The aim of this study was to examine the relationship between visual field (VF) loss, vision-related quality of life (QoL) and glaucoma-related symptoms in a large cohort of primary open angle glaucoma (POAG) patients. POAG patients with or without VF defects or “glaucoma suspect” patients were considered eligible. QoL was assessed using the validated versions of the 25-item National Eye Institute Visual Function Questionnaire (NEI-VFQ-25) and glaucoma-related symptoms were assessed using the Glaucoma Symptom Scale (GSS). Patients were classified as having VF damage in one eye (VFD-1), both eyes (VFD-2), or neither eye (VFD-0). 3227 patients were enrolled and 2940 were eligible for the analysis. 13.4% of patients were classified in the VFD-0, 23.7% in the VFD-1, and 62.9% in the VFD-2 group. GSS visual symptoms domain (Func-4) and GSS non-visual symptoms domain (Symp-6) scores were similar for the VFD-0 and VFD-1 groups . VFD-0 group had higher scores than VFD-2 both in Func-4 (p < 0.001) and Symp-6 domains (p = 0.035). Regarding the NEI-VFQ-25, our data demonstrated that bilateral VF defects are associated with vision-related QoL deterioration, irrespective of visual acuity. It is estimated that approximately 60 million people worldwide have glaucoma and 8.4 million patients are bilaterally blind1. Of the many types of the disease, primary open angle glaucoma (POAG) is by far the commonest in populations of European origin3. As a chronic, progressive, vision-threatening disease, POAG can severely affect vision-related quality of life (QoL). Visual decline is a direct consequence of the glaucomatous process and can lead to limitations of daily functioning and loss of autonomy, thus causing deterioration of vision-related QoL and significant psychological burden5. In addition to the degradation of QoL due to the disease-related visual decline, factors such as adverse events of medication, cost of treatment, or even the distress elicited by the mere diagnosis of an irreversible, potentially blinding disorder can adversely affect the patient’s sense of well-being and QoL13.Glaucoma constitutes a major global cause or irreversible visual loss14. Evidence has shown that patients with glaucoma often have problems with important daily activities such as walking15, driving18, or reading18, especially when perimetric damage is advanced or when both eyes are affected. Despite the recent interest in glaucoma-related QoL issues22, the relationship between vision-specific QoL and severity of visual field (VF) defects or number of eyes with perimetric loss warrants further exploration in sufficiently powered studies. In addition, the relationship between severity of VF damage or number of perimetrically affected eyes and glaucoma-related visual and non-visual symptoms needs to be better characterized in adequately sized studies.The importance of preserving vision-related QoL at a sustainable cost has become increasingly recognized in glaucoma management23, we described the methodology of the Italian Primary Open Angle Glaucoma Study (IPOAGS) and the baseline characteristics of the participants. In addition, that paper reported the association between vision-related QoL assessed with the 25-item National Eye Institute Visual Function Questionnaire (NEI-VFQ-25) and glaucoma-related symptoms assessed with the Glaucoma Symptoms Scale (GSS) questionnaire23. It also presented the association between the NEI-VFQ-25 and GSS scores with glaucoma severity in a sample of 3169 patients23. In the current paper, our analysis was primarily focused on the impact of glaucoma (in terms of vision-related QoL and glaucoma-related symptoms) according to the number of perimetrically affected eyes. Therefore, the aim of the current report is to describe the characteristics of IPOAGS patients who have no-, one-, or both eyes with visual field loss, and examine the association between the number of perimetrically affected eyes and NEI-VFQ-25 and GSS scores.In a previous paper of ours23. Briefly, twenty-one academic and non-academic Italian institutions were involved in the recruitment. Patients aged >18 years with a previous or new diagnosis  of POAG were invited to participate during regular visits and were consecutively enrolled. Patients were considered eligible for inclusion if they had optic nerve head damage typical for glaucoma, i.e. focal and/or generalized neuroretinal rim thinning or cup/disc ratio asymmetry >0.2 in the absence of other neurodegenerative diseases. The presence of characteristic glaucomatous visual field defects was not a prerequisite for inclusion. Women who were pregnant, breast-feeding or had plans to become pregnant were excluded. Other exclusion criteria were the concurrent abuse of alcohol or illicit substances, and the participation in any clinical trial that tested medications or medical devices within 30 days prior to recruitment. The validated Italian version of the NEI-VFQ-25 was used for the assessment of vision-related QoL24. The validated Italian version of the GSS Questionnaire25 was used for the assessment of glaucoma-related visual and non-visual symptoms.Details regarding the multicenter IPOAGS study have been described elsewhere28. The scoring procedure converts the pre-coded numeric values of each item to a score ranging from 0 to 100. Higher scores reflect better vision-related QoL. The global score is the mean score of all items that constitute 11 of the 12 subscales, with the exception of the single item that constitutes the general-health subscale.The NEI-VFQ-25 is a self-administered 25-item, 12-subscale questionnaire assessing the following: general health, general vision, ocular pain, near activities, distant activities, social functioning, mental health, role difficulties, dependency, driving, color vision, and peripheral vision29, a glaucoma specific tool, is a modified version of a checklist of symptoms developed by the Ocular Hypertension Treatment Study group. The tool includes 10 items grouped into two domains: Symp-6 for non-visual symptoms  and Func-4 for visual symptoms . The ten items assess each eye separately using a scale from 0 to 100, where zero indicates the presence of a very bothersome symptom and 100 the absence of the symptom. The domain score is the un-weighted average of the scores of the items that make up the domain in question. Similarly, the total GSS score is the mean of the 10 item scores. GSS scores can be calculated as average of the two eyes and for each eye separately.The GSS Questionnaire32. The Glaucoma Staging System 2 is a classification method31 that uses Mean Defect or Mean Deviation (MD) and Pattern Standard Deviation/Corrected Pattern Standard Deviation (PSD/CPSD) or Loss Variance/Corrected Loss Variance (LV/CLV) values (from either the 30-2/24-2 Zeiss-Humphrey tests or the G1/G1X/G2 Octopus programs) on a Cartesian coordinate diagram. The visual fields are divided in seven different stages by curvilinear lines from stage 0  through borderline to stage 5 . This nomogram allows the user to quickly determine the stage of the disease , the Glaucoma Staging System 2 has been demonstrated to be preferable for its ease of use for clinicians and researchers alike35. Furthermore, it has been used in population-based studies and clinical trials40.The severity of VF damage was classified according to the Glaucoma Staging System 2Based on the presence of glaucoma and perimetric damage, eyes were classified in three categories: a) eyes without signs of glaucoma (WOG), i.e. fellow eyes of patients with unilateral glaucoma; b) eyes with glaucoma but no VF damage (WOD), i.e. “pre-perimetric” glaucoma: VF stage 0-borderline; c) eyes with glaucoma and VF damage . Participants, on the other hand, were classified in three categories: patients without VF damage in any eye (VFD-0), patients with VF damage in one eye (VFD-1), and patients with VF damage in both eyes (VFD-2). Two analyses were performed, one considering patients as units of analysis, and one considering eyes as units of analysis.Descriptive summary statistics are presented as mean, standard deviation, minimum and maximum values for continuous variables, and as absolute frequency and percentage for categorical variables. The Chi-square test for trend and linear regression were used to investigate associations between VF and clinical characteristics. When considering patients as units of analysis a linear regression model was fitted to test the effect of number of eyes with VF damage on questionnaires scores . For each subscale, as well as for the total score of both the NEI-VFQ-25 and the GSS questionnaires, a multivariate model was fitted with the following covariates: age, best corrected visual acuity , previous treatment (treated versus untreated) and number of eyes with VF damage . VFD-0 was chosen as reference group for the latter variable; therefore p-values for VFD-1 and VFD-2 refer to the comparison of these groups versus VFD-0. For the “previous treatment” variable, untreated previously diagnosed or newly diagnosed patients were considered “untreated”, while previously diagnosed patients who had received medical and/or surgical treatment  were considered “treated”.When considering eyes as units of analysis, since we had to consider more than one measurement on the same subject , we needed to consider the correlation between these variables on the same subject. This analysis was performed with a mixed model in order to take into account the correlation between eyes of the same subject (performed with mixed procedure). In our analysis the covariance structure hypothesized was the unstructured matrix. “Unstructured” means that no constraints were imposed on the