was lower than recommended in all adult and most childhood populations . In the The Australian Bureau of Statistics (ABS) published the per capita contribution of the major and sub-major food groups to daily fibre intake from the 2011–2012 NNPAS . Foods aIntakes of the other food groups that are sources of dietary fibre, such as fruit, vegetables and legumes/beans, are also lower than recommended. In the 2011–2012 NNPAS, 71–77% of adults and 54% of children and adolescents did not meet the recommended daily serves for fruit (0.5–2 serves for children and two serves for adults), and 95–97% of adults and >99% of children and adolescents did not meet the recommended serves for vegetables and legumes/beans (2–5.5 for children and 5–6 for adults) 36], the A key finding of our study was that discretionary foods did not make a significant contribution to fibre intakes among high consumers. The leading fibre contributors consisted almost entirely of foods from the Five Food Groups for high fibre consumers, whereas among low consumers, potato products  in adults and savory pastry products  in children, which are predominantly discretionary, were in the top ten fibre contributors among low fibre consumers, but not among the top ten for high fibre consumers. Strengths of our study include the use of a large nationally representative sample of children and adults, making our results generalizable to the Australian population. We included the median fibre and total daily intake for sub-major and minor food groups among consumers of these foods, to determine if the differences in fibre intake between high and low consumers were related to the quantities of food eaten or the differences in the fibre content of the foods consumed. Further, we adjusted for the differences in energy intake in our analysis of the associations with ADG food groups. Limitations should also be considered. We used one day of dietary recall to increase the sample size, which may not reflect usual intakes. As with other nutrition surveys, dietary fibre intake from the 2011–2012 NNPAS was affected by under-reporting , and we Increased intakes of grain  foods, specifically whole/high fibre, and fruits and vegetables, and a lower intake of discretionary foods and beverages, were associated with higher fibre intake, in line with the Australian Dietary Guidelines. Cereal (grain) foods were the top sources of fibre in the Australian diet, and high consumers had greater intakes of wholegrain and higher fibre varieties. Similar food groups contributed to fibre intakes among high and low consumers, but high consumers ate more of these foods and chose varieties that were more fibre dense. Results from this analysis can inform the development of food based dietary interventions to facilitate increased fibre intakes, which are currently inadequate.


Alzheimer's disease (AD) and multiple sclerosis are major neurodegenerative diseases, which are characterized by the accumulation of abnormal pathogenic proteins due to oxidative stress, mitochondrial dysfunction, impaired autophagy, and pathogens, leading to neurodegeneration and behavioral deficits. Herein, we reviewed the utility of plant polyphenols in regulating proliferation and differentiation of stem cells for inducing brain self-repair in AD and multiple sclerosis. Firstly, we discussed the genetic, physiological, and environmental factors involved in the pathophysiology of both the disorders. Next, we reviewed various stem cell therapies available and how they have proved useful in animal models of AD and multiple sclerosis. Lastly, we discussed how polyphenols utilize the potential of stem cells, either complementing their therapeutic effects or stimulating endogenous and exogenous neurogenesis, against these diseases. We suggest that polyphenols could be a potential candidate for stem cell therapy against neurodegenerative disorders. Neurodegeneration refers to the progressive loss of neurons in the Central and Peripheral Nervous System (CNS and PNS). Genetic and environmental factors both play a vital role in the progression of neurodegenerative diseases including Parkinson's disease, Alzheimer's disease (AD), and multiple sclerosis (MS) . HallmarNeural stem cells (NSCs) are the cells of the brain that have the remarkable ability to develop into many different types of cells including neurons, astrocytes, and oligodendrocytes . These cPolyphenols comprise a set of naturally derived, synthetically synthesized, and semisynthetic organic chemicals characterized by the presence of multiple phenol structural units. They are mainly secondary metabolites of plants that are involved in defense and mostly present in fruits, vegetables, and cereals. They have immense benefits for health primarily due to their anti-oxidant properties. Many studies have highlighted their potential against a wide range of diseases . In thisβ). Aβ originates by the proteolytic cleavage of transmembrane protein, amyloid precursor protein (APP). Genetic, environmental, and physiological factors are involved in the progression of the disease . P. Pβ-indu pathway , 428. ThAD and MS are