Several epidemiological studies have determined the associations between coffee intake level and skin cancer risk; however, the results were not yet conclusive. Herein, we conducted a systematic review and meta-analysis of the cohort and case-control studies for the association between coffee intake level and malignant melanoma (MM) risk.Studies were identified through searching the PubMed and MEDLINE databases . Study-specific risk estimates were pooled under the random-effects model.2 = 63.5%] for those with highest versus lowest quantity of intake. In the dose-response analysis, the RR of MM was 0.955 (95% CI = 0.912–0.999) for per 1 cup/day increment of caffeinated coffee consumption and linearity dose-response association was found . Strikingly, no significant association was found between the decaffeinated coffee intake level and MM risk .Two case-control studies (846 MM patients and 843 controls) and five cohort studies  were identified. For caffeinated coffee, the pooled relative risk (RR) of MM was 0.81 [95% confidential interval (95% CI) = 0.68–0.97; P-value for Q-test = 0.003; IThis meta-analysis suggested that caffeinated coffee might have chemo-preventive effects against MM but not decaffeinated coffee. However, larger prospective studies and the intervention studies are warranted to confirm these findings. Malignant melanoma (MM) is a lethal type of skin cancer, and its incidence has been increasing worldwide for the past several years . Many faTo identify the eligibility studies that have determined the association between the coffee intake level and the risk for MM, two authors (Liu and Shen) independently searched the PubMED and MEDLINE databases with the terms “melanoma” or”skin cancer” in combination with “coffee” or “caffeine”. The electronic search was performed in November, 2015 and the eligibility studies should be online published online in peer-reviewed journals. The titles, abstracts and the full manuscripts were independently reviewed and assessed by the two authors, and the third author (Cai) joined the assessment of the manuscript if there was any discrepancy. In addition, we further checked the references of the retrieved studies and the published reviews or comments to identify any missing study in the literature search. In brief, the working flow chart of the eligible literature identified was presented as Epidemiological studies that were to be included in the current meta-analysis studies should meet the following criteria: 1) was a population- or hospital-based, case-control study or a prospective or retrospective cohort study; 2) provided the coffee intake level category and the corresponding relative risk (RR) or the odds ratio (OR) estimates and their confidential intervals (95% CIs) for MM; 3) not overlapped participants with other included studies. If overlapping populations were identified between studies, the most complete one was included in the meta-analysis; 4) be reported in the English language. Here, we excluded conference abstracts, reviews, ecological studies, cellular studies and animal studies. Studies that concerned the non-melanoma skin cancer were also excluded.We assessed the quality of the evidence, for each study, on the association between caffeinated or decaffeinated coffee intake level and melanoma risk using the Newcastle-Ottawa quality scale . For casThe following data was extracted from each study: the last name of the first author, the publication year, the study design , the country where the study was performed, the sample size (the number of participants for cohort studies and the number of patients and controls for case-control studies), the study period for the cohort studies (the year for the participants recruitment and the last following-up year), the types of coffee (caffeinated or decaffeinated), the method for the exposure assessment, the intake category for the coffee intake level and the corresponding relative risk (RR) or odds ratio (OR) estimates with their 95% confidential intervals (95% CIs), and the adjustments in the statistical analyses. If there were subgroup studies, each subgroup was recognized as individual studies. The meta-analysis studies were performed following the MOOSE  and PRIS2 statistic were used to assess the heterogeneity between the studies. Significant heterogeneity was considered when P < 0.05 for Q-test or the I2 was larger than 25%. To identify any individual study that may significantly affect the pooled estimates, the sensitivity analyses were performed through calculating the pooled risk estimates after excluding each single study from the meta-analysis repeatedly. The publication bias for the studies was assessed with the Begg’s funnel plots and further determined with the Egger’s linear regression test [www.r-project.org), Stata  and Review Manager (version 5.2.10) software. Two-sided P < 0.05 was considered to be statistically significant.The inverse variance weighting method was applied to calculate the summary estimates and the 95% CIs. The risk estimates for the highest, in comparison with the lowest, category for each study were extracted or calculated, and the squared inverse variance for the logarithm estimate was considered as the appropriate weight for each study. The ORs from case-control studies were assumed as the estimates of the RRs for prospective studies. The DerSimonian and Laird random-effects model that considers both within- and between-study heterogeneity were used in the pooling analyses . The Cocion test ,22. To iion test  to evaluIn the literature search, we have identified seven articles, reported from two case-control studies ,16 and f2 = 63.5%). However, no individual study significantly affected the pooled estimate as suggested by the sensitivity analyses. The funnel plot suggested there was no potential publication bias for the included studies  for those participants with the highest category of caffeinated coffee intake versus lowest category . Signifi studies , which wThe meta-regression analyses suggested that none of the study-level characteristics  significantly influence the results of multiple studies . In the To evaluate the dose-response relationship between the caffeinated coffee intake and risk for MM, five articles with eight prospective cohort studies were included in the generalized least squares trend estimation analysis ,11–14. W2 (0%) statistic suggested that no significant heterogeneity between the studies was evident. None of the study-level characteristics significantly affected the results of the multiple studies as suggested by the meta-regression analyses (Four studies (one case-control study and three cohort studies) with six subgroups have evaluated the association between decaffeinated coffee intake level and MM risk ,12,13,16analyses . The senanalyses  and the analyses .etc. Epidemiological studies have reported that coffee may have preventative effects against cardiovascular disease and cancer caused mortality [Regular coffee contains numerous bioactive compounds including polyphenols, diterpenes, trigonelline and caffeine ortality , type 2 ortality , stroke ortality , prostatortality  and endoortality . In contortality , bladderortality  and gastortality . Compounortality –34. It wcdc2 kinase [There were several mechanisms for the cancer preventative effects of caffeine against MM. Animal studies have suggested that caffeine inhibits the UVB-induced thymine dimers formation and reduces sunburn lesions in the epidermis of experimental mice ,36. Topi2 kinase  and the 2 kinase . Lu et a2 kinase . Abnorma2 kinase . Caffein2 kinase ,42. TherIn vivo studies have found that topical administration of diterpenes inhibits the inflammation in epidermal cells of mice [Although we did not find a statistically inverse relationship between decaffeinated coffee intake level and the MM risk, we could not exclude the possibility that there were other potential anticancer ingredients in coffee besides the caffeine. The predominant chlorogenic acid in coffee, 5-O-caffeoylquinic acid and its metabolite caffeic acid have been reported to suppress the UVB-induced skin carcinogenesis by inhibiting the cyclooxygenase-2 (COX-2) expression  or direc of mice –48. ConsMeta-regression studies suggested that no study-level characteristics including study design, study quality score, median or average following-up time, participant gender, or level of coffee intake significantly influence the heterogeneity between the studies. These factors may account for a small proportion of the heterogeneity between the studies. Other factors including the UV exposure level, the amount of the caffeine in the coffee, caffeine intake from other sources, the preparation method of coffee etc. may also contribute to the heterogeneity between the studies. In the stratification studies, we found the evidence for the protective effects of caffeinated coffee was more prominent in cohort studies than in case-control studies, which may be due to the relative higher quality of the cohort studies  and smalThere are several limitations for the current study. First, the ranges for coffee intake differed between the studies, which may lead to the heterogeneity of risk estimates between the groups. The dose-response analysis also found a significantly negative relationship between caffeinated coffee intake level and MM risk in which the RR was 0.96 (95% CI = 0.94–0.98) per 1 cup/day caffeinated coffee intake compared to non-drinkers. The coffee the participants consumed are typologically different both in preparation and in the coffee amount present in the cup, which may contribute to the heterogeneity between the studies. Second, all the studies were performed in the United States or European countries, so whether the associations noticed here could be externalized to other populations are still unknown. Larger prospective studies performed in other countries or populations are warranted. Third, the interactions between caffeinated coffee intake level and UV-light exposure level and their roles in the MM risk are largely unknown as caffeine reduced the UV irradiation induced DNA damage and enhanced UV induced cellular apoptosis. Fourth, in the meta-analysis of published studies, publication bias may lead to a biased false positive association as the small studies with null results may not yet published. Although we found no statistically significant publication bias here, we could not exclude the possibility that such bias existed. Last but not the least, the estimates from the individual studies was adjusted for different cofounding factors, which may also contribute to the heterogeneity between the studies and the interactions between the coffee intake level the cofounding factors in the melanoma risk were also hard to determine.In conclusion, this meta-analysis found that caffeinated coffee intake was negatively associated with the MM risk, but not so for the intake of decaffeinated coffee. Considering the high prevalence of coffee consumption and the rising incidence rate of melanoma, our study may provide important public health implications in the prevention of MM. However, more studies, especially the intervention studies are warranted to fully elucidate the chemo-preventive effects of caffeinated coffee against MM.S1 Fig(TIF)Click here for additional data file.S2 Fig(TIF)Click here for additional data file.S1 File(DOCX)Click here for additional data file.S2 File(DOC)Click here for additional data file.S1 Table(DOCX)Click here for additional data file.S2 Table(DOCX)Click here for additional data file.S3 Table(DOCX)Click here for additional data file.


