Influence of surgical insults for colorectal cancers on neuroendocrine and immune parameters

In surgery for colorectal cancer, a tendency of immune suppression was noted as seen in surgery for other types of gastro-intestinal cancer. This tendency was also found in the biological response, and it was related to the operative procedures and insults for rectal cancer. The degree of immunosuppression was milder in patients who underwent procedures that preserve the natural sphincter than in those who underwent colostomy. It is important for surgeons to avoid postoperative immunosuppression in order to prevent recurrence and improve prognosis. Given similar degrees of operative insult and stage of cancer, an operative procedure which causes as little immunosuppression as possible should be selected.

Proton magnetic resonance spectroscopy of the thalamus in patients with osteoarthritis of the hip

Objectives

The purpose of this study was to assess N-acetyl aspartate changes in the thalamus in patients with osteoarthritis of the hip using proton magnetic resonance spectroscopy.

Methods

Nine patients with osteoarthritis of the hip (symptomatic group, nine women; mean age 61.4 years (48 to 78)) and nine healthy volunteers (control group, six men, three women; mean age 30.0 years (26 to 38)) underwent proton magnetic resonance spectroscopy to assess the changes of N-acetyl aspartate in the thalamus.

Results

The ratio of N-acetyl aspartate to creatine plus phosphocreatine in the thalamus contralateral to the symptomatic hip in patients with osteoarthritis of the hip was significantly lower than the ratio of N-acetyl aspartate to creatine plus phosphocreatine in the thalamus in the control group (1.611 (range; 1.194-1.882) vs 1.355 (range; 1.043-1.502), p < 0.001). And, a strong negative correlation was detected between the ratio of N-acetyl aspartate to creatine plus phosphocreatine in the thalamus contralateral to the symptomatic hip in patients with osteoarthritis of the hip and pain duration (r = -0.83, p = 0.018).

Conclusions

We evaluated the ratio of N-acetyl aspartate to creatine plus phosphocreatine in the thalamus of patients with osteoarthritis of the hip by using proton magnetic resonance spectroscopy. We concluded that the ratio of N-acetyl aspartate to creatine plus phosphocreatine in the thalamus contralateral to the symptomatic hip in patients with osteoarthritis of the hip were significantly lower than those in the thalamus of the control group, and that pain duration was strongly related to the decrease of the ratio of N-acetyl aspartate to creatine plus phosphocreatine.

Proton magnetic resonance spectroscopy of the thalamus in patients with osteoarthritis of the hip

Objectives

The purpose of this study was to assess N-acetyl aspartate changes in the thalamus in patients with osteoarthritis of the hip using proton magnetic resonance spectroscopy.

Methods

Nine patients with osteoarthritis of the hip (symptomatic group, nine women; mean age 61.4 years (48 to 78)) and nine healthy volunteers (control group, six men, three women; mean age 30.0 years (26 to 38)) underwent proton magnetic resonance spectroscopy to assess the changes of N-acetyl aspartate in the thalamus.

Results

The ratio of N-acetyl aspartate to creatine plus phosphocreatine in the thalamus contralateral to the symptomatic hip in patients with osteoarthritis of the hip was significantly lower than the ratio of N-acetyl aspartate to creatine plus phosphocreatine in the thalamus in the control group (1.611 (1.194 to 1.882) vs 1.355 (1.043 to 1.502), p < 0.001). And, a strong negative correlation was detected between the ratio of N-acetyl aspartate to creatine plus phosphocreatine in the thalamus contralateral to the symptomatic hip in patients with osteoarthritis of the hip and pain duration (r = -0.83, p = 0.018).

Conclusions

We evaluated the ratio of N-acetyl aspartate to creatine plus phosphocreatine in the thalamus of patients with osteoarthritis of the hip by using proton magnetic resonance spectroscopy. We concluded that the ratio of N-acetyl aspartate to creatine plus phosphocreatine in the thalamus contralateral to the symptomatic hip in patients with osteoarthritis of the hip were significantly lower than those in the thalamus of the control group, and that pain duration was strongly related to the decrease of the ratio of N-acetyl aspartate to creatine plus phosphocreatine.