the most widespread neurodegenerative disorders characterized by the accumulation of abnormal proteins which give rise to the formation of pathogenic lesions. The severity of these disorders gradually increases with age of the individual. There exists no permanent treatment for these disorders. Therapies include anti-symptomatic drugs, monoclonal antibodies, stem cell therapy, and disease management. Studies are being carried out thoroughly on the use of stem cells as therapeutics against neurodegenerative disorders, and they are presenting promising results validating the safety and tolerability of stem cells in medicine. The use of therapeutic compounds coupled with stem cells for their stimulation is also being analyzed in regenerative medicine. Synthetic drugs and natural compounds such as polyphenols are being used for their potential stimulatory effect on stem cells against neurodegenerative diseases. The key focus of this review is, thus, to highlight the important factors involved in the pathogenesis of AD and MS and stem cell therapies currently utilized in the cure of these disorders and to appreciate the role of polyphenolic compounds in stimulating stem cell proliferation and differentiation as therapeutics against neurodegeneration.ε4, PSEN1, and PSEN2 genes increases the susceptibility of Aβ accumulation in individuals and presents a genetic predisposition to AD. Apart from the genetic factor, exposure to environmental toxicants further aggravates the disease pathogenesis. Harmful exposure to toxic metals like lead and mercury, pesticides like rotenone and paraquat, and xenoestrogens like bisphenols results in elevated aggregation of pathogenic Aβ. This aggregation further impairs the physiological and metabolic functions of the body. Increased levels of apoptotic caspases and proinflammatory factors, elevation of ROS and oxidative stress, and dysfunction of autophagy and mitochondrial biogenesis are all end results of the AD pathophysiology ultimately causing neuronal loss and neurodegeneration. The rescue of the loss of neurons via promoting neurogenesis is promising, and this is where stem cell therapy comes into play. The utilization of endogenous and exogenous NSCs, ESCs, MSCs, and iPSCs has depicted promising results against AD. These stem cells either are engrafted directly or further release factors which in turn stimulate the endogenous NSCs population, thereby bringing about neurogenesis. Stimulation of factors such as BDNF, NGF, VEGF, FGF2, Oct4, Sox2, Pax6, MAP2, and DCX; regulation of Wnt/β-catenin, sonic hedgehog, Notch, and autophagy pathways; and activation of Aβ digesting enzymes such as neprilysin are central to stem cell-induced therapy. Although stem cells cause neurogenesis and neuroprotection in AD, there is wide appreciation of the role of polyphenols in regulating stem cell proliferation and differentiation. Curcumin, resveratrol, green tea extracts, quercetin, and epigallocatechin gallate have been shown to cause neuroprotection in AD via regulation of the above-mentioned NSC markers and stem cell proliferation and differentiation pathways and downregulation of the apoptotic and oxidative stress, thus complementing the stem cell therapy in the treatment of AD.AD is a complex neurodegenerative disorder involving abnormal accumulation of pathogenic amyloid beta species leading to impaired neurogenesis and neuronal death. The presence of mutant APOE ∗15 gene, elevated apoptosis, and oxidative stress; increase in mitochondrial and ion-channel dysfunction; and exposure to environmental toxicants all lead to the pathogenesis of MS. Stem cell therapies complemented with polyphenol treatment have shown promising results in MS pathology although much work remains to be done. Quercetin, resveratrol, and curcumin have depicted positive results with MS by targeting the proinflammatory factors such as TNF-α, IFN-γ, and IL-2 and downregulating their expression. However, a great deal of research still needs to be carried out in studying the involvement of the role of polyphenols in regulating stem cells against MS.MS is another neurodegenerative disease, which is also caused by the accumulation of pathogenic proteins. It is more of an autoimmune disorder which ultimately leads to neuronal cell death. Genetic factors like presence of an abnormal HLA-DRB1The future perspectives involve further studies on the insights into mechanisms underlying the action of polyphenols in regulating stem cells against neurodegenerative disorders. A lot of polyphenols are still left unexplored, and very little research has been carried out to study their role in neurodegenerative disorders. Also, the role of polyphenols against other diseases such as disorders of the metabolism can be tested in case of neurodegeneration. Targeting of new molecular pathways and study of new physiological mechanisms need to be done pertaining to polyphenols and stem cells and how this can be useful in neurodegeneration. The notion of ineffectiveness of polyphenols due to natural origin needs to be abolished as these compounds hold potential promise in the area of medicine.