Eating disorders are serious mental illnesses that have a significant effect on afflicted individuals’ quality of life. Evidence has shown that they can be improved with treatment. Internet-based interventions are useful in engaging individuals with eating disorders in self-management and treatment. This study aimed primarily to identify the change in quality of life of individuals with disordered eating after participating in an open trial of an Internet-based self-help programme, and compared their quality of life at assessment with that of healthy controls. Factors affecting their quality of life were examined. Secondary outcomes related to symptom improvement were also reported.U test was employed to compare the difference in quality of life between participants with disordered eating and the healthy controls. Spearman rank order correlations were performed to examine the factors associated with quality of life.This study included 194 individuals with disordered eating and 50 healthy controls. The former group was recruited from eating disorder outpatient clinics and treatment units, as well as via information disseminated through various Internet websites, while the healthy controls were recruited from university student newspapers and university campuses. The Medical Outcomes Study Short Form Survey (SF-36v2) was used to assess participants’ quality of life. Other measures were used to assess their symptoms and motivational stages of change to recover from an eating disorder. The Wilcoxon signed ranks test and one-way repeated measures ANOVA were used to identify the change in quality of life of individuals with disordered eating from baseline to 1-, 3- and 6-month follow-ups. The Mann–Whitney The participants with disordered eating had significantly poorer quality of life than the healthy controls in both physical and psychological domains. The factors associated with their poor quality of life included dieting behaviour, use of laxatives, severe eating disorder psychopathology, depression and anxiety. Over a six-month follow-up period, a significant number of participants engaged in self-help behaviours using the Internet-based programme. They experienced improvements in their quality of life, eating disorder psychopathology, depression severity, anxiety level and motivational stages of change.Internet-based self-help programmes have the potential to enhance quality of life in individuals with disordered eating and could be useful adjuncts to professional treatment. Eating disorders are serious mental illnesses that impair cognitive function, judgment and emotional stability, and limit the life activities of the sufferers . Such diIndividuals with eating disorders have substantial impairment in quality of life, worse than those with other psychiatric disorders  , physicaThere is some evidence showing that quality of life can be improved with face-to-face treatment ,15, but This study aimed primarily to i) identify the change in quality of life of individuals with disordered eating after using an Internet-based self-help programme developed in the Asia-Pacific region, ii) compare their quality of life with healthy controls at baseline assessment, and iii) identify the factors affecting their quality of life. Other secondary outcomes related to the improvement in eating disorder psychopathology, depression severity, anxiety level and motivational stages of change were also examined.This study was an open trial of an Internet-based self-help programme, the “Smart Eating” programme, developed in the Asia-Pacific region by the first author. A randomised controlled design was not used due to the difficulty of recruiting a large number of participants with eating disorders. This difficulty can be related to the ego-syntonic nature of the disorders, ambivalence toward treatment and poor acceptability of treatments ,22. The Participants were required to complete an online registration in the self-help programme, and to choose their own usernames and passwords to log in to the programme. The online registration form elicited demographic information including gender, date of birth, body weight, body height, nationality, country of current residence, e-mail address, marital status, educational attainment, occupation, health history and treatments related to eating disorders, and assessment scores of the SCOFF questionnaire and EDE-Q, 5th edition (EDE-Q5). For security purposes, the demographic information and data provided by the users were protected by password and a special Web maintenance service.The SCOFF questionnaire is a 5-item quick screening tool that addresses the core features of anorexia nervosa and bulimia nervosa . A scoreThe Medical Outcomes Study Short Form Survey (SF-36 version 2) was administered through the Smart Eating programme to assess the participants’ quality of life. It is the most widely used generic quality of life measure for individuals with eating disorders . It contIn a large U.S. population study, SF-36 version 2 was identified to have high internal consistency reliability coefficients for all scales (well above 0.8) . The SF-Other health assessment questionnaires offered by the Smart Eating programme include the Eating Disorder Examination Questionnaire (EDE-Q5) , the EatHigher scores on the EDE-Q5, EDI-3, BDI-II, and BAI indicate more severe eating disorder psychopathology and associated psychological symptoms. Higher scores on the SF-36 and MSCARED indicate better perceived quality of life and higher motivation to change disordered eating behaviour.The participants were recruited by the first author. Those with disordered eating were recruited through personal approach or promotional leaflets distributed in two outpatient eating disorder clinics and two eating disorder treatment units, and information disseminated through various Internet websites. The healthy controls were recruited from two universities through university student newspapers and the on-campus distribution of promotional leaflets. Individuals were able to participate in the study if they were aged 16 to 50 years old  and identified themselves as healthy controls or suffering from an eating disorder as shown by the assessment scores of the SCOFF questionnaire or the EDE-Q5.Participants who successfully registered in the programme were invited via e-mail to complete six self-assessment questionnaires available in the self-help programme. After completing this baseline assessment, they received an e-mail with instructions on using the programme. The participants were reminded via e-mail to complete the six self-assessment questionnaires at the 1- and 3-month follow-up periods, as well as at the 6-month follow-up if possible. Participants with disordered eating were also followed up monthly through e-mail correspondence. The e-mails were standardised, enquiring about individual progress in using the programme and encouraging them to continue.The Smart Eating self-help programme comprises several components relating to healthy eating, family education, health assessment, motivation enhancement, self-help strategies, and psychological health promotion. The motivation enhancement component encourages individuals’ motivation to change and recover from an eating disorder. The self-help strategies introduced in the programme help individuals restore healthy weight; normalise eating patterns; manage dieting, bingeing, and purging; challenge negative automatic thoughts and thinking errors; develop problem-solving abilities; and prevent relapse. The psychological health promotion component covers strategies for coping with stress, body image alteration, low self-esteem, depression, and anxiety. The content of the programme incorporates expert input from eating disorder specialists and is consistent with treatment recommendations for eating disorders from different eating disorder practice guidelines, including those of the American Psychiatric Association (APA) , the NatTo acquire the maximum benefit from the Smart Eating programme, participants with disordered eating were recommended to go through its individual components in the following pattern as prescribed in the programme:1. Browse through the information on healthy eating2. Solicit support from family members to overcome an eating disorder, and ask them to view the information about family education3. Complete all health assessment questionnaires at baseline4. Work through the worksheets on motivational enhancement5. Follow the steps in the self-help strategies to overcome eating disorders6. Use different strategies to promote psychological health7. Complete all health assessment questionnaires again at 1-, 3- and 6-month follow-up intervals to monitor personal progressThe healthy controls in this study had access limited to the programme components of healthy eating, family education and health assessment. They could use the programme to find out whether they had an eating disorder or an associated psychological problem (e.g. anxiety or depression). Participants with disordered eating had access to all components of the programme, and used it to learn and apply various self-help strategies and perform online self-assessments to monitor their progress in eating disorder psychopathology, motivational stage of change, and psychological health. They also used the programme privately at a time and pace convenient to themselves. A tracking system was implemented to determine compliance with the programme regarding health assessment, motivation enhancement, self-help strategies and psychological health promotion.U test was employed to compare the differences in quality of life between participants with disordered eating and the healthy controls. Spearman rank order correlations were performed to examine the factors affecting individuals’ quality of life.The data were analysed using the Predictive Analytics Software (PASW 17.0) statistical package. Descriptive analysis was performed to identify participants’ demographic characteristics. The Wilcoxon signed ranks test and one-way repeated measures ANOVA were used to identify changes in the quality of life of individuals with disordered eating from baseline to the 1-, 3- and 6-month follow-ups. The Mann–Whitney A total of 362 individuals who identified themselves as having an eating disorder and 88 healthy controls registered in the programme from August 2006 to May 2012. The