Studies on leptospirosis : clinical aspects and pathophysiology - Chapter 5: Bleeding in patients with severe leptospirosis is not associated with activation of endothelial cells.

UvA-DARE is a service provided by the library of the University of Amsterdam (https://dare.uva.nl)

UvA-DARE (Digital Academic Repository)

Studies on leptospirosis : clinical aspects and pathophysiology

Wagenaar, J.F.P.

Publication date

2010

Link to publication

Citation for published version (APA):

Wagenaar, J. F. P. (2010). Studies on leptospirosis : clinical aspects and pathophysiology.

General rights

It is not permitted to download or to forward/distribute the text or part of it without the consent of the author(s) and/or copyright holder(s), other than for strictly personal, individual use, unless the work is under an open content license (like Creative Commons).

Disclaimer/Complaints regulations

If you believe that digital publication of certain material infringes any of your rights or (privacy) interests, please let the Library know, stating your reasons. In case of a legitimate complaint, the Library will make the material inaccessible and/or remove it from the website. Please Ask the Library: https://uba.uva.nl/en/contact, or a letter to: Library of the University of Amsterdam, Secretariat, Singel 425, 1012 WP Amsterdam, The Netherlands. You will be contacted as soon as possible.

%OHHGLQJLQSDWLHQWVZLWKVHYHUHOHSWRVSLURVLV

LVQRWDVVRFLDWHGZLWKDFWLYDWLRQRIHQGRWKHOLDO

FHOOV

-)3:DJHQDDU_{0+*DVHP}_{-&00HLMHUV}_{(&0YDQ*RUS}_DQG'30

%UDQGMHV _{'HSDUWPHQWRI,QWHUQDOPHGLFLQH6ORWHUYDDUW+RVSLWDO$PVWHUGDPWKH1HWKHUODQGV} _{'HSDUWPHQWRI,QWHUQDOPHGLFLQH'U.DULDGLKRVSLWDO'LSRQHJRUR8QLYHUVLW\} 6HPDUDQJ,QGRQHVLD _{'HSWV9DVFXODU0HGLFLQHDQG([SHULPHQWDO9DVFXODU0HGLFLQH$FDGHPLF0HGLFDO&HQWHU} 8QLYHUVLW\RI$PVWHUGDP$PVWHUGDPWKH1HWKHUODQGV _{'HSDUWPHQWRIYLURORJ\(UDVPXV8QLYHUVLW\5RWWHUGDPWKH1HWKHUODQGV} 6XEPLWWHG



&+$37(5

&KDSWHU



2EMHFWLYHV 7R LQYHVWLJDWH HQGRWKHOLDO FHOO LQYROYHPHQW LQ UHODWLRQ WR EOHHGLQJ

PDQLIHVWDWLRQVLQSDWLHQWVZLWKVHYHUHOHSWRVSLURVLVE\VWXG\LQJWKHG\QDPLFVRIWKH HQGRWKHOLDOFHOOVSHFLÀFPDUNHUVVROXEOH(VHOHFWLQV(VHOHFWLQDQGYRQ:LOOHEUDQG IDFWRUY:)

0HWKRGV &DVHV RI VHYHUH OHSWRVSLURVLV ZHUH LQFOXGHG LQ WKH 'U .DULDGL KRVSLWDO

6HPDUDQJ,QGRQHVLD%ORRGZDVWDNHQRQDGPLVVLRQDQGGXULQJIROORZXS7ZHQW\ KHDOWK\VXEMHFWVVHUYHGDVFRQWUROV 5HVXOWVSDWLHQWVZHUHLQFOXGHGRIZKLFKPDOHV7KHPHGLDQDJHZDV ,45\HDUV,QWRWDOSDWLHQWVGLGQRWVXUYLYH7KHPHDQV(VHOHFWLQ QJPO6'DQGY:)PHDQ6'OHYHOVZHUHVWURQJO\HOHYDWHGRQ DGPLVVLRQFRPSDUHGWRWKHFRQWUROVV(VHOHFWLQQJPOSY:)S %RWKPDUNHUVGHFUHDVHGGXULQJIROORZXSEXWGLGQRWUHDFKQRUPDOYDOXHV ,Q D VXEJURXS DQDO\VLV EHWZHHQ SDWLHQWV ZLWK EOHHGLQJ Q  DQG WKRVH ZLWKRXW EOHHGLQJ Q  V(VHOHFWLQ  QJPO YV  QJPO DQG Y:)  YV  OHYHOVZHUHQRWVLJQLÀFDQWO\GLIIHUHQW7KHUHZDVQRVWDWLVWLFDOGLIIHUHQFHLQERWK V(VHOHFWLQQJPOYVQJPORUY:)YVSODVPDFRQFHQWUDWLRQV EHWZHHQSDWLHQWVWKDWVXUYLYHGDQGWKRVHWKDWZHQWRQWRGLH &RQFOXVLRQ0DUNHUVRIHQGRWKHOLDOFHOODFWLYDWLRQDUHVWURQJO\HOHYDWHGLQSDWLHQWV VXIIHULQJIURPVHYHUHOHSWRVSLURVLVUHJDUGOHVVRIEOHHGLQJPDQLIHVWDWLRQVRURXWFRPH