Recovery of the blood flow around the femoral head during early corticosteroid therapy: dynamic magnetic resonance imaging in systemic lupus erythematosus patients

Disturbance of blood supply to the femoral head is a risk factor for corticosteroid-associated osteonecrosis. The aim was to measure blood supply of the proximal femur during corticosteroid therapy in systemic lupus erythematosus (SLE) patients. We repeatedly performed 78 dynamic MRIs of 19 hip joints in 19 SLE patients after initiation of corticosteroid administration for one year. Blood supply of the femoral head (epiphysis, growth plate, and metaphysis), the femoral neck, and the medial circumflex femoral artery were measured in terms of peak percent enhancement. At the first month, blood supply of the growth plate was significantly higher in the pediatric group (<15 years old) than in the adolescent and adult group (>15 years old). At the fourth month, blood supply in every part of the femoral head (epiphysis, growth plate, and metaphysis) was significantly higher in the pediatric group than in the adolescent and adult group. Multiple regression analysis revealed that blood supply to the femoral head depended on the number of days after initiation of corticosteroid administration and the age at the time of dynamic MRI. Blood supply to the femoral head is abundant in pediatric patients and is a function of the number of days after initiation of corticosteroid administration.

Association of genetic variants for susceptibility to obesity with type 2 diabetes in Japanese individuals

AIMS/HYPOTHESIS

In populations of East Asian descent, we performed a replication study of loci previously identified in populations of European descent as being associated with obesity measures such as BMI and type 2 diabetes.

METHODS

We genotyped 14 single nucleotide polymorphisms (SNPs) from 13 candidate loci that had previously been identified by genome-wide association meta-analyses for obesity measures in Europeans. Genotyping was done in 18,264 participants from two general Japanese populations. For SNPs showing an obesity association in Japanese individuals, we further examined diabetes associations in up to 6,781 cases and 7,307 controls from a subset of the original, as well as from additional populations.

RESULTS

Significant obesity associations (p < 0.1 two-tailed, concordant direction with previous reports) were replicated for 11 SNPs from the following ten loci in Japanese participants: SEC16B, TMEM18, GNPDA2, BDNF, MTCH2, BCDIN3D-FAIM2, SH2B1-ATP2A1, FTO, MC4R and KCTD15. The strongest effect was observed at TMEM18 rs4854344 (p = 7.1 × 10(-7) for BMI). Among the 11 SNPs showing significant obesity association, six were also associated with diabetes (OR 1.05-1.17; p = 0.04-2.4 × 10(-7)) after adjustment for BMI in the Japanese. When meta-analysed with data from the previous reports, the BMI-adjusted diabetes association was found to be highly significant for the FTO locus in East Asians (OR 1.13; 95% CI 1.09-1.18; p = 7.8 × 10(-10)) with substantial inter-ethnic heterogeneity (p = 0.003).

CONCLUSIONS/INTERPRETATION

We confirmed that ten candidate loci are associated with obesity measures in the general Japanese populations. Six (of ten) loci exert diabetogenic effects in the Japanese, although relatively modest in size, and independently of increased adiposity.

Comparison of brain N-acetylaspartate levels and serum brain-derived neurotrophic factor (BDNF) levels between patients with first-episode schizophrenia psychosis and healthy controls

BACKGROUND

N-acetylaspartate (NAA) levels and serum brain-derived neurotrophic factor (BDNF) levels in patients with first-episode schizophrenia psychosis and age- and sex-matched healthy control subjects were investigated. In addition, plasma levels of homovanillic acid (HVA) and 3-methoxy-4-hydroxyphenylglycol (MHPG) were compared between the two groups.

METHOD

Eighteen patients (nine males, nine females; age range: 13-52 years) were enrolled in the study, and 18 volunteers (nine males, nine females; age range: 15-49 years) with no current or past psychiatric history were also studied by magnetic resonance spectroscopy (MRS) as sex- and age-matched controls.

RESULTS

Levels of NAA/Cr in the left basal ganglia (p=0.0065) and parieto-occipital lobe (p=0.00498), but not in the frontal lobe, were significantly lower in patients with first-episode schizophrenia psychosis than in control subjects. No difference was observed between the serum BDNF levels of patients with first-episode schizophrenia psychosis and control subjects. In regard to the plasma levels of catecholamine metabolites, plasma MHPG, but not HVA, was significantly lower in the patients with first-episode psychosis than in control subjects. In addition, a significantly positive correlation was observed between the levels of NAA/Cr of the left basal ganglia and plasma MHPG in all subjects.

