P < 0.0001 for all the ARHI; 0.498, 0.318–0.780, P = 0.0023 for FL subgroup; 0.428, 0.292–0.628, P < 0.0001 for AL subgroup; 0.552, 0.399–0.764, P = 0.0003 for mSL subgroup). Subjects in the highest tertile of LTL were at less risk for ARHI than those in the lowest and middle tertiles . There was a descending trend of LTL as the degree of pure tone threshold average (PTA) aggravated. These results suggest that telomere attrition may be involved in the progression of ARHI.Age-related hearing loss (ARHI) is the most common sensory disorder in the elderly. Although telomere attrition has been shown as a determinant in the pathobiology of various age-related diseases, it remains unknown whether telomere length is associated with ARHI. We hypothesized that decreased leukocyte telomere length (LTL) increased the risk of ARHI. Thus, we measured LTL of 666 ARHI and 43 controls by an established quantitative PCR technique. Four audiogram shape subtypes of ARHI, including “flat shape (FL)”, “2–4 kHz abrupt loss (AL) shape”, “8 kHz dip (8D) shape” and “sloping shape (SL)” could be identified among the cases using K-means cluster analysis. Longer LTL was associated with the reduced incidence of ARHI (adjusted OR = 0.550, 95% CI: 0.420–0.721,  It is the most common sensorineural impairment among adults aged older than 50. Prevalence of ARHI in China is on a rapid increase due to the population aging. ARHI leads to auditory deterioration and communication difficulties which aggravate the unhealthy psychological status of the patients and reduce the quality of life for the elderly. Therefore, it is important to elucidate the influencing factors of ARHI and prevent the progression of it. Studies have shown that multiple genetic and environmental factors interacted during the development of ARHI, including genetic mutations such as mitochondrial DNA deletions2, altered vascular characteristics such as increased vascular permeability and excess production of reactive oxygen species (ROS)3. In current literature, free radical or mitochondrial clock theory of aging is the most intriguing among the various mechanisms that are postulated to participate in the course of ARHI. Hypoperfusion of the cochlear tissue triggered by a reduction in blood flow with aging leads to ischemia and formation of ROS. Accumulated free radical damage over time results in mitochondrial DNA deletions which may be associated with aging and presbycusis.Age-related hearing loss (ARHI), also known as presbycusis, is defined as a bilateral progressive high-frequency hearing loss that is demonstrated on an audiometric assessment by a pure tone audiogram4. They are essential for maintaining successful DNA replication and chromosomal integrity. Telomeres shorten by 30–200 base pairs with each division in somatic human cells and result in cell senescence when reach to Hyflick limit5. Evidence suggests that in most cell strains, it is oxidative damage that is principally responsible for the telomere loss by accumulation of single strand breaks6. During the process of oxidative stress, telomere is shortening at a faster speed and assessment of telomere length might be a significant indicator of disease progression. Accelerated telomere shortening leads to chromosomal instability which further increases the risk of genetic mutations and chromosome abnormalities. Since first reported by Harley et al.7 in 1990, increasing evidence indicates that, as a biomarker of cell senescence and oxidative stress, telomere shortening with aging is a determinant in the pathobiology of human age-related diseases such as cardiovascular disease8, type 2 diabetes9, and earlier mortality10 etc. Therefore, there is a hypothesis that changes in telomeres may predispose to the development of ARHI11 and it is possible that oxidative stress induced DNA damage in patients with ARHI could translate into accelerated telomere loss and a progression to the senescence of the hearing cells.Telomeres consist of repetitive DNA sequence TTAGGG extending from a few to 15 kilobases in length and some specific bound proteins at the end of the eukaryotic chromosomesUntil now, there has been no research to test the relationship between telomere length and ARHI. Since oxidative stress has a close association with both telomere length and ARHI, we hypothsized that ARHI patients would demonstrate shorter telomeres compared with controls. Hence, in our study, we measured mean leukocyte telomere length (LTL) in a large sampe size of ARHI patients and controls to analyze the role of telomere length in the pathophysiology of ARHI.DNA samples of 666 ARHI cases and 43 controls were available in this study. The characteristics of the study subjects is shown in Table TM standard description12, the 10 audiogram shapes could be described as follows based on the K-means cluster analysis: A flat (FL) shape (N = 92), An 8 kHz dip (8D) shape (N = 36), A 2–4 kHz abrupt loss (AL) shape (N = 305) and A mild sloping (mSL) shape (N = 233) .Based on the standards recommended by the World Health Organization in 2005, the degrees of hearing impairment were classified as: normal hearing: PTA lower than 25 dBHL; mild hearing impairment: 26–40 dBHL; moderate hearing impairment: 41–70 dBHL; severe and extremely severe hearing impairment: >71 dBHL. As presented in Table P = 0.0008).Limits for the tertiles of T/S ratio were divided as follows: less than 1.155 for the lowest tertile, 1.155–1.219 for the middle tertile, and greater than 1.219 for the highest tertile. Subjects in the highest tertile of LTL were at less risk of developing ARHI than those in the lowest and middle tertiles  randomly from the 666 ARHI patients. Then a logistic regression model was applied to estimate the association between LTL and the presence of ARHI adjusted for age (47 cases and 43 controls). We repeated the selection 100 times. 84% of them resulted in In conclusion, our study provides to our knowledge the first preliminary evidence that LTL is strongly associated with ARHI. This study suggests a new role for LTL as a mechanism in the pathophysiology of ARHI. In our study, a number of potential factors that may exert influence on telomere attrition in the elderly were not included such as medicine-taking status, lifestyles and other detailed health behaviors. Further studies among various ethnics, longitudinal cohorts are needed to vertify these findings.22. Thus, we measured the air and bone conduction thresholds of pure tones by the use of an audiometer  in a quiet room. Air and bone conduction thresholds were assessed at 0.25, 0.5, 1, 2, 4, 6, 8 kHz and 0.5, 1, 2, 4 kHz respectively. Diagnostic criteria of ARHL have been presented in our previous study23. Subjects with PTA of 0.5 kHz, 1 kHz, 2 kHz, and 4 kHz more than 25 dB in both ears were categorized as the ARHI cases, while those with PTA less than 25 dB in both ears were categorized as the controls. Blood sample was collected from each participant at the time of the physical examination. Informed consent was obtained from each subject. Ethics approval was obtained by the Ethics Committees of both Xinhua Hospital and Renji Hospital affiliated to Shanghai Jiao Tong University School of Medicine. The methods were carried out in accordance with the relevant guidelines, including any relevant details.Subjects for the cases and controls were recruited at the health check-up centers of Xinhua and Renji Hospital affiliated to Shanghai Jiao Tong University School of Medicine from July 2011 to December 2012. Health check-up centers provide the elderly with annual routine examinations including electrocardiography, chest X-ray and blood biochemical tests etc. As to hearing loss history, noise and ototoxic drug exposure information was collected. Then, an otoscopic examination was performed for each individual to exclude any ear pathology potentially affecting hearing. Clinically, the golden standard for measuring hearing impairment is pure-tone audiometry24. Relative telomere length for each sample was calculated as the telomere repeat copy number [T/S] ratio using 36B4 (single copy gene) as the reference gene. This strategy aimed to measure the difference between the experimental sample and a reference DNA sample in its ratio of telomere repeat copy number to single copy gene copy number. Thus T/S = 1 when the unknown DNA is equal to the reference DNA in its ratio of telomere repeat copy number to single copy gene copy number. In our study, all the experimental samples were diluted to the same concentration 5 ng/μl. Telomere (T) PCRs and single copy gene (S) PCRs were performed in duplicate for each sample on an ABI StepOnePlus Real-Time PCR System (Applied Biosystems) with 15 ng DNA as a template. Each 20 μl PCR reaction contained 10 μl QuantiNova SYBR Green master mix (2×) (Qiagen) and primers for telomere length measurement25: 140 nM Tel-F, 5′-CGGTTTGTTTGGGTTTGGGTTTGGGTTTGGGTTTGGGTT-3′; 140 nM Tel-R, 5′-GGCTTGCCTTACCCTTACCCTTACCCTTACCCTTACCCT-3′ or primers for determinations of the single copy gene 36B424: 140 nM 36B4u: 5′-CAGCAAGTGGGAAGGTGTAATCC-3′;140 nM 36B4d: 5′-CCCATTCTATC-ATCAACGGGTACAA-3′. The thermal cycling profile for both telomere and 36B4 started with a 95 °C incubation for 2 minutes, followed by 40 