values of covariance and variance. Therefore, the model estimates these quantities. Because there are about 6000 observations in our analysis, our study had the statistical power necessary to estimate the covariance structure from the data without compromising the efficiency of the model.Two multivariate analyses were performed to test the effect of presence and stage of VF damage at eye level on GSS questionnaire scores: the covariates of the first analysis included eye groups according to presence of glaucoma and VF damage , age, BCVA and previous treatment (treated versus untreated). The covariates of the second analysis included VF stage (according to the Glaucoma Staging System 2), age and BCVA. All analyses were performed with the SAS software (version 9.2).The study was conducted in accordance with the tenets of the Declaration of Helsinki and the Guidelines for Good Clinical Practice. The ethic committee of Brescia , and of each participating centre approved the protocol . For inclusion, patients had to provide informed consent after the nature and purpose of the survey were fully explained. The study was registered with clinicaltrials.gov (NCT01742104).The datasets generated during the current study are available from the corresponding author on reasonable request.From March 2012 to July 2013, 3227 patients were enrolled in 21 centers. Two hundred eighty seven patients were subsequently excluded due to incomplete filling of questionnaires (n = 58), incomplete data on staging (n = 47) or missing data on BCVA (n = 182). Consequently, 2940 patients were included in the per-eye analysis. As data on both eyes was not available for all patients, 2823 patients were included in the per-patient analysis. The demographic characteristics of the participants are presented in Table Three hundred seventy eight patients (13.4%) were grouped as VFD-0, 669 (23.7%) as VFD-1 and 1776 (62.9%) as VFD-2. Having more eyes with VF damage was associated with older age (p < 0.001) and worse BCVA (p < 0.001), but not with gender and race. Family history (p = 0.029), myopia (p = 0.012), diabetes (p < 0.001) and hypertension (p = 0.001) were all risk factors for having bilateral VF damage.The percentage of patients using glaucoma medications was increasingly higher as the number of eyes with VF defects increased . Similarly, the percentage of patients using systemic concomitant treatments was increasingly higher as the number of eyes with VF defects increased   out of 5729 eyes were classified as WOG, 1304 (22.8%) as WOD and 4319 (75.4%) as WD.Results of the GSS questionnaire based on presence of glaucoma and VF loss are depicted in Fig. The analysis of GSS results based on stage as determined with Glaucoma Staging System 2 is depicted in Fig. 42.In the current study, being older was associated with a higher number of perimetrically affected eyes. A possible explanation for this association is that glaucoma is a chronic disease of the elderly, and the chances of perimetric defects appearing in one or both eyes increase with advancing age. Moreover, we found that factors such as family history, myopia, diabetes and systemic hypertension were associated with bilateral VF damage. These conditions have not consistently been demonstrated to be risk factors for the onset and progression of the disease44, calcium channel blockers45 or diuretics46 have an influence on glaucoma risk. The exact effect of common systemic vasoactive medications on glaucoma risk remains to be determined. In the case of systemically administered β-blockers for instance, although this class of medications can have a protective effect in glaucoma because of a certain ocular hypotensive effect, the concurrent reduction in blood pressure may compromise optic nerve perfusion pressure47. In fact, evidence from population-based studies has shown that systemic hypotension may be associated with an increased prevalence and incidence of open-angle glaucoma50.The proportion of patients using concomitant systemic treatments was higher for those with VF damage. Evidence has shown that systemic medications such as statins22. In the Los Angeles Latino Eye Study for instance, adults with glaucoma experienced measurable loss in QoL early in the disease process22. Our data from a larger, ethnically different population are in accordance with those results: we found that patients with VF damage in one eye had lower vision-related QoL scores in three of twelve NEI-VFQ-25 subscales compared to patients without VF damage in any eye. There are several reasons for the deterioration of QoL in early glaucoma. The most important is obviously related to the adverse effects, inconvenience and cost of antiglaucoma medications53. Another reason may be the psychological burden of suffering from a potentially blinding disease54. This psychological pressure may explain the observation that even the diagnosis of “glaucoma suspect” is associated with deterioration of vision-related QoL56. At least in theory, a third reason that could explain the deterioration of vision-related QoL even in perimetrically unaffected glaucomatous eyes is that certain aspects of visual function beyond retinal sensitivity, such as color perception, contrast sensitivity and motion perception are affected early in the glaucomatous process58.Deterioration of vision-related QoL has been reported even in patients with early VF lossIn our study, both visual and non-visual glaucoma-related symptoms were more bothersome with increasing stage of perimetric damage. Of note, eyes with pre-perimetric glaucoma (or eyes suspicious for glaucoma) had worse score in the non-visual symptoms domain and worse total score at the GSS questionnaire than eyes without glaucoma. We believe that the worse symptom scores in these eyes are due to the use of anti-glaucoma medications.59. Several studies have shown that patients with binocular VF loss experience severe difficulties in activities of daily life, such as reading, moving around or driving18. The location of VF defects may also play an important role in the patients’ functioning and perception of vision-related QoL22. For example, Sawada et al.60 have shown that perimetric defects in the lower paracentral visual field of the better eye have the strongest correlation with NEI-VFQ-25 scores. These authors also reported that defects in the upper temporal visual field have a strong impact on the driving subscale of the NEI-VFQ-25 questionnaire , while defects at the lower peripheral visual field strongly correlate with subscales such as role limitation  and peripheral vision 60. Other investigators have found that superior perimetric defects in binocular integrated visual fields are associated with difficulty with near activities, while inferior perimetric defects in binocular integrated visual fields are associated with vision-specific role difficulties, as well as general and peripheral vision61.In the present investigation, patients with glaucoma and VF damage in both eyes had significantly worse scores in both the non-visual and the visual symptom domains of the GSS tool compared to patients without VF defects in any eye. The visual symptoms domain in particular showed good discrimination between patients with visual field defects in both eyes and patients without visual field defects in any eye. In patients with advanced glaucoma, the areas of VF defects in each eye may coincide, resulting in binocular VF loss64.Our report provides evidence that VF loss is associated with decreased vision-related QoL in a manner that is independent of BCVA deterioration. To date, several studies have shown that visual acuity loss is one of the causes associated with lower vision-related QoL in glaucoma patients80. However, our sample cannot be considered representative in a strict methodological sense because it was not formed by means of random inclusion from a central nationwide registry. Since such a registry is not available, our sample can be considered as close as possible to being representative by virtue of its wide-ranging geographical distribution, recruitment from diverse academic and non-academic centers, and size.The current study constitutes the largest investigation on vision-related QoL and glaucoma-related symptoms82. In general, the evaluation of QoL using a questionnaire has some limitations. One of them is that QoL assessment is subjective, so that patients with similar disability may rate their QoL differently. Another inherent limitation of this type of investigations is that self-reported visual ability can be impaired, at least to some extent, by several ophthalmic and systemic comorbidities and psychosocial constraints. Conceivably, even when VF indices such as MD are comparable, a multitude of diverse determinants such as spatial distribution and depth of VF scotomas or speed of VF deterioration may affect differently patients with dissimilar lifestyles and expectations83. A certain limitation of our eye-level analysis is that the “non-glaucomatous” eyes (WOG) were not eyes of healthy controls, but fellow eyes of patients with monocular glaucoma  compared to patients with VF defects in one eye, and better NEI-VFQ-25 scores in all subscales compared to patients with VF defects in both eyes. At the eye level analysis, after adjusting for age and BCVA, eyes without glaucoma had significantly better scores than eyes with glaucoma that had VF defects or eyes with glaucoma that did not have VF defects in both the visual and non-visual symptom domains of the GSS instrument. A significant inverse relationship between VF stage and both the visual and non-visual symptom scores of the GSS tool was seen after adjustment for age and BCVA.