former group is referred to as the participants with disordered eating in this study. Among them, 194 (53.6%) participants with disordered eating and 50 (56.8%) healthy controls initiated their baseline health assessment with the Smart Eating programme, and their findings are reported in this paper . Their mean body mass index (BMI) was 21.25 . Among them, 82 (42.3%) were not receiving any specialist treatment for eating disorders, and 112 (57.7%) were receiving treatment. The treatment was provided by psychiatrists/medical practitioners , psychologists/counsellors , dieticians  or a mental health nurse specialist . Some of the participants reported taking medication , and a few were using Chinese herbal medicine , acupuncture , naturopathy , or nutritional supplements  in their treatment. Among the healthy controls, there were 45 females and 5 males. Their ages ranged from 17 to 48 years (mean age 24.7). Their mean BMI was 20.7 . Most of the participants were Australian or Hong Kong Chinese. A majority of them had a secondary education or higher. Table th edition) when they registered in the Smart Eating programme. According to the assessment scores, 191 participants with disordered eating scored at least 2 on the SCOFF questionnaire or had at least one subscale score on the EDE-Q5 falling in the clinically significant range (≥ 4). The three remaining participants had non-significant assessment scores but reported participating in treatment for their eating disorders, and two had low BMI (15.59 and 16.53). Thus, all 194 participants with disordered eating had a clinically significant eating disorder based on their SCOFF questionnaire/EDE-Q5 scores or their treatment for an eating disorder. The participants with disordered eating had significantly higher mean scores in the SCOFF questionnaires (3.36) and the Eating Disorder Examination Questionnaire  than the healthy controls  and mental health domains . Their quality of life in the mental health domains was also worse than in the physical health domains. This was also shown from the lower score in the Mental Component Summary scale (MCS) than the Physical Component Summary scale (PCS) of SF-36. Table s=-0.165, p<0.05) and use of laxatives  , Global EDE-Q5 , EDI-3 , BDI-II  and BAI  , general health , vitality  and mental health .To identify the factors associated with poor quality of life in participants with disordered eating, Spearman rank order correlations were performed among various variables concerning eating disorder psychopathology, depression severity, anxiety level, motivational stages of change and quality of life. The findings revealed that quality of life  had a significant negative correlation with dieting behaviour , working through motivation enhancement exercises , learning how to improve body image , and using self-help strategies to overcome eating disorders . Other self-help behaviours included identifying strategies for overcoming depression , managing anxiety , coping with stress , and boosting self-esteem .Seventy participants (36.1%) used the programme for at least 1 month. The Wilcoxon signed ranks test identified significant improvement in their quality of life , particularly in the domains of bodily pain , general health , social functioning  and emotional role functioning  from baseline to 1-month follow up. The improvement in quality of life continued at the 3-month follow up for 47 participants , who also experienced significant improvements in their general health , social functioning , emotional role functioning  and mental health , as shown by the result of the one-way repeated measures ANOVA. At the 6-month follow up, 34 participants were still using the programme. Table In view of the number of participants with disordered eating who did not complete the follow-up health assessment and self-help programme, an intention-to-treat analysis was also performed. This type of analysis is used for clinical trial data in which the outcomes of all participants, including those who drop out prematurely, are included in the analysis. The last observation carried forward (LOCF) method was used, in which the missing values of the outcome variables are replaced by the most recent known values before the participants were lost to follow up . This isThe intention-to-treat analyses revealed significant increases in their SF-36 and MSCARED scores from baseline to 1-, 3- and 6-month follow-ups and significant decreases in their EDE-Q5, EDI-3 and BDI-II scores  were already in treatment, but they also used the programme. This implies that the programme could be a useful adjunct to their professional treatment.As expected, there was a significant difference in the clinical features between participants with disordered eating and the healthy controls. The difference was recognised in their assessment scores on the SCOFF questionnaire, EDE-Q5, EDI-3, BDI-II, BAI and SF-36, which showed that participants with eating disorders had severe eating disorder symptoms, depression and anxiety, resulting in poorer quality of life. Their quality of life was much worse than that of healthy controls in all the domains studied in the SF-36. Consistent with earlier findings, this study confirmed several associated factors affecting individuals’ quality of life, including dieting, use of laxatives, severe eating disorder psychopathology and the existence of psychiatric comorbidity such as anxiety and depression -9. A sigThis study had several limitations. One was the convenience (non-random pragmatic) sampling method. Another was the open trial design of the self-help programme. The third limitation was the difficulty of recruiting a large sample of healthy controls due to the lack of incentives for them to initiate the programme for health assessment. In addition, there was a high attrition rate, although the majority of participants used the programme for at least a month. High attrition rates are common in studies using self-help treatments for eating disorders (0–69.7%)  and natuFuture studies using the Smart Eating programme are recommended. The effectiveness of the programme in enhancing quality of life in individuals with eating disorders could be further evaluated in a randomised controlled study. Also, the effect of the programme could be compared with specialist treatment only and the condition of combining both specialist treatment and the programme.Eating disorders have a significant impact on individuals’ quality of life. Sufferers of eating disorders report significantly poorer quality of life than healthy controls in all physical and mental health domains. This poor quality of life can be associated with eating disordered behaviours, symptom severity, depression and anxiety. The Smart Eating online self-help programme developed in the Asia-Pacific region for people with eating disorders has the potential benefit of engaging individuals in self-help behaviour and treatment, and improving their quality of life. It could be a useful adjunct to professional treatment.The authors declare that they have no competing interests.SL, JM and JR contributed to the design of the study and data collection. SL analysed the findings and drafted this paper. All authors read and approved the final manuscript.


Improvements in knee osteoarthritis (OA) symptoms with platelet-rich plasma (PRP) have been attributed to its ability to modify intra-articular inflammatory processes. Photo-activation of peripheral blood also improves inflammatory mediators associated with OA, however combined photo-activated PRP (PA-PRP) has not been investigated. This pilot study assessed the feasibility, safety and symptomatic and functional change following injections of PA-PRP compared to hyaluronic acid (HA) in people with knee osteoarthritis (OA).Thirty seven people with knee OA were enrolled in this double-blind randomized controlled pilot study set in a sports medicine clinic. Participants were randomly allocated to receive three injections of either PA-PRP or HA. The patients and the administering doctor were blinded to group allocation. Outcomes included recruitment and safety data, 100 mm visual analogue pain score (VAS), the Knee Osteoarthritis Outcome Score (KOOS), Knee Quality of Life (KQoL) scale, maximum hopping distance and number of knee bends in 30 s at four and 12 weeks.p < 0.01, ETA = 0.686), KOOS Pain , KQoL Physical  and KQoL Emotional subscales  at four and 12 weeks. The PA-PRP group also significantly improved hoping  and knee bends  at four or 12 weeks. The HA group showed improvements on only the KOOS Function subscale at 12 weeks . After controlling for baseline values, there were no significant between-group differences at either time-point.Twenty three (62 %) participants met the inclusion criteria, of which 12 (32 %) were randomized to the PA-PRP group and 11 (30 %) to the HA group. Two participants did not complete the intervention and two withdrew following their first assessment. Minor pain and swelling during the injection period was reported by two participants from the PA-PRP group. The PA-PRP group demonstrated significant improvements in the VAS (This study provides proof-of-concept evidence concerning the feasibility and safety of PA-PRP injections necessary to inform a larger clinical trial in people with knee OA. Our preliminary results also suggest PA-PRP improves self-reported pain, symptoms and lower extremity function, however no between-group differences were found. Photo-activated PRP may provide a safe and effective novel treatment for knee OA.ACTRN12611000651987 Osteoarthritis is a leading cause of musculoskeletal pain worldwide and the knee is one of the most commonly affected joints. Prevalence of knee OA is expected to increase with an aging population and growing rates of obesity, and projections of total knee replacements are predicted to increase by approximately 600 % over the next 25 years . As therRecent research suggests that growth factors and other cytokines released by platelets in response to injury or pathology may modulate inflammatory processes and contribute to the maintenance or regeneration of tissue structures , 11. ConRecent unblinded and non-randomized pilot and prospective studies investigating the clinical efficacy of intra-articular injections of PRP in patients with knee OA have demonstrated clinical improvement in self-reported pain and symptoms with no major