Question:
You will be presented with the full text of a biomedical research paper. Please write an abstract for this paper. Your response should include the abstract and no additional text.

Paper text:
the number of older adults affected by dementia has been rising significantly in japan and
 a number of other countries1 , 2 .
mild cognitive impairment ( mci)3,4,5,6 is considered to be a
 preclinical stage of dementia .
studies have revealed that approximately 10% to 15% of people
 with mci progressed to dementia annually7,8,9 . in
 order to reduce the number of people who experience cognitive dysfunction , it is important
 to delay , or even reverse , the progression of mci to dementia .
while aging is regarded as the greatest risk factor for
 cognitive dysfunction10 , several studies
 have indicated that habitual exercise and physical activity may have a beneficial effect on
 the prevention of dementia11,12,13,14,15 .
a wide variety of exercises , such as walking , have been recommended for older adults in
 efforts to maintain and promote health .
aquatic exercises in particular are recommended for
 older adults with obesity and osteoarthritis16,17,18 .

one such aquatic exercise regimen is synchronized swimming , which is suitable for older
 adults , as the swimmer may stand on the floor of a shallow pool19 .
while a number of studies have indicated that land - based exercise exerts a beneficial
 effect on cognitive function in older adults11,12,13,14 , no studies to date have examined the
 effect of synchronized swimming on cognitive function in older adults .
the study participants were recruited from among 23 women practicing synchronized
 swimming - exercise at a sport club in fukushima - ku , osaka city , japan ( ss group ) .
all
 participants provided written informed consent , after having gained a full understanding of
 the present study .
the study was approved by the ethics committee of the osaka university of
 health and sport sciences ( approval number 15 - 21 ) . synchronized swimming
was performed in a shallow pool from 1.2 to 1.3 meters in depth and
 the participants were allowed to touch the bottom of the pool with their hands and feet
 during the performance .
participants who had participated in the olympic games or the
 domestic competitions for seniors were excluded .
participants practiced synchronized
 swimming twice a week for 90 minutes under the supervision of an instructor , who had been a
 member of the japanese synchronized swimming team .
the ages of participants in the ss group
 ranged from 49 to 85  years ( mean age : 69.8  11.6  years ) , and the duration of synchronized
 swimming experience ranged from 1 to 39  years ( mean year : 23.9  12.6  years ) .
control participants were recruited age - matching women with exercise custom other than
 synchronized swimming .
they were 36 individuals participating in a health promotion program
 at our university in 2015 , and provided written informed consent as controls ( age range :
 4977  years ; mean age : 67.0  6.0  years ) . among the participants in the control group , 16
 participants exercised three or four times a week ,
17 exercised once or twice a week , and 3
 exercised one to three times a month .
cognitive functions was compared between the two groups using the japanese version of the
 montreal cognitive assessment ( moca - j)20 .

the moca is a brief cognitive test containing test items related to memory , language ,
 executive function , working memory ( attention ) , visuospatial recognition , abstract thinking ,
 and orientation21 .
the sensitivity and
 specificity of the moca - j in screening for mci has been demonstrated20 .
the assessment takes only approximately 10 minutes to
 complete , and a number of studies have demonstrated the effectiveness of moca - j as a
 screening tool for mci21,22,23 .
total scores of less than 26 points may be indicative of mild cognitive
 impairment .
information on the presence of neurological disease , psychiatric disease , alcoholism , and
 hospitalization was collected via an interview .
unpaired t - tests were used to compare results
 between the ss group and control group when data were normally distributed , while u tests
 were performed when the data were not normally distributed .
two - sided p values of < 0.05
 were considered to indicate a statistically significant difference .
no significant differences in education level were observed between the control and ss
 groups ( 12.1  2.0 and 12.2  1.8  years , respectively ) . in addition , no significant
 differences in total moca - j scores were observed between the two groups ( 22.2  3.6 and 23.2
  3.1 , respectively ) .
twenty - nine participants in the control group and 17 in the ss group
 scored below 26 on the moca - j and were suspected of having mci ( table 1table 1.comparison of moca - j between the control group and the ss groupscorecontrol group ( n=36)ss group ( n=23)moca - j<2629 ( 80.6)17 ( 73.9)267 ( 19.4)6 ( 26.1)no significant differences are shown between the two groups .
moca - j : japanese version of montreal cognitive assessment ; ss : synchronized
 swimming ) . with regard to moca - j sub - scores , significant differences in delayed recall
 ( p=0.005 )
however , no significant differences were
 observed with regard to measures of but not in visuospatial / executive function , naming ,
 attention , language , abstraction , or orientation ( table
 2table 2.comparison of moca - j sub - score between the control group and the ss groupcontrol group ( n=36)ss group ( n=23)visuospatial / executive function ( 5)3.5  1.03.4  1.0/5naming ( 3)2.9  0.43.0  0.0attention ( 6)4.9  1.14.8  1.0language ( 2)1.6  0.91.7  0.8abstraction ( 2)1.1  0.80.9  0.7delayed recall * ( 5)1.8  1.73.0  1.4orientation ( 6)5.8  0.45.6  0.7total scores22.2  3.623.2  3.1values are shown as the mean  sd . *
moca - j : japanese version of montreal cognitive assessment ; ss : synchronized
 swimming values are shown as the mean  sd . * p<0.005 for the difference between the two groups .
no significant differences in years of education or total moca - j scores were observed
 between the ss group and the control group in the present study .
the results of total moca - j
 scores in the present study align with those of a previous report involving 1,552
 participants ( mean age : 72  years ; mini - mental state examination score > 24 points ) living
 in sasaguri , fukuoka prefecture , in which mean the moca - j score was 22.4  3.024 .
however , in the comparison of moca - j
 sub - score in the present study , delayed recall scores , which are considered indicative of
 recent memory function , were significantly higher in the ss group than in the control
 group .
suzuki et al.25 conducted an
 exercise - based intervention program that included exercise , calculation , word - chain game ,
 and multiple tasks using a ladder diagram program ( 90 minutes two times per week for 6
 months ) with participants aged 65  years or older experiencing mci .
significant differences
 in mini - mental state examination , wechsler memory scale - logical memory i , word fluency
 test - category , and word fluency test - letter scores were observed following this
 intervention . in synchronized swimming , participants must swim and act in a coordinated
 manner with other swimmers while performing to music .
in other words , the swimmers are
 required to perform multiple coordinated tasks in an aquatic setting to be more complex than
 those of the multicomponent exercise program developed by suzuki et al25 .
moreover , it has been reported that group music intervention
 delayed the deterioration of cognitive function , particularly short - term recall among aging
 adults with mild and moderate dementia26 .

performing to music in synchronized swimming might be one of the reason that delayed recall
 scores were significantly higher in the ss group than in the control group .
voelcker - rehage et al.22 reported that
 not only physical fitness , as indexed by cardiovascular fitness and muscular strength , but
 also aspects of motor fitness , such as movement speed , balance , motor coordination , and
 flexibility exhibit associations with executive control and perceptual speed .
they further
 demonstrated physical and motor fitness to be differentially related to various cognitive
 processes using functional brain magnetic resonance imaging . given that most synchronized
 swimmers exhibit good cardiopulmonary function , muscle strength , and flexibility27 , it is also possible that enhanced
 physical fitness may exert direct positive effect on cognitive function . according to a report by suzuki et al.28 , 12 months of multicomponent exercise
in particular , positive effects were
 observed for general cognitive function , immediate memory , and language ability .
we
 therefore consider that synchronized swimming exerted beneficial effects on cognitive
 function in the participant who experienced synchronized swimming for one year . in conclusion , the results of the present study suggest that synchronized swimming may
 improve cognitive function in older adults , particularly with regard to recent memory . no relevant disclosures .

Answer:
[ purpose ] the purpose of the present study was to examine cognitive function in
 middle - aged and older adults regularly engaging in synchronized swimming - exercise .
 [ subjects and methods ] twenty - three female synchronized swimmers ranging in age from 49 to
 85  years were recruited for the present study .
 the duration of synchronized swimming
 experience ranged from 1 to 39  years .
 the control group consisted of 36 age- and
 gender - matched community - dwelling middle - aged and older adults ( age range : 49 to
 77  years ) .
 cognitive function was evaluated using the japanese version of the montreal
 cognitive assessment ( moca - j ) and compared between the synchronized swimmers and control
 participants .
 [ results ] no significant differences in mean total moca - j scores were
 observed between the synchronized swimmers and control participants ( 23.2  3.1 and 22.2
 3.6 , respectively ) .
 twenty - nine subjects in the control group and 17 in the synchronized
 swimming group scored below 26 on the moca - j , indicative of mild cognitive impairment .

 significant differences in delayed recall  but not in visuospatial / executive function ,
 naming , attention , language , abstraction , or orientation  were also observed between the
 two groups . [ conclusion ] the results of the present study suggest that synchronized
 swimming has beneficial effects on cognitive function , particularly with regard to recent
 memory .


Question:
You will be presented with the full text of a biomedical research paper. Please write an abstract for this paper. Your response should include the abstract and no additional text.