No difference in dental visits and expenses were found between diet groups. Vegetarian diets are associated with significantly lower medical care expenditure and could be an effective strategy to alleviate the medical–economic burden in selected populations.Vegetarian diets and lifestyle have been shown to reduce the risk of many chronic non-communicable diseases, which now accounts for the major global burden of diseases. We aimed to determine the contribution of vegetarian diets and lifestyle to the actual direct medical cost in a population-based study. Through linkage to the National Health Insurance Research Database of Taiwan, we compared the health care utilization and medical expenditure of 2166 vegetarians and 4332 age-sex-matched omnivores recruited from the Buddhist Tzu Chi Foundation. Diet and lifestyle questionnaires were self-administered and prospectively collected. We used the general linear model to estimate the 5-year average medical expenditure in vegetarians versus omnivores while adjusting for age, sex, education, exercise habits, smoking, and alcohol drinking. Medical expenses related to non-diet associated lifestyle factors  were estimated through a comparison with the published population medical cost data standardized to match the age and sex characteristics of the cohort. Tzu Chi vegetarians had significantly lower outpatient visits. This translated into 13% lower outpatient ( In the Global Burden of Disease Study, population growth, ageing, and decreased death rates shift the disease patterns from communicable, maternal, neonatal, and nutritional causes toward non-communicable diseases . The bigVegetarians typically consume more grains, legumes, vegetables, fruits, and nuts . Vegan dVegetarian diets, by exerting protection against certain diseases, may be an effective strategy to reduce medical care utilization and expenditure, but the actual amount is difficult to calculate since other factors associated with a vegetarian lifestyle  might also play significant roles. Several studies have attempted to estimate the medical cost related to meat consumption or vegetarian diets by published relative risk of common chronic diseases ,17, but This study aims to examine the actual direct contribution of vegetarian diets and lifestyle to healthcare utilization and expenditure in Taiwan. Effects of a vegetarian diet vs. an omnivorous diet on healthcare costs were analyzed by linking a non-smoking, non-alcohol drinking community-based Buddhist cohort (one-third are vegetarians) to the National Health Insurance Research Database. In addition, we compared the cohort participants’ medical expenditure to those of the general population to estimate expenditure related to other lifestyle factors. We hypothesized that vegetarians incur a lower medical expenditure due to lower risks for chronic non-communicable diseases. The Tzu Chi Vegetarian Study (TCVS) is a prospective cohort established to investigate the association between vegetarian diets and chronic disease incidences. Thus far, the cohort has published its results on the incidence of gout . The TCVThe Buddhists Tzu Chi Foundation has many sites throughout Taiwan. In 2005, community leaders in all Tzu Chi sites were invited to distribute research questionnaires to their local community volunteers, and collect and send these questionnaires back upon completion. The study was approved by the Institutional Reviewer Board at the Dalin Tzu Chi Hospital (IRB number: B10403020). Signed informed consent was obtained from all study participants (first page of the questionnaire).In Taiwan, the National Health Insurance (NHI) Program is a government sponsored universal health insurance program that covered 96% of the population in 2001 and expanded to 100% coverage by 2010 ,30. The At enrollment, the participants filled out a questionnaire with sections on demographic information, medical histories, and lifestyle habits including smoking, alcohol drinking, physical activities and diet. The diet section was adopted from the Food Frequency Questionnaire (FFQ) used in the Nutrition and Health Survey in Taiwan (NAHSIT), and included 57 items on food or food groups, and 10 items on cooking methods and cooking oil. A similar questionnaire was later validated among Tzu Chi volunteers and showed good reliability and validity . Vegetarp < 0.05 was considered statistically significant. To estimate the medical expenditure from the Taiwanese population, we used the medical cost statistics from the official website of the Taiwan Ministry of Health and Welfare [The study protocol is shown in  Welfare . PopulatDietary intake (selected items in the FFQ) of the omnivores and vegetarians are shown in . The lower medical expenditure was consistent across the age group strata, though less significant in those aged ≥50. When examining subgroups by sex, we found that a larger discrepancy in medical cost between vegetarians and omnivores were found mainly in females. In this prospective study, we found that vegetarians had a significantly lower direct medical expenditure (15%) when compared with omnivores in our group. A reduction in the medical expenses was found for the treatment of several diet and lifestyle related non-communicable disease and conditions including hypertension, dyslipidemia, and depression. In our study, vegetarian dietary pattern  was associated with a lower total and outpatient medical expense than the omnivorous dietary pattern . The contrast in the dietary patterns also translated into a difference in medical expenditure associated with hypertension, coronary heart disease, and depression. Large prospective US and European cohort studies and meta-analyses of epidemiological studies have indicated that the consumption of red meat is associated with an increased risk of total mortality, cardiovascular disease, colorectal cancer, and type 2 diabetes in both men and women . The totThe omnivore group had an additional 10% reduction of medical expenses when compared with age and sex-matched estimates of the general population of Taiwan, probably as a result of the unique lifestyle of our cohort. Participants of this cohort are devoted Buddhists; they neither smoke cigarettes nor drink alcohol. These participants also volunteer actively in various community services such as recycling, helping the poor, and participating in disaster relief activities. The impacts of smoking and alcohol drinking on healthcare utilization and expenditure have been reported extensively. The annual medical cost related to smoking in the United States has been estimated to be 6–8% of the total personal healthcare expenditure . A recenStrength and Limitations: The strength of this study includes the prospective design to lessen recall bias, and the high follow-up rate due to the nearly complete coverage of the NHI which reduces selection bias. The availability of actual medical expense data enabled us to calculate the direct cost, rather than just estimations based on the relative and absolute risk of diseases. This study also demonstrated the unique contribution of a vegetarian diet to medical expenditure since the lifestyles between vegetarians and omnivores in our study were similar, except for dietary preferences. However, there were several limitations in our study: (1) lifestyle habits such as smoking, alcohol drinking, and physical activity were reported by the study participants and not measured objectively; (2) diet was assessed only at the baseline, and change over time is possible, though this would tend to attenuate the association toward the null; (3) actual medical utilization and expenditure could be influenced by healthcare seeking behaviors in which health conscious individuals may be more likely to seek medical care or detect diseases at an earlier stage, which may initially make them more “costly”, but should reduce long-term medical expenses; and (4) our study was based on a group of devoted Buddhists who abstain from alcohol and tobacco, and generalizability to the whole population requires confirmation from other studies.In short, our study demonstrated that a healthy lifestyle  may reduce the total direct healthcare expenditure by 10% and vegetarian diets may further reduce medical care expenditure by 15% . These results are consistent with other published studies and suggest that the promotion of a vegetarian diet may be a hopeful strategy to reduce the medical–economic burden in selected populations.