cycles of 5-seconds denaturation at 95 °C and 1-minute annealing/extension at 60 °C. Serially diluted reference DNA standards ranging from 1.25 to 40 ng/μl  were used to generate standard curves respectively for telomere and 36B4 assays on each 96-well plate and all standard curves had a good linearity (R2 > 0.99). All the experiments were conducted by laboratory personnel blinded to the case-control classification. The intra- and inter-assay coefficient of variations (CVs) were 1.2% and 6.5% respectively for the telomere length measurement.According to a series of standard procedures, genomic DNA was isolated from peripheral blood leukocytes . The extracted DNA was quantified on a Nanodrop 2000 (Thermo Scientific) and was stored at −80 °C until the time of assay. An established and validated quantitative polymerase chain reaction (qPCR) technique was adopted for the telomere length measurement26, K-means cluster analysis was used to categorize audiometric shapes in SPSS (version 22) after calibrating the audiometric data to zero dB at 0.25 kHz for baseline homogeneity. It is a stepwise fashion to observe the exact number of audiogram shapes. Clustered results were tested by ANOVA. Optimal end-point should be a maximal F and minimal mean square errors which can explain the heterogeneity among the final number of categorized audiogram shapes and the homogeneity within a specific clustered shape best. Then an age adjusted logistic regression model was used to estimate the association between LTL and ARHI when taking T/S ratio as a continuous variable and ARHI as a binary variable (cases vs controls). A trend analysis was conducted to determine whether LTL was shortened with the hearing impairment worsening. Then, T/S ratio of LTL was divided into three sections among all the subjects: the lowest, middle and highest tertile. Odds ratios (ORs) and 95% confidence intervals (CIs) for the risk of ARHI for the highest tertile compared with the lowest and middle tertiles were calculated with the age adjusted logistic regression model. All reported probability values were two-tailed and the criterion for significance was set at P = 0.05. Statistical analysis was performed with SAS software, version 9.2.Kolmogorov–Smirnov normality test was performed to examine the distribution of T/S ratio and age. Linear regression model was employed to assess the correlation between LTL and age. According to the classification system designed by Cheng-Yung LeeSupplementary Table 1


Cathepsin L, a lysosomal endopeptidase expressed in most eukaryotic cells, is a member of the papain-like family of cysteine proteases. Although commonly recognized as a lysosomal protease, cathepsin L is also secreted and involved in the degradation of extracellular matrix proteins. Previous studies demonstrated that the secretion of cathepsin L was stimulated by basic fibroblast growth factor (bFGF) and bFGF-enhanced axonal terminal sprouting of motor neurons. Based on these results, although it has never been directly investigated, we hypothesized that extracellular cathepsin L may induce axonal growth.To confirm the hypothesis, the axonal growth activity of recombinant cathepsin L was evaluated in cultured cortical and spinal cord neurons. Treatment with recombinant cathepsin L significantly enhanced axonal growth, but not dendritic growth. This result indicated that extracellular cathepsin L may act as a new neuronal network modulator. Cathepsin L, a lysosomal endopeptidase expressed in most eukaryotic cells, is a member of the papain-like family of cysteine proteases. Cathepsin L plays a major role in antigen processing, tumor invasion and metastasis, bone resorption, and turnover of intracellular and secreted proteins involved in growth regulation. Although commonly recognized as a lysosomal protease, cathepsin L is also secreted and involved in degradation of extracellular matrix proteins  , 2.+ T cells [Cathepsin L is expressed in almost all tissues, including the brain . In the  T cells  and recu T cells , while c T cells . This co T cells . AlthougThe secretion of cathepsin L is stimulated by various factors. Gene transfer of bFGF or recombinant bFGF treatment in skeletal muscle significantly increased secretion of cathepsin L . AnotherAll animal experiments were performed in accordance with the Guidelines for the Care and Use of Laboratory Animals of the Sugitani Campus of the University of Toyama. The Committee for Animal Care and Use of the Sugitani Campus of the University of Toyama approved all the protocols in the current study. The respective approval number for animal experiments is A2014-INM1. Every effort was made to minimize the number of animals used. All mice were housed in a controlled environment , with free access to food and water.d-glucose , and 2 mM l-glutamine , on 8-well chamber slides  coated with 5 μg/ml poly-d-lysine , at 37 °C, in a humidified incubator with 10% CO2. The seeding cell density was 2.9 × 104 cells/cm2.Embryos were removed from ddY mice  at 14 days of gestation. The cortices or spinal cords were dissected; the dura mater was removed using micro tweezers. The tissues were minced, dissociated, and grown in cultures with neurobasal medium , which included 12% B-27 supplement , 0.6% The density of axons and dendrites were measured at 3 days after culture. Cells were treated with recombinant mouse cathepsin L  for 4 days. The neurons were fixed with 4% paraformaldehyde  for 90 min and were immunostained with a monoclonal antibody against phosphorylated neurofilament-H  as an axonal marker. A polyclonal antibody against microtubule-associated protein 2  was used as a dendritic marker. The first antibody reaction was performed in PBS containing 5% normal goat serum  and 0.3% Triton X-100 . Alexa Fluor 488-conjugated goat anti-mouse IgG  and Alexa Fluor 594-conjugated goat anti-rabbit IgG  were used as the secondary antibodies. Nuclear counterstaining was performed using DAPI . Fluorescent images were captured with a 10× objective dry lens  using a charge-coupled device camera  on an inverted microscope . A total of 12–20 images were captured per treatment. The lengths of the pNF-H-positive axons and MAP2-positive dendrites and were measured using a MetaMorph analyzer , which automatically traces and measures the neurite length without measuring the cell bodies. The sum of the axons or dendrite length was divided by the number of MAP2-positive neurons, which were counted by the MetaMorph analyzer.Total RNA was extracted from the cells using TRIsure™ , according to the manufacturer’s instructions. The concentrations of the obtained total RNA were measured at 260 nm and the spectrum peak patter was used to evaluate the quality of total RNA. Single-stranded complementary DNA (cDNA) was produced from total RNAs (0.5 μg), using an incubation of 50 pmol of random 6-mer primer and 50 units of reverse transcriptase, in 10 μl of reaction solution, at 42 °C for 15 min, according to the manufacturer’s instructions . A total of 1 µl of the obtained cDNA solution was used as a real-time PCR template. Specific primers for cathepsin L (Accession No. AF121837), i.e., AATACAGAGCCGAGTTCGCT (forward) and TAGAACTGGAGAGACGGATG (backward), were used to produce a 142-bp product. The PCR mixture contained cDNA solution  and 0.5 μM of each primer in the reaction solution, with a premix of Taq DNA polymerase and SYBR Green . PCR was performed by using a real-time PCR machine , with the following: (1) 95 °C for 30 s; (2) 40 cycles of 95 °C for 5 s, 55 °C for 10 s, and 72 °C for 20 s. A linear calibration standard line was obtained using the values of the control treatment. Figure t-tests  with a post hoc Dunnett’s test Fig. , and unpsts Fig. , using GWe evaluated the effect of recombinant cathepsin L on axonal growth and dendritic growth of cultured cerebral cortex neurons and spinal cord neurons. The pro form of the recombinant mouse cathepsin L, which consisted of a signal peptide residues 1–17), pro-region (residues 18–113), and mature chain (residues 114–334), was used in the current study since secreted cathepsin L exists mainly in the pro form . This fo–17, pro-Cathepsin L could be distributed and work in various organelles, such as the lysosome, cytosol, nucleus, and extracellular matrix. Although the applied recombinant cathepsin L would not have penetrated the neurons, it is possible that extracellular cathepsin L might affect the intracellular expression of cathepsin L. Therefore, the mRNA level of cathepsin L in cortical neurons was measured after a 4-day recombinant cathepsin L treatment. The cathepsin L treatment did not affect the expression level of neurons.The current study indicated for the first time that extracellular cathepsin L stimulates axonal growth, but not dendritic growth, in cortical neurons and spinal cord neurons Fig. . Since tA recent report demonstrated that immunoreactivity for cathepsin L was detected in nerve fibers bundles and some nerve cell bodies . In the Extracellular cathepsin L stimulate axonal growth in cortical neurons and spinal cord neurons.The mechanism by which cathepsin L-induced axonal growth remains unknown.In vivo evidence demonstrating cathepsin L-mediated axonal growth has not been obtained yet.