Paper text:
descriptive investigation of a cluster of 5 sfts cases following exposure to an index patient who died from the disease was performed . a 77-year - old male farmer who died from sfts
five other cases in the cluster included a 32-year - old male intensive care unit ( icu ) physician ( case 1 ) , a 48-year - old male icu consultation physician ( case 2 ) , a 42-year - old younger son of the index patient ( case 3 ) , and a 45-year - old older son of the index patient ( case 4 ) , as well as a 43-year - old male mortuary beautician ( case 5 ) .
the investigation included a review of circumstances and medical records , specimen collection , virus isolation , real - time polymerase chain reaction for viral rna detection , and sequencing and serological tests ( capture enzyme - linked immunosorbent assay [ elisa ] for immunoglobin [ ig ] m antibody , antigen sandwich elisa for igg antibody , and microneutralization tests [ mnt ] ) .
as for risk assessment of transmission factors , all contactors of the index patient during the period from the beginning ( 25 september 2010 ) to the end ( 8 october 2010 ) were classified through 3 types of contacts , including blood , droplet , and possible airborne contacts . the investigation was reviewed and approved by the ethics committee of china center for disease control and prevention ( cdc ) , which uses international guidelines to ensure confidentiality , anonymity , and informed consent .
the index patient was from an sfts - endemic region and first had onset of illness on 25 september 2010 ; was admitted to a local hospital on 28 september with a high fever of 39.5c and vomiting ; and the infection was identified through initial laboratory testing of thrombocytopenia , leukocytopenia , and elevated aspartate aminotransferase level .
the patient was diagnosed as a suspected sfts case , and transferred to the intensive care unit the next day , where he received ribavirin , dexamethasone , omeprazole , and cryoprecipitation for therapy . on 2 october 2010 ,
his condition deteriorated with hypersomnia , shortness of breath , and mouth mucosal bleeding . on 3 october
, he appeared confused and showed dyspnea , then was intubated and mechanical ventilated . on 4 october ,
the patient was in shock and comatose , developed disseminated intravascular coagulation and multiple organ dysfunction syndrome , and died the next day .
an important observation was that the index patient had unique hemorrhagic symptoms , including bleeding from mouth mucosa , gastrointestinal lumen , and lungs , which was rare in previously identified sfts patients .
the patient s fever remained high ( 39c40c ) until death , although lowered somewhat by giving dexamethasone .
clinical laboratory values ( table 1 ) showed unusually high level of tissue enzymes , blood urea nitrogen , and creatinine , which might indicate impaired liver , heart , and kidney functions .
consistent with the largely reduced platelet count , the index patient had a significantly elongated activated partial thromboplastin time , which represented a largely impaired coagulation function .
immediately after death , the corpse was transferred to the patient s home in a local village for a funeral ceremony , then transferred to a crematorium 3 days later .
laboratory analysis of a cluster of severe fever with thrombocytopenia syndrome patients in china alt , alanine aminotransferase ; ast , aspartate aminotransferase ; ldh , lactate dehydrogenase ; aptt , activated partial thromboplastin time .
 , negative ; + , weak positive ; + + + , strong positive .
viral rna copies were calculated according to standard reaction curves , which were established using serially diluted in vitro rna transcripts as standard samples .
virus load was determined based on an average conversion coefficient between virus copies and virus titer presented as 50% tissue culture infective dose ( tcid50/ml ) .
serum samples collected in the acute phase were subjected to immunoglobin ( ig ) m detection with igm antibody capture enzyme - linked immunosorbent assay ( elisa ) , with horseradish peroxidase  conjugated recombinant severe fever with thrombocytopenia syndrome bunyavirus ( sftsv ) nucleoprotein as the detection agent .
serum samples collected in the convalescent phase were subjected to igg detection with sandwich elisa by using recombinant sftsv nucleoprotein as the detection agent .
values for igm antibodies , igg antibodies , and mnt are the reciprocals of the serum dilution .
risk factors were assessed using logistic regression analysis ; p  <  .05 was considered to be statistically different .
epidemiologic investigations began with interviews with 5 secondary sfts patients and 58 other individuals who had exposure to the index patient from onset of the illness until cremation .
we found that all 5 secondary cases had possible blood contact through skin or mucosa .
case 1 , the local icu doctor , performed the intubation for the index patient , resuscitating the patient before his death .
case 2 , the consultant doctor , traveled from a nonendemic area to the local hospital for a medical consult with the patient , and the patient s blood dropped on his hand when he was helping an icu nurse draw blood without wearing gloves .
case 3 , the younger son of the index patient , was a long - distance truck driver not living in the same village , and directly touched the blood flowing from the deceased patient s mouth and nose when he cried on the corpse .
case 4 , the older son of the index patient , was also a long - distance truck driver , and took care of the dead body and was wiping off the blood from the face of the corpse .
case 5 , a local mortuary beautician , did the make - up for the corpse with gloves and mask , but took them off twice during the procedure . the above 5 cases all developed the disease 715 days after exposure , with only 3 of them having contact with blood after death . in comparison with the index patient
, all 5 secondary cases had minor clinical features ( table 1 ) , without obvious hemorrhagic manifestations , so they did not receive dexamethasone therapy . except for the major risk factor of blood contact , droplet contact ( n  =  4 ) , which included 3 medical staff who were involved in the intubation and the index patient s daughter who cared for him before death ,
in addition , the risk factor of possible airborne transmission ( being in the icu room or funeral room without mask protection ) was also assessed among all 63 exposed individuals . of them , the medical doctors and nurses ( n  =  16 ) were with protection ; and the others were without ( n  =  47 ) , including icu patients who were staying in the same room ( n  =  8) , family members (
n  =  3 ) , and visitors to the funeral room where the corpse was kept ( n  =  35 ) .
the multivariate analysis ( logistic regression analysis ) showed that blood contact was the most likely mode of transmission ( p  <  .001 ; table 1 ) .
it is noticeable that the serum collected from the index patient on the day he died contained a relatively high amount of sftsv , which reached about 3.55    10 viral rna copies / ml ( calculated as 9.67    10 50% tissue culture infective dose [ tcid50]/ml ) .
this number was about 100  000-fold higher than viral copies detected in the serum samples of the 5 secondary patients , which ranged from 10 to 10 copies / ml ( table 1 ) .
all 5 patients had virus - specific igm antibodies in the acute phase , and elevated virus - specific immunoglobin g ( igg ) antibodies in the convalescent phase . the index patient , however , had minimal or undetectable levels of virus specific igm antibodies on day 11 after onset of fever ( table 1 ) . compared with the entire genomic sequence of the virus strain isolated from the index patient ,
cases 2 and 3 were nearly 100% identical , and provided genetic evidence for the epidemic findings on the possible transmission of sftsv from the index patient to secondary patients .
here , we reported the person - to - person transmission of sftsv with a cluster of 6 sfts patients that occurred in shandong province of eastern china .
investigation studies revealed that all 5 secondary infected patients had possible contact with the index patient s blood .
of them , only case 1 ( icu doctor ) had evidence of droplet contact contamination ( during intubation ) but not blood contact , but we included him also as a blood contactor because he performed intubation without protective face shield and goggles , therefore he had an extremely high risk of blood contact through unprotected skin and mucosa .
the risk assessment revealed that blood contact was the major risk factor for the human - to - human transmission of sftsv .
additionally , 3 secondary patients who only had contact with the index patient after death were still infected , which indicated that sftsv - infected blood may remain infectious for a long time , even after patient death .
it is notable that the level of virus copies in the index patient s serum was extremely high , but with no detectable igm or igg antibodies , which suggested that his immune responses to limit the replication of sftsv were severely impaired .
the patient had no immune system disease , thus the minimal immune responses might be due to the early and sustained application of glucocorticoid , which has a side effect of repressing immune functions ; clinical physicians should take note of this finding .
clinically , sfts is easily confused with hemorrhagic fever with renal syndrome caused by hantavirus   and human anaplasmosis .
the hantavirus - specific igm antibodies were not detected in the sfts patients serum samples ( data not show ) . due to the limitation of our study , we were not able to detect rickettsia infection , which was previously reported in outbreaks of nosocomial infections
. however , the methods we used for diagnosis of sfts patients were well validated , and the human - to - human transmission of sftsv we described in this study could not simply be classified as being nosocomial transmission ; specially , 3 of the 5 secondary cases that occurred in the household .
additionally , the lessons of person - to - person transmission of sftsv we learned from this study highlighted the necessity of establishing standard precautions for avoiding direct contact and blood - based transmission .
this work was supported by the china mega - project for infectious diseases ( 2008zx10004 - 001 , 2009zx10004 ) from the ministry of science and technology and ministry of health of the people s republic of china .
conflicts that the editors consider relevant to the content of the manuscript have been disclosed .

Answer:
severe fever with thrombocytopenia syndrome bunyavirus is a newly discovered bunyavirus with high pathogenicity to human .
 the transmission model has been largely uncharacterized .
 investigation on a cluster of severe fever with thrombocytopenia syndrome cases provided evidence of person - to - person transmission through blood contact to the index patient with high serum virus load .


Question:
You will be presented with the full text of a biomedical research paper. Please write an abstract for this paper. Your response should include the abstract and no additional text.