Hearing loss is one of the leading causes of disability worldwide. Patients with hearing loss experience impaired quality of life, as well as emotional and financial consequences that affect both themselves and their families. Idiopathic sudden sensorineural hearing loss (ISSNHL) is a common but difficult to treat condition that has a sudden onset of ≤ 72 hour associated with various etiologies, with the majority of cases being idiopathic. There exists a wide range of therapeutic options, however, the uncertainty surrounding their comparative efficacy and safety makes selection of treatment difficult. This systematic review and network meta-analysis (NMA) assessed the relative effects of competing treatments for management of ISSNHL.A protocol for this review was registered with PROSPERO (CRD42017073756). A detailed search of MEDLINE, Embase and the Cochrane Library from inception to February 8th, 2018 was carried out by an experienced information specialist. Grey literature was also searched. Screening full-text records, and risk of bias assessment were carried out independently by two reviewers, and disagreements were resolved through consensus or third party adjudication, while data was collected by one reviewer and verified by a second reviewer. Bayesian network meta-analyses (NMA) were performed to inform comparisons between interventions for a priori specified outcomes that included pure tone average (PTA) improvement and hearing recovery.The search identified a total of 1,138 citations, of which 613 remained for review after removal of duplicates. Of these, 23 publications describing 19 unique studies  met our a priori eligibility criteria, that were assessed to be at unclear or high risk of bias on several domains. We identified data on several interventions for ISSNHL therapy and were able to construct treatment networks consisting of six intervention groups that included placebo; intratympanic (IT) steroid; IT plus systemic steroid; per oral (PO) steroid; intravenous (IV) steroid; and IV plus PO steroid for our NMAs. IT plus systemic steroids demonstrated the largest difference in PTA improvement compared to placebo , followed by IV plus PO steroids , IT steroids . We observed that the difference of PTA improvement between each intervention and placebo diminished over time, attributed to spontaneous recovery. The binary outcomes of hearing recovery demonstrated similar relative ordering of interventions but were less sensitive than PTA improvement to capture the significant differences between interventions and placebo.Unclear to high risk of bias trials rated IT plus systemic steroid treatment as the best among the six interventions compared, and all active treatments were better than placebo in improving PTA. However, it should be noted that certain comparisons were based on indirect evidence only or few studies of small sample size, and analyses were unable to control for steroid type and dosage. Given these limitations, further data originating from methodologically sound and rigorous trials with adequate reporting are needed to confirm our findings. Hearing loss is one of the leading causes of disability worldwide. This isSSNHL, while a somewhat common form hearing loss, is difficult to treat and has major impacts on mental health and quality of life. The annual incidence of SSNHL in the United States is about 27 cases per 100,000 population ,9 and isOur published review protocol for this systematic review provides detailed information on the methodological approach to evidence searching and synthesis, eligibility criteria, study screening and selection, data extraction and quality assessment. We incuThis review adheres to methods recommended by the Cochrane Collaboration for conduct of systematic reviews of interventions, and con®, including Epub Ahead of Print and In-Process & Other Non-Indexed Citations, and Embase Classic+Embase. We also searched the Cochrane Library on Wiley. All searches were performed up to Feb 8th, 2018. Searches utilized a combination of controlled vocabulary  and keywords , and a randomized controlled trial (RCT) filter was applied in MEDLINE and Embase. Syntax was adjusted according to the needs of each database, and animal-only and opinion pieces were removed where possible. The search was peer reviewed prior to execution by a second information specialist using the PRESS Criteria49] and AHarms data were reported in very few of the included trials, and thus again no NMAs were feasible to compare data from all interventions. Data are narratively summarized next.Regarding withdrawals due to harm, two studies reported relevant data. One study reported that one of 24 patients (4.1%) receiving treatment with IV EGb761 (ginkgo biloba extract)+ methylprednisolone+ Oral EGb761 withdrew from the study due to skin eruption. AnotherRegarding tympanic membrane perforation after intratympanic injection of drug or placebo, two studies reported no cases of residual or persistent tympanic perforation  reported data on at least one adverse event such as nausea, vomiting, and headache–50,54,55Due to a lack of data, we were unable to carry out analyses for the a priori subgroups of interest outlined in our published protocol that included gender, age, prevalence of dizziness, patients’ prior history of steroid use, number of days since onset of hearing loss (or time to treatment), and severity of initial hearing loss.Figures A-F in Two studies assessed steroids with and without complementary medicine interventions  after 7 days of systemic steroids with simultaneous IT and systemic steroids in conjunction, which demonstrated no significant difference in hearing gain or earlier recovery rate. Among the 44 patients in the former group, 15 showed complete or partial recovery within 7 days of systemic treatment and did not receive IT dexamethasone treatment. Park and colleagues recommended the use of IT dexamethasone after 7 days of systemic steroid treatment to reduce the risk associated with unnecessary intratympanic injections. We present the NMA-based forest plots of its performance compared with other treatments in term of PTA improvement, responders’ recovery and total recovery in Figures A-C in Park el al. (2011)Three prior systematic reviews assessed PTA improvement (decibels) using meta-analysis–60. Han Three previous reviews assessed dichotomous outcomes of hearing recovery using meta-analysis. Sabbagh et al (2016) reportedIn our review, hearing measured by PTA improvement and by the two binary outcomes responders’ recovery and total recovery demonstrated similar relative orderings of therapies, but slightly different properties of the outcomes were noticed: 1) PTA improvement was more sensitive to capturing differences between interventions and placebo than the binary outcomes of hearing recovery, which were less informative due to dichotomization; and 2) responders’ recovery was more sensitive to identification of differences between interventions and placebo than total recovery.While a strength of this study is its novelty as the first NMA evaluating interventions for this condition, there are also several limitations that should be noted, several of which pertain to limitations of the included studies. We encountered numerous reporting limitations in several studies, including limited reporting of study design information relevant for risk of bias appraisals; many studies failed to provide sufficient information on how patient randomization was implemented, how sequence generation was performed, or if and how treatment allocation was concealed. We encourage authors to reference their trial protocols for transparency purposes. Poor reporting of study design features and methodology may affect internal validity of trials and their associated findings, thus representing a form of waste of resources . Second, there was a lack of clarity about reported effect estimates in several primary studies. For example, it was often unclear if the reported outcome for PTA improvement referred to the difference of PTA change between interventions, or only the difference in post-treatment values between interventions. To address this difficulty, we consulted our clinical experts and contacted the authors of the original trials to request clarity. We strongly encourage authors to carefully define their outcomes along with associated effect estimates. A third limitation of our review is the large between-study standard deviations that were estimated from our network meta-analyses, which may be a consequence of the diverse time of outcome assessment across studies. Analyses presented in Unclear to high risk of bias trials rated IT plus systemic steroid treatment as the best among the compared six nodes. However, consideration of our findings may be limited by no studies or few studies with small sample size for some pairwise comparisons, not having accounted for the types of steroids and dosages, and lack of high quality RCTs. Given the stated limitations of the existing data, further research originating from methodologically sound and rigorous trials with adequate reporting is needed to confirm our findings.S1 Text(DOCX)Click here for additional data file.S2 Text(DOCX)Click here for additional data file.S3 Text(DOCX)Click here for additional data file.S4 Text(DOCX)Click here for additional data file.S5 Text(DOCX)Click here for additional data file.S6 Text(DOCX)Click here for additional data file.S1 Data(XLSX)Click here for additional data file.