Cisplatin is an effective drug used in the treatment of many cancers, yet its ototoxic potential places cancer patients, exposed to this drug, at risk of hearing loss, thus negatively impacting further on a patient's quality of life. It is paramount for health care practitioners managing such patients to be aware of cisplatin's ototoxic properties and the clinical signs to identify patients at risk of developing hearing loss. English peer-reviewed articles from January 1975 to July 2015 were assessed from PubMed, Science Direct, and Ebscohost. Seventy-nine articles and two books were identified for this review, using MeSH terms and keywords such as “ototoxicity”, “cisplatin”, “hearing loss”, and “ototoxicity monitoring”. This review provides an up-to-date overview of cisplatin-associated ototoxicity, namely, its clinical features, incidence rates, and molecular and cellular mechanisms and risk factors, to health care practitioners managing the patient with cancer, and highlights the need for a team-based approach to complement an audiological monitoring programme to mitigate any further loss in the quality of life of affected patients, as there is currently no otoprotective agent recommended routinely for the prevention of cisplatin-associated ototoxicity. It also sets the platform for effective dialogue towards policy formulation and strengthening of health systems in developing countries. Cancer places a huge burden on society and has been identified as the leading cause of death in both more and less economically developed countries . ProjectThe basis for chemotherapy is anticancer drugs containing platinum, that is, cisplatin (cis-diamminedichloroplatinum II) and carboplatin  . Other cSince its discovery in the 1970s , namely,Ototoxicity refers to the hearing disorder that results from the temporary or permanent inner ear dysfunction after treatment with an ototoxic drug . Other dHowever, Malhotra  indicateThe review identified peer-reviewed articles available from January 1975 to July 2015 on the topic of cisplatin-associated ototoxicity and ototoxicity monitoring and included English articles only. The same researcher conducted the literature search and reviewed the abstracts and articles for inclusion in the study. Studies were identified using keyword and MeSH term searches of electronic databases depicted in In order to be selected, the article had to present data on either cisplatin ototoxicity and/or ototoxicity monitoring in human participants, and no research designs were excluded. Running these searches yielded a total of 2106 records, of which 1581 were excluded based on the title and/or abstract as well as duplication. Eighty-five relevant articles, comprising six national and 79 international articles, were selected. Information was also obtained from four internationally published books. A perusal of narrative reviews of other auditory pathologies was conducted in an attempt to determine areas of significance for an overview of cisplatin ototoxicity. This resulted in the following eight areas being included: the mechanisms of cisplatin ototoxicity, clinical presentation, risk factors, incidence rates in adults and children, the effect on quality of life, ototoxicity monitoring, otoprotective strategies, and management of an ototoxic hearing loss.Cisplatin ototoxicity is produced by several distinct mechanisms  as depic“Creation of reactive oxygen species,Depletion of antioxidant glutathione and its regenerating enzymes,Increased rate of lipid peroxidation,Oxidative modifications of proteins,Nucleic acids damage by caspase system activation andS-Nitrosylation of cochlear proteins” .With the cellular mechanisms of cisplatin-associated ototoxicity including damage to the outer hair cells, supporting cells, marginal cells of the stria vascularis, spiral ligament, and the spiral ganglion cells [The molecular mechanisms of cisplatin ototoxicity therefore include the following:on cells , it is eon cells . The outon cells , 28. Thion cells , 28. KnoCisplatin-associated ototoxicity usually manifests as irreversible, progressive , bilaterThe degree of hearing loss is often variable and is related to the dose; that is, the higher the cumulative dose, the greater the ototoxic effect , 36. TheThe incidence of cisplatin ototoxicity is variable in adults  and chilOtotoxicity poses a major problem to the cancer patient, as the quality of life after receiving cisplatin chemotherapy may be negatively affected due to hearing loss, resulting in social, emotional, and vocational difficulties, as effective communication is often hindered. Tasks that normal hearing persons take for granted may become challenging and frustrating . In addiThe impact of an ototoxic hearing loss may be more profound for infants and young children who are at a critical stage of their speech and language development . FurtherAdvancements in medical knowledge and technology, such as screening and early detection of several cancers, have resulted in notable improvements in relative five-year survival rates for cancer , 65. TheThe nature of ototoxicity is such that it often goes undetected until speech intelligibility is affected  and is uAudiological monitoring should aim to identify the hearing loss early and reduce its impact on the individual's life by means of proper medical and hearing intervention . ProspecIn countries without ototoxicity management guidelines, the “Guidelines for the Audiological Management of Individuals receiving Cochleotoxic Drug Therapy” developed by the American Association of Speech-Language-Hearing Association  may, conThe audiological assessments should incorporate a detailed case history, otoscopic examination, immittance audiometry, speech audiometry, DPOAEs, and conventional and extended high frequency audiometry  (HFA) , 73. TheMonitoring audiological evaluations during treatment and the one- and three-month follow-up evaluations include case interview, otoscopy, and immittance audiometry as well as air conduction pure tone and objective testing . HoweverIf a patient on cisplatin chemotherapy is still responsive and alert, the protocol presented above would be suitable. However, a patient who has limited responsiveness may be required to undergo the same audiological evaluations, except speech audiometry. Patients who are responsive as well as those who have limited responses can undergo both behavioural and objective testing. However, those patients who are too ill or too young to respond should undergo only objective testing, such as otoscopy, tympanometry, acoustic reflexes, and DPOAEs or ABRs .While pure tone audiometry in the conventional frequency range is suitable for evaluating hearing in the range responsible for speech understanding, as well as for differential diagnosis, it is less sensitive to detecting early ototoxic change , 70. TheThe ototoxicity monitoring protocol proposed by ASHA  represenOver the years, a number of studies have investigated the use of otoprotectants with cisplatin, their purpose being to protect the inner ear from any injury while not interfering with the antitumor effects of cisplatin . Otoprot d-or l-Methionine, methylthiobenzoic acid, lipoic acid, tiopronin, glutathione ester, sodium thiosulfate [ S-methyltransferase, and catechol-O-methyl transferase, may be responsible for susceptibility to hearing loss [Nearly all of the otoprotective agents are sulfur- or sulfhydryl-containing compounds (thio compounds), known as antioxidants, and potent heavy metal chelators . The numosulfate , Melatonosulfate , Vitaminosulfate , N-acetyosulfate , Dexametosulfate , and Resosulfate . Howeverosulfate . Furtherosulfate . Intratyosulfate , 90. Theosulfate . AlternaIf a cisplatin-associated hearing loss results in communication difficulties, it is the audiologist's ethical responsibility to begin or recommend aural rehabilitation . However“Extended bandwidth” hearing aids. These hearing aids are able to amplify sounds at and above 8000 Hz. However, there is limited data indicating significant improvements in speech recognition with the use of this technology .Hearing aids with frequency lowering technology achieved by linear frequency transposition, nonlinear frequency compression, or spectral envelope warping. Frequency lowering is used to overcome the limits of either the bandwidth of the device or the functional bandwidth of the ear, by lowering high frequency energy to a region that is more likely to provide and/or benefit from audible sound . While tFurthermore, with the recent developments in hearing aid technology, a patient with an ototoxic hearing loss is more likely to receive the desired amplification benefit. These developments in technology includeThis review has highlighted that cisplatin ototoxicity is a frequent adverse event of cisplatin chemotherapy that may negatively affect the quality of life of patients with cancer. The different molecular and cellular mechanisms involved in cisplatin-associated ototoxicity highlight the complexity of this condition and the consequent difficulty in identifying an effective otoprotective agent. The varying incidence rates reported in both adults and paediatrics may be due to the different audiological tests employed in the monitoring of the cancer patient's hearing status and therefore highlight the importance of the use of extended high frequency audiometry and DPOAEs in ototoxicity monitoring. An audiological monitoring programme comprising a team of health care professionals, knowledgeable about cisplatin ototoxicity, may therefore serve to improve evidence-based service delivery to these patients.