adverse events , 15–17. The use of low-level light irradiation to activate peripheral blood (photo-activation) has also been shown to improve biological factors associated with osteoarthritis , 23. StuThis was a single centre, double-blind, randomized controlled pilot study comparing PA-PRP to HA. We chose HA as the active comparator as it is one of the most commonly used injective treatments for knee OA , and recBased on recommendations for determining sample sizes for pilot studies , 30, we Group allocation and concealment was performed by an independent staff member not involved with the assessment of participants. Participants were randomly allocated following baseline data collection on a 1:1 basis using a computer generated randomization list. Both groups completed the PA-PRP collection and activation phase of the intervention as explained below, and the syringe was then provided to the independent staff member. The staff member either retained or discarded the syringe containing the PA-PRP depending on group allocation. The syringe containing the PA-PRP, or an identical looking syringe containing HA , was then occluded and returned to the treating doctor for administration. This process ensured the blinding of both the patient and treating doctor. All injections were performed at weekly intervals.To obtain the PRP, 48.5 ml of the patient’s blood was collected using venipuncture, then centrifuged (Premiere XC-2000) at 2,000 rpm for five minutes. The plasma and buffy coat containing platelets was drawn from the top of the sample and placed in a sterile tube and centrifuged again at 3,000 rpm for three minutes. This double-spin approach has been shown to produce PRP that is higher in leukocytes , which wParticipants were placed in a supine position and sterile drapes were placed around the surrounding area. Next, the participant’s symptomatic knee was cleaned with chlorhexadine and iodine solution and the knee was anaesthetised using an intra-articular injection of 5 ml of 1 % Xylocaine. Following activation, 3 ml of PA-PRP or HA was injected under ultrasound guidance  into the symptomatic region using an anteromedial approach. Following the injection, passive flexion and extension of the knee was performed 10 times, after which the participant remained resting in the supine position for approximately 10 min. Participants were advised to take paracetamol if they experienced any pain, and to limit their weight bearing activities for the subsequent 24 h, followed by gradual resumption of normal activities.Prior to treatment, baseline demographic data was collected. Feasibility was recorded using recruitment and retention rates, and safety was assessed by recording the number and nature of adverse events. Adverse events were recorded weekly for the first month using participant phone calls, and at one and three month during the follow up assessment visits. To evaluate symptom severity, participants first completed a 100 mm Visual Analogue Scale (VAS) to rate their average knee pain over the previous week, with terminal descriptors of “no pain” and “worst pain possible” . To docuFinally, recent research suggests that validated self-report questionnaires and objective functional tests should be employed in combination to fully assess mobility-related outcomes in people with knee OA . ConsequAll surveys and functional tests were completed at baseline, four weeks and at a final follow-up at 12 weeks following the final treatment injection, as this timeframe has been shown to demonstrate symptomatic improvements in previous studies using other PRP preparation methods , 20, 40.p < 0.05 was used to determine statistical significance.The Statistical Package for Social Sciences (SPSS) software (Version 17) was used to analyse the data. Normality was assessed using skewness and kurtosis statistics and the Shapiro-Wilk test. To determine whether PA-PRP and HA had an effect on outcome variables, one way Repeated Measures Analysis of Variance (RM ANOVA) were conducted to compare baseline, four and 12 week follow-up scores for the VAS, KOOS, KQoL-26 and functional tests for each group. An analysis of covariance (ANCOVA) was used to assess between-group changes in the primary and secondary outcomes, with group allocation as the fixed factor and corresponding baseline outcome values as covariates. This technique has been reported to be the optimal method to analyse continuous data in clinical trials . An alphp > 0.05).Twenty three (62 %) of the 37 enrolled people with knee OA  met the inclusion criteria. Two participants did not complete the allocated intervention; one from the PA-PRP group who withdrew due to minor injection-related pain and swelling which resolved without further treatment, and one from the HA group who suffered an acute meniscal tear unrelated to the treatment. Two additional participants withdrew from the study due to other unrelated injuries after the four week follow up assessments. Consequently, data was available for 21 participants  for the four week follow up and for 19 participants at 12 weeks . Post hoc tests showed that the reduction in pain at four weeks was significantly less than baseline , however the 11.4 mm reduction in VAS at 12 weeks was not statistically significant. No significant reductions in pain were found for the HA group.Average pain recorded using the 100 mm VAS reduced from baseline at the four and 12 week follow up time points for both the PA-PRP and HA groups , the KQoL-26 Physical subscale  and the KQoL Emotional subscale  . Table p = 0.025; 12 weeks: 22.33, 95 % CI 11.86 to 32.80, p = 0.001, ETA = 0.799) and knee bend  performance, whereas changes in physical function in the HA group were not found to be significant. To investigate between-group differences in mean change scores on the 100 mm VAS, KOOS, KQoL-26 and functional tests, ANCOVA was performed adjusting for baseline scores (Table p > 0.05).For the PA-PRP group, significant improvements were found at both follow up time points in the KOOS Pain subscale (4 weeks: 13.33, 95 % CI 4.66 to 22.01, This was a double-blind randomized controlled pilot study comparing intra-articular injections of a novel form of PRP activated with ultraviolet light compared to HA. The results demonstrate the feasibility of this technique in people with knee OA and show no serious adverse events were reported. There was a significant decrease in VAS pain for the PA-PRP group at four weeks that was greater than the minimal clinically important improvement level of 19.9 mm. The 24 % decrease below baseline pain levels at 12 weeks was not found to be statistically significant and no improvements in pain were found in the HA group. The PA-PRP group also demonstrated significant improvements in the KOOS Pain subscale at four and 12 weeks, and significant improvements in the KQoL-26 Physical and Emotional subscales. In contrast, the only significant improvement in the HA group was in the KOOS Functional subscale at 12 weeks. Finally, whilst the PA-PRP group significantly improved their performance on the functional measures of hopping and knee bend at 12 weeks, no significant improvements in lower extremity function were found in the HA group. Despite these improvements in the PA-PRP compared to the HA group, there were no significant between-group differences on any measures after adjusting for baseline variation. These preliminary results provide initial feasibility, safety and treatment data that may be used to inform a future large clinical trial to investigate whether this novel form of photo-activated PRP has symptomatic and functional benefits in people with knee OA.Of the 23 people who met the inclusion criteria, two participants did not complete the allocated intervention and two additional participants withdrew from the study following the four week follow-up appointment. These four patients were evenly spread between groups, and with the exception of one, were all due to new injuries unrelated to the treatment. One of the PA-PRP patients however did withdraw due to minor injection-related soreness, whilst another two also reported minor pain and swelling following an injection. In all instances, symptoms resolved within a week and no further adverse events were reported during the intervention or follow-up period.Previous RCTs have investigated the efficacy of PRP compared to HA or saline , 42, 43 The lack of between-group differences found in our pilot study may also be partly due to our PRP preparation method. We used a double spin technique which has previously been shown to produce PRP that is higher in leukocyte concentration when compared to PRP prepared using a single spin technique . Indeed,There are some limitations that may have influenced the outcomes of our study. Firstly, as mentioned the small sample size of this pilot trial reduces statistical power which may make more definitive conclusions problematic, and the relatively short follow-up period of our study may have been too brief to determine between-group differences. A larger clinical trial is needed to confirm our results. Furthermore, we did not include a minimum VAS pain score as part of our screening criteria, resulting in greater variation in baseline pain and self-reported symptoms. This produced high baseline standard deviations which would have decreased the probability of finding differences between the PRP and HA groups, particularly with the small sample size. Finally, we did not examine how photo-activation modifies PRP. Given the benefits of photo-activation have been attributed to its influence upon the concentration of proinflammatory cytokines and leucocyte-derived anti-inflammatory factors , 23, andThis randomized controlled pilot study provides feasibility and safety data for the use of PA-PRP in people with knee OA that may help to inform a larger clinical trial. Although under-powered to assess efficacy, our preliminary results also provide some evidence that PA-PRP improves self-reported pain, subscales of the KOOS and KQoL-26, and tests of lower extremity functional ability in knee OA patients. However these improvements were not found to be significantly greater than those of the HA group. Future clinical trials with larger sample sizes and longer follow up periods should investigate whether this novel photo-activated PRP method improves symptoms and function over that of HA in people with knee OA.