Numerous studies have noted that populations treated with statins have increased risk for new-onset diabetes mellitus; however, the underlying molecular mechanisms are not fully understood. Interestingly, familial hypercholesterolemia (FH) patients with mutations in the low-density lipoprotein receptor (LDLR) gene are protected against diabetes mellitus (DM), despite these patients being subjected to long-term statin therapy. Since the common pathway between FH and statin therapy is LDLR-mediated cellular cholesterol uptake, the arising question is whether the LDLR plays an important role in the diabetogenic effect of statins. Indeed, given that statins can regulate the LDLR expression in liver and peripheral tissue, there is a possible mechanism that the increased LDLR causes cellular cholesterol accumulation and dysfunction in pancreatic islets, explaining why statins fail to increase the risk of DM in FH patients. In this paper, with regarded to recent literatures, we highlight the role of LDLR in the pathophysiology of cholesterol-induced pancreatic islets dysfunction, which may provide the key link between statins treatment and the increased risk of new-onset diabetes mellitus. Statins are first-line drugs for treating hypercholesterolemia and used for primary and secondary CVD prevention. However, with the increasing clinical application of statins, accumulated evidence from clinical trials suggests that statins can increase the risk of new-onset DM, but the underlying pathological mechanism remains to be determined . StatinsPrevious studies suggest that statins also act by inhibiting glucose transporter 4, isoprenoid, Coenzyme Q10, Dolichol Biosynthesis and other mechanisms to cause insulin resistance and diminished insulin secretion in patients . Neverthin vitro and in vivo studies  (Table 1) (Table 1). They also concluded that long duration of high statin treatment did not seem to be associated with diabetic risk in FH patients. These results were confirmed by other studies (Table 1) (Table 1)  . This phTable 1) . SkoumasTable 1) . A recenTable 1) . Data frFigure 1). SREBP-2 is known as a transcription factor, which efficiently stimulates transcription of LDLR and other sterol-regulated genes  . On the one hand, cellular cholesterol accumulation may lead to increased oxysterols, which are the natural ligands for liver X receptor (LXR). Activation of LXR can positively regulate transcription of inducible degrader of the LDLR  to degrade the LDLR    . As a reigure 1) . In statigure 1) . Neverthigure 1) . On the igure 1) . In contIn vitro, the addition of LDL-C to rat islet β cells results in cell death in an LDLR-depended manner (In-vivo studies provide further evidences that the LDLR may play a key role in islet function (Hyperlipidaemia increases the risk for both CVD and T2DM, suggesting that lipid-lowering drugs for treating CVD may also have protective effects on pancreatic islets and thus prevent the onset of T2DM. For instance, bezafibrate that is a fibrate drug used as a lipid-lowering agent to treat hyperlipidaemia, is also proven that can reduce the incidence and delay the onset of T2DM in high risk patients . In addid manner , while td manner . Furtherfunction . Using tfunction . Similarfunction . Not onlfunction . CombineThe common pathway in FH and statin-induced DM is LDLR-mediated uptake of LDL-C, and elucidation of this pathway may help us to understand the potential mechanism for the diabetogenic effects of statins. Moreover, this pathway closely associates with the pharmacological effect of statins but is independent of the type of statin. If this pathway is proven, we can not only utilize it to prevent the diabetogenic effects of statins but can also target this pathway to treat T2DM.QY proposed this hypothesis and analyzed the literatures and wrote the manuscript. YC collected the literatures and revised the manuscript. CBX contributed to crucial revisions in the manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


It is unclear whether the treatment of an HIV infection with highly active antiretroviral therapy (HAART) affects intensive care unit (ICU) outcomes. In this paper, we report the results of a systematic review and meta-analysis performed to summarize the effects of HAART on the prognosis of critically ill HIV positive patients.Methodological Index for Non-Randomized Studies (MINORS) tool.A bibliographic search was performed in 3 databases  to identify articles that investigated the use of HAART during ICU admissions for short- and long-term mortality or survival. Eligible articles were selected in a staged process and were independently assessed by two investigators. The methodological quality of the selected articles was evaluated using the Twelve articles met the systematic review inclusion criteria and examined short-term mortality. Six of them also examined long-term mortality (≥90 days) after ICU discharge. The short-term mortality meta-analysis showed a significant beneficial effect of initiating or maintaining HAART during the ICU stay . The data analysis of long-term outcomes also suggested a reduced mortality when HAART was used, but the effect of HAART on long-term mortality of HIV positive critically ill patients remains uncertain.This meta-analysis suggests improved survival rates for HIV positive patients who were treated with HAART during their ICU admission. The epidemiology of human immunodeficiency virus (HIV) infection and acquired immune deficiency syndrome (AIDS) has changed since the introduction of highly active antiretroviral therapy (HAART) in 1996 . The morHIV-infected people are at higher risk for critical illnesses than demographically matched HIV-negative individuals with similar comorbidities . OpportuHowever, it is still uncertain which aspects of the clinical management of HIV affect the patient’s outcome in the ICU. The use of HAART in this setting, as initiation or maintenance, is still a matter of concern, due to possible changes in its bioavailability, associated adverse effects, and the risk of induction of viral resistance ,8,10.Therefore, we performed a systematic review and meta-analysis of published studies that focused on the impact of HAART on the outcomes of HIV-infected patients admitted to the ICU. To our knowledge, a systematic review on the use of HAART during the ICU stay has not been performed so far. Consequently, our hypothesis was that the use of HAART during critical illness could influence the short-term  and/or the long-term  outcomes.http://www.crd.york.ac.uk/PROSPERO/): registration number CRD42015026739.This study was registered on the International Prospective Register of Systematic Reviews (PROSPERO http://www.ncbi.nlm.nih.gov/pubmed/), Web of Science (Thomson Reuters http://wokinfo.com/) and Scopus (Elsevier http://www.scopus.com/) to identify studies published in English from the time that HAART was considered a viable treatment option and that investigated the prognostic factors for survival or mortality in critically ill adult patients with HIV/AIDS. The search was conducted for short-term and long-term mortalities.An electronic search was performed on 09/14/2017 using three online medical reference databases: PubMed  AND .Specific string terms were used for Scopus due to its search engine characteristics: search—TITLE-ABS-KEY (hiv) OR TITLE-ABS-KEY (aids) AND TITLE-ABS-KEY  OR TITLE-ABS-KEY (intensive care) OR TITLE-ABS-KEY  OR TITLE-ABS-KEY  AND SUBJAREA  AND PUBYEAR > 1995.The articles were identified in a staged process whereby titles were initially screened for potential eligibility by a single reviewer (HBA). Exclusion criteria were as follow: review articles, letters to the editor, opinions, or comments; articles that evaluated pregnant women or pediatric populations; articles that lacked HIV-or ICU-specific data; and articles that lacked an outcome evaluation or had no outcome of interest .Following this selective review, the abstracts were read by two reviewers (HBA and CRS) for possible eligibility. Articles were eligible if the following criteria were met: publication date after 01/01/1996; study of adult humans (age>18 years); information collected after HAART was approved for use; risk factors for the outcomes of interest; and clear and available information about the outcome of interest: short-term mortality , or long-term (≥90 days) mortality after ICU discharge.Finally, the reviewers (HBA and CRS) searched full-text articles that focused specifically on the impact of the use of HAART during the ICU stay and/or the prognosis of critically ill HIV patients and included articles that reported short- and long-term mortality data in regression analyses. The bibliographies of the articles were also reviewed to determine if any relevant studies could be considered. Disagreements between reviewers were resolved by a third reviewer (AMJ).www.project-redcap.org) sheets independently by HBA and CRS (data extraction sheets available on request). The following data were collected from each article: study design, method of data collection, number of HIV patients, mortality with and without HAART and demonstrated strength of association  and/or hazard (HR) ratios, 95% confidence intervals (95%CI), and p-values (<0.05) for each of the studied outcomes). The methodological quality of reporting of the selected articles was assessed by two reviewers (HBA and CRS) using the Methodological Index for Non-Randomized Studies (MINORS) tool score system [Data was extracted onto standardized data extraction REDCap (web-based data capture tool for research studies e system .http://tech.cochrane.org/revman/download) after importing REDCap data as Microsoft Excel 2016 compatible spreadsheets files. The comparison of the dichotomous primary outcome  was conducted using a conventional Mantel-Haenszel random effects meta-analysis and posterior sensitivity analyses, which were reported as odds ratios with 95% confidence