Participants visited the lab for RMR and substrate oxidation measurements after an overnight fast (10–12 hr) at weeks 0, 6 and 12. Fasted blood samples were taken at baseline and after 12 weeks of supplementation. There were significant increases in the EPA (413%) and DHA (59%) levels in red blood cells after FO supplementation, with no change of these fatty acids in the OO group. RMR and substrate oxidation did not change after supplementation with OO or FO after 6 and 12 weeks. Since there was no effect of supplementation on metabolic measures, we pooled the two treatment groups to determine whether there was a seasonal effect on RMR and substrate oxidation. During the winter season, there was an increase in FA oxidation (36%) with a concomitant decrease (34%) in carbohydrate (CHO) oxidation (p < 0.01), with no change in RMR. These measures were unaffected during the summer season. In conclusion, FO supplementation had no effect on RMR and substrate oxidation in healthy young males. Resting FA oxidation was increased and CHO oxidation reduced over a 12 week period in the winter, with no change in RMR.Fish oil (FO) has been shown to have beneficial effects in the body via incorporation into the membranes of many tissues. It has been proposed that omega-3 fatty acids in FO may increase whole body resting metabolic rate (RMR) and fatty acid (FA) oxidation in human subjects, but the results to date are equivocal. The purpose of this study was to investigate the effects of a 12 week FO supplementation period on RMR and substrate oxidation, in comparison to an olive oil (OO) control group, in young healthy males . Subjects were matched for age, RMR, physical activity, VOTrial Registration: ClinicalTrials.gov NCT02092649 Omega-3 polyunsaturated fatty acids are a family of fatty acids (FAs) characterized by unique physical and structural properties that influences several aspects of metabolism and physiology in the human body ,2. Incre+/K+) ATPase . A one-way repeated measures ANOVA was performed to determine the effect of time on CVintra for both groups. When significance was found, Tukey post hoc tests were used.Paired t-test comparisons were performed on OO and FO groups to determine if any differences existed between consecutive day measurements at weeks 0, 6 and 12, and for blood analyses at weeks 0 and 12. Unpaired t-tests were performed between summer and winter groups at baseline (Week 0) to determine if any differences existed on metabolic measurements.A two-way repeated measures ANOVA with a post-hoc Tukey test was used to examine changes in metabolic measurements and RBC fatty acid profiles using treatment (OO—FO or summer—winter) and time (Weeks 0–6–12) as fixed effects.Statistical significance was declared at the 0.05 level. GraphPad Prism program, version 6.0  was used for statistical analysis. All data were checked for normality before any analysis was performed.The subjects from the OO and FO supplementation groups were well matched at week 0 for physical characteristics and blood measurements . SupplemThere were no group differences on RBC fatty acid composition of EPA (p = 0.99) and DHA (p = 0.99) at baseline. RBC levels of EPA were increased in the FO group from 0.6 (week 0) to 3.1% (week 12) of total FAs (p < 0.001). Similarly DHA levels in RBC were increased from 2.9 to 4.6% of total FAs (p < 0.001). There was no effect of OO supplementation on EPA (p = 0.99) and DHA (p = 0.86) RBC levels .There was a high degree of repeatability between consecutive day metabolic measurements at weeks 0, 6 and 12, as there were no differences between days Tables . The one2, VCO2, RER, and RMR after consecutive morning measurements on three different occasions. This variation was similar in the OO and FO groups  ranged from 1.76–4.89% for VOs Tables . CVintras Tables .2, RMR, and substrate oxidation did not change following 6 and 12 weeks of FO or OO supplementation  during the 12 week supplementation period Tables , the dation Figs .2 or RMR after 6 and 12 weeks  and 12 tested in the winter (n = 6 OO and n = 6 FO) were analyzed. There was no difference between groups at baseline (p > 0.1). There was no change in VO12 weeks  in the s12 weeks . There wThe primary finding of this well-controlled study was that 12 weeks of FO supplementation had no effect on RMR and substrate oxidation in young, healthy males. A secondary finding was that FA oxidation was increased and carbohydrate oxidation decreased over a 12 week period during the winter season, independent of supplementation and with no change in energy expenditure. In addition, this study determined that the intra-individual coefficient of variability (CVintra) between repeat measures was 2–4% for RMR and 11–22% for whole body substrate oxidation prior to and following 6 and 12 weeks of supplementation.One of the problems with studying whole body energy expenditure and substrate oxidation is the biological and measurement variability that exists between day to day measurements . In factThe previous work that examined the effects of FO supplementation in healthy young adults on whole body RMR and FA oxidation is limited and controversial. For example, Couet et al.  reportedIn the present study, in order to minimize biological and measurement variability, subjects were matched for age, body mass, height, and metabolic measurements  and randAlthough the content of omega-3s in skeletal muscle membranes was not measured, previous studies have demonstrated incorporation of omega-3s into whole muscle , as wellInterestingly, we also recently reported that 6 and 12 weeks of FO supplementation significantly increased RMR in both older females  and male2, but had a significantly lower RER, during the winter season in comparison to summer, when measured in a thermoneutral environment. In the present study, there was no change in energy expenditure after 12 weeks in both groups, however there was a significant increase in FA oxidation (36%) with a concomitant decrease in CHO oxidation (34%) in the winter group, independent of supplementation. A possible explanation for the increase in FA oxidation may be due to the increasing cold exposure experienced by the participants during the months that bracketed this 12 week study—average monthly outdoor temperatures of +9.2, +0.1, -1.4 and -9.0°C. Indeed, during chronic cold exposure there is an increased β-adrenergic response [Ambient temperature is known to influence RMR and substrate oxidation when measured in a thermoneutral environment. RMR also appears to be influenced by geographical location and variability between populations ,37. Plasresponse  which maresponse . Future The authors acknowledge that the present study has limitations. The use of olive oil as a placebo could have some biological effects, however a previous study from our laboratory used the same dose and observed no change in either whole body RMR or substrate oxidation . AdditioIn conclusion, our results indicate that when biological and measurement variability was minimized, 12 weeks of FO supplementation did not affect RMR and substrate oxidation in healthy young males. There was a seasonal effect, independent of supplementation, on whole body substrate oxidation, where fatty acid oxidation increased and carbohydrate oxidation decreased over a 12 week period during winter, when measured in a thermoneutral environment.S1 CONSORT Checklist(DOC)Click here for additional data file.S1 Trial Protocol(DOCX)Click here for additional data file.