Paper text:
the reverse shoulder arthroplasty was approved by the fda in 2004 and has proven a very effective prosthesis for treatment of cuff tear arthropathy and other shoulder conditions requiring arthroplasty in the setting of a deficient rotator cuff . however , in some series , the overall revision rate for the reverse shoulder is approximately 10% , with instability and infection being the most common precipitating causes.[13 ] studies have also shown that aseptic loosening may contribute to 7% of failures , but as indications expand and long - term follow - up increases , the incidence of aseptic loosening will likely increase .
have further shown that pain increases with longer term follow - up of reverse replacements ( 510 years ) .
therefore , in the future , surgeons will be faced with difficult choices when revising the reverse prosthesis , and optimal management of the failed reverse replacement is not known .
when instability or loosening of a reverse prosthesis does occur , retention of the reverse prosthesis can be performed by ( 1 ) increasing deltoid tension with additional polyethylene or metallic spacers , ( 2 ) increasing constraint with a retentive cup or ( 3 ) revision of the humeral or glenoid components.[514 ] however , due to poor bone stock , infection or refractory instability , removal of a reverse replacement ( explant ) or conversion to hemiarthoplasty can be required .
we present a series of failed reverse replacements that were converted back to hemiarthroplasty with either a metallic prosthesis or preformed antibiotic shoulder spacer for infection , instability or glenosphere loosening . to date , there are few reports of reverse replacement conversion to hemiarthroplasty , and none specifically examining the shoulder function in this unique group .
we examine a group of patients after conversion of failed or infected reverse shoulder replacement to hemiarthroplasty ; the level of function and pain in this group is important for surgeons and patients considering a revision reverse shoulder replacement .
from 2008 to 2010 , the senior author performed 115 primary and revision shoulder arthroplasty procedures . as part of the shoulder registry ( irb#10 - 000859 )
, seven patients were identified that had presented to the senior author 's clinic with a reverse replacement that was dislocated ( 3 ) , infected ( 4 ) or loose ( 3 ) .
all of the failed reverse replacements in this study were referred from outside hospitals for tertiary care ; revision surgery was performed an average of 9.2 months after implantation of the reverse prosthesis .
patients with known infection were treated with explant of the reverse prosthesis using a slot osteotomy , cement extraction with an oscar device ( orthosonics , chatham , nj , usa ) and conversion mean size of the defect from 273 ( n = 3 ) ( exactech , interspace , gainesville , fl , usa ) .
this antibiotic spacer was cemented in place with additional antibiotic - loaded cement ( tobramycin and vancomycin ) . in three cases of gross loosening of the glenosphere
these patients were treated with removal of glenosphere only , bone grafting of glenoid with allograft including cancellous bone chips and demineralized bone matrix , and retention of the humeral stem by converting it via the manufacturer 's guidelines to a hemiarthroplasty ( n = 4 ) . at the time of reverse
removal in this elderly population , the bone stock of the glenoid was cavitary and uncontained , not deemed of sufficient quality to support immediate replacement of a single - stage revision glenosphere .
preoperative computated tomography ( ct ) was also used in four patients to evaluate the glenoid bone stock , but was not clinically very useful due to metal artifact .
this group of seven patients status post removal of reverse replacement were contacted for reevaluation with physical exam and outcome scores specifically for this study .
one patient who had been converted from a dislocated , infected reverse replacement to preformed antibiotic spacer chose not to participate , but has not had any further surgery .
the case details of the remaining six patients who consented for examination and inclusion in this study are contained in table 1 .
details of six cases of failed reverse shoulder arthroplasty converted to hemiarthroplasty using either a metallic head and retention of the reverse stem or an explant and implantation of a preformed antibiotic - loaded cement hemiarthroplasty
there were three males and three females ( average age 74.5 years ) who had had an average of three previous shoulder surgeries including the index reverse replacement .
the reverse replacement had been implanted an average of 9.2 months before failure of the prosthesis required removal .
radiographic evidence of technical problems with the index reverse arthroplasty surgery was present in five of six cases , with superior implantation of the glenosphere ( n = 4 ) being the most common .
average follow - up after removal of reverse replacement was 26.5 months ( range 1041 months ) .
the decision to include patients with less than 2-year follow - up was made to maximize inclusion of patients that have been offered conversion back to reverse replacement .
shoulder function was very poor postoperatively ( average forward elevation of 42.5 degrees and average external rotation near zero ) , but the pain level was generally low .
sf-12 scores were similar to us averages in the 75 years - plus age group .
anterosuperior escape was present in five patients ( vas instability score averaged 4.7 [ range 08 ] ) . in the sixth patient , there was static radiographic anterior subluxation ( case 1 ) .
in the four cases where bone graft was used for glenoid deficiency , radiographic follow - up showed good incorporation of graft and reimplantation with a reverse prosthesis seemed feasible , although none of the patients elected to have this performed .
a peripherally inserted central catheter ( picc ) line was inserted and culture - specific intravenous antibiotics were administered for 6 weeks postoperatively .
there were no reoperations and , to date , no patient has accepted an offer to be converted back to a reverse replacement .
a 58-year - old male ( case 2 ) presented 6 months after reverse arthroplasty for failed fracture fixation with anterior dislocation of the prosthesis .
notice the superior placement of the glenosphere with slight superior tilt . at the time of revision surgery , no combination of glenosphere or reverse humeral component could result in stability as the prosthesis levered out with adduction past 40 degrees .
removal of a well - fixed glenosphere and baseplate was performed and glenoid bone stock was not sufficient for immediate revision of the baseplate to an improved position .
( c and d ) conversion to large head hemiarthroplasty and bone grafting of glenoid defect .
cultures were positive for p. acnes at the time of revision a 74-year - old female ( case 4 ) underwent reverse replacement for severe cuff tear arthropathy ( a ) .
the glenosphere loosened at 8 months postoperatively with breakage of the inferior screw ( c ) .
( d and e ) ap and axillary views after conversion to hemiarthroplasty an 80-year - old man ( case 5 ) presented with a draining sinus and a dislocated , infected reverse replacement 6 months after primary reverse replacement at an outside institution that was complicated with reoperation the same day after a recovery room dislocation .
glenosphere position is acceptable , but the entire humeral head was essentially resected , likely compromising stability .
( c and d ) postoperative radiographs of preformed antibiotic spacer preoperative draining sinus an intraoperative photograph after irrigation and debridement , removal of glenosphere , slot osteotomy and cementation of preformed antibiotic spacer ( exactech interspace , gainesville , fl , usa ) with additional antibiotic - loaded cement .
notice how the humeral head is devoid of any soft tissue attachments creating a shoulder with profound anterosuperior escape
in farshad and gerber 's review of reverse arthroplasty complications , they state that the optimal management for a failed reverse arthroplasty is not known and that complications that require removal of the prosthesis result in poor shoulder function .
once a severe complication in reverse arthroplasty is established , retention of a stable reverse prosthesis is difficult and multiple reoperations are common .
gallo et al . reviewed a series of nine cases of reverse replacement requiring revision for instability in the setting of subscapularis deficiency .
in these nine patients , three eventually required explant , three remained chronically dislocated and three were concentrically intact . in a retrospective review of
describe their experience with dislocation and infection of reverse prosthesis . in a series of 284 reverse replacements ,
the rate of instability was similar in patients with primary ( 11 of 212 [ 5% ] ) and revision ( six of 72 [ 8% ] ) reverse arthroplasty . the rate of infection was higher in the revision ( five of 72 [ 7% ] ) than in the primary ( three of 212 [ 1% ] ) group . in this series
, the authors reported that a stable noninfected prosthesis was present in only 12 of 25 shoulders revised for infection or instability , and multiple reoperations for both persistent infection and recurrent instability were common in this series . in 2008 , norris presented a series of 26 revision reverse replacements for various causes .
not all series of revision reverse arthroplasty have reported such a high rate of rerevision and reoperation .
if retention of the reverse shoulder prosthesis in the setting of infection , dislocation or loosening is to be performed , the reoperation rate could be as high as 50% , and there is a potential for multiple reoperations and eventual resection arthroplasty . because of poor bone stock , persistent infection or persistent instability , conversion back to reverse replacement is not always possible in the immediate revision setting .
in addition , due to the very elderly nature of this population and the often presence of severe medical comorbidities , a surgical strategy that could result in multiple reoperations can be unwise .
for this reason , conversion of the reverse replacement to metallic or cement hemiarthroplasty is an attractive option , especially in the multiply operated patient unwilling to harbor further surgical risk .
there seems to be less risk of reoperation using this surgical strategy , and the option remains to revise back to reverse replacement at a later date .
however , successful single - stage treatment of infected and loose reverse replacements have been reported in the literature .
grammont revised one patient who was revised on postoperative day 1 due to an intraoperative glenoid fracture , and this patient maintained only 40 of active elevation and had persistent shoulder pain .
frankle reported on two patients who were converted to a hemiarthroplasty because of insufficient bone stock and a deep infection ; these patients rated the outcome of their revision as good and satisfactory . in another large series of reverse replacements ,
steinmann reported on a subset of four patients who were converted to a hemiarthroplasty as a result of loosening of the glenoid component in three and recurrent instability in the other .
three of these patients had moderate pain and one had severe persistent pain , and patient satisfaction was low .
this case series can be criticized for the small number of patients included and only very short - term follow - up .
while the short - term follow - up may be used to predict future shoulder function , pain has been shown to increase with time .
therefore , it is possible that shoulder pain after hemiarthroplasty will become more significant over time , compelling patients to seek further treatment such as reimplantation of a reverse prosthesis . despite these limitations ,
the literature is very sparse on  what comes next ?  after reverse replacement .
we felt that this is the optimal time to report this series as it provides a snapshot of patients that are now candidates for reimplantation of reverse replacement to restore shoulder function .
in addition , we feel that this series does provide the shoulder arthroplasty surgeon with several pieces of useful information : ( 1 ) in five of six patients , technical error was evident on postoperative radiographs with superior placement of the glenosphere often with superior tilt accounting for three cases of glenosphere loosening and one case of dislocation .
these technical errors likely resulted in the average failure of the index reverse replacement at 9.2 months .
. the reoperation rate of this series will certainly increase if patients choose to have conversion back to reverse replacement .
( 3 ) pain level was acceptable in most patients after conversion of reverse to hemiarthroplasty , with an average vas pain score of 2.4 .
( 4 ) shoulder function was poor , with anterosuperior escape present in five of six patients .
this escape is likely accentuated by reversion to a state where the deltoid is again detensioned .
failure of reverse replacement will increase in the future , with expansion of indications to younger patients and longer term follow - up .
the optimal treatment for a failed reverse replacement is unknown and often very unique to each individual patient and each mode of failure .
when counseling a patient with an infected , dislocated or loose reverse replacement , the patient should understand that attempts at retention and salvage of the reverse configuration of their shoulder is not always successful and can be associated with a high rate of reoperation .
this small series of patients shows that safe removal of a reverse replacement and conversion to hemicement spacer or hemiarthroplasty can provide the shoulder with a relatively low pain level , but that the shoulder will be nearly devoid of meaningful function postoperatively .
every effort should be made to meticulously assure proper initial implant placement and avoid infection in primary reverse replacement .
in addition , when complications do occur , retention of the reverse replacement is necessary to maintain shoulder function as conversion to hemiarthroplasty results in poor function .
the failed reverse replacement can result in extraordinarily difficult salvage situations and therefore we echo the sentiment published by rockwood that the reverse replacement should be implanted most frequently by shoulder arthroplasty specialists prepared to treat the severe complications encountered too frequently by even the world 's experts .
removal of the reverse shoulder replacement and conversion to hemiarthroplasty results in a shoulder with minimal meaningful function but with an acceptably low level of pain .
this information can be helpful when discussing preoperatively the relative risk of revision reverse arthroplasty versus conversion to hemiarthroplasty in patients with a failed reverse replacement .