Many studies have demonstrated that the pathophysiology and clinical symptoms of Parkinson's disease (PD) are inhomogeneous. However, the symptom-specific intrinsic neural activities underlying the PD subtypes are still not well understood. Here, 15 tremor-dominant PD patients, 10 non-tremor-dominant PD patients, and 20 matched normal controls (NCs) were recruited and underwent resting-state functional magnetic resonance imaging (fMRI). Functional brain networks were constructed based on randomly generated anatomical templates with and without the cerebellum. The regional network efficiencies  were further measured and used to distinguish subgroups of PD patients  from the NCs using linear discriminant analysis. The results demonstrate that the subtype-specific functional networks were small-world-organized and that the network regional efficiency could discriminate among the individual PD subgroups and the NCs. Brain regions involved in distinguishing between the study groups included the basal ganglia , limbic regions , the cerebellum, and other cerebral regions . In particular, the performances of the regional local efficiency in the functional network were better than those of the global efficiency, and the performances of global efficiency were dependent on the inclusion of the cerebellum in the analysis. These findings provide new evidence for the neurological basis of differences between PD subtypes and suggest that the cerebellum may play different roles in the pathologies of different PD subtypes. The present study demonstrated the power of the combination of graph-based network analysis and discrimination analysis in elucidating the neural basis of different PD subtypes. Parkinson's disease (PD) is a movement-related neurodegenerative disorder that has a broad range of clinical symptoms, including resting tremor, slowness of movements, rigidity, and gait disturbance The pathological changes observed in tremor-dominant PD patients differ from those observed in non-tremor-dominant PD In the present study, we investigated the brain functional network topology related to two PD patient subtypes  via combining graph-based network analysis and linear discriminant analysis. We also explored the role of the cerebellum in the PD functional network. To this end, we collected resting-state functional MRI (R-fMRI) data from 15 tremor-dominant PD patients, 10 non-tremor-dominant PD patients, and 20 matched normal controls (NCs). Two types of functional brain networks for each participant were constructed based on high-resolution, randomly generated anatomical templates with and without the cerebellum. A graph-based network efficiency metric was then employed to characterize the topological organization of each functional brain network. Then, a non-parameter permutation test and a linear discriminant analysis were combined to determine whether the regional network efficiency could distinguish the mixed PD patients and the PD subtypes from the NCs.Twenty-five right-handed PD patients and 20 matched NCs were recruited for the present study. The PD patients underwent neurological examinations and were scored using the Unified Parkinson's Disease Rating Scale (UPDRS), Hoehn & Yahr Scale (H-Y stage), and Mini-Mental State Examination (MMSE). All the patients were diagnosed according to the UK PD Brain Bank Criteria. A total of 15 tremor-dominant PD patients with classical parkinsonian resting tremor with (n = 13) or without (n = 2) action or postural tremor and 10 non-tremor-dominant patients with bradykinesia (n = 5) or akinesia (n = 5) were collected. Patients in advanced stages of PD (H-Y > = 4) or with cognitive impairments (MMSE <28), secondary parkinsonism, atypical parkinsonian disease or a history of any substance dependence, head trauma, or claustrophobia were excluded from the study. In the hours before and during MRI scanning, the patients were not given any medication, to avoid measuring the effects of the medications on patients as much as possible. All participants gave written, informed consent before participating in the present study. This study was approved by the Institutional Review Board of the Guangzhou University of Traditional Chinese Medicine.2, and 180 volumes. The 3D structural images were acquired using a T1-weighted MP-RAGE sequence: TR  = 1160 ms, TE  = 4.21 ms, TI  = 900 ms, flip angle  = 15°, FOV  = 256×256 mm2, matrix  = 512×512, slice thickness  = 1 mm, and 192 sagittal slices.All participants were scanned using a 1.5T Siemens Avanto MR scanner  with a 12-channel phased-array head coil in the Department of Radiology of the Second Affiliated Hospital of Guangzhou University of Traditional Chinese Medicine. During data acquisition, the participants were asked to lie quietly in the MR scanner with their eyes closed. Resting-state functional images were acquired using a gradient-echo echo-planar imaging (GE-EPI) sequence. R-fMRI images were collected using an echo-planar imaging sequence with the following parameters: 30 axial slices; repetition time  = 2000 ms; echo time  = 39 ms; gap  = 1 mm; slice thickness  = 4 mm; flip angle  = 90°; matrix  = 64×64; field of view  = 240×240 mmhttp://www.nitrc.org/projects/gretna/) and SPM8 software (http://www.fil.ion.ucl.ac.uk/spm/software/spm8/). For each participant, the first 5 volumes were discarded to allow for scanner stabilization. The remaining R-fMRI data were then corrected for the intra-volume acquisition time delay between slices and geometrical displacements due to head movement. After checking the head motion parameters, none of the participants were excluded based on the criterion of a displacement of >3 mm or an angular rotation of >3° in any direction. Notably, the head-motion profiles  were matched between the PD patients and NCs . All realigned functional data were spatially normalized to Montreal Neurological Institute (MNI) space using an optimal 12-parameter affine transformation and nonlinear deformations. The normalized R-fMRI data were then resampled to a 3-mm isotropic resolution and smoothed using a 4-mm isotropic kernel. The resulting images were temporal bandpass filtered (0.01–0.1 Hz), and linear trends were removed. Finally, several nuisance signals, including 24-parameter head-motion profiles R-fMRI data preprocessing was performed using the GRETNA toolbox . The network nodes were defined using a high-resolution, randomly generated anatomical atlas The Pearson correlations between the processed time series of any pair of ROIs were calculated, and the edges were defined as the FC strength between ROIs. These correlation coefficients were normalized using Fisher's r-to-z transformation, as follows: p-values were below a threshold of statistical significance  were retained In parallel, two sets of functional networks  for each participant, corresponding to the two templates, were constructed. To further remove spurious interregional correlations, only those correlations whose corresponding The constructed functional weighted networks were further fed into graph-based network efficiency analyses. Here, the global and local efficiencies were calculated to characterize parallel information flow within the networks of the PD patients  and the NCs.The global network efficiency is a measure of a network's capacity for parallel information transfer between nodes via multiple series of edges The local network efficiency was calculated as the mean of the local efficiencies across all nodes within a network. The local efficiency of The global and local efficiencies were normalized by the corresponding mean derived from 100 random networks. The topological organization of the weighted functional network was investigated using the normalized global efficiency  and local efficiency . Specifically, a network is thought to be a small-world network if it has a normalized local efficiency greater than 1 and a normalized global efficiency approximately equal to 1. The ratio of Gamma to Lambda  was used to measure the small-world property of the network.The nodal efficiency was measured to characterize the nodal properties of these functional networks. The nodal efficiency measures the mean shortest path length between a given node To investigate whether the network nodal properties carry enough discriminative information to distinguish the PD patients from the NCs, we investigated whether the network nodal efficiency metrics  could be used to determine a pattern that performed well in distinguishing PD patients from NCs. Here, discrimination analysis was used to identify a distinguishing pattern that incorporated a feature selection approach.p<0.05, uncorrected). Briefly, for each network metric, we estimated the t-statistic to determine whether a between-group difference existed, and we then randomly assigned the parameter values into two groups to recalculate the t-statistic for the two randomized groups. We repeated this process for 10,000 permutations and obtained 10,000 t-statistics; we were thus able to estimate an empirical distribution of the group difference. The 95% confidence interval for the empirical distribution, generated using a two-tailed test, was used to determine the significance levels of the between-group differences. Before these permutation tests, multiple linear regressions were used to remove the effects of age and gender.Before the classification of subjects as PD patients or NCs was validated, feature selection was performed to reduce the dimensions of the data. For feature selection, significant between-group differences in network efficiency were inferred using nonparametric permutation tests Maximum uncertainty linear discriminate analysis (MLDA) The PD subtype classification findings obtained via analyses of network node efficiencies together with linear discrimination analysis were further validated using network property metrics  of the functional weighted networks were investigated. We found that differences in regional efficiencies of the functional weighted networks were able to classify the PD patients  from the NCs. However, the regional local and global efficiencies in the functional networks performed differently in distinguishing the PD patients from the NCs. The regional local efficiency of the two types of functional networks both performed well in distinguishing the PD patients from the NCs. In contrast, the regional global efficiencies for the cere-AAL1024 and AAL1024 networks yielded inconsistent results. The global efficiency of the network corresponding to the cere-AAL1024 template rather than that of the AAL-1024 template could effectively distinguish the PD patients from the NCs, suggesting that the cerebellum may influence the global efficiency of the functional network in PD patients .The regional efficiencies of the functional brain networks for patients with tremor-dominant and non-tremor-dominant PD, considered separately, were able to distinguish these patient groups from the NCs better than the regional efficiencies for the mixed group of PD patients. However, the regional efficiency of the functional network was not equally effective in distinguishing the tremor-dominant PD patients and the non-tremor-dominant PD patients from the NCs. The local efficiency of the functional brain networks was able to discriminate both the tremor-dominant and non-tremor-dominant PD patients from the NCs. Global efficiencies derived from the functional brain network related to the cere-AAL2014 template were better able to distinguish patients with different PD subtypes  from the NCs. However, the global efficiency of the functional brain network generated using the AAL1024 template distinguished tremor-dominant PD patients from NCs but failed to distinguish the non-tremor PD patients from the NCs. These results are shown in In the present study, we investigated the role of feature selection in distinguishing the mixed group of PD patients from NCs. We found that the feature selection approach significantly influenced the performance of the classifier. The accuracy of the classifier performance without feature selection was almost at a random level .By using a feature selection approach, we determined the regions that acquired distinguishing information that could be used to discriminate between the mixed group of PD patients and the NCs. The nodal efficiency of the functional brain network demonstrated the presence of significant network disruption in many regions in the mixed group of PD patients, and these regions associated with network disruptions were predominantly distributed across the limbic system, cerebellum, brainstem, basal ganglia, and the frontal, temporal and parietal