CONCLUSION

These results suggest that brain NAA levels in the left basal ganglia and plasma MHPG levels were significantly reduced at the first episode of schizophrenia psychosis, indicating that neurodegeneration via noradrenergic neurons might be associated with the initial progression of the disease.

A Novel Prodrug of Salicylic Acid, Salicylic Acid-glycylglycine Conjugate, Utilizing the Hydrolysis in Rabbit Intestinal Microorganisms

The hydrolysis of salicylic acid-glycylglycine conjugate (salicyl-glycylglycine) following oral, intravenous, intracaecal and rectal administration (434, 72, 36 and 36 μmol kg−1, respectively: equivalent to salicylic acid) was examined in rabbits to develop a novel prodrug of salicylic acid. Salicylic acid was detected in the blood 2 h after oral administration of salicyl-glycylglycine and it reached a maximum level (55·6 μg mL−1) at 15 h, whereas a small amount of salicyl-glycylglycine was found in the blood. In contrast, unchanged salicyl-glycylglycine was found mainly in the blood following its intravenous administration, suggesting the involvement of presystemic deconjugation in the hydrolysis of salicyl-glycylglycine. Immediate and very extensive salicyclic acid formation in the caecum was observed following intracaecal administration of salicyl-glycylglycine, suggesting that the intestinal microorganisms were responsible for the biotransformation of this compound. In-vitro incubation of salicyl-glycylglycine with caecal content showed that salicyl-glycylglycine was hydrolysed efficiently in the caecum. Consequently, the blood concentration of salicylic acid was prolonged extensively following rectal administration of salicylglycylglycine, indicating the usefulness of salicyl-glycylglycine as a prodrug of salicylic acid.

Development of a Prodrug of Salicylic Acid, Salicylic Acid-l-alanine Conjugate, Utilizing Hydrolysis by Rabbit Intestinal Microorganisms

The hydrolysis of salicylic acid-l-alanine conjugate (salicyl-l-alanine) following oral, intravenous, intracaecal and rectal administration (60, 10, 5 and 5 mg kg−1, respectively: salicylic acid equivalent) was examined in rabbits. Salicylic acid was detected in the blood 2 h after oral administration of salicyl-l-alanine and reached a maximum concentration at 10 h, whereas salicyl-l-alanine was rapidly eliminated. In contrast, unchanged salicyl-l-alanine only was found following intravenous administration of salicyl-l-alanine, suggesting that presystemic de-conjugation of salicyl-l-alanine was involved. The intestinal mucosal de-conjugation of salicyl-l-alanine was not recognized in the in-situ intestinal sac preparation with complete mesenteric venous blood collection. Immediate and very extensive salicylic acid formation in the caecum was found following intracaecal administration of salicyl-l-alanine. After oral pretreatment of rabbits with kanamycin sulphate, a significant inhibition of salicylic acid formation following intracaecal administration of salicyl-l-alanine was observed, indicating that the intestinal microorganisms were responsible for the biotransformation of salicyl-l-alanine. In-vitro incubation of salicyl-l-alanine with gut contents showed that the major source of its hydrolysis was the hind gut. Consequently, the blood concentration of salicylic acid was prolonged extensively following rectal administration of salicyl-l-alanine, suggesting the usefulness of salicyl-l-alanine as a prodrug of salicylic acid.

Formaldehyde measurements in residential indoor air using a developed sensor element in the Kanto area of Japan

We undertook this to determine the formaldehyde concentration in Japanese houses and the relationship between formaldehyde levels and the age and temperature of a house using a sensor element that we developed for time-integrated measurements of formaldehyde concentration in actual environments. We evaluated the correlation between the formaldehyde concentration estimated by the dinitrophenylhydrazine (DNPH)-derivatization method and that obtained with our sensor element. We found a linear relationship between the two results indicating that reliable measurements can be performed using the developed sensor element in actual environments. The indoor concentration of formaldehyde was determined in a study of 34 homes in the Kanto area of Japan, between September 28 and October 27, 2007. We obtained the highest formaldehyde concentrations of 92 ± 15 μg/m(3) for apartments 0-2 years after their renovation, and a simple linear relationship was found between formaldehyde concentration and the age of the apartment. We also found that the formaldehyde concentration in a room containing furniture increased by 10% when the temperature increased by 1°C.