Answer:
background : the reverse total shoulder replacement has become a popular treatment option for cuff tear arthropathy and other shoulder conditions requiring arthroplasty in the setting of a deficient rotator cuff . despite a revision rate of as much as 10% , to date
 , there are few reports of reverse replacement conversion to hemiarthroplasty , and none specifically examining shoulder function.materials and methods : six patients with a reverse replacement that was dislocated , infected or loose were revised an average of 9.2 months after the reverse replacement .
 two of the three patients that were dislocated also had a known deep infection .
 patients with known infection were treated with explant of the reverse prosthesis and conversion to a preformed antibiotic spacer hemiarthroplasty . in three cases with gross loosening of the glenosphere without infection , treatment
 was performed with removal of glenosphere only , bone grafting of glenoid with allograft and conversion of humeral stem to hemiarthroplasty .
 patients were evaluated with outcome scores and physical examination an average of 26.5 months after removal of the reverse prosthesis.results:the average range of motion postoperatively was forward elevation 42.5 degrees and external rotation 1.7 degrees .
 the vas pain score was 2.42 ( range 06 ) ; simple shoulder test was 3.17 ( range 15 ) ; and ases score was 52.1  8.5 .
 there were no reoperations to date , and five patients had anterosuperior escape.conclusions:safe removal of a reverse replacement and conversion to hemicement spacer or hemiarthroplasty can provide pain relief in those patients with a dislocated or infected reverse replacement .
 however , the shoulder will likely have very poor function and anterosuperior escape postoperatively .
 further studies are needed to determine the optimal treatment for the failed reverse shoulder replacement.level of evidence : therapeutic level iv .


Question:
You will be presented with the full text of a biomedical research paper. Please write an abstract for this paper. Your response should include the abstract and no additional text.

Paper text:
ivm was initially introduced by pincus and enzmann ( 1935 ) , using immature rabbit oocytes capable of undergoing spontaneous maturation and fertilization in vitro .
the first group that succeeded in producing a child via ivm were trounson et al .
( 1994 ) , using oocytes recovered from an untreated ovary in patients with polycystic ovaries .
in - vitro maturation ( ivm ) has advanced significantly from its initial description to its current widespread clinical applications . despite these advances , however , there are still many controversial issues surrounding this treatment . given that ivm is an emerging protocol ( at least in humans ) ,
there are many controversial areas of debate , and especially regarding the subject of the best candidates for ivm ; how should we select our patients ?
we have conducted a review of the literature in the pubmed database from 1999 - 2013 for publications concerning the indications of ivm and examined the possibility that ivm results may be comparable to standard ivf . taking into consideration that no standard protocol exists up to present in different centres , all forms of ivf ( unstimulated , stimulated , oestrogen suppressed ) are considered together .
several studies covered different indications for ivm : patients with normo - ovulatory cycles ( dal canto et al . , 2006 ; fadini et al . , 2009 ; mikkelsen et al . , 1999 , 2001 ) ,
polycystic ovarian syndrome ( pcos ) or normo- ovulatory women with polycystic ovaries ( pco ) ( child et al .
, 2001 , 2002 ; soderstrom - anttila et al . , 2005 ) , fertility preservation ( huang et al . , 2010 ; maman et al . , 2011 ;
2010 ) , poor ovarian response ( ivm may serve the last choice of treatment after the failure to achieve pregnancy in traditional ivf ) ( liu et al . , 2003 ) and in rare conditions such as rescue of oocytes which have failed to mature in stimulated cycles ( tan and child , 2002 ) or cases with unexplained primarily poor quality embryos ( hourvitz et al . , 2010 ) .
normo - ovulatory women may be treated with ivm . since early studies , ( child et al .
, 2001 ; mikkelsen et al . , 1999 , 2000 , 2001 ; soderstrom - anttila et al . , 2005 ) in which a 4%-25% clinical pregnancy rates were reported , there has been a constant improvement in results in normo - ovulatory patients of up to 30% pregnancy rate ( fadini et al . ,
( 2006 ) as well suggested that ivm was a good treatment with a comparable pregnancy rate to ivf , mainly due to the italian law , which allows a maximum of three oocytes per ivf cycle and prohibits embryo or zygote ( 2pn cells ) cryopreservation .
ivm oocytes fertilize and undergo development in vitro with rates similar to in vivo matured control oocytes . in ivm cycles
implantation and pregnancy rates are lower compared with controlled ovarian stimulation treatments , but accurate patient selection can improve ivm clinical outcome ( fadini et al . , 2013 ) .
the main advantages of the ivm protocol in normo - ovulatory patients are : elimination of the side - effects of drug stimulation and reduction of the costs of the entire procedure , both in terms of time consumption and patient costs for drugs .
pcos patients are prone to develop ovarian hyperstimulation syndrome ( ohss ) with conventional ivf treatments .
a potentially useful alternative for women with pcos is earlier retrieval of immature oocytes from small antral follicles , without using hormonal stimulation , followed by ivm of those oocytes .
substituting ivm in pcos patients eliminates the risk of ohss and lowers the cost of treatment . from early 2000 until the present ,
studies have demonstrated a encouraging pregnancy and delivery rate in pcos patients undergoing ivm treatments of 21.9%-29.9% ( child et al . , 2001 , 2002 ; ellenbogen et al .
recent publications report up to 32%-44% pregnancy and 22 - 29% delivery rates ( shalom - paz et al .
, 2011 , 2012 ) , comparable with ivf pregnancy rates results of 38%-45% ( shalom - paz et al . , 2012 ) . in another study of junk and yeap ( 2012 )
the transfer of a single blastocyst embryo obtained after ivm in patients with pcos was proposed .
they obtained a live birth rate of 42.4% per oocyte collection and 45.2% per embryo transfer . in 20 oestrogen suppressed in vitro maturation cycles
the implantation , pregnancy and delivery rates were 17.5% , 40% and 40% respectively ( vitek et al . , 2013 ) .
indeed sart lists higher clinical pregnancy rate for young women as >  46% in 2012 .
however in europe the pregnancy and delivery rates in this group of patients undergoing icsi was 35.5% and 24.3% respectively ( ferraretti et al . , 2013 ) . de ziegler et al . ( 2012 ) opposed the need of ivm in the gnrh antagonist era .
however , his results did nt take into consideration the fact that with gnrh - agonist used as a trigger to control the risk of ovarian hyperstimulation syndrome , higher pregnancy losses were observed ( humaidan et al . , 2005 ) .
on the other hand , the dual trigger approach ( gnrh - agonist + lowhcg ) revealed 2.9% of ohss complications
( griffin et al . , 2012 ) . even applying the strategy of ovarian stimulation using the combination of gnrh antagonist with gnrh agonist to trigger ovulation and freezing all of the oocytes or embryos for later use ( devroey et al . ,
2011 ) do not eradicated ohss totally as severe ohss after gonadotropin - releasing hormone ( gnrh ) agonist trigger and  freeze - all  approach in gnrh antagonist protocol was described ( fatemi et al . ,
the emerging technology of ivm in oocyte retrieval has recently become another option for fertility preservation .
this procedure can be done without hormonal stimulation and within a short time frame ; oocytes being collected during the follicular phase , within up to 13 days from cancer diagnosis and the resulting embryos either vitrified or fertilized and cryopreserved ( huang et al . , 2010 ;
2010 ) . to shorten the period of time until cancer treatment , studies by maman et al .
therefore , in cases of cancer patients , especially in which hormonal treatment is contraindicated and those who must start chemotherapy without delay , ivm might be the only option to preserve fertility .
however , up to now , no data are available concerning pregnancy rates in this group of patients .
one flow of ivm had been suggested , as mature eggs at retrieval often give rise to embryos that result in live birth pointing that they are not  really  ivm oocytes .
however , from 1224 oocytes retrieved in ivm cycles only 15.6% were found mature up to six hours after retrieval vs. 64.9% that matured in vitro after 6 - 48 hours ( ellenbogen et al . , 2011 ) .
no differences were found regarding fertilization and cleavage rates or top quality embryos developed from either oocytes ( ellenbogen et al . , 2011 ) .
. however , soderstorm - anttila et al . ( 2006 ) showed comparable complications and malformations for babies born after undergoing ivm and ivf .
( 2007 ) described a normal pregnancy course for ivm patients compared to ivf cycles .
( 2012 ) reported normal growth and development of 196 babies born from ivm cycles .
recently , chian and cao ( 2014 ) reported 1421 healthy infants born following immature oocyte retrieval and ivm .
those changes are established during oocyte growth , and ivm may modify the normal maturation of the oocytes ( bao et al . , 2000 ) . moreover ,
may have deleterious effects on the organization of the meiotic spindle and chromosome alignment of human oocytes .
this finding may be a possible explanation for the reduced developmental potential of oocytes matured in vitro compared with those matured in vivo ( li et al . ,
however despite the great achievements obtained in treating infertile couples by standard ivf during the last 34 years , it has become evident in recent years that ovarian stimulation , although a central component of ivf , may itself have detrimental effects on oogenesis , with production of aneuploidity ( baart et al . , 2007 ) , reduced embryo quality , lower endometrial receptivity and perhaps also perinatal outcomes ( santos et al . , 2010 ) .
in vitro maturation of oocytes is a simple procedure . it is an economical and less stressful procedure for women .
puncture is simple and safe and it can improve the disrupted endocrine environment and induce a spontaneous recovery of ovulation and pregnancy in women with pcos without other infertile factors . it can avoid short - term complications , such as ovarian hyperstimulation syndrome and possible long - term complications , such as hormone dependent neoplasm s including breast and ovarian cancers .
studies to date have not identified an alarming rate of congenital anomalies in ivm children , and studies which have followed up children to the age of 2 years old have provided reassuring results regarding their growth and development .
ivm holds great promise as an alternative to assisted reproductive technologies and may be the procedure of choice not only for infertile patients but also for obtaining oocytes for donation or fertility preservation .
improving embryonic - endometrial synchrony through pharmaceutical or other manipulation of endometrial / uterine receptivity will hopefully result in future improvements in ivm success rates .
proper counselling of these patients about advantages and disadvantages of the procedure should be performed routinely .
the goal of the art is to help patients fulfil their most basic desires of reproduction and continuity , using technology that was only imaginary not long ago .
these techniques are not yet flawless and may be associated with taking some calculated risks and courageous decision making , without which we would never have been able to help so many people and create so many happy families .