cortex .We further explored the discriminating regions that performed well in distinguishing the individual PD subtypes from the NCs. We found that the information required to distinguish the PD subtype from the NCs was predominantly obtained from observations of the limbic system , basal ganglia , cerebellum, insula and cingular cortex regions. These results are shown in The network nodal efficiency  was also used to distinguish between the PD patient subtypes and NCs. The results suggested that the network nodal efficiency could also effectively discriminate the different subtypes of PD from each other. The network nodal efficiency patterns derived from the networks generated using the cere-AAL1024 and the AAL1024 templates were both able to perform well in the classification of PD subtypes . We furtThe findings of the present study were validated using the rganized .. When sIn the present study, we measured the topological organization of the functional brain networks of PD patients and analyzed regional network efficiency to distinguish the mixed PD group and PD subtype groups from the NCs. The main findings demonstrated that analysis of the regional network efficiency  could effectively distinguish the tremor-dominant PD patients and the non-tremor-dominant PD patients from the NCs and that this ability to distinguish among the groups was influenced by the cerebellum.The present study demonstrated that brain functional network efficiency could distinguish the PD patients from the NCs. PD is commonly attributed to dysfunction of basal ganglia circuits , triggered by insufficient numbers of dopaminergic nigrostriatal neurons The local and global efficiencies of the functional brain networks performed differently in differentiating the mixed PD group from the NCs. Specifically, we found that the local network efficiency, rather than the global efficiency, consistently performed well in identifying PD. The local efficiency is indicative of the ease of information transfer in the immediate neighborhood of each node within a network. Thus, the finding that local efficiency provides information that is useful for PD discrimination might suggest that obvious changes have occurred in connections between individual regions and adjacent regions in PD patients within functional brain networks. We also found that the performance of the global efficiency in identifying PD patients was dependent on the type of functional network that was examined . Further analysis showed that the global network efficiency performed differently in distinguishing between individual subtypes of PD. The network types influenced the performance of global efficiency data in distinguishing the non-tremor-dominant PD patients from the NCs. However, the ability to identify tremor-dominant PD was independent of the network type examined. These findings suggest that the physiological basis of tremor-dominant and non-tremor-dominant PD differ and that the cerebellum may play an important role in global network information translation.Many studies have indicated that the patterns of dopaminergic neurodegeneration The cerebellum may play different roles in the functional networks observed in tremor-dominant and non-tremor-dominant PD. We found that the cerebellum significantly influenced network properties, which in turn influenced the ability to distinguish between non-tremor PD patients and NCs. Previous studies have shown that the cerebellum plays important roles in the pathology of PD In the present study, certain regions, such as the basal ganglia, limbic regions , cerebellum, and several cerebral regions , were observed to be able to distinguish individual PD subtypes from the NCs. Previous studies have demonstrated that neural circuits  play important roles in the pathophysiology of PD ork well . These oSeveral issues should be addressed in future work. First, the sample size in this study was small, which may affect the conclusions of this study. Second, the present study revealed the regions in PD patients with altered regional efficiency; whether these regions could construct a sub-network should be further investigated. Third, although the network efficiency has been shown to effectively reflect the spatial topological organization of a network, other metrics of functional brain networks should also be used to identify PD subtypes in the framework of the present study.The present study measured the spatial organization of the functional brain network of PD patients and examined regional network efficiency to discriminate PD patients from NCs. We found that regional efficiency data carry enough information to identify PD patients; however, the local efficiency and the global efficiency performed differently. The local efficiency effectively distinguished the PD patients from the NCs; the global efficiency was able to distinguish the tremor-dominant PD patients from NCs but was dependent on the cerebellum to distinguish non-tremor-dominant PD patients from the NCs. The present study suggests that functional network efficiency is altered in PD patients and demonstrates the importance of the cerebellum in functional brain networks. This study also showed the different neural substrates of tremor-dominant and non-tremor-dominant PD.S1 FigSpatial properties of the whole-brain functional networks. The network category is the same with that of (TIF)Click here for additional data file.S1 TableClassifier performances of the mixed PD from NCs without feature selection. LE, local efficiency; GE, global efficiency; aAAL1024 template with cerebellum; bAAL1024 template without cerebellum.(DOC)Click here for additional data file.S2 TableClassifier performance based on the network nodal properties.aAAL1024 template with cerebellum; bAAL1024 template without cerebellum; NC, normal control; T, tremor PD; NT, non-tremor PD; the content of the check indicates the sensitivity/specificity/accuracy of the classifier performance, respectively.(DOC)Click here for additional data file.


In patients with severe calcific aortic stenosis, balloon aortic valvuloplasty (BAV) is routinely performed in order to pre-dilate the stenosed aortic valve prior to transcatheter aortic valve implantation (TAVI). Although pre-dilation is considered to be essential for the preparation of the valve landing zone, there is no clear evidence to support its clinical value. In contrast, BAV has been suggested to be linked to several complications. Notably, while preliminary evidence has supported the feasibility and safety of TAVI without pre-dilation, larger studies directly comparing the benefit/risk profile of TAVI in the presence and absence of pre-dilation are required.Therefore, a prospective, two-armed, multicenter registry (EASE-IT) was designed to obtain essential data concerning procedural success rates, adverse events, and mortality in a large cohort of patients undergoing transapical (TA)-TAVI using the Edwards SAPIEN 3 balloon expandable heart valves with and without pre-ballooning.Data provided by EASE-IT will be used to assess the relevance of BAV during the TAVI procedure and to investigate associations between patient characteristics and outcomes. Therefore, results obtained from the EASE-IT registry could contribute to reduced rates of TAVI-associated morbidity and mortality in patients with severe, calcific aortic stenosis.NCT02127580ClinicalTrials.gov Identifier:  Degenerative aortic stenosis (AS) is characterized by the narrowing of the aortic heart valve and most frequently is associated with progressive calcification and fibrosis of the valve leaflets. It represents the most common form of valve disease in the Western world and is associated with an estimated 5-year survival rate of 32% in the absence of treatment –3. Thus,Since the introduction of TAVI , 9, pre-So far, only preliminary studies have investigated the clinical value of pre-dilation of stenosed aortic valves in patients receiving self-expandable THVs through the transfemoral (TF) route , 19 or bAlthough these preliminary investigations have started to evaluate the safety of TAVI without pre-dilation, larger datasets directly comparing TAVI in the presence and absence of BAV are required to fully assess the risks and/or benefits associated with elimination of the pre-dilation step. For this reason, we have designed a prospective, two-armed, multicenter registry (EASE-IT) to compare the safety and efficacy of TA-TAVI using Edwards SAPIEN 3 with and without pre-ballooning. EASE-IT aims to document adverse events, mortality, and procedural data in order to assess the importance of pre-dilation during TAVI and to identify potential associations between patient characteristics and outcomes.th 2014 and confirmation obtained at each site participating in ROUTE prior to patient enrollment. All patients are required to provide written informed consent prior to participation. The investigation commenced in April 2014.EASE-IT is a multicenter, prospective, two-armed, observational registry. Enrollment of 200 subjects will take place at up to 10 study-sites in Germany. Approval was obtained by the Ethics Committee of the Landesärztekammer Stuttgart on February 25Sites are selected based on prior experience with TA-TAVI  and the ability to enroll a minimum of two patients per month. All participating sites have been, independent of this registry, trained in the use of the Edwards SAPIEN 3 and Ascendra Balloon Catheter according to the manufacturer’s instructions for use  and by means of exhaustive fundamentals training . This will be followed by on-site training as specified by the Edwards Standard Operating Procedure.Patient eligibility for EASE-IT will be based on the following criteria: (1) indication for TAVI in accordance with the Edwards SAPIEN 3 instructions; (2) eligibility for TAVI with and without BAV; and (3) at least 18 years of age. Patients with contraindications based on instructions for use of either TAVI or the Ascendra Balloon Catheter will be excluded from the study. Additionally, patients meeting any of the following criteria will be excluded: (1) logistic EuroSCORE I >50%; (2) mitral or tricuspid valvular insufficiency (> grade II); (3) previous aortic valve replacement; (4) uncontrolled atrial fibrillation; (5) left ventricular or atrial thrombus by echocardiography; (6) recent cerebrovascular event (within the last 3 months);and (7) high probability of non-adherence to follow-up requirements . Each participating center must document 10 consecutive cases with BAV and 10 cases without BAV.Notably, TA-TAVI with pre-dilation is to be performed as previously described by Walther et al. , whereasThe primary evaluation criteria at 1 month will consider the combined endpoint of all-cause mortality, stroke, non-fatal myocardial infarction, acute kidney injury, and pacemaker implantation within 30 days after TAVI as to VARC2 , which must be signed electronically by investigators and/or designees Table . The eCRA total of 20% of the sites  will be selected at random for monitoring following completion of patient follow-up and documentation. Source data verification will be performed for all patients in these centers. Also, 100% source data verification will be conducted for the following serious adverse events: death, stroke, major bleeding, valve complications, vascular complications, permanent pacemaker implantation, and renal failure. For data analysis, linearized rates and actuarial probability statistics will be used for adverse event reporting, and Kaplan-Meier analyses will be performed for survival and adverse event outcomes when appropriate.The sample size for EASE-IT was established based on previously reported event rates and the feasibility to detect an absolute risk reduction for the primary endpoint of 13% at 30 days while taking into consideration a 10% drop out rate , 20. IntEASE-IT represents a prospective, multicenter, two-armed registry aimed at documenting the course of patients undergoing TA-TAVI using the Edwards SAPIEN 3 with or without pre-dilation via BAV. Information provided by EASE-IT will be used to assess the value of pre-dilation during TAVI procedures and to investigate associations between patient characteristics and outcomes. Thus, results obtained from the EASE-IT registry should have several important implications.vs. without BAV). Thus, the comparative analysis that can be performed from information collected during the EASE-IT registry will be fundamental for establishing the importance of pre-dilation during TA-TAVI.Although recent pilot studies have preliminarily suggested the feasibility and safety of performing TF-and TA-TAVI without pre-dilation of