PRACTICAL IMPLICATIONS

This study contributed to the measurements of indoor formaldehyde levels. We have used a newly developed sensor for time-integrated measurements of formaldehyde concentrations. This sensor does not need a power supply during exposure to air, and does not need special skills to use. This research showed that homeowners successfully deployed the sensor at the desired place and desired period in their house by themselves. Formaldehyde is emitted by various off-gassing sources, such as furniture. Therefore, for example, homeowners may want to measure the change of formaldehyde levels in their house before and after installing new furniture. This sensor may also be deployed by occupants to reduce the cost of a large-scale exposure assessment study.

He/Ar-atom scattering from molecular monolayers: C60/Pt(111) and graphene/Pt(111)

Supersonic He and Ar atomic beam scattering from C(60) and graphene monolayers adsorbed on a Pt(111) surface are demonstrated in order to obtain detailed insight into a gas-molecule collision that has not been studied in detail so far. The effective masses and phonon spectral densities of the monolayers seen by different projectiles are discussed based on classical models such as the hard cube model and the recently developed smooth surface model. Large effective masses are deduced for both the monolayers, suggesting collective effects of surface atoms in the single collision event. The effective Debye temperature of graphene was found to be similar to that reported in highly oriented pyrolytic graphite (HOPG), indicating that the graphene is decoupled well from the Pt substrate. A much smaller Debye-Waller factor was found for the C(60) layer, probably reflecting the strong C(60)-Pt(111) interaction.

Spontaneous repair of asymptomatic osteonecrosis associated with corticosteroid therapy in systemic lupus erythematosus: 10-year minimum follow-up with MRI

Systemic lupus erythematosus (SLE) patients are at high risk of developing osteonecrosis. This study utilized MRI to document the long-term natural history of asymptomatic osteonecrosis associated with corticosteroid therapy in SLE patients. Two hundred and one SLE patients treated with high-dose corticosteroids were prospectively observed from 1986 to 1997. The inclusion criterion was that patients had received periodic MRI examinations of all their hip and knee joints for ≥10 years. Joints that were already collapsed and symptomatic at the first examination were excluded. Five hundred and thirty-seven joints (251 hips and 286 knees) were identified in 144 patients, with a mean follow-up period of 13.6 years (range, 10—20 years) and a follow-up rate of 73%. Mean age of SLE onset was 26 years, and the mean highest oral corticosteroid dosage was 57 mg/day. Osteonecrosis developed in 238 (44%) of 537 joints. At final follow-up, 117 (49%) of these 238 joints demonstrated spontaneous repair in the necrotic area. Osteonecrosis completely disappeared in 21 joints. Enlargement of osteonecrosis was noted in 35 joints (15%) following increased steroid dosage because of SLE recurrence. Finally, 52 joints (22%) were collapsed. Spontaneous repair of asymptomatic osteonecrosis was observed, whereas enlargement occurred only after corticosteroid dosage increases. Lupus (2010) 19, 1307—1314.

A proposed model for an optimal mentoring environment for medical residents: a literature review

PURPOSE

To develop a model of the optimal mentoring environment for medical residents. The authors propose that such an environment is a function of a relationship that rests upon a set of interactional foundations that allow a protégé to capitalize on the strengths of the mentor, and it facilitates behaviors that will enable the protégé to develop and internalize the requisite knowledge, skills, and attitudes (KSAs) as fully as possible.

METHOD

The authors searched the literature using Web of Science and Google Scholar in 2007-2008 to identify articles addressing the mentoring process and the context in which it occurs (mentoring environment), and the effect both have on KSA development. The authors distilled the attributes of a good mentor that were consistent across the 20 papers that met inclusion criteria and described good mentoring of residents or curricula for training mentors or residents.

RESULTS

The authors identified six interactional foundations that underlie the optimal mentoring relationship: emotional safety, support, protégé-centeredness, informality, responsiveness, and respect. These foundations enable protégés to engage in four key developmental behaviors: exercising independence, reflecting, extrapolating, and synthesizing.

CONCLUSIONS

This model identifies mentoring practices that empower protégés to engage in developmental behaviors that will help them become the best physicians possible. Educators may use this model to develop training tools to teach attendings how to create an optimal mentoring environment. Researchers can use the model to help guide their future investigations of mentoring in medicine.