intervals (CI). Heterogeneity of study-specific results was quantified using the descriptive I2 inconsistency measure. Possible publication bias was inspected using asymmetry tests (funnel plots).The software used for data analysis was the Review Manager 5.3.5 for Mac OS X . Conversely, the length of follow-up was diverse among the selected studies: 5 studies followed patients up to hospital discharge, 2 studies followed patients for 6 months, another 2 studies followed patients for a year, and 3 other studies presented different periods of follow-up. The selected 12 articles were conducted in various countries and were published between 2003 and 2015. All the articles were single center retrospective cohort studies, with an absolute total number of 1,584 HIV patients who were admitted for intensive care. Generally, the characteristics of the population in most studies were similar. The mean CD4 cell count was below 200 cells/mmThe methodological quality of the 12 studies were heterogeneous. Although all studies were retrospective in nature and the main goals were stated, there was bias in the assessment of endpoints, loss of follow-up was common (5 out of 12 studies), and the control group was not equivalent or contemporary to the studied group (6 out of 12). No study reported calculation of the its sample size. The twelve criteria used for scoring are detailed on the Appendix in 2 77%) with a significance level of p<0.00001. The funnel plot analysis showed four studies [The meta-analysis of eleven articles –15,17–23 studies ,15,21,22We investigated whether the initiation or maintenance of HAART during the ICU stay were associated with the outcome. The information on HAART prescription during the ICU stay was not uniform across all articles. It was reported in only 6 articles ,19–21,23Six articles ,19,21,22This systematic review and meta-analysis is a comprehensive assessment of the possible effect of the use of HAART, during ICU stay, in critically ill HIV positive patients. It provides data from a total of 1,584 critically ill HIV positive patients from 12 studies, all of which were retrospective in nature and presented roughly similar population characteristics. Our data highlights a reduction in short-term mortality with the use of antiretroviral treatment during the ICU stay. There was also an observed trend for lower long-term mortality with the use of HAART in this setting. However, we noticed a wide heterogeneity of methodological quality among the studies, which precludes a stronger assertion about the protective effects of HAART for critically ill HIV patients.Prescribing HAART in the ICU setting presents distinct challenges related to drug interactions , doses aA sensitivity analysis was performed , and the period of publication (before or after 2005 and 2010).However, there was a difference of beneficial effect between the ICU and hospital mortalities subgroups: the use of HAART did not significantly impact the hospital mortality after the random effects analysis. This discrepancy might be explained by the fact that 3 ,15,21 ouAn assessment of symmetry in a funnel plot is typically subjective. Any evaluation is particularly challenging when the number of studies is small; funnel plots are considered unreliable methods of investigating potential bias if the number of studies is less than 10 Moreover, the heterogeneity analysis showed a substantial variability between studies. There was also high heterogeneity of methodological quality as expressed by the MINORS score. A meta-analysis of retrospective studies is expected to face the challenges of high heterogeneity and publication bias .The patient population in different institutions and countries probably pertained unique characteristics and treatment preferences or protocols that influenced the spectrum of the disease. There were significant differences between hospital admission and discharge policies, as well as differences in practice patterns of the local staff . These vThe articles presenting long-term outcomes disclosed very few ICU data. It was difficult to relate the critical and acute illness to a very long-term outcome. The long-term benefits of HAART are undeniable for the non-hospitalized patient, and well established on the literature ,5,30–36.This study has some limitations. Missing odds ratio values in some of the original articles made it unfeasible to calculate the meta-analysis using an adjusted odds ratio. Additionally, missing data and the small number of studies did not allow for a meta-analysis of the long-term outcomes. Clinical practice and demographics may differ across time, institutions, and countries. No randomized clinical trials were identified in the literature review; and observational retrospective studies may present heterogeneities, missing data, biases and confounders that could that have reduced the strength of our observations.The clinical implication of these findings is to support the initiation or maintenance of HAART in all HIV critically ill patients, as soon as the clinical condition dictates, even during an ICU stay. This meta-analysis suggests a promising trend for better outcomes in patients whom were treated with HAART during their ICU stay. Future randomized clinical trials are necessary to answer this question.S1 FileFile with all the supporting information.(DOCX)Click here for additional data file.S2 FileThe 27 checklist items pertain to the content of a systematic review and meta-analysis, which include the title, abstract, methods, results, discussion and funding.(DOCX)Click here for additional data file.


Tyrosine kinase inhibitors of the epidermal growth factor receptor (EGFR) are becoming the standard treatment option for patients with advanced non-small cell lung cancer (NSCLC) harboring an EGFR mutation, but the economic impact of this practice is unclear, especially in a health resource-limited setting. A decision-analytic model was developed to simulate 21-day patient transitions in a 10-year time horizon. The health and economic outcomes of four first-line strategies  among patients harboring EGFR mutations were estimated and assessed via indirect comparisons. Costs in the Chinese setting were estimated. The primary outcome was the incremental cost-effectiveness ratio (ICER). Sensitivity analyses were performed. The icotinib strategy resulted in greater health benefits than the other three strategies in NSCLC patients harboring EGFR mutations. Relative to PC alone, PC followed by pemetrexed maintenance, gefitinib and icotinib resulted in ICERs of $104,657, $28,485 and $19,809 per quality-adjusted life-year gained, respectively. The cost of pemetrexed, the EGFR mutation prevalence and the utility of progression-free survival were factors that had a considerable impact on the model outcomes. When the icotinib Patient Assistance Program was available, the economic outcome of icotinib was more favorable. These results indicate that gene-guided therapy with icotinib might be a more cost-effective treatment option than traditional chemotherapy. Lung cancer is the most frequent malignancy and the most common cause of cancer-related death among males and females in the worldwide . Based oSmall-molecule tyrosine kinase inhibitors (TKIs), such as erlotinib, gefitinib and afatinib, could specifically inhibit epidermal growth factor receptor (EGFR)-dependent pathway activity, could prolong OS and/or progression-free survival (PFS) in patients with advanced NSCLC and harboring an EGFR mutation , 9. ThusCompared to the control strategy Table , the pemIn the comparison between the icotinib and control strategies, the most influential variables were the cost of pemetrexed, the EGFR prevalence and the utility of PFS. Altering these parameters might yield substantial changes in the ICER Figure . Other pThe CEACs are showed in Figure This study to firstly examine the cost-effectiveness of four licensed competing first-line treatment options recommended in current Chinese clinical practice , and ourIn the study from Japan, the marginal cost and effectiveness of the screening strategy (EGFR mutation testing followed by gefitinib treatment) per patient were estimated to be approximately $1,180 and 0.036 QALYs, respectively, leading to a marginal cost of $32,500 per additional QALY gained. These findings demonstrated that the EGFR screening strategy in Japan is cost-effective . By usinOur study also found that the icotinib strategy was less expensive than the pemetrexed maintenance and gefitinib strategies, which were inferior owing to their smaller health benefits and higher costs. One plausible explanation for this finding is that the cost per cycle of the icotinib strategy was lower than that of the pemetrexed maintenance and gefitinib strategies. One recently published study of second-line treatment for advanced NSCLC showed 5-year QALYs of 0.279 and 0.269 and medical costs of $10,662.82 and $13,127.57 in the icotinib and gefitinib groups, respectively, suggesting that icotinib was a less expensive strategy than gefitinib . ConsistThis study has several limitations. First, owing to no clinical data evaluating these four first-line alternatives in one trial, a network meta-analysis was performed in the present study for an indirect comparison, where the patient characteristics were assumed to be similar although the moderate heterogeneity was detected. Second, a Weibull survival model was used to simulate the lifetime outcomes. This approach was another limitation of this study, although the results of the sensitivity analysis suggested that the model outcome was not sensitive to the variables related to HR of PFS. Third, some key clinical inputs, such as the survival data for the gefitinib and pemetrexed maintenance strategies, were extracted from distinct RCTs with different study designs conducted on the Western population. To minimize potential bias and uncertainty in outcomes, we tested