the stenosed aortic valve –20, thesNotably, a recent imaging study suggested that new silent cerebral lesions appear in approximately 90% of patients undergoing TAVI , with thRegarding exclusion of the pre-dilation step during TAVI, the resulting simplified approach might reduce the procedural time, amount of contrast agent used, and duration of fluoroscopy as indicated by Wendler et al. . In thisFurthermore, results obtained by EASE-IT regarding the importance of pre-dilation during TAVI might only be applicable to the Edwards SAPIEN 3, and not other commercially available devices. In this regard, another ongoing prospective, randomized trial has been initiated by a group at Bonn University  in order to investigate the 30-day composite endpoint in patients with severely impaired LVEF (≤35%) undergoing TAVI using MCV devices. Therefore, EASE-IT registry results, which are likely to be reported after completion of the SIMPLIFy TAVI trial (scheduled to end December 2014), should hold particular significance with regard to the generalizability of the impact of BAV on TAVI outcome as related to distinct devices and populations. Indeed, studies testing the importance of the pre-dilation step will need to be carried out for specific delivery systems, routes, and patient populations in order to conclusively determine whether the use of BAV is beneficial. Therefore, EASE-IT will be essential for contributing to the body of data necessary for establishing the value or risk associated with pre-dilation procedures during TAVI.Although EASE-IT represents a critical step for examining the importance of performing pre-dilation during TAVI procedures involving Edwards SAPIEN 3, the study might display limitations related to its design. Indeed, the non-randomized nature of the registry could lead to potential bias, as investigators will assign patients into the “with BAV” and “without BAV” groups at their discretion while patients are eligible for either route. In addition, because we ask for patients eligible in principal for TAVI with AND without BAV we will miss those only eligible for one of the routes. This cannot be avoided, however, if we want to compare both techniques in one patient population. We have chosen to use the observational design because we only incompletely know the variables affecting the decision and are thus not able, without a pilot documentation like the present one, to properly assess the variables necessary for the decision and these might deserve a prospective assessment in an upcoming randomized controlled trials.Nevertheless, inclusion into the EASE-IT trial requires that patients be eligible for TAVI with and without BAV, which could alleviate the potential for bias. In addition, registry data tend to be less complete when compared to randomized clinical trials. However, in this regard, 20% of the sites will be randomly selected for monitoring following completion of patient follow-up and documentation. Source data verification will be performed for all patients in these centers. Moreover, it is possible that the 6-month follow-up will not be sufficient to detect differences in long-term adverse outcomes between the groups with and without pre-dilation. Thus, future randomized clinical trials may be needed in order to assess the long-term effects associated with eliminating BAV from the TA-TAVI procedure.The EASE-IT registry will provide essential data concerning procedural success rates, adverse effects, and mortality in a large cohort of patients undergoing TA-TAVI with and without pre-dilation. This information is essential for determining the benefits or complications that might be associated with the pre-dilation step during TAVI. Therefore, results obtained from EASE-IT could contribute to reducing rates of TAVI-associated morbidity and mortality in patients with severe AS.


Adenoviruses are non-enveloped icosahedral viruses with trimeric fibre proteins protruding from their vertices. There are five known genera, from which only Mastadenoviruses have been widely studied. Apart from studying adenovirus as a biological model system and with a view to prevent or combat viral infection, there is a major interest in using adenovirus for vaccination, cancer therapy and gene therapy purposes. Adenoviruses from the Atadenovirus genus have been isolated from squamate reptile hosts, ruminants and birds and have a characteristic gene organization and capsid morphology. The carboxy-terminal virus-distal fibre head domains are likely responsible for primary receptor recognition. We determined the high-resolution crystal structure of the Snake Adenovirus 1 (SnAdV-1) fibre head using the multi-wavelength anomalous dispersion (MAD) method. Despite the absence of significant sequence homology, this Atadenovirus fibre head has the same beta-sandwich propeller topology as other adenovirus fibre heads. However, it is about half the size, mainly due to much shorter loops connecting the beta-strands. The detailed structure of the SnAdV-1 fibre head and other animal adenovirus fibre heads, together with the future identification of their natural receptors, may lead to the development of new strategies to target adenovirus vectors to cells of interest. Adenoviruses can cause respiratory disease, eye disease, myocarditis and gastro-enteritic disease (among others) and have been studied as a molecular biology model system Adenoviridae family contains five genera: Mastadenovirus , Aviadenovirus  with clinical signs of pneumonia Snake Atadenovirus 1 (SnAdV-1) was first isolated from a corn snake  method. This is the first Atadenovirus for which the structure of the fibre head has been determined. Knowledge of the structure will lead to better understanding of the infection mechanism of the virus and may allow the design of chimeric adenoviruses with novel cell targeting properties.Escherichia coli, purification by nickel affinity chromatography followed by strong anion exchange chromatography and crystallization by sitting drop vapour diffusion have been reported before P212121 space group crystal forms and one I213 space group crystal form) and, later, from one crystal containing amino acids 171–345 . As the native protein did not contain methionine residues in the 234–345 stretch, leucines 322 and 324 were mutated to methionine for selenomethionine derivatization De novo structure solution by MAD  was performed using a multi-wavelength dataset obtained for selenomethionine-containing crystals of the I213 space group from 234–345 construct. The AUTOSHARP pipeline Expression of N-terminally six-histidine tagged SnAdV-1 fibre protein constructs 171–345 and 234–345 in P212121 crystal forms and F23 crystal form were solved by molecular replacement using PHASER P212121 both had four trimers in the asymmetric unit. The purified 171–345 construct protein crystallized in space group F23 after a period of about one year and density for residues 171–231 was absent, indicating a possible proteolysis event during crystallization. Refinement statistics for all models are given in I213 selenomethionine derivative), 4D1F , 4D1G , 4D0V (I213 native) and 4UMI . Structure superpositions were performed using the secondary structure element matching option of CCP4MG The structures of I213 has a three-fold crystallographic symmetry axis). Phasing statistics were very good  being well-resolved. Coordinates and individual atom anisotropic temperature factors were refined at 1.33 Å resolution, leading to excellent agreement of the model with the data.The purified 171–345 construct protein crystallized in space group The fact that density for residues 171–231 was absent even when maps were calculated using low-resolution reflections only, combined with the long lag-time before crystallization, indicates a possible proteolysis event during crystallization. Two other observations support this hypothesis. The first is that there is no room in the crystal lattice at the bottom of the head domain to accommodate a shaft domain ; the secWhen the structures of the fibre head monomer of the different crystal forms are superimposed, no significant differences in main chain conformations were observed. The r.m.s.d. (root mean square difference) between the structures is less than 0.38 Å and even the loop regions superimpose very well, suggesting little flexibility. When trimers are superimposed, the r.m.s.d. is less than 0.5 Å, suggesting the orientation of the monomers in the trimer is also fixed. Given the structural similarity between the crystal forms, the description below is based on the highest-resolution structures obtained, but is general to all structures.The SnAdV-1 fibre head is the first Atadenovirus protein structure to be solved at atomic resolution . The heavs. six). The beta-strands in the structure are connected by either loops or beta-turns. Seven such connections exist; three loops  of variable size and four beta-turns  of two residues each. The CD and IJ loops contain 7 residues each, while the DG loop is longer, 16 residues. In SnAdV-1, an alpha-helix of eight residues is present in the DG-loop, rather than beta-strands like in Human Adenovirus 5.In the trimer, the ABCJ-sheet is partially buried, facing the inside, while the GHID-sheet is mainly solvent-exposed. This means that the ABCJ-sheet contributes the majority of inter-monomer contacts. The strands making up the buried sheet are longer than those of the exposed sheet  gets buried upon trimer formation. Eleven hydrogen bonds and ten salt bridges are contributed by each monomer to the assembly. The majority of these residues responsible for inter-monomer interactions are located on strands B, C and J. Approximately 8.5 kcal/mol of energy is required to dissociate the trimer into monomers, as calculated by PISA The trimeric packing of SnAdV-1 fibre head is highly stable, exemplified by the fact that to visualize monomers on a sodium dodecylsulphate-gel, boiling the protein in protein sample buffer containing dodecylsulphate for a few minutes is necessary before sample loading Although surface-exposed loops play the most important roles in adenovirus fibre-receptor interaction, surface charge may also have an effect Extensive surface loops present on fibre heads of other adenoviruses may favour the possibility of altering the antigenic nature of the fibre head by mutation; the relative absence of loops suggests that SnAdV-1 and perhaps Atadenoviruses in general have less need for this mechanism. Knowledge of the snake immune system is limited, although, like in mammals, it consists of innate, cell-mediated and humoral mechanisms In conclusion, the fibre head domain of Snake Adenovirus 1 is the first Atadenovirus protein for which the atomic structure has been solved. The compact trimeric structure is very stable as a result of extensive non-covalent interactions between its monomeric units, forming the trimer. The structure is the smallest among known adenovirus fibre head structures, while it retains the same overall beta-sandwich topology and may therefore be seen as a “minimal” adenovirus fibre head fold. The structure is even more similar to the head domains of certain dsDNA bacteriophage receptor binding proteins and the dsRNA-virus (reovirus) fibres, which prompts the question whether this similarity is the result of divergent or convergent evolution, or perhaps horizontal gene transfer events.An important application of adenoviruses is their use as vectors for human gene and cancer therapy and for vaccination purposes. Animal adenoviruses may be of special interest due to the lack of neutralizing antibodies in human sera against them. The detailed structure of the SnAdV-1 fibre head and other animal adenovirus fibre heads, together with future identification of their natural receptors, may lead to the development of new strategies to target adenovirus vectors to cells of interest.S1 FigurePacking of the F23 space group crystal. A. Bottom view. One SnAdV-1 fibre head trimer is shown in cyan, orange and blue. Asterisks indicate the amino-terminal Glu232, while a hash sign indicates where the shaft domain is expected to be. B. Side view of A. There is not enough room for a shaft domain in the crystal packing; furthermore, the amino-terminal ends of the structure point away from each other and from the three-fold symmetry axis where the shaft domain is expected to be.(TIFF)Click here for additional data file.S2 FigureDisorder prediction (DISEMBL program). A peak in predicted disorder probability between residues 230 and 236 suggests there may be some flexibility between the putative shaft domain and the head domain.(TIFF)Click here for additional data file.