Intramammary challenge of lipopolysaccharide stimulates secretion of lingual antimicrobial peptide into milk of dairy cows

Lingual antimicrobial peptide (LAP) belongs to the beta-defensin family in cattle and is found in bovine milk. However, it is unclear whether LAP is involved in the early immune response to mammary infection. The aim of the study was to investigate the changes of LAP concentration in milk after intramammary challenge with lipopolysaccharide (LPS), the gram-negative bacteria cell membrane component, in dairy cows. Milk was collected before and after LPS or phosphate-buffered saline (control) challenge every hour for 12 h on d 0 and twice daily from d 1 to 7. Somatic cell count (SCC), LAP concentration, and lactoperoxidase (LPO) activity in the milk were measured. Somatic cell count started to increase at 2 h postchallenge and remained high until d 5 (694 +/- 187 x 10(3 )to >1,000 +/- 0 x 10(3) cells/mL at d 0; >1,000 +/- 0 x 10(3) cells/mL at d 1 to 3; 684 +/- 194 x 10(3 )to 829 +/- 108 x 10(3 )cells/mL at d 4; 527 +/- 197 x 10(3 )to 656 +/- 145 x 10(3 )cells/mL at d 5). Somatic cell count increased in the control cows, although the levels were lower compared with those in the LPS challenge group. The LAP concentration in milk increased significantly at 2 h post-LPS-challenge and was maintained at high levels until d 2 (8.6 +/- 0.6 to 17.5 +/- 2.3 nM). In the control cow infused with phosphate-buffered saline, there was no increase of LAP concentration in milk (5.1 +/- 0.6 to 7.2 +/- 0.8 nM). Increase of LPO activity in the milk was observed at 6 h after LPS challenge and continued until d 3 (4.7 +/- 0.3 to 9.4 +/- 1.1 U). No increase of LPO activity was observed in the milk of control cows. The increase and subsequent decrease in LAP concentration after LPS challenge occurred earlier than those of LPO activity. In multiparous cows with LPS infusion, there was a significantly negative relationship between the days leading to the basal levels in LAP concentration and LPO activity (r = -0.75). These results suggest that LPS induces secretion of LAP into milk within hours and that LPO may have a synergistic antimicrobial function with LAP in mammary glands of dairy cows.

Development of new osteonecrosis in systemic lupus erythematosus patients in association with long-term corticosteroid therapy after disease recurrence

OBJECTIVES

Systemic lupus erythematosus (SLE) patients are at high risk of developing osteonecrosis, as they require corticosteroid therapy for life. The purpose of this study was to use periodic MRI analysis to clarify (1) the incidence of new osteonecrosis associated with long-term corticosteroid therapy in SLE patients, and (2) the risk factors for delayed osteonecrosis in SLE patients.

METHODS

We prospectively studied 291 joints (134 hips and 157 knees) in 106 SLE patients without osteonecrosis after initial corticosteroid therapy, with a mean follow-up period of 13.6 years and a follow-up rate of 71%. All patients had undergone periodic MRI examination of the hip and knee joints for >10 years.

RESULTS

New osteonecrosis developed in 6 joints (3%) and only occurred after SLE recurrence in association with increased corticosteroid doses (to>30 mg/day [p=0.008]). New lesions were delayed for a mean 5.9 years after initial corticosteroid administration. The mean time from SLE recurrence to appearance of new lesions was 6.2 months. SLE recurrence occurred in 131 joints (45%), while SLE was well controlled in 160 joints (55%).

CONCLUSIONS

We suggest that with respect to long-term effects, total cumulative dose and duration of corticosteroid therapy do not contribute to osteonecrosis. However, SLE recurrence is a risk factor for new osteonecrosis. We recommend MRI screening for osteonecrosis at SLE recurrence.

Radiosurgery for arteriovenous malformations with gamma-knife: a multivariate analysis of factors influencing the complete obliteration rate

Seventy-two patients with arteriovenous malformations (AVMs) were treated with gamma-knife and subsequently analyzed to determine what factors influenced the obliteration of AVMs. The volume of nidi ranged from 0.3 to 21.7 ml (mean 3.9 ml) and the marginal dose ranged from 9 to 31.5 Gy (mean 21.4 Gy). The cumulative obliteration rates of all cases were 41% at 2 years, 67% at 3 years, and 89% at 4 years. Multivariate analysis demonstrated that only the two variables of flow rate (P = 0.020) and dose planning with axial MRI (P = 0.045) had correlation with the obliteration rate. Other variables such as size, marginal dose, and embolization had no statistical correlation with the obliteration rate. It may be very important to evaluate the AVM flow rate to predict the effect of gamma-knife radiosurgery on AVMs, even when the nidi volumes are small.