Answer:
retrieval of immature oocytes from unstimulated ovaries , followed by in vitro maturation ( ivm ) was originally proposed in order to avoid side effects of gonadotropin administration .
 the target is to eliminate or significantly reduce the risk of ovarian hyperstimulation syndrome ( ohss ) in patients with polycystic ovary syndrome ( pcos ) , drug cost and burden on patients .
 this technology was also suggested in treatment of normo - ovulatory women , fertility preservation or infrequent conditions such as failure of oocytes to mature or repeated development of poor quality embryos . in this study
 we intended to examine the possibility that ivm results may be comparable to standard ivf . a pubmed database search from 1999 - 2013 was carried out for publications concerning the indications of ivm and study the possibility that ivm results may be comparable to standard ivf.in vitro maturation of the oocytes procedures obtained up to 35% clinical pregnancy rate in young women , comparable with in vitro fertilization ( ivf ) in many programs .
 the obstetric and perinatal outcomes of ivm cycles are comparable with ivf / icsi cycles.in conclusion ivm may gradually replace ivf in certain cases , as the technique continues to develop and pregnancy rates continue to increase , being a promising and simple alternative approach to standard ivf in various indications .


Question:
You will be presented with the full text of a biomedical research paper. Please write an abstract for this paper. Your response should include the abstract and no additional text.

Paper text:
chikungunya ( chikv ) and dengue ( denv which is divided into 4 serotypes , 1 to 4 ) viruses are both arthropod - borne viruses belonging respectively to the genus alphavirus , togaviridae family and flavivirus , flaviviridae family , and transmitted to humans via a bite of infected aedes mosquitoes ( aedes aegypti , aedes albopictus ) . over the past two decades , they have caused multiple worldwide outbreaks , particularly in tropical and sub tropical areas .
recent chikv outbreaks started in kenya in 2004 , spread over the indian ocean region , reached india causing in all more than 1.5 million cases .
then , numerous imported cases were reported in different parts of the world , an outbreak occurred in italy , while autochthonous cases were reported in france .
in central africa , outbreaks occurred in democratic republic of congo , cameroon , gabon and republic of congo .
as for dengue fever ( df ) , its incidence has grown dramatically around the world , rising more than 30-fold in recent decades .
two fifths of the world 's population are at risk of infection , and who currently estimates there are 50 million dengue infections each year .
the disease is now endemic in more than 100 countries in africa , the americas , the eastern mediterranean , south - east asia and the western pacific . during the last decade ,
denv epidemics have occurred in some east and west african countries , including cape verde where more than 17,000 df cases due to serotype 3 were notified . in practice ,
the global picture of both chikungunya and df is similar in their classical forms , so they can be confused particularly in areas where they cocirculate . after variable incubation period ,
both diseases start abruptly with acute fever , arthralgias , myalgias , headaches , rash and fatigue .
arthralgias are often incapacitating in chikv infection and can persist for several years in some patients . for denv infection , after the initial febrile phase , hemorrhagic manifestations can occur , leading to dengue hemorrhagic fever ( dhf ) indeed dengue with shock syndrome ( dss ) . and finally , in addition to denv , reports of deaths in la reunion island were directly attributed to chikv .
furthermore , there is no comparative study of the two infections , still lesser in a concurrent outbreak . here
, we compare the clinical features and the laboratory findings for 343 laboratory - confirmed patients from the concurrent chikv / denv outbreak which occurred in gabon in 2010 .
franceville , the main town of the haut ogooue province , 512 km south - east from libreville ( capital of gabon ) , is located at altitude 333 meters , at the end of the transgabon railway and the national 3 road , in a savannah ecosystem constituted by forest gallery ( figure 1 ) .
there are 5 health care capacities ( hcc ) including 2 public hospitals with 170 beds in all and the medical unit of the centre international de recherches medicales de franceville ( cirmf ) .
a concomitant chikv/ denv outbreak raged 11 towns and one village of the southeast , from february to july 2010 , and recorded 1127 laboratory confirmed cases in franceville .
the cirmf was included as a partner of the moh , in the response to this outbreak , and implicated in active surveillance , case management and diagnostic . as part of these activities ,
a prospective study was initiated , and the investigations were considered as a component of the public health response and authorized by the regional health director .

map of gabon with location of the gabonese chikungunya outbreak in 2010 . at the time of the outbreak ,
the moh provided a case definition including 2 categories : a suspected case was a patient presenting with at least one of the following symptoms : fever , arthralgias , myalgias , headaches , rash , fatigue , nausea , vomiting , diarrhea , bleeding , and jaundice ; a confirmed case was a suspected case with laboratory confirmation .
all suspected cases consulting in the cirmf medical unit were examined and demographic and clinical data collected in standardized questionnaire .
blood samples were collected in two 7-ml edta vacutainer tubes and one 7-ml dry tube ( vwr international , france ) .
the tubes were stored in the dark at + 4c until arrival at the laboratory .
thick and thin blood films were stained with 20% giemsa and examined for malaria parasites .
hematological ( hematology analyser act 10 , beckman coulter ) and biochemical ( creatinine , ast , alt ) tests were performed ( automatic analyser hitachi model 902 , roche diagnostics ) .
samples were tested for chikv and denv rna genomes by using taqman qrt - pcr technology and specific primers and probes . when used during the acute phase ( 17 days after onset of symptoms ) , the taqman qrt - pcr technology has a sensitivity of up to 80% and specificity of 100% .
results were expressed as averages ( with their sd ) and percentages ( with their 95% confidence interval , ic ) .
the student 's t test was used to compare laboratory parameters and continuous clinical variables . for qualitative variables , the chi square test or fisher 's exact test were used as appropriate .
franceville , the main town of the haut ogooue province , 512 km south - east from libreville ( capital of gabon ) , is located at altitude 333 meters , at the end of the transgabon railway and the national 3 road , in a savannah ecosystem constituted by forest gallery ( figure 1 ) .
there are 5 health care capacities ( hcc ) including 2 public hospitals with 170 beds in all and the medical unit of the centre international de recherches medicales de franceville ( cirmf ) .
a concomitant chikv/ denv outbreak raged 11 towns and one village of the southeast , from february to july 2010 , and recorded 1127 laboratory confirmed cases in franceville .
the cirmf was included as a partner of the moh , in the response to this outbreak , and implicated in active surveillance , case management and diagnostic . as part of these activities ,
a prospective study was initiated , and the investigations were considered as a component of the public health response and authorized by the regional health director .

at the time of the outbreak , the moh provided a case definition including 2 categories : a suspected case was a patient presenting with at least one of the following symptoms : fever , arthralgias , myalgias , headaches , rash , fatigue , nausea , vomiting , diarrhea , bleeding , and jaundice ; a confirmed case was a suspected case with laboratory confirmation .
all suspected cases consulting in the cirmf medical unit were examined and demographic and clinical data collected in standardized questionnaire .
blood samples were collected in two 7-ml edta vacutainer tubes and one 7-ml dry tube ( vwr international , france ) .
the tubes were stored in the dark at + 4c until arrival at the laboratory .
thick and thin blood films were stained with 20% giemsa and examined for malaria parasites .
hematological ( hematology analyser act 10 , beckman coulter ) and biochemical ( creatinine , ast , alt ) tests were performed ( automatic analyser hitachi model 902 , roche diagnostics ) .
samples were tested for chikv and denv rna genomes by using taqman qrt - pcr technology and specific primers and probes . when used during the acute phase ( 17 days after onset of symptoms )
, the taqman qrt - pcr technology has a sensitivity of up to 80% and specificity of 100% .
results were expressed as averages ( with their sd ) and percentages ( with their 95% confidence interval , ic ) .
the student 's t test was used to compare laboratory parameters and continuous clinical variables . for qualitative variables , the chi square test or fisher 's exact test were used as appropriate .
the sex ratio m / f was 0.99 and the mean age was 3015 ( range , 177 years ) . among these 433 patients ,
343 ( 79.2% ) were laboratory confirmed with 270 ( 62.3% ) chikv+ , 53 ( 12.2% ) denv+ .
the sex ratio m / f was 0.85 for the chikv group , 0.55 for the denv group and 1 for the chikv / denv group , and the mean age was respectively 3016 ( range 1 77 years ) , 3114 ( range , 576 years ) , and 3612 ( range , 174 ) .
hospitalization was required for 39 ( 14.4% ) chikv+ , 2 ( 3.7% ) denv+ ( p=0.02 ) , and 6 chikv / denv+ patients .
headaches and hemorrhage were more frequent ( p respectively 0.01 and 0.001 ) in the denv+ group than in the chikv+ group ( table 1 ) , and myalgias were more frequent in the chikv and denv groups than in the chikv / denv group ( p = 0.005 and 0.02 respectively ) .
similarly , leukopenia and lymphopenia were more frequent ( p respectively 0.02 and 0.001 ) in the denv+ group than in the chikv+ group ( table 2 ) .
there was no difference in biological parameters between the co - infected group and the other groups .

table 1comparison of clinical signs between chikungunya and dengue - infected patients during the 2010 outbreak in gabon.chikv+denv+pn%n%hospitalization3914.323.60.02clinical symptomsfever234865292.90.16arthralgia22783.54783.90.93myalgia19571.74071.40.96headache19069.94885.70.01asthenia21478.74478.60.72skin rash11140.81526.80.06pruritus7326.81119.60.26digestive signs87321934.50.86hemorragy51.8712.50.001chikv , chikungunya virus ; denv , dengue virus .

table 2comparison of biological parameters between chikungunya and dengue - infected patients during the 2010 outbreak in gabon.chikv+denv+pmeansdmeansdbiological parametershaemoglobin12.31.711.91.140.49leucocytes52431676339015170.02lymphocytes222821614012430.001platelets23308981750225600608240.77asat171118100.38alat453550340.58cratinine963288320.14chikv , chikungunya virus ; denv , dengue virus .