Both multimorbidity and activities of daily living (ADL) disability and instrument activities of daily living (IADL) disability are common among elderly individuals. ADL/IADL disability may reduce individuals’ capacities for independent living and quality of life. This study aimed to examine the association between multimorbidity and ADL/IADL disability.A multi-stage cluster sample of 2058 residents aged 80 or older was investigated in Shanghai, China. Multimorbidity was defined as the simultaneous presence of two or more chronic diseases with ten common chronic conditions under consideration. Subjects who responded that they “need partial or full assistance” to any ADL/IADL items were defined as having ADL/IADL disability. We examined the association of multimorbidity with ADL/IADL disability, adjusted for socio-demographic characteristics by using logistic regression.Of respondents, 23.23 % had ADL disability, 37.90 % had IADL disability, and 49.17 % had multimorbidity. After adjusted socio-demographic characteristics, a graded association was showed between ADL disability and the quantity of chronic conditions: odds ratio (OR) for 1 condition, 1.53; OR for 2 conditions, 2.06; OR for 3 conditions, 3.23; OR for 4 or more conditions, 5.61. Similar associations were also observed between the quantity of chronic conditions and IADL disability.The quantity of chronic conditions had relatively strong association with both ADL and IADL disability. Initiating prevention of additional chronic conditions and interventions on clusters of diseases may decrease the potential risk of ADL/IADL disability. Additionally, more attention should been given to the older low-income women living with relatives/non-relatives with multimorbidity. Populations around the world are rapidly aging, and “healthy well” must be a global priority . HoweverStudies have suggested that chronic diseases may result in disability in the elderly. Although disability can be defined in a number of ways, the activities of daily living (ADL) and instrument activities of daily living (IADL) are considered the most common ways . Uddin eAs a result of increasing longevity, multiple comorbid conditions, or “multimorbidity”, have also become more common among elderly individuals , 9. HoweMost of previous studies were conducted in high-income countries, but social demographic status has been found strongly associated with the prevalence of multimorbidity and disability, regardless of whether social demographic status is measured by age, race, or area-based deprivation , 15. TheSince the proportion of elderly individuals aged 80 or older would increase as the aging process, and those people were more easily affected by chronic diseases . Hence, This study used data of a large-scale survey initiated by Shanghai Health and Family Planning Commission from March to September 2013. This survey was designed as a multi-stage cluster study representative of the elderly population in Shanghai, China. In total, 8525 residents were investigated from 15 communities. Face-to-face interviews were conducted at participants’ homes by the staff of each surveyed neighborhood committee, each of which was trained by professional investigators from the workshop. Each participant completed the questionnaire independently. Detailed description of study, sample design, and quality control process is provided elsewhere . In thisAll participants or their family members signed an informed consent  and the study protocol received approval by the Ethics Committee of the Shanghai Medical and Technology Information Institute.Our primary outcome variable of interest was ADL disability, as measured by self-report and investigators’ observation and judgment: bathing, dressing, toileting, transferring (getting in and out of bed or chair), eating, and getting around the home , 18. As As most publications, multimorbidity is defined as the simultaneous presence of two or more chronic diseases in this study , 22–24. Social demographics included age, gender, income and living arrangement. Respondents were categorized into four age groups: 80 to 84, 85 to 89, 90 to 94, and 95 or older. Income was grouped into two categories: low , and moderate (>100 % of the standard). Living arrangement was categorized as five groups: living alone, with spouse only, with spouse and children, with children only, and with other relatives/non-relatives.Analyses were performed using SAS statistical package 9.2 . After calculating descriptive statistics, bivariate analysis was used to examine the association of each socio-demographic factors and chronic diseases status with ADL/IADL disability in unadjusted models. Then, we used multiple logistic regression models to examine the association between multimorbidity and ADL/IADL disability after adjusting age, gender, income, and living arrangement.This study included 2058 participants. Overall, 23.23 % of respondents reported ADL disability and 37.90 % reported IADL disability. As Table As Table As Table Age was significantly associated with ADL disability in both unadjusted model and adjusted model, and the OR was raised sharply as the growth of the age. Difference by age for IADL disability was larger than ADL disability, but they were in the same direction. Female and low income were significantly associated with ADL/IADL disability in unadjusted models, but after adjusting socio-demographic characteristics, Female and low income were only significantly associated IADL disability. Compared with participants living alone, all other living arrangements were significantly associated with ADL/IADL disability, and those living with other relatives/non-relatives had the highest risk .As studies implied, the association between specific chronic diseases and ADL/IADL disability may vary, such as diabetes, hypertension, and dementia , 20, 25.A systematic review of studies on multimorbidity suggests different operational definitions of multimorbidity might influence the burden or impacts of multimorbidity . But, thIn addition, primary health care general practitioners take most of the responsibility for prevention and treatment of chronic diseases in China. Since the chronic conditions included in this study were treated for the most part by primary health care general practitioners. Findings from this study confirm the importance of developing and providing interventions for managing multimorbidity and preventing additional chronic conditions to reduce potential for ADL/IALD disability among elderly individuals in community settings. Based on our findings, we suggest that primary health care and public health practitioners should pay more attention on managing multimorbidity and preventing additional chronic conditions among community-dwelling elderly population.In addition, other researches on patterns of chronic conditions also support the importance of recognizing multimorbidity in other aspects: firstly, multimorbidity is increasingly prevalent among older population all over the world ; secondlThe relationship between socio-demographic characteristics was partly consisted with previous studies. As we all knew, advanced age is probably one of the most important factor related to functional decline, even some studies suggest the increase in relative risk of functional loss is about 2.0 for each 10-year increase in age . HoweverLiving arrangement was associated with ADL/IADL disability in previous studies, this relationship also confirmed in this study . ElderlyThis study has several strengths. Firstly, the prevalence of multimorbidity reported in this study was based on a list of chronic conditions that included the most common conditions among a large representative community sample; thus our findings provided representative fundamental data for horizontal comparison between different countries and regions. Secondly, our findings demonstrated consistent and graded association between likelihood of disability in ADL/IADL and the quantity of chronic conditions. These findings mean that the differences of the heterogeneity or severity of chronic conditions couldn’t conceal the impact of the quantity of chronic conditions. To primary health care and public health practitioners, these information reminded that the individuals with mild chronic conditions also should been pay more attention. To the best of our knowledge, our study is the first to focus on the association between multimorbidity and ADL/IADL disability among the community-dwelling oldest-old population, especially including all eight IADL items. Thirdly, we found the association between socio-demographic characteristics and ADL/IADL disability that the low-income women living with relatives/non-relatives were more likely to experience ADL/IADL disability. And these findings provided simple and useful information for primary health care general practitioners and public health workers to screen for those at high risk of ADL/IADL disability among the elderly. As health resources are precious and finite, they should be used more specifically and efficiently.Our study has several limitations. Because the sample was cross-sectional, we were not able to identify the causation between multimorbidity and onset of ADL/IADL disability. However, our findings provide new data to support earlier researches that show multimorbidity may be an important factor of ADL disability, and our findings extend this association from ADL to IADL , 14. OnlThis study demonstrates that, the quantity of chronic conditions has relatively strong association with both ADL and IADL disability. Initiating prevention of additional chronic conditions and interventions on clusters of diseases may decrease the potential risk of ADL/IADL disability. Considering the age of the objective population, all these measures should been planned and in taken in advance. Additionally, more attention should been given to the older low-income women living with relatives/non-relatives with multimorbidity.