the impact using sensitivity analyses. Fourth, the current analysis did not fully examine other potentially competing alternatives for advanced NSCLC, such as afatinib, erlotinib and bevacizumab –22, becaIn summary, from the perspective of Chinese health care system, gene-guided icotinib therapy for newly diagnosed advanced NSCLC harboring EGFR mutations is a cost-effective alternative relative to chemotherapy containing pemetrexed and gefitinib, based on the higher efficacy and lower cost of icotinib treatment.A mathematical model was constructed to measure the ten-year clinical and economic outcomes of first-line treatments for patients with advanced NSCLC. A hypothetical cohort with confirmed stage IIIb or IV NSCLC and positive for an EGFR mutation was created to compare four potential competing strategies: four-cycle chemotherapy based on pemetrexed plus cisplatin (PC) (control strategy), PC chemotherapy followed by maintenance with pemetrexed (pemetrexed strategy) or initial targeted treatment with gefitinib (gefitinib strategy) or icotinib (icotinib strategy) Figure . After tThe primary outcomes were disease-free life years (LYs), overall LYs, quality-adjusted life-years (QALYs) and cost. Cost and QALYs were discounted at an annual rate of 5%, in line with Chinese guidelines for pharmacoeconomic evaluations. The costs are shown in 2015 US dollars. Incremental cost-effectiveness ratios (ICERs), presented as cost per additional QALY gained, were examined. We used 3× the per capita gross domestic product (GDP) of China in 2015  as the cost-effectiveness threshold according to the WHO recommendations.The transition parameters and proportions were based on meta-analyses or RCTs to the greatest possible extent. The PARAMOUNT trial reported the efficacy of pemetrexed maintenance therapy after PC-based induction chemotherapy in patients with non-squamous NSCLC. The results showed a median PFS time of 6.9 months for the pemetrexed group and 5.6 months for the placebo group ; in that study, PFS was measured from the beginning of induction treatment (rather than from the time of randomization) . The CONt was calculated using the following formula: S(t) = P(T≥t) = exp(γ-λt). The transition probability at a given cycle t was calculated using the following formula: P(t) = 1 - exp[γ - λtγλ(t - 1)]. The Weibull survival curves of the three alternative strategies were derived using the adjusted Weibull scale  and shape  parameters, as previously described in published studies , 4544, 4One-way and probabilistic sensitivity analyses were performed to examine the uncertainty in the model. In the one-way sensitivity analyses, relevant parameters were changed one-by-one to their respective upper and lower boundaries in order to explore the sensitivity of the findings to plausible variations in specific data inputs. The results of the one-way sensitivity analyses are presented in a Tornado diagram. The ranges of the parameters used in the one-way sensitivity analyses were obtained from the published literature; when reported data were not available, a range of ±25% of the base-case value was used Table  and 2. F


Three-dimensional (3D) bioprinting is on the cusp of permitting the direct fabrication of artificial living tissue. Multicellular building blocks (bioinks) are dispensed layer by layer and scaled for the target construct. However, only a few materials are able to fulfill the considerable requirements for suitable bioink formulation, a critical component of efficient 3D bioprinting. Alginate, a naturally occurring polysaccharide, is clearly the most commonly employed material in current bioinks. Here, we discuss the benefits and disadvantages of the use of alginate in 3D bioprinting by summarizing the most recent studies that used alginate for printing vascular tissue, bone and cartilage. In addition, other breakthroughs in the use of alginate in bioprinting are discussed, including strategies to improve its structural and degradation characteristics. In this review, we organize the available literature in order to inspire and accelerate novel alginate-based bioink formulations with enhanced properties for future applications in basic research, drug screening and regenerative medicine. Three-dimensional 3D) printing aims to integrate living cells in three-dimensional biomaterials. This revolutionary technology permits the automated and reproducible production of 3D functional living tissues by depositing layer-by-layer biocompatible materials  with a high-precision positioning of cells. This technique permits the fabrication of 3D, scalable and precise geometries that are not offered by other strategies such as two-dimensional 2D) cell cultures or standard 3D cell cultures . There eD cell cuD printinIn this sense, hydrogels are undoubtedly the most extended biomaterials used as cell matrix in bioinks as they can be employed as cell matrix and be tailored to mimic or replace native tissue . The cheAlginate is a naturally occurring, non-toxic, biodegradable and non-immunogenic linear polysaccharide composed of guluronic and mannuronic acids . Apart fd-mannuronic (M) and α-l-guluronic acids (G) . Though the gelation process in the presence of such cations is not completely understood, it is believed that cations bind both G blocks and M blocks [Some 3D bioprinting applications (such as extrusion) require a fast gelation process. By generating ionic interchain bridges, alginate solutions offer fast gelling when mixed with multivalent cations . In inkjet-based bioprinting, the bioinks employed are less viscous (<10 mPa·s) and have lower cell densities (<16 × 106 cells/mL). This method offers cell viabilities of around 90%. The laser-assisted bioprinting requires bioinks with viscosities ranging between 1 and 300 mPa·s and medium cell densities of around 108 cells/mL. The cell viability in this method is very high (>95%). The viscosity of an alginate-based bioink depends on the alginate concentration, the molecular weight of the alginate used , and the cell density and phenotype of the cells. These are the parameters that researchers must take into account in order to tune the viscosity of the alginate-based bioinks. Another important rheological feature of aqueous alginate solutions is the shear-thinning, where the viscosity decreases as the shear rate increases. The viscosity also depends on the temperature at which the printing was performed—the viscosity decreases as the temperature increases. In comparison to other polymers, alginate is reasonably easy to print, as it is easy to handle and extrude while protecting the encapsulated cells. Even though it is non-cell-adhesive by itself [Each bioprinting methodology requires bioinks with certain rheological properties . Extrusiy itself , in termOnce the material is printed, the hydrogel should degrade appropriately, permitting the cells to produce their own extra cellular matrix. The alginate creates long-term persistent cell-laden hydrogels, whereas its slow degradation kinetics can be tuned by oxidation   or by mo® from Gesim, or Revolution from Ourobotics, recommend the employment of alginate as a bioink.The discharge of the hydrogels during extrusion bioprinting restricts the use to low-weight alginate hydrogels, which, depending on the application, exhibit poor mechanical properties. However, as we will see in further examples, the alginate structural and mechanical properties required for each printed tissue, as well as the biomimicry properties needed in each case, can be tuned by incorporating other biomaterials in the scaffold or by employing different hydrogel fabrication methods. As an example, there already exists a commercially available bioink named CELLINK, which, combining nanocellulose and alginate, presents shear-thinning and fast crosslinking features, making it valuable for soft tissue engineering applications . MoreoveIn the next section, we will summarizes the most recent advances in 3D bioprinting that have used alginate as (a component of the) bioink.3 [As isolated cells die in spaces of volumes less than 3 mm3 , the lim3 . The cre3  for the 3  utilized3  also obt3 , by blen3 , vasculaWe can conclude from this section that alginate-based bioinks are the most used in coaxial needle–assisted vascular tissue bioprinting, due to the fast ionic crosslinking ability of the alginate. The use of coaxial needles permits tuning the gelation kinetics of alginate-based bioinks with a relatively high precision by adjusting the concentrations of the alginate and the crosslinker.Gelatin and alginate, as well as hydroxyapatite, were used to make a novel hydrogel composite for bone printing . A two-sThe mechanical properties of the alginate for bone bioprinting are poor  have been combined to increase the cell proliferation. In order to enhance its cellular adhesion, the addition of Arg-Gly-Asp adhesion peptides to alginate bioink exhibits great results. Furthermore, the uses of oxidized alginate and/or sodium citrate seem to be promising strategies to accelerate the slow degradation of the alginate in regenerative medicine applications. With regard to the employment of alginate in cartilage printing, its combination with electro-spinning has been used in successful works, as well as mixing the alginate with other biopolymers as polycaprolactone or nanocellulose. With reference to the bioprinting of vascularized tissues, the employment of coaxial  nozzle assemblies for printing alginate-based bioinks highlights excellent results. Regarding the mechanical requirements needed for bone tissue engineering, notable improvements have been made by combining alginate with other biomaterials such as gelatin, hydroxyapatite, polycaprolactone, polyphosphate or biosilica. We hope this review will help other researchers improve alginate-based bioinks by employing previous strategies summarized here, or to inspire new bioink formulations for future 3D bioprinting studies.