Zalophus californianus) and the Pacific harbor seal (Phoca vitulina richardii), is yet to be analyzed. In response to the concerns expressed by local fishermen about the impact of the presence of pinnipeds on their communities’ marine reserves, we conducted underwater surveys around four islands in the Pacific west of the Baja California Peninsula: two without reserves (Todos Santos and San Roque); one with a recently established reserve (San Jeronimo); and, a fourth with reserves established eight years ago (Natividad). All these islands are subject to similar rates of exploitation by fishing cooperatives with exclusive rights. We estimated fish biomass and biodiversity in the seas around the islands, applying filters for potential California sea lion and harbor seal prey using known species from the literature. Generalized linear mixed models revealed that the age of the reserve has a significant positive effect on fish biomass, while the site (inside or outside of the reserve) did not, with a similar result found for the biomass of the prey of the California sea lion. Fish biodiversity was also higher around Natividad Island, while invertebrate biodiversity was higher around San Roque. These findings indicate that marine reserves increase overall fish diversity and biomass, despite the presence of top predators, even increasing the numbers of their potential prey. Community marine reserves may help to improve the resilience of marine mammals to climate-driven phenomena and maintain a healthy marine ecosystem for the benefit of both pinnipeds and fishermen.Community marine reserves are geographical areas closed to fishing activities, implemented and enforced by the same fishermen that fish around them. Their main objective is to recover commercial stocks of fish and invertebrates. While marine reserves have proven successful in many parts of the world, their success near important marine predator colonies, such as the California sea lion ( Marine reserves are geographic areas designated for the conservation and management of ecosystems and natural resources . While dZalophus californianus) and Pacific harbor seals (Phoca vitulina richardii), but also northern elephant seals (Mirounga angustirostris) and Guadalupe fur seals  [Panulirus interruptus) and abalone  [Most islands in the Pacific Ocean off the west coast of the Baja California Peninsula, Mexico, have important populations of pinnipeds, mainly California sea lions (wnsendi) . Local frrugata) , with corrugata) . On Todorrugata) , an aquaBuzos y Pescadores de la Baja California, S.C.L. , with the advice of the non-governmental organization Comunidad y Biodiversidad A.C. (Community and Biodiversity) (COBI), established two marine reserves around Natividad Island  or flatfish (Citharichthys spp.), but also on squid  and octopuses (Octopus spp.) [One of the concerns the fishermen expressed during marine reserve planning meetings with biologists is that the implementation of these marine reserves would solely benefit the pinnipeds on the islands, especially the populations of Pacific harbor seals and California sea lions. They expected that the reserves would facilitate the growth of these populations, thus neutralizing their intended positive effect in terms of available resources for the fishermen. Similar concerns have been expressed for the marine reserves in Puget Sound, Washington, anticipating that harbor seals would be attracted to increased prey abundance in these areas . In thisus spp.) .Spheniscus demersus) colony found that the foraging effort in the colony next to the reserve reduced by 25 to 30% compared with the year prior to the establishment of the reserve. Meanwhile, no significant difference in foraging effort between both years was found in another colony which did not have an established marine reserve [Haliotis rufescens) has shown lower densities in marine reserves where sea otters (Enhydra lutris) have been reintroduced [Few studies have focused on the possible effects of no-take marine reserves on top predators. A comparison between undisturbed and exploited coral reef communities found significantly higher top predator (such as sharks) biomass and density on undisturbed communities . Researc reserve . However reserve . Red abatroduced . In conctroduced .Natividad and San Jeronimo islands may be effective in increasing overall fish biomass and diversity, despite the pinniped populations on the islands.In light of the above, we hypothesized that the marine reserves established at To assess the above described effect, we compared fish biomass and diversity around four islands off the west coast of the Baja California peninsula: two without marine reserves–Todos Santos and San Roque; San Jeronimo, with reserves established the same year as our surveys were conducted; and, Natividad, with reserves that had been established for eight years (since 2006) by the time our surveys were conducted in 2014. There are important harbor seal colonies at all of these sites, while, on Todos Santos, San Jeronimo and Natividad, California sea lion colonies are also found.We conducted underwater surveys around four islands along the Pacific coast of the Baja California peninsula, Todos Santos, San Jeronimo, Natividad and San Roque, with important sea lion and harbor seal rookeries  Fig 1)..Fig 1). Universidad Autónoma de Baja California . Each diver stood suspended on the water column at a depth of between 9 and 22 meters, and took a series of point-count snapshots of the fish present in the 360° around their position and at a distance of up to two meters, for 15 minutes [The surveys comprised the use of survey cylinders and were undertaken by divers from the local community, certified by COBI for scientific diving, and by scientific divers from the  minutes . The div2) and recording all macroinvertebrates one meter to the right and left of the transect line [For macroinvertebrates, a different team of divers swam close to the bottom, at a depth of between 11 and 24 meters, following a 30-meter long transect  version 3.5.3 to construct the GLMMs [In order to analyze the effect of the implementation of marine reserves on the biomass around these islands, we constructed different generalized linear mixed models (GLMM) . Fish bihe GLMMs .The same analysis was employed using the biomass of potential California sea lion and Pacific harbor seal prey, but using a filter database of fish biomass constructed according to the known prey of each pinniped species , 25, 26.a posteriori Tukey tests, while a Kruskal-Wallis test was applied to establish invertebrate diversity. Minitab 17 was used for both analyses [Species accumulation curves were used to measure fish and macroinvertebrate species richness, while Simpson’s diversity index, using EstimateS 9.1, measured biodiversity . We chosanalyses .Fish biomass, considering all species and survey points both within marine reserves and beyond (n = 55), was highest around Natividad Island, followed by San Roque, San Jeronimo and Todos Santos islands . After fIn all models, the data show a gamma distribution. According to its AIC value, the best model uses the fish biomass as the response variable and both the level of protection of the site (inside or outside of a reserve) and the years since the marine reserve were established as explanatory variables . The resAfter filtering the biomass of potential California sea lion prey, the best model used potential prey biomass as the response variable, and the protection of the sampling site and the years since the establishment of the marine reserve as explanatory variables . In thisThe best model for the biomass of potential Pacific harbor seal prey had the same variables, with none of the explanatory variables having a significant effect on the biomass of potential prey. In this model, it was the protection of the sample site that had a small negative effect on biomass Tables  and S3.Although fish species richness was higher around Natividad than the other islands (n = 31), the sampling effort here was also higher, as can be seen in the fish species accumulation curve . The effFinally, the macroinvertebrate species accumulation curve  shows thThe results of the present research showed that, even though similar exploitation methods and rates are found on all four islands studied here , fish biIn the case of San Jeronimo, the date on which the reserve was established was too close to the survey dates to show any significant improvements over islands without reserves. However, as with the results for Natividad, an effective increase both in biomass and in biodiversity may also be expected at San Jeronimo Island.Synodus lucioceps), flatfish (Citharichthys spp.) rockfish (Sebastes spp.) and toadfish (Porichthys notatus), as well as octopus (Octopus spp.) and squid  [All four islands under study have important harbor seal colonies, with colony sizes of 473 individuals on Todos Santos, 523 on San Jeronimo, 724 on Natividad and 633 on San Roque recorded during the pupping season of 2009 . Their dlescens) . When thlescens) .California sea lion colonies are typically larger than harbor seal colonies because their population in the region is much higher, estimated at 33,447 in 2010 , compareOur results showed that the biomass of potential California sea lion prey was higher around Natividad, with the model showing a significant effect of the age of the reserves, with Natividad the only island with eight-year-old reserves at the time of sampling. Around San Jeronimo, which has a colony with a similar size, the prey biomass mean was up to four times lower. This indicates that the implementation of marine reserves has not only the potential to recover fisheries production, but also to increase potential pinniped prey biomass and overall fish diversity, thus potentially benefiting pinniped populations , 9.The last point discussed above is important in two main ways. Firstly, it would give these predators more resilience to cope with adverse oceanographic conditions, such as the El Niño-Southern Oscillation , 39, minIn conclusion, our results show that overall fish biomass and diversity increases after marine reserves have been established for a number of years, even in the presence of large pinniped colonies. These reserves also have the potential to mitigate climate-induced stress on their populations, as well as increasing potential prey biomass; therefore, they may help pinniped population health and, by increasing prey availability, may reduce competition for common resources between fishermen and pinnipeds.S1 Table(PDF)Click here for additional data file.S2 Table(PDF)Click here for additional data file.S3 Table(PDF)Click here for additional data file.