we conducted a comparative study of clinical and biological data of patients with chikungunya and dengue viruses infections during a concurrent outbreak which occurred in south east gabon in 2010 .
of the 343 individuals included in the study , 270 were chik+ , 53 were denv+ , and 20 were co - infected ( chik+/den+ ) .
headaches , hemorrhage , leukopenia and lymphopenia were significantly more frequent in denv+ patients . in our opinion ,
thus , the circulation during this epidemic of other arboviruses such as west nile , rift valley fever and yellow fever viruses , can not be ruled out . to our knowledge , this is the first comparative study of these two diseases .
, chikungunya is described in the literature as a dengue - like disease , due to their common symptoms .
nevertheless , the existence of incapaciting joints pain located at the extremities seems specific of chikungunya .
this distinction is difficult in tropical areas where many other diseases , such as malaria , typhoid fever , influenza , share the same symptoms .
so , in our field experience , these diseases are clinically indistinguishable , and the problem of differential diagnosis may be compounded during concomitant chikv / denv outbreaks in a malaria endemic area . in their classical form , the hemorrhage constitutes an inconstant sign .
bleeding is generally minimal , non life - threathning , and can not assist for the differential diagnosis .
this entity is more recognizable , leading , with the shock syndrome , to the severity of the disease .
these hematological disorders are non specific and can not also assist for the differential diagnosis .
patients with mixed infection did not seem to have more severe symptoms or biological disorders , suggesting no additive effect of the two viruses .
the clinical and biological differences detected in our analysis are not useful in the field .
so , our study confirms that the two diseases are clinically similar and need for laboratory confirmation for their recognition . since their appearance in 2007 in the north of the country , these viruses have spread in the south east , together with the vector aedes albopitus .

Answer:
chikungunya ( chikv ) and dengue ( denv ) viruses , both arboviruses , have caused multiple outbreaks worldwide .
 their clinical features are poorly described in africa and there is no comparative study , although chikungunya is considered as a dengue - like disease .
 we conducted a comparative study of clinical and biological data from chikv and denv positive patients during the 2010 gabonese outbreak .
 patients consulting with general symptoms and having laboratory confirmation for chikv or denv were included .
 clinical and biological data were recorded .
 statistical analyses were performed using epi info .
 a p value < 0.05 was considered significant . in all , 270 chikv+ , 53 denv+ and 20 co - infected patients were included in the study .
 headaches , hemorrhage , leukopenia and lymphopenia were significantly ( p respectively 0.01 , 0.001 , 0.02 and 0.001 ) more frequent in denv+ patients than in chikv+ .
 there was no additive effect of the two viruses.these clinical and hematological disorders are non specific and can not assist for the differential diagnosis .
 these diseases are clinically indistinguishable , and need for laboratory confirmation .


Question:
You will be presented with the full text of a biomedical research paper. Please write an abstract for this paper. Your response should include the abstract and no additional text.

Paper text:
in the previous issue of critical care , rhodes and colleagues   report on significantly increased levels of circulating dna in patients admitted to the intensive care unit ( icu ) in comparison with healthy controls .
they show plasma dna levels to be an independent predictor of mortality and the development of sepsis in these patients . in sepsis and trauma , circulating nucleosomal dna is positively correlated with disease severity and adverse outcome . in cancer ,
interestingly , in systemic lupus erythematosus , an autoimmune disease in which nucleosomal dna functions as autoantigenic target , no correlation of circulating nucleosomal dna with disease severity can be found ; instead there is a correlation with anti - nucleosomal dna antibodies .
dna in plasma most probably circulates bound to proteins in the form of mononucleosomes and/or oligonucleosomes and is released after the cleavage of easily accessible linkage sites of cellular dna by endonucleases after cell death .
a mononucleosome consists of a core particle composed of an octamer of two copies each of histones h2a , h2b , h3 and h4 , around which a stretch of helical dna 146 base pairs in length is wrapped .
oligonucleosomes are composed of variable amounts of mononucleosomes connected by intact linker dna with a variable length of 15 to 100 base pairs containing a ' linker ' histone h1 . once released into the circulation , nucleosomes seem to be protected by their structure from further degradation by endonucleases . in healthy individuals ,
the concentration of circulating dna is low , because dead cells are removed efficiently from circulation by phagocytes .
circulating dna has a short half - life ( 10 to 15 minutes ) and is removed mainly by the liver .
accumulation of dna in the circulation can result from an excessive release of dna caused by massive cell death , inefficient removal of the dead cells or a combination of both .
rhodes and colleagues demonstrate that increased circulating dna not only predicts the development of sepsis but also mortality in patients admitted to the icu .
moreover , they show that patients requiring renal support have significantly higher values of circulating dna than patients with sufficient renal function .
unfortunately , the authors provide no information on liver function , because most nucleosomal dna is efficiently cleared by the liver and only a small fraction is eliminated by the kidney .
our recent study in patients with sepsis showed that nucleosomal dna increased with disease severity , but we found no difference in nucleosome levels in patients with severe renal insufficiency and normal renal function , respectively .
other studies in patients with trauma and stroke showed that increased circulating dna levels were correlated with morbidity and mortality .
hence , assessment of circulating dna offers a useful tool for predicting mortality and morbidity of patients admitted to the icu .
further studies on circulating dna in icu patients , including more patients and other scoring systems for illness severity such as saps ii ( simplified acute physiology score ii ) , logistic organ dysfunction and apache ii ( acute physiology and chronic health evaluation ii ) scores , are needed to establish circulating dna as a predictor for mortality and morbidity in patients admitted to the icu .
quantification of circulating nucleosomes can be assessed either by real - time quantitative pcr ( rq - pcr ) or immunological assays .
however , contamination of a sample with nucleated cells can affect the apparent concentration of circulating dna .
chiu and colleagues   showed that a two - step procedure of sample centrifugation ( 800 g or 1,600 g ) followed by either high - speed centrifugation or filtration was superior to a single centrifugation step only .
nevertheless , a 13.5-fold variation in circulating dna levels over 3 days can be detected in female volunteers .
therefore , even though an appropriate sample preparation protocol may be used , notable variation requires a careful interpretation of circulating dna levels .
nucleosomal dna can also be assessed by elisa technique as recently described by different groups . in our laboratory
we developed an elisa with the use of a mouse monoclonal anti - histone 3 antibody ( clb - ana/60 ) as a catching antibody and a monoclonal mouse antibody recognizing an epitope exposed on complexes of histone h2a , histone h2b and double - stranded dna , present only on nucleosomes , as a detection antibody .
this technique renders quantitative determinations reliable and reproducible . also with elisa , careless blood withdrawal and delayed centrifugation
can result in false positive results , and insufficient storage conditions can lead to false negative results . moreover , sandwich elisas are vulnerable to false positive results resulting from xenoantibodies , c1q , rheumatoid factors and anti - nucleosome antibodies ( l aarden , unpublished work ) . a comparison of rq - pcr and elisa methods revealed a high concordance in the quantification of circulating dna in plasma and serum .
quantification should preferably be performed in plasma because , probably as a result of the clotting process , higher levels of circulating dna can be measured .
however , determination of circulating dna by rq - pcr seems to be more sensitive than by elisa .
the lowest circulating dna level measured by rq - pcr in the present study was 14 ng / ml , which corresponds to 2,121 genome - equivalents / ml ( assuming a dna content of 6.6 pg per cell ) . however , circulating dna can be detected by rq - pcr up to 2 genome - equivalents / ml . in our recent study on nucleosome levels assessed by elisa , we reported a detection limit of 35 units / ml , which corresponds to 3,500 cells / ml .
further improvement of the assay improved the detection limit to 1,000 cells / ml . fully automated systems in dna isolation , pcr mixture preparation and rapid thermal cycling profile offer a quick and sensitive tool for quantifying circulating dna in plasma .
however , these systems require considerable amounts of plasma : reliable dna extraction for rq - pcr requires at least 200 l of plasma , whereas only 25 l suffices for elisa .
assessment of circulatory dna is a useful tool for predicting morbidity and mortality in patients admitted to the icu .
elisa = enzyme - linked immunosorbent assay ; icu = intensive care unit ; lod = logistic organ dysfunction ; rq - pcr = real - time quantitative polymerase chain reaction .

Answer:
in various diseases , such as cancer , autoimmune disease , sepsis or myocardial infarction , elevated levels of circulating dna can be measured . however , its predictive value is under debate . circulating dna in plasma is protein - bound ( nucleosomal ) dna .
 quantification of circulating dna can be performed by real - time quantitative pcr or immunological methods such as elisa .
 the diagnostic value of both methods can be impaired by inappropriate handling of the samples .
 assessment of circulating dna in patients admitted to the intensive care unit offers a tool for predicting morbidity and mortality .


Question:
You will be presented with the full text of a biomedical research paper. Please write an abstract for this paper. Your response should include the abstract and no additional text.