The risk factor associated with presence of SIT-reactors in dairy herds located in this region was purchasing dairy cows from dealers . From this study, it was concluded that geographic clustering was identified for dairy farms with SIT-reactors in these provinces, and the cattle movements through cattle dealers increased the risks for SIT-reactor farm status.The objective of this case-control study was to identify farm-level risk factors associated with bovine tuberculosis (bTB) in dairy cows in northern Thailand. Spatial analysis was performed to identify geographical clustering of case-farms located in Chiang Mai and Chiang Rai provinces in northern Thailand. To identify management factors affecting bTB status, a matched case-control study was conducted with 20 case-farms and 38 control-farms. Case-farms were dairy farms with at least single intradermal tuberculin test- (SIT-) reactor(s) in the farms during 2011 to 2015. Control-farms were dairy farms with no SIT-reactors in the same period and located within 5 km from case-farms. Questionnaires were administered for data collection with questions based on epidemiological plausibility and characteristics of the local livestock industry. Data were analyzed using multiple logistic regressions. A significant geographic cluster was identified only in Chiang Mai province ( Mycobacterium bovis, is an important disease affecting the agricultural economy of Thailand and is associated with public health risks as a zoonotic disease [Bovine tuberculosis (bTB), caused by disease . The dis disease , 3. Data disease . caudal fold SIT test to all adult dairy cows (age ≥ 1 year). SIT-reactors in infected dairy herds are culled and slaughtered [In Thailand, the Department of Livestock Development (DLD) is implementing a program to test and eradicate infected dairy cattle annually based on application of theughtered . Howeverughtered . OngoingSeveral studies have identified risk factors for bTB across multiple countries worldwide , 7. Many M. bovis than younger ones [Risk factors affecting bTB can be divided into 3 levels, including animal, farm, and regional or country levels . In infeger ones . Large dger ones , 13. Morger ones . Animal ger ones , 9, 12. ger ones . In regiger ones , 13. HowThis study was a retrospective case-control study conducted in Chiang Mai and Chiang Rai provinces in Thailand. Chiang Mai and Chiang Rai provinces are located in northern Thailand adjacent to Myanmar and Laos . The num caudal fold SIT-reactor during 2011 to 2015. Control-farms were selected from the population of dairy farms in these provinces with no detected or reported SIT-reactor during the same period. An increased skinfold thickness ≥ 5 mm after 72 h at the injection site of intradermal injection of purified protein derivative of M. bovis was the cut-off used to categorize caudal fold SIT-reactors [Bovine tuberculosis test status information from dairy herds in Chiang Mai and Chiang Rai provinces during 2011 to 2015 was obtained from the Thailand DLD. Case-farms were defined as dairy farms with history of at least onereactors .Geographical coordinates of a total of 931 farms in the selection provinces were obtained from the DLD for spatial cluster analysis. Regarding the definitions of case-farms described in previous section, 16 case- (SIT-positive) and 844 SIT-negative farms in Chiang Mai province and 4 case- (SIT-positive) and 67 SIT-negative farms in Chiang Rai province were included for spatial cluster analysis.A matched case-control study was designed to identify farm management factors associated with bTB in Chiang Mai and Chiang Rai provinces. Each case-farm was geographically matched with 2 control-farms located within a 5 km radius of the case-farm. In Chiang Rai province, 1 of the case-farms did not have any neighboring dairy farm located within 5 km. Therefore, 20 case- and 38 control-farms were included in this study. Questionnaires were administered to case- and control-farms to collect farm-level information on general herd management, herd profile, breed, history of bTB and cattle movements in and out of the herd, disease outbreaks, other animal species kept, types and levels of herd contacts, water sources, and workers information through interviews of the owners of case- and control-farms by a study investigator. The questionnaire consisted of closed- and open-ended questions and was pretested on 5 farms in Chiang Mai province to assess the clarity of questions, with modification to capture aspects of management initially missed.Spatial clustering analysis of 20 case-farms and 911 SIT-negative farms was conducted using the Bernoulli model of the spatial scan statistic. The null hypothesis was that the distribution of case-farms locations was random. The model compares the observed number of case-farms within all possible circular spatial windows in the study area with the expected number of bTB-positive farms. The test was performed by using the Satscan software version 9.1.1.p < 0.05) and Pearson product-moment correlation for continuous variables (cor ≥ 0.5). In case of multicollinearity , the variable with higher biological plausibility was retained for multivariate analysis.For identification of farm-level risk factors, data were analyzed in 2 stages using R version 3.2.2. In the first stage, categorical and continuous variables were first screened using univariate logistic regressions with a random effect representing each case-control grouping. Evaluation of multicollinearity among predictor variables was assessed using chi-square test for categorical variables ( p ≤ 0.2 and without marked multicollinearity among the candidate variables were included in the full multivariate logistic regression for model selection. A stepwise procedure based on the Akaike Information Criterion (AIC) was performed by using the bestglm package [In the second stage of risk factor analyses, variables from the univariate analysis with package  in R verAll dairy farms in the case-control study (data available from questionnaire) were small-holders, with a mean herd size of 21 milking cows (range: 4–47). Mean herd sizes of dairy farms in Chiang Mai and Chiang Rai provinces were 21 and 24 milking cows, respectively. Most of the farms housed cattle in free stalls with zero grazing. Tied stall housing was observed in 20% of farms in Chiang Mai province, but not in Chiang Rai province. In all study herds, cows typically were fed twice daily with concentrate feed and ad libitum roughage. Roughage and concentrate feed were fed separately; total mixed ration feeding systems were not used in this area. Farms typically utilized a bucket-type milking machine for milk collection.p < 0.05) as shown in A cluster of case-farms was identified in 4 districts of Chiang Mai province with 14.7 km in radius  calculated for this model was 0.74 (95% CI: 0.7–0.8); therefore, the final model had moderate discrimination capacity. The accuracy of the model prediction was 74% when calculated with cross-validation.The final model for bTB risk factors prediction fitted the data well when tested with the Hosmer–Lemeshow goodness-of-fit From cluster analysis of spatial data of SIT-reactor and nonreactor farms in this study, significant clustering was identified in Chiang Mai province. Identification of spatial clusters of disease and causal mechanisms related to this clustering could be useful for improving eradication programs in this area. The primary risk factor for SIT-reactivity at farm-level was related to cattle movement. In the final logistic regression model of the current study, purchasing cows from cattle dealers posed the highest risk for bTB infection, and case-farms had odds of engaging in this practice nearly 6 times higher than control-farms. This practice poses risk to cattle producers because the farm of origin of the cattle purchased is not known by the new owners, including whether the animals had originated from farms with history of SIT-reactor cattle. Cattle movements have also been identified as major factors associated with bTB outbreaks in other regions, including cattle moved from endemic areas to previously bTB-free farms , 12, 19.In this study, a large cattle market was located within the identified bTB geographic cluster. The convenience of cattle trading due to the accessibility to the cattle market within the clustered area may have led to an increased rate of purchasing cows through dealers, which consequently increased frequencies of cattle movements in this area. In Thailand, while cattle movements across province boundaries are regulated by the Thailand DLD, with creation of movement records as a result, movements within a province are not regulated. Therefore, farmers purchasing cattle from unknown sources within a province  may have experienced higher disease introduction risks associated with these unregulated animal movements compared to other farmers.A limitation of this study was that the prevalence of bTB in Chiang Mai and Chiang Rai was quite low, with limited power for clustering analysis. Therefore, further spatial analyses should be performed in other areas in this region to evaluate the consistency of these findings across the overall region to improve understanding of the epidemiology of the disease.Risk factors associated with bTB status have been previously reported in other regions of the world, including herd size, use of specific management practices, lack of performance of diagnostic tests, and movement of cattle . The movEradiation of bTB with endemic in cattle populations around the world is challenging. One recent report has estimated the costs in a developing country under different scenarios of cattle testing  demonstrFrom results of this study, we conclude that purchasing dairy cows from cattle dealers was strongly associated with SIT-reactivity on dairy farms in northern Thailand. A prudent disease control recommendation is for cattle owners to decrease the risk of bTB infection through cattle introductions and to ask for verification that dairy cattle introduced to their herds are from bTB-test negative farms. Additional study to provide further clarification of these risk factors would lead to improved understanding of the epidemiology of bTB infection on dairy farms in this region, which could support the likelihood of successful bTB eradication and control programs in the country.