Non-alcoholic fatty liver disease (NAFLD) and smoking have similar mechanisms of promoting colorectal polyps. The potential link between NAFLD and smoking in men and colorectal polyps has not been adequately evaluated. The aim is to investigate this association.A retrospective cross-sectional study was conducted on 2409 individuals undergoing a health check. Univariate and multivariate logistic regression were performed for analyzing the association between risk factors and colorectal polyps. Individuals were divided into four groups: Q1: NAFLD (-)/smoking (-); Q2: NAFLD (+)/smoking (-); Q3: NAFLD (-)/smoking (+); Q4: NAFLD (+)/smoking (+). Logistic analyses were used to explore associations for the whole study population and stratified groups.The prevalence of colorectal polyps was 38.8% in males, and that of colorectal polyps in smokers and individuals with NAFLD were 47.0% (428/911) and 42.9% (267/622), respectively. With Q1 as reference, subjects with NAFLD (+) and smoking habits (+) had the highest ORs for colorectal polyps , adenomatous polyps , non-adenomatous polyps , ≥ 3 polyps  and proximal polyps  after adjusting for confounding variables.Men with NAFLD and smoking habits have an increasing risk of colorectal polyps. Colorectal cancer is regarded as one of the most common human malignancies and the second leading cause of cancer-related death worldwide –3. ColonStudies describing the mechanisms underlying the association between various risk factors and colorectal polyps are abundant and complex. The crucial role of insulin resistance and chronic inflammation in the occurrence and carcinogenesis of colorectal polyps has been reported in several experimental and observational studies , 10–13. Men with NAFLD and smoking habits should be carefully monitored for the incidence of colorectal polyps. A cohort study by Claudia et al. reported that 1091 NAFLD patients enrolled in the non-alcoholic steatohepatitis clinical research network (NASH CRN) studies with liver biopsies exhibited accelerated progression of liver disease in the presence of smoking . A recenTherefore, the primary focus of the present study was to explore the association between NSM and colorectal polyps and provide evidence for the early detection of colorectal polyps.The demographics and clinical features of 2409 eligible participants are shown in Table Univariate and multivariate logistic regression analyses of the risk factors for colorectal polyps are presented in Table To obtain a deeper understanding of the association between NSM and colorectal polyps, individuals were divided into four groups Q1, Q2, Q3 and Q4) according to the different statuses of NAFLD and smoking. The baseline characteristics of NAFLD and smoking status in men are shown in  and Q4 aThe analysis conducted according to the presence, type , location, size and number of colorectal polyps is shown in Table The present study is the first to investigate the possible association of NSM and colorectal polyps. In our study, after controlling for confounding factors, the ORs for colorectal polyps in male individuals with a history of smoking and NAFLD were higher compared to individuals of the Q1 group. Furthermore, in the Q4 group, the ORs for adenomatous polyps (OR = 2.06), non-adenomatous polyps (OR = 1.97), ≥ 3 polyp number (OR = 2.05) and proximal polyps (OR = 1.58) remained higher than those in the other groups. Thus, our study demonstrated that men with NAFLD and a history of smoking have a higher risk for colorectal polyps, especially proximal polyps and multiple polyps .A number of previous reports have suggested that NAFLD and smoking are risk factors for colorectal adenomatous polyps and neoplasms , 17, 21.Over the past two decades, many epidemiologic studies have demonstrated that smoking was associated with an increased risk for colorectal hyperplastic polyps and adenomatous polyps , 14. TobChronic inflammation is a well-known mechanism in the development of colorectal polyps. Cigarette smoking is known to increase inflammatory biomarkers, cause oxidative stress and exert pro-inflammatory effects in many organs, such as diabetic nephropathy, pancreatitis, hepatic steatosis and gastrointestinal mucosal diseases –26. FurtThe role of insulin resistance in colorectal polyps is well recognized . CigaretOur study has several limitations that need to be acknowledged. First, a high proportion of individuals undergoing health checks were office workers with a sedentary lifestyle. This particular group might differ from the general Chinese population with regard to nutritional habits and physical exercise. Therefore, a bias could have been introduced. It is possible that lifestyle habits in this population, such as consumption of high calorie, high fat diets and physical exercise might differ from those in the general population. Second, this was a single center study with a small sample size. A multicenter study with a large sample size should be conducted to further corroborate the association in the next step. Third, although the standard criterion for diagnosis of NAFLD is liver biopsy, it is too invasive for use in routine health examinations. The diagnosis of fatty liver was based on ultrasound imaging with 94% sensitivity and 84% specificity .In conclusion, our study demonstrated that NSM was positively correlated with the prevalence of colorectal polyps, which should pay more attention to colonoscopy examination in their routine physical checkup.This retrospective cross-sectional study involved individuals who were participating in a routine clinical physical examination at the Medical and Health Care Center of the First Affiliated Hospital of Wenzhou Medical University from September 2014 to November 2016. All individuals underwent physical examination, laboratory testing and an interview on lifestyle, medical history and medication use with a standard questionnaire. A total of 6035 participants  were screened. Among this large study group, 3626 participants met the study exclusion criteria: incomplete intestine preparation; incomplete colonoscopic examination; female; incidence of carcinoma, inflammatory bowel disease or chronic liver disease ; alcohol consumption >140 g/week and missing relevant data (such as tobacco use and colonoscopies). The protocol followed the tenets of the Treaty of Helsinki.2). Blood pressure was measured with an automatic instrument  at the brachial artery of the person in a seated position after they had at least fifteen-minute rest.The clinical research coordinators collected physical assessment data, including age, sex, height, weight, smoking, alcohol use, systolic blood pressure (SBP) and diastolic blood pressure (DBP) of all subjects. At every visit, height and weight were measured by a team of trained nurses twice in the morning during health examination. While weight was measured without heavy clothing and recorded to the nearest 100 g, height was measured without shoes and recorded to the nearest mm with a stadiometer. BMI was calculated as dividing the weight (kg) by the height squared , triglyceride (TG), total cholesterol (TC), high density lipoprotein-cholesterol (HDL-C), low density lipoprotein-cholesterol (LDL-C), alanine aminotransferase (ALT), aspartate aminotransferase (AST), alkaline phosphatase (AKP), γ-glutamyltransferase (γ-GT) and albumin (ALB) levels were subsequently analyzed by an automated analyzer . The 13 C-urea breath test was performed with an infrared spectrometer to identify Following the full bowel preparation with 4 L polyethylene glycol lavage solution, colonoscopy  was performed on each participant by endoscopists (graduate degrees or more) who had at least 5 years of experience in colonoscopic examination at the First Affiliated Hospital of Wenzhou Medical University. The diagnosis of colorectal polyp was established following the recommendation of the World Health Organization (WHO). A macroscopic visible protrusion from the surface of the colorectal mucosa was considered to be a colorectal polyp . The exaFatty liver was diagnosed by professional technicians using abdominal ultrasonography, following the guidelines for the assessment and management of NAFLD in the Asia-Pacific region . NAFLD wRegardless of smoking at the time of the study or former smoking habits, individuals with cessation of less than one year were defined as smokers. In addition, the definition of metabolic-related indicators were defined as follows: (1) Obesity: BMI ≥ 25 in both genders; (2) Hypertension: SBP ≥ 140 mmHg and/or DBP ≥ 90 mmHg or previously diagnosed; (3) Hyperglycemia: FPG ≥ 6.1 mmol/L or previously diagnosed; (4) Dyslipidemia: TG ≥ 2.26 mmol/L (200 mg/dL) and/or TC ≥ 6.22 mmol/L (240 mg/dL) and/or HDL-C < 1.04 mmol/L (40 mg/dL) and/or LDL-C ≥ 4.14 mmol/L (160 mg/dL) .Data analyses were performed using SPSS (SPSS version 23.0 for Windows), and continuous variables were expressed as the mean ± standard derivation (SD). Student’s t-test was used to compare significant differences between polyp-free group and colorectal polyps group. Univariate and multivariate logistic analyses were performed to determine the unadjusted association of clinical and laboratory parameters with prognosis. To further analyze the possible interactive effects of NAFLD and smoking on the prevalence of colorectal polyps in men, individuals were divided into four groups: Q1: NAFLD (-)/smoking (-); Q2: NAFLD (+)/smoking (-); Q3: NAFLD (-)/smoking (+); Q4: NAFLD (+)/smoking (+), according to the different conditions of NAFLD and smoking. Multiple logistic regression analyses were used to analyze the possible effects of NAFLD and smoking on the prevalence of colorectal polyps in men after adjustment for confounding factors including age, obesity, hypertension, hyperglycemia, dyslipidemia and alcohol use. Then, stratified analyses were also performed to determine whether the association between NSM and colorectal polyps persisted in each subgroup  after adjusting for confounding factors. A two-sided P value of less than 0.05 was considered statistically significant, and each odds ratio (OR) was presented together with its 95% confidence interval (CI).