Paper text:
twenty - one animals ( 16 cattle and 5 sheep ) showing clinical signs suggestive of bluetongue were sampled by the federal agency for the safety of the food chain on august 18 , 2006 , at 11 farms in northeastern belgium . two serologic tests that detect antibodies against the major serogroup antigen vp7 ( bluetongue virus antibody competitive elisa [ celisa ] ; veterinary medical research and development inc . ,
pullman , wa , usa and competitive vp7 bluetongue kit ; idvet , montpellier , france ) identified 21 virus - positive animals .
two newly developed and validated reverse transcription  quantitative pcrs ( rt - qpcrs ) that detected btv strains representing the 24 serotypes ( 4 ) were then conducted to determine whether these seropositive animals also had viral rna . the first assay ( rt - qpcr_s1 ) , which amplified a 357-nt fragment in segment 1 , detected virus in erythrocytes of the 21 seropositive animals ( mean cycle threshold [ ct ] value 29.0 ) . the second assay ( rt - qpcr_s5 ) , which amplified a 94-nt fragment in segment 5 , detected virus in the same 21 seropositive animals ( mean ct value 26.5 ) . the 2 serologic tests and the 2 molecular assays detected btv in 21 animals from 11 belgian farms within 14 hours .
virus isolation was conducted on august 18 , 2006 , by injection of blood from infected sheep into 11-day - old embryonated chicken eggs , followed by passage on bhk-21 cells ( atcc - ccl10 ) as previously described ( 5 ) .
the specificity of the cytopathic effect observed 48 hours after passage on bhk-21 cells was confirmed by rt - qpcr and electron microscopy ( figure 1 ) after fixation and negative staining as previously described ( 6 ) .
two virus neutralization tests were conducted on 2 virus strains isolated by the belgian and the french reference laboratories at 2 belgian farms 30 km apart .
each strain was also partially neutralized by reference serum against serotype 18 , which confirmed cross - neutralization between serotypes 8 and 18 ( 7 ) .
to september 14 , 2006 , the study farms were screened for animals with clinical signs of bluetongue .
blood samples were tested by serologic tests or rt - qpcr . for cattle , 97 ( 68% ) of 142 samples had antibodies to btv and 32 ( 78% ) of 41 samples contained viral rna ( table 1 ) . however , for sheep , only 23 ( 29% ) of 79 samples had antibodies to btv and 15 ( 45% ) of 33 samples contained viral rna . other diseases that cause similar signs might explain this lower frequency in sheep .
contagious ecthyma was diagnosed by using pcr and electron microscopy for several sheep that showed bluetonguelike signs but did not have antibodies to btv or viral rna .
agreement between celisa and rt - qpcr results was analyzed for 124 animals ( table 2 ) .
one sample negative by rt - qpcr_s1 and rt - qpcr_s5 was positive by celisa .
although this result might reflect lack of specificity of the celisa , elimination of btv rna from the animal several weeks after being infected can not be ruled out .
a false - negative result in the rt - qpcr is unlikely because 1 ) 2 different rt - qpcrs that amplified 2 different segments were used , 2 ) the quality of the rna was confirmed by a third rt - qpcr that quantified mrna of -actin , and 3 ) both rt - qpcrs are highly sensitive ( they can detect 0.01 infectious doses of virus ) ( 4 ) .
false - positive results were not observed with the idvet celisa when we analyzed 650 negative serum samples from artificial insemination centers and field samples collected from belgian livestock in 2004 and 2005 .
seven animals with bluetonguelike clinical signs were positive according to each rt - qpcr but negative according to the celisa ( table 2 ) .
these results support the finding that rt - qpcr can be used to detect viral rna in infected animals before antibodies are detectable .
celisa , competititve elisa ; rt - qpcr ,  reverse transcription  quantitative pcr .
samples with different results in celisa and  rt - qpcr_s5 were retested with rt  qpcr_s1 ( 4 ) .
this latter test always  confirmed the result of the rt - qpcr_s5 . on september 14 , 2006 ( 4 weeks after the first identification of btv in belgium ) as many as 84 belgian farms had at least 1 btv - infected animal .
the maximal distance between herds in this study was 110 km ( figure 2a ) .
most outbreaks were confirmed in the area where the disease was initially detected ( area i , figure 2 ) .
most ( 64% ) infected animals showed a high virus load with individual ct values < 30 .
of the remaining animals , 30% had moderate virus loads ( ct values 3035 ) and 6% had ct values > 35 .
the high ct values for the latter animals might have remained undetected had pooled blood samples been analyzed .
thus , results of pooled samples need to be validated before being used for diagnosis .
none of the animals from zones iii and iv showed a ct value < 30 , whereas all animals from zone ii showed low ct values , which are indicative of high virus loads .
lower virus loads and acute clinical signs in animals from zones iii and iv might indicate onset of infection . however , we can not rule out decreased infection in these animals because they also had positive serologic results that indicated infection for at least 45 days .
further epidemiologic studies are required before conclusions can be drawn on the evolution of these epidemics .
a ) distribution of outbreaks of bluetongue ( shaded areas ) reported in belgium from august 18 through september 14 , 2006 .
b ) cycle threshold ( ct ) values observed in different zones as a result of conducting reverse transcription
btv has been detected and its isolation and characterization have considerably progressed in the first weeks of the epidemics .
results of virus neutralization tests for 2 belgian isolates and molecular characterization of the dutch btv strain by the community reference laboratory ( 8) indicate that btv serotype 8 is present in belgium and the netherlands .
although this observation suggests 1 serotype circulating in northern europe after a common virus introduction , it must be confirmed by detailed epidemiologic studies .
northward spread of bluetongue in europe has been correlated with climate warming ( 9 ) . however ,
one characteristic of the current epidemics of bluetongue is the severity of clinical signs reported in cattle ( 10 ) .
the present results also demonstrate that clinical signs observed in cattle are more specific than those observed in sheep . confusing clinical signs in sheep
underline the need for developing diagnostic tests to discriminate between bluetongue and other confounding diseases such as contagious ecthyma , border disease , and foot - and - mouth disease .
our results also indicate the usefulness of rt - qpcr , which detected viral rna in recently infected animals with clinical signs of bluetongue but no detectable antibodies to btv .
the rt - qpcr and elisa are independent but complementary tests because they detect viral rna and virus - specific antibodies , respectively .
these tests indicated that an outbreak of bluetongue was occurring in belgium . despite high sensitivity of rt - qpcr ( 4 )
, our results suggest that using this test with pooled samples might not detect animals with low viral loads .
rt - pcr  positive results in animals that are no longer infectious ( 11 ) should also be considered before deciding whether pooled samples are acceptable .

Answer:
bluetongue has emerged recently in belgium . a bluetongue virus strain was isolated and characterized as serotype 8 .
 two new real - time reverse transcription  quantitative pcrs ( rt - qpcrs ) that amplified 2 different segments of bluetongue virus detected this exotic strain .
 these 2 rt - qpcrs detected infection earlier than a competitive elisa for antibody detection .


Question:
You will be presented with the full text of a biomedical research paper. Please write an abstract for this paper. Your response should include the abstract and no additional text.

Paper text:
indications for covered self - expandable metallic airway stent removal include recurrent mucous plugging of the stent , excessive or recurrent granuloma formation , migration of the stent , stent infection , recurrence of stenosis , stent failure , stent fractures and accomplishment of treatment . usually , it is tedious to remove a stent because of their embedding in the bronchial mucosa and epithelization of the inner surface .
granuloma formation at the extremities is a relative common occurrence in covered metallic stents possibly resulting from the radial force applied against the airway wall and the friction exerted .
we report a case of covered self expandable metallic stent removal with a rigid bronchoscope under general anesthesia .
the case is unique because it had almost all the common complications associated with the stent placement but it was successfully removed without much ado . to the best of our knowledge
this is the first case of successful removal of a complete stent reported from india .
a 21 year old female presented with complaints of increasing dyspnoea and cough with pain chest for last two weeks .
patient had a past history of benign tracheal stenosis which was opened up by endobronchial electro surgery followed by placement of a self expandable metallic airway covered stent .
x - ray chest done one and a half year back showed stent well in place [ figure 1 ] .
x - ray chest done one and a half year back showing stent well in place bronchoscopy was done under local anesthesia and a stenosis was observed well above the level of the stent [ figure 2 ] with granulation tissue inside the stent [ figure 3 ] , lower end of the stent was fractured , carina was not visualized and stent was seen entering upper part of right main bronchus [ figure 4 ] .
the beveled edge of the rigid scope was advanced between the stent wall and the airway mucosa thus creating a space between them .
the circular extraction loop at the upper end of the metallic stent was grasped with a rigid optical alligator forceps and pulled in the lumen of rigid bronchoscope with continuous winding movements gradually separating the stent from the tracheal wall . immediately after that
this is one of the rare cases of successful removal of self expandable metallic airway covered stent in benign tracheal stenosis .
stenosis above the level of the stent granulation tissue inside the stent and at the margins fracture of stent at its lower end ( stent is seen at upper part of right main bronchus , carina is not visualized ) the stent after removal
the management of patients with tracheal / bronchial strictures of benign etiology can be quite challenging .
though surgical tracheal sleeve resection and reconstruction remains the gold standard for most benign airway strictures , non - surgical modalities such as laser photocoagulation and resection , balloon dilatation , electrocautery and stenting of the airway have been developed to deal with airway stenosis .
various inoperable benign airway disorders are considered for airway stenting , like post intubation tracheal stenosis , tracheal burn or trauma , tracheo - broncho - malacia and extrinsic compression of trachea . though silicone prostheses are considered to be first choice in benign diseases
their use is less suited , especially in airway wall malacia or distal and angular stenosis where sems are preferred .
the disadvantages of the silicone stents are high migration rate , small lumen to wall thickness ratio and difficulty in clearing the secretions . on the other hand
, the major drawback for placement of sems in benign situations is their difficult repositioning and removal in situations like excessive granulation tissue , stent fractures and stent migration .
the complications of stent removal include significant oozing , tracheal mucosal dehiscence , tracheal puncture requiring thoracotomy , retained stent pieces , need for restenting , respiratory failure , tracheotomy , and even death . in our case ,
various authors have come up with different methods of removal of the stent , like the technique of nashef et al . , which was similar to that of rolling spaghetti on a fork , but much more difficult and at least equally messy .
they further observed that there may be several fractures of the stent , which have to be removed piece by piece . in our case
filler et al . , used a metal suction catheter to dissect the stent from the airway wall before extraction with the forceps .
zakaluzny et al . , employed a rigid suspension laryngotracheoscope and used optical forceps to dissect the stent from the airway wall .
alligator forceps were then employed to grasp and extract the stent through the rigid scope while the scope was advanced further into the airway .
we first separated the stent from the tracheal wall and then removed all the works ( scope , forceps and the stent ) in one piece .
to conclude , this case is unique for many reasons , firstly , it had almost all of the complications that can be associated with stent placement ( stenosis of trachea at the upper end of the stent , extensive granuloma formation , migration of the stent downwards and fracture of the stent at its lower end ) , secondly , we were able to remove the stent in toto [ figure 5 ] and lastly , there were no complications after removal of the stent .
further studies are needed to re evaluate their removal successfully and safely and to produce better designed and technically superior stents like bio - absorbable stents which may not have to be removed at all .