Although we have some basic understanding of the neurochemical mechanisms of the antidepressants, the network-level effect of antidepressant treatment is still not fully understood. This study was conducted to investigate the effects of antidepressant on functional brain networks of patients with major depressive disorder (MDD). We performed resting-state fMRI scans on 20 first-episode drug-naive MDD patients at baseline and after escitalopram medication for 8 weeks. Twenty healthy controls also received MRI scans with an 8-week interval. The graph theory indices, long- and short-range functional connectivity strength (FCS), were computed to characterize the brain connectivity. The analysis of covariance was conducted on FCS maps of patients and controls to obtain the interaction effect of group and time, which indicate treatment-related effect. Following treatment, increased long-range FCS in the bilateral posterior cingulate cortex/precuneus and right thalamus in MDD patients at baseline were reduced. Meanwhile, increased short-range FCS in the bilateral ventromedial prefrontal cortex and left amygdala in patients were reduced, while reduced short-range FCS in the right parahippocampal gyrus was increased. Results suggest that the brain regions associated with negative emotional processing and regulation, and self-referential function could be modulated by escitalopram treatment; long- and short-range FCS are differentially affected by antidepressant. Antidepressant drugs are commonly used treatments for MDD. However, the network-level mechanisms via which the neurochemical changes induced by antidepressants could translate into clinically meaningful effects is still not fully understood. Investigating the network-level effects of antidepressants may help to find more promising biomarkers for treatment evaluation of MDD.Major depressive disorder (MDD) is a globally prevalent disorder with multi-dimensional clinical features involving emotion, cognition, and somatic domains. MDD has been conceptualized as a brain disorder that affects information exchange across large-scale neural systems5. There is considerable evidence from the R-fMRI studies that MDD was abnormal in functional connectivity (FC) within several neural systems involving default mode network (DMN)9, salience network9, cognitive control network9, as well as cortical-limbic emotional regulation circuit11. A recent meta-analysis showed anomalous resting-state FC among the frontoparietal network, dorsal attention network, DMN, affective network, and ventral attention network in MDD1. Further, intervention studies showed that antidepressant medication could partly reserve the abnormalities of intrinsic FC of MDD patients. For instance, 8-week treatment with sertraline could exert a therapeutic effect on MDD patients by strengthening the cortical-limbic connectivity13. Escitalopram treatment additionally increased the amplitude of low-frequency fluctuation in the prefrontal cortex (PFC) and cingulate gyrus14. Another study showed that duloxetine treatment for 8 weeks decreased connectivity in the components of anterior DMN with the right dorsolateral, right superior frontal premotor cortex, and left inferior frontal gyrus, but increased the connectivity in the components of the DMN with the pregenual and subgenual cingulate cortex, right hippocampus, and middle occipital gyrus15.Resting-state functional magnetic resonance imaging (R-fMRI), which examines the temporal correlation of spontaneous fluctuation of the blood-oxygen-level dependent (BOLD) signals across brain regions, provides a powerful tool to investigate the whole-brain functional network17. Graph theory provides a powerful means to quantitatively investigate the topological organization of brain connectivity. A number of topological properties, including small-worldness, network hubs, and modularity, have been characterized in the human brain18. Functional connectivity strength (FCS) is a voxel-wise data-driven approach for identifying the functional hubs and connectivity patterns of brain networks19. The voxels with higher FCS values indicate larger numbers of functional connections with other voxels, suggesting stronger ability of information transfer20. Abnormal FCS has been revealed in MDD patients, such as reduced FCS in the bilateral middle cingulate cortex and increased FCS in the right occipital cortex21.The brain is composed of complex biological systems that integrate signals from multiple brain regions to ensure effective information processing23. The balance between long- and short-range connectivity is important for efficient information processing22. Functional brain hubs with higher long-range FCS (lFCS) are mainly located in the posterior cingulate cortex (PCC)/precuneus, medial and lateral PFC, insula, and lateral temporal and parietal cortices. Meanwhile, short-range FCS (sFCS) are prominently located in the medial PFC, lateral PFC, insula, sensorimotor, and visual cortices23. The lFCS integrates information among distinct modules and hubs24, and operates at a higher time and metabolic cost25, whereas the sFCS reflects the local efficiency of brain activity and operates at a lower cost25. A few of studies have suggested that the brain regions showing FCS alterations in MDD patients varied with the anatomical distance of brain connectivity. Specifically, reduced sFCS in the right orbitofrontal cortex, bilateral superior temporal gyrus, bilateral precuneus, insula, right inferior parietal lobule, and occipital regions were observed in MDD patients27. In this context, it may be important to consider the potential effect of connectivity distance in the investigation of neural mechanism of MDD.Physical distance has a potential influence on the spatial distribution of brain connectivity28. However, it remains unclear whether the effects of antidepressants on brain connectivity are dependent on anatomical distance. For this reason, we conducted this work to examine the changes in the lFCS and sFCS in first-episode, drug-naive patients with MDD following escitalopram treatment for 8 weeks. We hypothesized that the clinical improvement of MDD patients would be associated with the normalization of the lFCS and sFCS in brain regions across the medial PFC and limbic system, which are important for emotional processing and regulation, and self-reflection29.In previous report, we have investigated the effect of escitalopram treatment on FCS in MDD patients. We found abnormally increased FCS in the bilateral dorsomedial PFC and reduced FCS in the hippocampus in MDD patients at baseline, which was reversed after 8-weeks treatment; the FCS reduction in the dorsomedial PFC was significantly correlated with symptomatic improvementThere were no significant differences in age, gender distribution, and educational level between MDD patients and HCs Table . The HRSAs shown in Fig. A significant interaction effect of group and time on the lFCS was observed in the bilateral PCC/precuneus and right thalamus Fig. ; Table 20w − HRSD8w/HRSD0w * 100%)  Fig. .Figure 428 in the same group of subjects, suggesting that the distance-dependent FCS is valuable for the investigation of neural mechanism of antidepressant treatment.To our knowledge, this is the first study to investigate the effect of antidepressants on distance-dependent resting-state FC (indexed by lFCS and sFCS) in MDD. We found significant treatment effects on the lFCS and sFCS of MDD patients. Specifically, abnormal lFCS and sFCS in the cotical  and limbic  regions in patients were normalized after treatment. These treatment-related regions was not been observed in our previous study23. The PCC integrates the information from multiple domain-specific systems with a limited number of long-distance connections30 and acts as a mediator for self-related cognitive processes such as episodic memory32. Here, we found increased lFCS in the PCC/precuneus in MDD patients at baseline, which was inhibited by escitalopram treatment. These findings were compatible with previous studies, which showed a reversal of increased resting-state FC33 and nodal centrality34 in the PCC/precuneus in MDD patients after antidepressant treatment. In this context, it is plausible to propose that increased lFCS in the PCC/precuneus reflects an over-recruitment of large-scale brain networks, which may be associated with excessive memory for negative information seen in MDD patients. Down-regulating the connectivity strength of the PCC/precuneus may be potential pathway for MDD treatment. Further, a positive correlation was observed between reduction in lFCS of the PCC/precuneus and the improvement of depressive symptoms (assessed as reduction rate of HRSD scores). Based on the physiological significance of the PCC/precuneus, we propose that inhibiting the PCC/precuneus hyperconnectivity may contribute to normalized collaboration of multiple neural networks, which is important for the improvements of clinical symptoms of MDD.We found a significant effect of escitalopram treatment on the FCS in cortical midline structures, including the bilateral PCC/precuneus and bilateral vmPFC. DMN  shows very high activation at rest and is considered as a nexus of connectivity that integrates information from various neural systems35. Compelling evidence has highlighted MDD-related alterations in the vmPFC, with decreased gray matter volume29 and cortical thickness36, increased activity during the rest6 and negative self-referential emotional processing37 was observed in MDD patients. Excessive vmPFC-amygdala coupling has been thought to contribute to negative affect, MDD onset in vulnerable populations, and persistent experience of negative emotional distress in MDD patients38. This region appears critical for clinical response to antidepressant treatment, as its decreased activity was observed in MDD patients following different kinds of treatments, such as antidepressant medication39, placebo40, ECT41, cognitive behavioral therapy39, as well as repetitive transcranial magnetic stimulation (rTMS)42. Combined with these previous reports, the current study indicates an inhibitory effect of escitalopram on the increased sFCS in the vmPFC of MDD patients, which indicates that antidepressant may inhibit the excessive self-referential thoughts by decreasing the connectivity strength of the vmPFC.Connecting with subcortical regions, the vmPFC is involved in automatic emotional regulation and self-referential activity, such as rumination43. The cognitive model of MDD proposes that excessive amygdala reactivity to external stimuli was associated with the generation of negative emotion44, which was supported by convergent evidence that among MDD patients, the amygdala was exaggeratedly activated under negative affective stimuli45. The signals of negative emotion are then routed by the thalamus to emotional regulation cortical regions46. Antidepressant medication, especially SSRIs, might act on the limbic regions directly by inhibiting exaggerated activity of the amygdala, thalamus, and other limbic regions in MDD patients when receiving negative emotional stimuli48. Moreover, SSRI treatment  inhibited the hyperactivity of the amygdala and thalamus in healthy group in response to negative stimuli even after 7-day antidepressant medication49. Antidepressants may also act by up-regulating the FC of