Hydrochlorothiazide is not known to cause hearing disorder. The Eritrean Pharmacovigilance Centre, however, has received cases of hearing disorder, including irreversible deafness, associated with hydrochlorothiazide. The aim of this study is, therefore, to assess the causal relationship between hydrochlorothiazide and hearing disorder.Data was retrieved from the WHO global adverse drug reaction database, VigiBase™. A search on VigiBase™ was made on August 6, 2017 using “hydrochlorothiazide” as drug substance, and “ototoxicity”, “decreased hearing”, and “vestibular disorder” as reaction terms. Cases were retrieved using VigiLyze™ and exported to an Excel spreadsheet for descriptive analysis. Causality was assessed using Austin Bradford-Hill criteria and labeledness of the reaction was evaluated through a thorough literature review including the summary of product characteristics.From 1972 to August 2017, 94 cases of hearing disorder associated with hydrochlorothiazide were submitted from 18 countries to VigiBase™. The median age was 64 years with almost equal male to female ratio. In 53.2% of the cases, hydrochlorothiazide was reported as the only suspected drug. Of these, 26 cases encountered hearing disorder following the sole intake of hydrochlorothiazide. Reaction was marked as “serious” in 36% of the cases and median time to reaction onset was 3 days. Outcome was reported as reversible in 66.7% of the cases. Reaction resolved in 17 cases following withdrawal of hydrochlorothiazide and recurred in one case after subsequent rechallenge with the product. Consistency of cases and a dose–response relationship was also observed in this case series.This case series assessment found a suggestive causal relationship between hydrochlorothiazide and hearing disorder. Taking the inherent limitations of this study into account, results should be interpreted with caution and further studies are required to validate the safety signal. Hydrochlorothiazide is a thiazide diuretic that is used in the treatment of hypertension and edema either as the sole therapeutic agent or in combination with other drugs , 2. To tEven though HCTZ is not known to cause hearing disorder, the Eritrean Pharmacovigilance Centre received two cases of hearing disorder, including irreversible deafness, associated with the use of HCTZ. The objective of this study is, therefore, to assess the causal association between HCTZ and hearing loss through data mining on the WHO global adverse drug reaction database, VigiBase™.Data was retrieved from the WHO global adverse drug reaction database, VigiBase™, which is developed and maintained by the Uppsala Monitoring Centre (UMC), Sweden. The database captures adverse drug reaction reports submitted from National Pharmacovigilance Centres of more than 120 countries. A search on VigiBase™ was made on August 6, 2017 using “hydrochlorothiazide” as drug substance, and “ototoxicity” [preferred term (PT)], “hearing decreased” [high-level term (HLT)], and “vestibular disorder” (HLT) as reaction terms [World Health Organization Adverse Reaction Terminology (WHO-ART)]. All relevant information like the reaction outcome, seriousness, information component (IC), outcome of rechallenge/dechallenge, and patients’ background characteristics were extracted using VigiLyze™, a tool developed by the UMC for data mining and analysis of adverse drug reactions (ADR) in VigiBase™. IC value is a measure of disproportionality of drug ADR in VigiBase™ , 12. A pThe series of cases were then subjected to Austin Bradford-Hill criteria  to assesThe Eritrean Pharmacovigilance Centre has received two cases of HCTZ-associated hearing disorder. In both cases, HCTZ was the sole suspect with no other concomitants. The causality assessment using Naranjo adverse drug reaction probability scale  was founA 50-year-old hypertensive woman, 75 kg, Tigrigna ethnic group, was prescribed with enalapril 20 mg two times a day and hydrochlorothiazide 25 mg three times a day for the management of hypertension. Upon taking the medications, a pharmacist told her to take two times enalapril 20 mg and three times hydrochlorothiazide 25 mg, overall five tablets a day. The poor lady mistakenly understood the five tablets a day as “five times a day” and for that she took hydrochlorothiazide 25 mg five times a day for 3 days starting from June 10, 2013. She experienced loss of balance and dizziness on the first day and complete hearing loss on the third day following the intake of HCTZ. The patient was followed for 6 months and despite dose reduction, her condition was irreversible.A 65-year-old man, Bilen ethnic group, experienced hearing loss, epigastric discomfort, and nausea following the intake of oral hydrochlorothiazide 25 mg two times a day for mild hypertension on May 5, 2015. The reaction (hearing loss) started the same day as the intake of HCTZ and started to resolve 1 day after discontinuation of the suspected drug.From 1972 to August 2017, a total of 94 cases of hearing disorder associated with HCTZ were submitted from 18 countries to the VigiBase™. The reactions reported were tinnitus (50), deafness (23), decreased hearing (16), vestibular disorder (4), and deafness nerve (1). Age was reported in 72 (77%) of the cases and around 47% of them were between 45 and 74 years with a median age of 64 . In 17 of the cases, reaction abated following withdrawal of HCTZ and in one case reaction recurred after reintroduction of HCTZ , and other drugs taken concomitantly like acetylsalicylic acid (ASA) . As the From this case series assessment, it can be concluded that there is a suggestive causal association between HCTZ and hearing disorder. As it may cause irreversible hearing loss, this association warrants further study to substantiate the safety signal through epidemiologic studies. Taking into consideration the impact of hearing loss, difficulty in communication, loss of balance, incapacity, dependency and accidents, healthcare professionals should be cautious in prescribing ototoxic drugs concomitantly with HCTZ. Besides, they should also advise patients to avoid or minimize over-the-counter drugs, which are believed to be ototoxic like NSAIDS. We also recommend healthcare professionals to do routine hearing assessment for patients taking HCTZ.


TCs), novel interstitial cells, have been identified in various organs of many mammals. However, information about TCs of lower animals remains rare. Herein, pancreatic TCs of the Chinese giant salamanders (Andrias davidianus) were identified by CD34 immunohistochemistry (IHC) and transmission electron microscopy (TEM). The IHC micrographs revealed CD34+TCs with long telopodes (Tps) that were located in the interstitium of the pancreas. CD34+TCs/Tps were frequently observed between exocrine acinar cells and were close to blood vessels. The TEM micrographs also showed the existence of TCs in the interstitium of the pancreas. TCs had distinctive ultrastructural features, such as one to three very long and thin Tps with podoms and podomers, caveolae, dichotomous branching, neighbouring exosomes and vesicles. The Tps and exosomes were found in close proximity to exocrine acinar cells and α cells. It is suggested that TCs may play a role in the regeneration of acinar cells and α cells. In conclusion, our results demonstrated the presence of TCs in the pancreas of the Chinese giant salamander. This finding will assist us in a better understanding of TCs functions in the amphibian pancreas.Telocytes ( Telocytes (TCs) have been confirmed as a novel type of interstitial/stromal cell Andrias davidianus (Amphibia: Caudata) In the last 10 years, TCs have been identified in many organs of various animals, especially in mammals, including human, pig, gerbil, mouse, rat, degu and canine et al. et al. 4  for 1 hr, dehydrated in a concentration series of ethanol, infiltrated with propylene oxide/araldite mixture and embedded in araldite. After the samples were sectioned, the sections were stained with 1% uranyl acetate and Reynold's lead citrate for 20 min. The stained sections were observed and photographed by a high‐resolution digital camera connected to the TEM . The long and short diameters of the TC cell bodies, the width of the podoms and podomers of the Tps and the length of the Tps were measured in the IHC and TEM images by Image Pro‐plus 7.0 software . Additionally, the diameters of secretory granules of the α cells and zymogen granules of exocrine acinar cells were also measured. Data were analysed by Excel software .This work was approved by the Ethical Committee for Animal Care and Use of Jiangxi Agricultural University after relevant ethical review according to the National Institutes of Health Guide for the Care and Use of Laboratory Animals. The 2.5‐year‐old Chinese giant salamanders  were raised with simulated ecological breeding technology in their primary habitat provided by an artificial breeding farm in the mountain area of Jiangxi province, China. After putting on the ice, the Chinese giant salamanders were killed and the pancreases were quickly excised and fixed in 4% paraformaldehyde and 2.5% glutaraldehyde/phosphate‐buffered saline (PBS)  respectively. The immunohistochemistry (IHC) was performed according to the protocol provided by the anti‐CD34 antibody manufacturer . The 3,3‐diaminobenzidine (DAB) was used as the chromogen. The sections were then counterstained with haematoxylin and mounted. Finally, the sections were photographed by BM 2000 light microscopy . TEM was conducted according to the methods of Yang +) TCs were stained brown in the Chinese giant salamander pancreas (Fig. + TCs nuclei were immune negative and stained blue as a result of the haematoxylin counterstaining. The pancreatic exocrine acinar cells were negative, cone‐shaped and contained round nuclei in their basal portions. The apical portions of the exocrine acinar cells had many small, round and foam‐type zymogen granules. The CD34+ TCs were frequently observed in the interstitium of the pancreas (Fig. + TCs were frequently observed in close proximity to the blood vessels (Fig. + TCs were pyriform, triangular or spindle shaped. A characteristic feature of the CD34+ TCs was the presence of one to three very long Tps (Fig. + TCs, as measured on IHC images, were 17.29 ± 4.55 μm, 9.46 ± 1.32 μm and 25.91 ± 10.80 μm respectively. In addition, the blood cells were also CD34+, but the vascular endothelia were negative (Fig. The cell bodies and Tps of CD34 immune‐positive (CD34eas Fig. . The CD3eas Fig.  and wereels Fig. . The celTps Fig. . The TpsTps Fig. . The podTps Fig. . The aveTCs and their Tps were also observed in the interstitium among the pancreatic exocrine acini as shown in the TEM micrographs Figs. , 4, 5, 6et al. Previous investigations have documented that TCs are present in the pancreas of several mammals, such as human, rat, cat and degu The authors declare that there are no conflicts of interest.