The Edinburgh Postnatal Depression Scale (EPDS), originally developed in Britain, is one of the most widely used screening instruments for assessing symptoms of the Perinatal Common Mental Disorders (PCMDs) of depression and anxiety. However, its potential to detect PCMDs in culturally diverse low- and lower-middle income countries (LALMICs) is unclear. This systematic review aimed to appraise formally validated local language versions of the EPDS from these resource-constrained settings.Following the PRISMA protocol, we searched MEDLINE-OVID, CINAHL-Plus and PUBMED to identify studies reporting translation, cultural adaptation and formal validation of the EPDS to detect PCMDs among women in LALMICs. The quality of the studies meeting inclusion criteria was assessed using standard criteria and a new process-based criteria; which was developed specifically for this study.We identified 1281 records among which 16 met inclusion criteria; three further papers were identified by hand-searching reference lists. The publications reported findings from 12 LALMICs in14 native languages. Most of these local language versions of the EPDS (LLV-EPDS) had lower precision for identifying true cases of PCMDs among women in the general perinatal population compared to the original English version. Only one study met all criteria for culturally sensitive translation, the others had not established the comprehensibility of the local version amongst representative groups of women in pre-testing. Many studies tested the LLV-EPDS only amongst convenience samples recruited at single health facilities. Diagnostic interviews for confirmation of mental disorders could have been influenced by the mental health professionals’ lack of blinding to the initial screening results. Additionally, even when diagnostic-interviews were carried out in the local language, questions might not have been understood as most studies followed standard diagnostic protocol which had not been culturally adapted.Most of the LLV-EPDS from non-English speaking low- and middle-income-countries did not meet all criteria for formal validation of a screening instrument. Psychometric properties of LLV-EPDS could be enhanced by adopting the new process-based criteria for translation, adaptation and validation.The online version of this article (doi:10.1186/s12884-016-0859-2) contains supplementary material, which is available to authorized users. There is growing recognition of mental health problems among women living in resource-constrained, World Bank defined low- and lower-middle-income countries (LALMICs) who are pregnant or have recently given birth. In order to address persistently high maternal and child morbidity and mortality and promote the survival, health and development of infants in these settings, national governments have expressed increasing interest in improving maternal mental health , 2. To oThe Edinburgh Postnatal Depression Scale (EPDS) is one of the most widely used screening instruments for assessing symptoms of perinatal depression and anxiety , 4. It aTo improve early detection and treatment of PCMDs, the local language versions of the EPDS (LLV-EPDS) needs to accurately identify people with a PCMDs. However, it has been found that the LLV-EPDS had relatively lower discriminant validity for correctly identifying cases of PCMDs , 4 than There are three systematic reviews on the validity of non-English versions of the EPDS. Two of these studies were focused on publications from high and middle-income countries, and included few studies from low-income countries , 4, whilWe used the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) protocol for identifying, screening and eligibility of studies  Additio. Three iThere were four inclusion criteria: studies on translation and/or cultural adaptation and/or validation of the EPDS; that enrolled women who were pregnant and/or had recently given birth; which were conducted in World Bank defined LALMICs, and with reports published in English language, peer-reviewed journals.In addition to implementing the search strategy, the reference lists of articles meeting inclusion criteria were searched to identify any studies that had not been found. In order to obtain copies of studies published in non-indexed or local journals, we corresponded with authors via email, if we did not receive a response we wrote to the editor of the journal. By learning the journal was no more published, we sought a copy of the publications through interlibrary loan.We used two approaches to assess the methodological quality of the selected publications. First, overall quality was assessed using the criteria recommended by Mirza and Jenkins . As recoThe Mirza & Jenkins  and FishWe extracted data from selected studies using data-extraction format Table .Table 1SAdherence to the 33 process-based criteria were organised into two sections: Culturally Sensitive Translation and Empirical Validation using three response options: Yes/Not mentioned/Not needed Tables . In lineIn total 1281 records were identified using the search strategy, after removal of duplicates and studies which did not meet inclusion criteria, including six articles published in languages other than English , but not conducted in LALMICs,19 studies, all quantitative, remained , such discussions were held amongst diverse health professionals and in two studies professional translators were also included , 30. OnlNine studies reported pre-testing the preliminary versions of the LLV-EPDS, however only four of these studies  , 33, 35 The other type of amendment aimed to establish semantic equivalence of the LLV-EPDS in the local context. Altogether four studies , 33, 35 p < 0.01). The operational equivalence test, which is to investigate whether the local version can achieve similar outcomes when administered by self-report as by an interviewer was slightly lower  [The tests of conceptual and operational equivalence of these LLV-EPDS with the original English version was performed only for the Bangla version EPDS. The test showed a higher conceptual equivalence, with the original English EPDS  .There were 17 studies on psychometric validations of 14 LLV-EPDS from 12 countries; due to inclusion of two studies from each of five countries: Ethiopia , 35, IndGeneration of data on performance of these 14 LLV-EPDS was mainly carried out by recruiting study participants from ante- or postnatal or immunisation clinics (13/17 studies) –38, 40. Diagnostic interviews were carried out to establish clinical cut-off points. Of the 17 studies, in 11studies all participants who were screened using LLV-EPDS were also recruited for diagnostic interviews. In three studies, all those scoring higher than certain scores  and a randomly selected sample of woman who scored below the cut-offs were included. In the remaining two studies, about half the participants were included Table .Psychiatrists or psychologists carried out the diagnostic interviews in 12/17 studies, but in eight of these publications, it is not clear if they were blinded to the initial screening results , 37, 40.The 17 studies of the 14 LLV-EPDS revealed wide variation in their psychometric properties. The range of cut-off scores selected for detecting any common mental disorder was 3/4 to 11/12; and where specific conditions were listed, the range of cut-off scores was 3/4  to 13/14To our knowledge, this systematic review is the first assessment of EPDS versions translated and adapted for use in low- and lower-middle-income countries (LALMICs). Additionally, this is the first study to use a new set of process-based criteria Fig.  to assesWe found that of the 82 countries classified by the World Bank (in 2015) as LALMICs, the Edinburgh Postnatal Depression Scale (EPDS) had been formally validated in 12 14.6 %) countries in 14 native languages. We found psychometric properties of these 14 LLV-EPDS from low-and middle-income countries were lower than that for the original English EPDS  % countr, 4 and AA central finding of our systematic review is that utility of these 14 local versions EPDS for screening PCMDs is questionable, as none met the recommended validation standard of ≥80 % in the three key parameters: sensitivity, specificity and positive predictive value . The proSub–optimal sensitivity and specificity in these LLV-EPDS might also have been attributable to the recruitment of women who did not represent the wider perinatal population during empirical validation  from low-and lower- middle income countries are of some value, but most of them had deficiencies in translation, cultural adaptation and validation processes. Screening instruments with poor psychometric properties might have far-reaching implications for clinical practice, public policy and research. We recommend a systematic approach to the translation, cultural adaptation and empirical validation of local language versions of the EPDS that adheres to the steps outlined in Fig.