cortico-limbic mood-regulation circuit, as increased connectivity between the amygdala and the anterior cingulate cortex12, dorsal PFC50 was observed in MDD patients after SSRI treatment, while decreased FC in the amygdala with the precuneus and posterior cingulate cortex was found after SSRI treatment50. In this context, reduced sFCS in the amygdala of MDD patients following treatment observed in this study may lead to an alleviation of excessive negative processing, which may mitigate the information transmission load for negative emotion between the thalamus and cortical brain areas. Together with our findings of the FCS reduction in the amygdala and thalamus after treatment, we propose that escitalopram treatment may inhibit the signals transmission for negative emotion along the cognitive hierarchy.We also observed significant changes in the FCS of the limbic system regions, including the reduction of sFCS in the left amygdala and the lFCS in the bilateral thalamus, and the increase of the sFCS in right PHG in MDD patients following treatment. The amygdala generates emotional reactions to external stimuli, whereas the thalamus is responsible for the distribution of afferent signals and considered as a “relay” that forwards signals from subcortical areas to cerebral cortex51 and is important for adaptive control of the stress through negative feedback inhibition52. Previous studies have shown reduced hippocampal volume51 and low hippocampal activation in response to happy faces in MDD patients45, as well as reduced negative FC between the hippocampus and inferior parietal cortex, cerebellum53, dorsomedial PFC54. More and more evidence highlights the role of the hippocampus in the successful treatment of MDD, as increased hippocampal responses to happy faces after escitalopram treatment55, increased hippocampal volume56 and FC57 after ECT treatment were observed in MDD patients. In our current work, we found that escitalopram could normalize reduced sFCS in the right PHG, which indicates antidepressant may enhance the information communication between PHG and nearby brain regions; such an change may be helpful for strengthening the regulation of stress response and emotional memory in MDD patients.The hippocampus refers to the emotional memorySeveral issues need to be further addressed. First, as an open-label design, the absence of untreated or placebo-treated control groups make it difficult to determine whether the changes in FCS were due to pharmacological effect or other combined factors. However, there may be some potential ethical problems to recruit a group of patients who are currently experiencing severe depressive episodes and make them untreated or be given placebo for 8 weeks. Further studies could recruit patients with mild or moderate depressive episode, and placebo, other antidepressant drugs or psychotherapy could be used to help to clarify whether the brain function changes are induced by certain antidepressant treatment or other factors. Second, it is hard for our study to investigate the neural differences between treatment responders and nonresponders. Future studies could try to include treatment non-responders to seek some neural differences between treatment responder and non-responders. Last, there may be some changes before clinical improvement, future researches could collect the fMRI data at the early stage of the treatment to examine the acting mechanisms of antidepressant drug and predictors of treatment response.The current study demonstrated that antidepressant treatment with escitalopram was associated with changes in resting-state distance-dependent FCS in MDD patients. Reversed abnormal FCS within the cortical-limbic circuit in MDD patients after escitalopram treatment may be important for the alleviation of excessive negative emotion and self-referential thoughts. This study thus provides new evidence for the understanding of neural mechanism of antidepressant treatment.58, a short structured diagnostic interview for Diagnostic and Statistical Manual of Mental Disorders, 4th fourth edition (DSM-IV). Inclusion criteria included an acute depressive episode, total score of the 17-item Hamilton Rating Scale for Depression (HRSD)59 ≥18, and the illness duration ≤24 months. Patients comorbiding with any other Axis I disorder, Axis II personality disorder or mental retardation in recent one year were excluded.Thirty-six first-episode drug-naive patients with MDD were recruited from the Peking University Institute of Mental Health and the Beijing Anding Hospital of Capital Medical University between May 2010 and January 2013. The patients were diagnosed by a psychiatrist using the Mini-International Neuropsychiatric Interview (MINI)Among the initial 36 patients, one had excessive head movement during scanning; one reported serious adverse effects after 2 days of medication; two patients stopped medication during the study period for some personal reasons; five patients refused to participate in the second MRI scans; and seven patients changed to other antidepressant drugs due to a poor response to escitalopram during the study period. Finally, 20 patients completed the whole study. Twenty age (±5 years), gender, and education (±5 years) matched healthy control (HC) subjects were recruited from the local community. All HCs had a HRSD score less than 7 at baseline and 8-week follow-up. HCs with a HRSD score of more than 7, any current or lifetime psychiatric disorders, or a history of major psychiatric or neurological illness in their first-degree relatives were excluded.Exclusion criteria for all subjects included serious medical or neurological illness, a history of significant head trauma, substance dependence or abuse within the last year, current or previous use of psychotropic drugs, a history of electroconvulsive therapy (ECT), acutely suicidal or homicidal, current pregnancy or breastfeeding, or any contraindications to a MRI scan. All the subjects were right-handed as determined by the Edinburgh Handedness Scale. Written informed consent forms and experimental protocol were approved by the Ethics Committee of the Sixth Hospital  of Peking University, and we obtained written informed consent forms from all the subjects before the study. The demographic and clinical characteristics of the subjects were provided in Table Patients were treated with oral escitalopram at 5 or 10 mg/day, then was increased to 10–20 mg/day within 7 days, and continued at this dose until they finished the 8-week study in accordance with the ethical principles originating in the Declaration of Helsinki and the International Conference on Harmonization Good Clinical Practice guidelines. The dose adjustment was accorded to the clinical judgment of the psychiatrist and the patient’s consent. The final doses of escitalopram were 20 mg/day for 15 patients, 15 mg/day for 4 patients, 10 mg/day for one patient. All of the 20 patients were given clinical assessment at baseline and the end of the 8th week. They all showed a clinical response to escitalopram treatment, defined as a reduction of 50% decrease from the baseline HRSD score; eleven of them (55%) achieved clinical remission with a HRSD-17 score of 7 or below. All patients received escitalopram without any other psychotropic medication or psychotherapies.2; thickness/gap, 4.0 mm/0.8 mm; 30 slices covering the whole brain. The total acquisition time was 7 minutes. After the functional imaging scans, a high-spatial-resolution T1-weighted magnetization-prepared rapidly acquired gradient-echo (MPRAGE) sequence was acquired sagittally  to achieve better registration.MRI scans were performed with a 3.0-T imaging system . The resting-state functional images were collected with a gradient-echo echo-planar imaging sequence with the following parameters: repetition time (TR) msec/echo time (TE) msec, 2000/30; flip angle, 90; matrix, 64 × 64; and field of view, 210 × 210 mmFor the resting-state functional scans, subjects were instructed to keep their eyes closed, remain still without head movement, not think of anything in particular, and not fall into sleep during the scan. Patients underwent the fMRI scans before and after treatment for 8 weeks. The HCs were scanned with the same procedures. The R-fMRI scan was carried out in accordance with relevant guidelines and regulations.http://rfmri.org/DPARSF)60, which is based on Statistical Parametric Mapping . After removal of the first ten volumes, the remaining 200 volumes were corrected for different signal acquisition times. The functional volumes were motion-corrected using a six-parameter rigid-body transformation. Then, several nuisance signals including the six head motion parameters, global mean signal, signals from the cerebrospinal fluid and white matter, and linear detrend were regressed out. Derived images were normalized to Montreal Neurological Institute (MNI) space (3 mm3 isotropic). Then, the transformed images were band-pass filtered (0.01–0.1 Hz) to reduce the effects of low-frequency drift and high-frequency noise.The R-fMRI images were preprocessed with Data Processing Assistant for Resting-State fMRI  mask that was generated by setting a threshold of 0.2 on the mean map of all GM maps involving all subjects. To improve normality, the individual correlation matrices were transformed to z-score matrices using a Fisher r-to-z transformation.23. The lFCS was derived as the average correlation between a given voxel and voxels to which the Euclidean range  was more than 75 millimeter from the given voxel, while the sFCS was derived as the average correlation between a given voxel and other voxels that were less than 75 millimeter from the given voxel. Considering the ambiguous interpretation of negative correlations after removal of the global signal, we conservatively restricted our analysis to positive correlations above a threshold of r = 0.2; such a threshold was chosen to eliminate the voxels with weak correlations attributable to signal noise. The FCS maps were further smoothed with a 6 mm Gaussian kernel.The lFCS and sFCS were calculated according to the procedures described previouslyWe performed a two-way repeated-measures analysis of variance (ANCOVA), with the group (patient and control groups) used as a between-subject factor, and time (baseline and 8th weekend) used as a repeated measure. The significant interaction effect of group and time was used to indicate the treatment effect on lFCS and sFCS. The variables including age, gender, educational level were used as covariates. We used Gaussian random field theory to correct for multiple comparisons with a cluster threshold of p < 0.05 and z > 2.3. Following the ANCOVA test, post-hoc t-tests were performed on the clusters showing significant interaction effects of group and time. Specifically, the mean values of the FCS in these clusters were extracted from the patient and HC groups at two time points and were compared by two-sample t-tests between groups.Pearson correlation analysis was performed to examine the correlations between changes in the mean values of FCS in clusters showing significant interaction effect of group and time and reduction rate of HRSD scores following treatment. The statistical significance was set at p < 0.05, uncorrected for multiple comparisons.Corresponding author, Tianmei Si, owns the data, and the data can be available.