To obtain kinematic accelerations with high accuracy and reliability, multiple Global Positioning System (GPS) receivers with a single antenna can be used for airborne gravimetry. The data collected from each receiver can be processed for kinematic accelerations that may be combined using simple averaging. Here, however, uncorrelated errors from instrument errors in each receiver also will be included that degrade the final solutions. Therefore, in this study, the wavenumber correlation filter (WCF) is applied to extract only the higher positively correlated wavenumber components of the kinematic accelerations for the enhancement of the final solution. The in situ airborne GPS data from two receivers were wavenumber-correlation-filtered to show about 0.07835 Gal improvement in accuracy relative to the solution from the raw kinematic accelerations. Global Positioning System (GPS) has been widely used in the fields which require accurate positioning in 3-D space. Nowadays, however, the GPS is also used in various non-positioning applications such as GPS meteorology and geodesy ,2,3. Oneequation  given byBy Equation (1), the accuracy of the gravity depends directly on the accuracy of the measured kinematic accelerations. The kinematic accelerations, in turn, are usually computed by taking second-order time-derivatives of the aircraft’s positions measured in relative positioning mode using single or multiple GPS stations . The kinIn general, the gravity-based kinematic accelerations from multiple receivers should exhibit high positively correlated signals, whereas the minimally or negatively correlated signals reflect measurement noise in the kinematic accelerations. Thus, to separate the highly correlated signals from the noise components, the wavenumber correlation filter (WCF) can be applied, which computes correlation coefficients (CCs) between the signal’s frequency components according to the cosines of their phase differences. This method has been successfully applied to the geophysical and geodetic data obtained from the repeated survey tracks to significantly improve their signal-to-noise properties ,10,11,12In this paper, airborne kinematic accelerations are enhanced using the WCF. The signal-to-noise results show significant accuracy improvement and can be obtained by suppressing the minimally and negatively correlated wavenumber components. k-th wavenumber correlation coefficients k-th Fourier transform wavevectors of the kinematic accelerations for receiver To apply WCF, the Fourier transforms are taken of the estimated kinematic accelerations from both receivers. The kinematic accelerations are next analyzed for their evectors ,9.The CC for each frequency component from both datasets can be computed and compared with the predefined correlation tolerance In 2009, the National Geographic Information Institute (NGII) of South Korea conducted airborne gravity surveying for a new geoid model of the Korean peninsula and surrounding marine areas. The survey was flown by Cessna Grand Caravan at speeds of about 280 km/h and a constant altitude of 10,000 feet. GPS data were collected from both GPS receivers and six ground-based continuously operating reference stations (CORS) at an interval of 1 s. GPS measurements were collected using both receivers connected to a single antenna with the kinematic accelerations of the aircraft being computed using the network-based PVA model proposed by . Figure The power spectra for the receiver A- and B-measured kinematic accelerations are compared in The CCs for all wavenumber components pairs were computed by Equation (3) as presented in Using the tolerance 2 , 0.0011657 m/s2 , and 0.0003725 m/s2  in the respective X, Y, and Z components. Comparing the noise estimates in the tables also suggests that WCF obtained noise suppression improvements in the X, Y, and Z components of roughly 27%, 27%, and 20%, respectively.The It should be noted, however, that the WCF reduction of noise is but one contributor in the overall error propagation equation of the gravity signal’s estimation. Additional contributions include the effects of the data smoother, end matching of the flight lines, and the coordinate transformation . HoweverEffective airborne gravity surveying requires accurate kinematic acceleration determinations. This study investigated the enhancement of the kinematic accelerations determined from GPS data obtained by two receivers from a single antenna. The WCF was applied to extract the positively correlated, larger magnitude (i.e.,


Between WD and PD grade 3 GEP-NECs, there was a significant difference in the distribution of Ki67 index. There was no significant difference of treatment efficacy between WD and PD grade 3 GEP-NECs . Tumor response to EP occurred in 5 of 7 patients with Ki67 > 60% and 7 of 24 with Ki67 ≤ 60%, which was significantly different . Among grade 3 GEP-NECs, there was a significant difference in ranges of Ki67 index between WD and PD NECs. Higher levels (> 60%) of Ki67 index might be a predictive marker for efficacy of EP as a standard regimen in grade 3 GEP-NECs.We investigated the impact of pathologic differentiation (well or poorly differentiated) in metastatic grade 3 GEP-NEC patients receiving etoposide and platinum (EP)-based therapy, and evaluated a more exact Ki67 index cut-off point to select patients with grade 3 GEP-NEC who might benefit from EP-based therapy. A total of 31 patients with metastatic grade 3 GEP-NECs receiving EP-based therapy were included in this study. Primary sites included 13 foregut-derived GEP-NECs [stomach ( Neuroendocrine tumors (NETs) consist of a heterogeneous group of malignancies that arise from neuroendocrine system. The origin of NETs are mostly gastroenteropancreatic (GEP) which is arising in the foregut, midgut, or hindgut . Even thRecent studies have described the existence of uncommon well differentiated GEP-NETs that exhibit characteristic morphologic features of low or intermediate grade neoplasms but have a proliferative rate that breaches the threshold for WHO classification of G3 neuroendocrine neoplasms. Well differentiated and poorly differentiated groups of NETs have different clinical courses and different treatment outcomes, , 9 but lHerein, we investigated the impact of pathologic differentiation (well or poorly differentiated) in metastatic grade 3 GEP-NEC patients receiving etoposide and platinum-based therapy. Simultaneously, we evaluated a more exact Ki67 index cut-off point to select patients with grade 3 GEP-NEC who might benefit from etoposide plus platinum-based therapyn = 4), duodenum (n = 4), and pancreas (n = 5)], and 2 hindgut-derived GEP-NECs of the rectum. Sixteen unclassified GEP-NETs originated from 7 gall-bladder (GB), 6 liver and 3 unknown primary sites. According to pathologic differentiation, 14 patients had well differentiated and 17 had poorly differentiated grade 3 GEP-NECs . Table P = 0.043).As first-line chemotherapy, 31 patients with grade 3 metastatic GEP-NEC received etoposide plus cisplatin. Complete response (CR) was achieved in one patient (3.2%). Eleven partial responses (35.5%) were observed, for a response rate (RR) of 38.7%. Table P = 0.163)   was 8.2 months (95% CI 4.7–11.7) Figure . There w) Figure . In addi) Figure .Cytotoxic chemotherapy is the main tool for metastatic grade 3 GEP-NEC. Etoposide plus platinum (EP) has been considered as standard regimen in NEC, based on similarities between NEC and small cell lung cancer (SCLC) . HoweverWe observed that the EP regimen yielded a superior tumor response in Ki67 > 60% grade 3 GEP-NECs than in those with Ki67 ≤ 60%. This finding was consistent with a recent landmark study . In thisThere are many differences in both clinicopathological and genomic aspects of well and poorly differentiated NETs . GenomicPersonalized medicine means the use of an each patient’s molecular and clinicopathological data to inform diagnosis, prognosis, treatment, and prevention of cancer, and has become a primary goal of many studies in oncology . The detThe present study has some drawbacks, such as a too small sample size and heterogeneous patient population. There was also an inherent selection bias as retrospective natures, since only those G3 NE neoplasms receiving platinum were included. This means only the most aggressive of the well differentiated G3 NE tumors may have been included, since less aggressive G3 well differentiated NE tumors may not have been treated with platinum. Nevertheless, this analysis demonstrates that grade 3 GEP-NECs could be morphologically classified into well and poorly differentiated NETs. Additionally, among grade 3 GEP-NECs, there was a significant difference in ranges of Ki67 index between well and poorly differentiated NETs. Higher levels (> 60%) of Ki67 index might be a predictive marker for efficacy of EP as a standard regimen in grade 3 GEP-NECs.Among patients pathologically diagnosed with metastatic grade 3 GEP-NECs at Samsung Medical Center between June 2013 and March 2016, 31 GEP-NEC patients receiving etoposide and platinum-based therapy were included in this study. The following clinicopathologic characteristics were collected for all 31 patients: age, gender, primary site, pathologic differentiation, Ki67 index and information on chemotherapy. Tumors of all patients were reviewed and classified by grade according to the 2010 WHO classification using mitosis and Ki67 labeling index. Mitosis was reported as G1 (< 2/10 HPF), G2 (2–20/10 HPF), and G3 (> 20/10 HPF). The Ki67 labeling index was G1 (≤ 2%), G2 (3–20%), and G3 (> 20%). Based ot-test or Fisher’s exact test or by one-way analysis of variance, as appropriate. The best cut-off value for Ki67 regarding the response rate was determined from receiver operating characteristic (ROC) curve analysis. Progression free survival (PFS) was measured as the time from date of chemotherapy to the date of first documented disease progression or death. PFS was estimated using the Kaplan-Meier method with log-rank analysis. A two-sided P-value of less than 0.05 was considered significant. All analyses were performed using SPSS version 19.0 .Descriptive statistics are reported as proportions and medians. Treatment outcomes were response rate (RR) and progression-free survival (PFS). Correlation between pathologic differentiation or Ki67 index and treatment outcome was analyzed using the