Answer:
covered self expandable metallic airway stents ( sems ) have been used for benign tracheal stenosis , post intubation tracheal stenosis , tracheal burn or trauma , tracheo - broncho - malacia , and extrinsic compression of trachea .
 their placement is considered to be permanent , with open surgery the only way to remove the stent , though there are few cases reports of their removal with the bronchoscope , but the complications after their removal are very high . in our patient , one and a half years after placement of sems , she developed cough with dyspnoea , video bronchoscopy showed stenosis above the level of stent with granulation tissue inside the stent , stent fracture in lower part and stent migration to right main bronchus , thus she had all conceivable complications of stent placement .
 the stent was removed with the help of rigid bronchoscope under general anaesthesia .
 she was discharged the following day .
 the case is being reported because it was unique in having all the possible complications of stent placement , and rare as we could take out the stent in toto .
 thirdly , the stent could be removed without any complication .


Question:
You will be presented with the full text of a biomedical research paper. Please write an abstract for this paper. Your response should include the abstract and no additional text.

Paper text:
dipeptidyl peptidase4 ( dpp4 ) inhibitors improve glycemic control in patients with type 2 diabetes by preventing degradation of two incretin hormones , glucagonlike peptide1 ( glp1 ) and glucosedependent insulinotropic polypeptide ( gip ) , that are secreted from the intestine on ingestion of various nutrients .
recent studies have shown associations of dpp4 inhibitors efficacy with age and fasting plasma glucose levels , as well as baseline glycated hemoglobin ( hba1c ) and body mass index ( bmi ) , but clinical parameters that predict the efficacy of dpp4 inhibitors are largely unknown .
the present study showed that alterations in hba1c level on administration of dpp4 inhibitors as monotherapy are associated with estimated intake of fish , estimated intake of dietary n3 polyunsaturated fatty acid ( pufa ) , and serum levels of eicosapentaenoic acid ( epa ) and docosahexaenoic acid ( dha ) .
the protocol was approved by the ethics committee of kansai electric power hospital , and carried out in accordance with the principles of the declaration of helsinki . a total of 72 untreated japanese patients with type 2 diabetes ( the japan diabetes society criteria of 2010 ; age 64.6    11.3  years ; duration of diabetes 9.0   8.9  years ; baseline hba1c 7.2    0.7% ; bmi 24.5    4.3  kg / m ) who had been on diet and exercise therapies participated in the current study .
dpp4 inhibitors ( sitagliptin , alogliptin or vildagliptin ) were given for 4  months and no other antidiabetic drugs were used during the period .
a total of 59 patients received sitagliptin , 12 received alogliptin and one received vildagliptin .
hba1c levels were determined before the initiation of dpp4 inhibitors and 4  months after the initiation of dpp4 inhibitors , and were shown in national glycohemoglobin standardization program values , as recommended by the japan diabetes society . fasting serum levels of dha , epa and arachidonic acid ( aa ) were determined based on fatty acid composition of total lipids including phospholipids , triglycerides and cholesteryl esters in the serum of 20 patients ( age 63.1    11.7  years ; duration of diabetes 6.7    5.7  years ; baseline hba1c 7.0    0.8% ; bmi 24.2    3.1  kg / m ) before initiation of dpp4 inhibitors .
selfadministered 3day food records , which were recorded during the 4month period , were analyzed for estimated intake of various nutrients using healthy maker pro 501 ( mushroomsoft co. , ltd . ,
all statistical calculations were carried out using pasw statistics 18 ( sas institute inc . ,
cary , nc , usa ) , including linear regression analyses of the associations between changes in hba1c levels and various parameters .
multiple linear regression analyses were carried out to identify the parameters potentially associated with hba1c reduction , and simple regression analyses were carried out to evaluate their contributions .
in the present study , dpp4 inhibitors , similarly to previous reports , significantly reduced hba1c levels , but not bodyweight ( before initiation of dpp4 inhibitors 7.2    0.7% ; 4  months after initiation of dpp4 inhibitors 6.7    0.6% [ paired ttest , p  <  0.01 vs before ] ) .
multiple regression analysis of hba1c reduction ( hba1c ) taking into account sex , age , duration of diabetes , bmi , baseline hba1c and estimated intake of various food categories in 3day food records showed that hba1c was well correlated with baseline hba1c , but not with bmi ( table  1 ) .
hba1c also showed a significant association with estimated intake of fish and seafood in the food records ( figure  1a and table  1 ) . among fish and seafood , estimated intake of fish , but not shellfish and other seafood , showed a significant association with hba1c ( table  s1 ) .
the beneficial effects of fish on human health have been partly attributed to pufa , such as epa and dha .
hba1c was significantly correlated with estimated intake of epa and dha , along with baseline hba1c ( figure  1b and table  s2 ) . as
serum epa and dha levels might serve as markers for intake of corresponding fatty acids ( figure  s1 ) , we analyzed associations of hba1c with serum epa and dha levels .
serum levels of epa and dha , but not n6 pufa arachidonic acid , were well correlated with hba1c ( figure  1c ) .
although hba1c reduction showed a significant association with estimated intake of milk products ( table  1 ) , we were unable to find nutrients in milk products , including saturated fatty acids , that were responsible for the association .
multiple regression analysis regarding changes of glycated hemoglobin ( hba1c ) levels ( hba1c ) by taking into account sex , age , duration of diabetes , body mass index ( bmi ) , baseline hba1c ( national glycohemoglobin standardization program [ ngsp ] ) and estimated intake of various food categories in 3day food records in 72 patients with type 2 diabetes .
statistical calculation was carried out using pasw statistics 18 ( sas institute inc . ) .
b and  denote nonstandardized and standardized regression coefficients , respectively . for analysis of changes of hba1c levels ,
the correlation coefficient squared ( r ) was 0.550 and the fvalue with 15 degrees of freedom was 3.499 for a pvalue of 0.003 .
( a ) correlation between estimated intake of fish and seafood with glycated hemoglobin ( hba1c ) reduction ( national glycohemoglobin standardization program [ ngsp ] , % ) 4  months after initiation of dipeptidyl peptidase4 inhibitors ( hba1c ; n  =  72 ) .
( b ) correlation between estimated intake of eicosapentaenoic acid ( epa ) , docosahexaenoic ( dha ) with hba1c ( n  =  72 ) .
( c ) correlation between serum levels of epa , dha and arachidonic acid ( aa ) with hba1c ( n  =  20 ) .
linear regression analyses were carried out to calculate the correlation coefficient ( r ) and pvalues .
we find that changes of hba1c levels on administration of dpp4 inhibitors are associated with estimated intake of fish and estimated intake of dietary n3 pufa , as well as serum epa and dha levels . despite being a retrospective cohort study with a limited sample size ,
these findings are clinically important in two respects : ( i ) the efficacy of dpp4 inhibitors can be predicted by serum epa and dha levels ; and ( ii ) consuming more fish with diet therapy can enhance the efficacy of dpp4 inhibitors .
furthermore , the current findings suggest that the differing efficacies of dpp4 inhibitors found among different ethnicities might be partly a result of differences in fish consumption .
although many studies have shown the beneficial effects of dietary n3 pufa from fish , the mechanisms involving dietary n3 pufa in dpp4 inhibitor efficacy have not yet been investigated .
although epa and dha have been shown to prevent excessive adiposity , thereby ameliorating insulin resistance in animal models , the effects of n3 pufa on glycemic control in type 2 diabetes itself are somewhat controversial .
interestingly , it has been found that epa and dha enhance glp1 secretion , possibly through free fatty acid receptors , such as gpr120 , in glp1secreting cells and mice .
it is thus possible that dietary n3 pufa and dpp4 inhibitors synergistically increase biologicallyactive glp1 levels to facilitate maintenance of glycemic control , but it remains to be determined whether epa and dha enhance glp1 secretion in patients with type  2 diabetes . in addition , whether the present findings hold true for dpp4 inhibitors in general is not known , as most of the patients in the current study received sitagliptin or alogliptin , and vildagliptin patients were limited .
we find that the reduction of hba1c by dpp4 inhibitors significantly correlates with estimated intake of fish , estimated intake of epa and dha , and serum levels of epa and dha .
figure s1 correlation between estimated intakesand serum concentrations of eicosapentaenoic acid ( epa ) anddocosahexaenoic ( dha ; n  =  16 ) .
table s1 association of glycated hemoglobin(hba1c ) reduction and estimated intake of fish , shellfish and other seafood table s2 association of glycated hemoglobin(hba1c ) reduction and estimated intake ofpolyunsaturated fatty acids click here for additional data file .

Answer:
abstractthis study was initiated to identify clinical and dietary parameters that predict efficacy of dipeptidyl peptidase4 inhibitors .
 a total of 72 untreated japanese patients with type 2 diabetes who received dpp4 inhibitors ( sitagliptin , alogliptin or vildagliptin ) for 4  months were examined for changes of glycated hemoglobin ( hba1c ) and body mass index ( bmi ) , and selfadministered 3day food records , as well as serum levels of eicosapentaenoic acid ( epa ) and docosahexaenoic acid ( dha ) .
 dpp4 inhibitors significantly reduced hba1c ( before initiation of dpp4 inhibitors 7.2    0.7% , 4  months after initiation of dpp4 inhibitors 6.7    0.6% [ paired ttest , p  <  0.01 vs before ] ) .
 multiple regression analysis showed that changes of hba1c were significantly correlated with baseline hba1c , as well as estimated intake of fish .
 furthermore , changes of hba1c were significantly correlated with serum levels of epa ( r  =  0.624 , p  <  0.01 ) and dha ( r  =  0.577 , p  <  0.01 ) .
 hba1c reduction by dpp4 inhibitors is significantly correlated with estimated intake of fish and serum levels of epa and dha .
 ( j diabetes invest , doi : 10.1111/j.20401124.2012.00214.x , 2012 )