Stratified analyses for selecting appropriate target patients with diabetic peripheral neuropathy for long-term treatment with an aldose reductase inhibitor, epalrestat

AIMS

The long-term efficacy of epalrestat, an aldose reductase inhibitor, in improving subjective symptoms and nerve function was comprehensively assessed to identify patients with diabetic peripheral neuropathy who responded to epalrestat treatment.

METHODS

Stratified analyses were conducted on data from patients in the Aldose Reductase Inhibitor-Diabetes Complications Trial (ADCT). The ADCT included patients with diabetic peripheral neuropathy, median motor nerve conduction velocity > or = 40 m/s and with glycated haemoglobin (HbA(1c)) < or = 9.0%. Longitudinal data on HbA(1c) and subjective symptoms of the patients for 3 years were analysed (epalrestat n = 231, control subjects n = 273). Stratified analyses based on background variables (glycaemic control, grades of retinopathy or proteinuria) were performed to examine the relationship between subjective symptoms and nerve function. Multiple logistic regression analyses were conducted.

RESULTS

Stratified subgroup analyses revealed significantly better efficacy of epalrestat in patients with good glycaemic control and less severe diabetic complications. In the control group, no improvement in nerve function was seen regardless of whether symptomatic benefit was obtained. In the epalrestat group, nerve function deteriorated less or improved in patients whose symptoms improved. The odds ratio of the efficacy of epalrestat vs. control subjects was approximately 2 : 1 (4 : 1 in patients with HbA(1c) < or = 7.0%).

CONCLUSION

Our results suggest that epalrestat, an aldose reductase inhibitor, will provide a clinically significant means of preventing and treating diabetic neuropathy if used in appropriate patients.

The characteristics of dorsal-root ganglia and sensory innervation of the hip in rats

Using a rat model the characteristics of the sensory neurones of the dorsal-root ganglia (DRG) innervating the hip were investigated by retrograde neurotransport and immunohistochemistry. Fluoro-Gold solution (FG) was injected into the left hip of ten rats. Seven days later the DRG from both sides between T12 and L6 were harvested. The number of FG-labelled calcitonin gene-related peptide-immunoreactive or isolectin B4-binding neurones were counted. The FG-labelled neurones were distributed throughout the left DRGs between T13 and L5, primarily at L2, L3, and L4. Few FG-labelled isolectin B4-binding neurones were present in the DRGs of either side between T13 and L5, but calcitonin gene-related peptide-immunoreactive neurones made up 30% of all FG-labelled neurones. Our findings may explain the referral of pain from the hip to the thigh or lower leg corresponding to the L2, L3 and L4 levels. Since most neurones are calcitonin gene-related peptide-immunoreactive peptide-containing neurones, they may have a more significant role in the perception of pain in the hip as peptidergic DRG neurones.

Economic impact of extended treatment with peginterferon alpha-2a and ribavirin for slow hepatitis C virologic responders

It is difficult to achieve a sustained virologic response from antiviral therapy for genotype 1 hepatitis C virus-infected patients without a sufficient virologic response in the early weeks after treatment. However, a recent study has reported on the effectiveness of an extended course of treatment with peginterferon alpha-2a plus ribavirin for slow virologic responders. The aim of this study was to evaluate the economic impact of an extended course of treatment. A Markov cohort model of hepatitis C was designed in order to demonstrate the clinical states, based on the assigned transition probabilities over 30 years. The slow virologic responders treated with an extended 72-week course of therapy could increase by 0.55 the quality-adjusted life years (=15.35-14.80) and reduce the lifetime cost by $2762 (=71 559-69 438) in comparison with those treated by the standard 48-week course. One-way sensitivity analyses did not change the cost-effectiveness. Therefore, the extended 72 weeks of treatment with peginterferon alpha-2a plus ribavirin for slow virologic responders could be cost-effective in comparison with the standard 48 weeks of treatment.