To examine the factors associated with caregivers’ burden in individuals providing care to family members suffering from serious mental illness.This Cross Sectional Study was carried out at Armed Forces Institute of Mental Health, Rawalpindi, from May 2015 to December 2015. A purposive sample of 120 family caregivers  who were taking care of patients with serious mental illness  for at least one year were recruited from the hospital and assessed through Zarit Burden Interview (ZBI) and Brief COPE inventory. The decline in functional status, and diminished physical capacity compromising the independent living of the care recipient was assessed through Katz Index of Independence in Activities of daily living (ADL) and Lawton Instrumental activities of daily living (IADL).The results suggest that the longer the duration of illness , with increased impairments of care-recipients,  the more the burden experienced by the caregivers. Moreover, caregivers who were married , less educated , lived in rural area , had lower monthly income  provide longer hours of caregiving  and used avoidant coping behavior  reported significantly higher caregiver burden than caregivers who were unmarried, more educated, lived in urban area and had better income.The results of study demonstrate that caring for family members with serious mental illness impacts the caregivers’ wellbeing. It, therefore, highlights the need for support and counseling services for the caregivers to reduce the burden of caring. Providing care to family members suffering from prolonged illness challenges the wellbeing of the caregivers. The task of caregiving becomes further challenging if the family member is suffering from a serious mental illness as the stigma of mental illness adds to this burden of caring. This assumes a critical significance as the prevalence of mental illness is gradually increasing with approximately 151 million people suffering from depression and 26 million from schizophrenia .The patients suffering with serious mental illness develop a strong dependency on caregivers mainly due to the significant impairment associated with their illness. This dependency and responsibility for caring affect quality of life of caregivers impacting their health, work, socializing, relationships and adds to their distress.6Care givers’ burden is slowly being recognized in Pakistan, especially in the context of chronic conditionsThe study included 120 family members  who were primary care givers, for at least one year, of patients suffering from schizophrenia, bipolar disorder or Major depressive disorders without any comorbid illness. They were approached from both outpatient and inpatient departments of Armed Forces Institute Mental Health (AFIMH) Rawalpindi.Care recipient’s physical health status were assessed through Katz Index of Independence in Activities of daily living (ADL)The data was first checked for normality and accuracy then analyses were carried out with the help of SPSS (version 18). The skewness of the data was found to be in the accepted range . The statistical analyses were carried out to determine mean differences through t-test and ANOVA and prediction analysis were carried out through regression analysis after analyzing the association through Pearson’s and biserial correlations between various factors and outcome variable.The mean age of care-recipients was 34.6 years (SD = 12.3), and predominantly women (61%) who had serious mental illness (major depressive disorder (46%), bipolar disorder (42%) and schizophrenia (32%). They included parents (25%), children (30%), siblings (25%), and spouses (24%).The caregivers who were married , less educated , lived in rural area , and had lower monthly income  experienced significantly higher caregivers’ burden than caregivers who were unmarried, more educated, lived in urban area and had better income.The analysis of increasing levels of burden , show thMoreover, except for caregivers’ age and gender, moderate to strong significant relationships exists between caregiver‘s socio-demographical factors ; illness-related factors , caregiving-related factors (hours of caregiving and coping behavior of caregivers) and caregivers’ burden . The hieThe study examined the contribution of socio-demographic and illness related factors to the burden experienced by caregivers of patients with serious mental health conditions. The findings suggest that all three groups of predictors  explained caregivers’ burden. The illness-related factors, indicating functional status of care-recipients, were the most significant predictors in the study, contributing to 17% of caregiver burden, followed by caregivers’ socio-demographical and caregiving-related factors, each of which represented 16% and 12% of caregivers’ burden respectively. The findings highlight that caring for family members with serious mental health conditions compromises the wellbeing of the caregivers and the risk increases for caregivers who live in a rural area, have minimum education, meager income and have limited resources to engage in problem solving. It also highlights that with increased dependency on caregivers, more hours of caring would be expected from the caregivers; which would exhaust the caregivers’ capacity to manage care demands with problem solving style. This may lead to resorting to emotion-focused strategies, i.e. practices based on religion or social connections such as venting or sharing and religious practices and rituals. This may also result in caregiver’s fatigue leading to avoidance of responsibility. It appears plausible that the demands of caring, along with caregivers own emotional load would reduce their capacity to focus the care demand in a pragmatic manner. The distress experienced due to increasing care needs of the mentally ill family member thus compromises the quality of life of the caregivers. The care recipient being a close family member, cost and stigma of mental illness,The study highlights the need to counsel the family caregivers and facilitate them when they accompany their family members for their health needs. This is important to ensure the sustained care received by the mentally ill patients and help the caregivers’ stay in good health themselves to take care of the care demands. Furthermore, as many socio demographic factors- for instance income, education, residence in rural areas- contribute to caregiver’s burden, a formal care giving service needs to be established which is regulated by government. This is a neglected area in Pakistan and requires the attention of all stakeholders. Besides making the formal caregiving service available, the approach to community wellness and mental healthThe study though highlights the role of socio demographic and illness related factors as contributing to caregivers’ burden, the sample was limited to one tertiary care setting where most of the patients were entitled for treatment because of either having served in Armed Forces or having a family member serving in Army. It is expected that level of burden would change if the cost to treatment is also involved as other associated sociodemographic factors are seen in this study to increase the burden. It would, therefore, be of interest to carry out further research which rectifies this limitation.A moderate to severe level of caregivers’ burden was found among individuals caring for family members suffering from serious mental illness. Functional decline of care-recipients followed by caregivers’ socio-demographical factors and caregiving-related factors were found to be the most significant predictors of caregivers’ burden.SS: Contributed to research design and analysis, supervised the research, sought approval from the Study Site and Ethical board. Improved and updated the write up for publication.JK: Designing, Data Collection, Statistical data analysis and Interpretation of data, preparation of the manuscript.