$%675$&7

/HSWRVSLURVLVDQGHQGRWKHOLXP



/HSWRVSLURVLVLVDQLQIHFWLRXVGLVHDVHRIJOREDOLPSRUWDQFH7KHGLVHDVHLVFDXVHG E\VSLURFKHWHVWKDWDUHVSUHDGE\WKHXULQHRILQIHFWHGDQLPDOV0XFRXVPHPEUDQHV VPDOO FXWV DQG DEUDGHG VNLQ DUH WKH XVXDO SRUWV RI HQWUpH$OWKRXJK WKH FOLQLFDO FRXUVHYDULHVZLGHO\OHSWRVSLURVLVFDQEHIDWDOLQXSWRRIDOOFDVHV7KHPRUH FRPPRQPLOGIRUPRIOHSWRVSLURVLVLVFKDUDFWHUL]HGE\QRQVSHFLÀFV\PSWRPVVXFKDV DFXWHIHYHUKHDGDFKHFKLOOVDQGP\DOJLD,QWKHVHYHUHVWIRUPVWKHFOLQLFDOSLFWXUH RIOHSWRVSLURVLVHQFRPSDVVHVMDXQGLFHUHQDOIDLOXUHDQGDSSDUHQWKHPRUUKDJLQJRI VNLQ PXFRXV PHPEUDQHV DQGRU OXQJV 3DWKRORJLFDO ÀQGLQJV FRQÀUP ZLGHVSUHDG KHPRUUKDJLQJDQGHQGRWKHOLDOFHOOGDPDJHWKURXJKRXWWKHERG\DVDFOLQLFDOKDOOPDUN 

$OWKRXJKWKHSDWKRSK\VLRORJ\RIWKHKHPRUUKDJLFGLDWKHVLVLQOHSWRVSLURVLVLVXQFOHDU EOHHGLQJ PLJKW EH WKH UHVXOW RI HQGRWKHOLDO G\VIXQFWLRQ  8QGHU SK\VLRORJLFDO FRQGLWLRQV WKH YDVFXODU HQGRWKHOLXP LQKLELWV FRDJXODWLRQ SUHYHQWV SODWHOHW DJJUHJDWLRQ DQG GXH WR ORZ OHYHOV RI H[SUHVVHG DGKHVLRQ PROHFXOHV LW SUHFOXGHV DGKHUHQFHDQGPLJUDWLRQRIOHXFRF\WHV,QMXU\RUDFWLYDWLRQRIHQGRWKHOLDOFHOOVLQ UHVSRQVHWRSDWKRJHQVRULQÁDPPDWRU\F\WRNLQHVFDQFDXVHEOHHGLQJGXHWRORVVRI LQWHJULW\RIWKHEORRGYHVVHORUFRQVXPSWLRQFRDJXORSDWK\ &XUUHQWO\VHYHUDOELRPDUNHUVDUHDYDLODEOHWKDWDUHWKRXJKWWREHDJRRGUHÁHFWLRQ RIHQGRWKHOLDOFHOODFWLYDWLRQDQGGDPDJH(VHOHFWLQ(/$0LVVXFKDPROHFXOH DVLWLVH[FOXVLYHO\H[SUHVVHGRQHQGRWKHOLDOFHOOV([SRVXUHRIHQGRWKHOLDOFHOOV WRHQGRWR[LQRUSURLQÁDPPDWRU\F\WRNLQHVOHDGVWRDPDVVLYHLQFUHDVHRI(VHOHFWLQ VXUIDFHH[SUHVVLRQ$QLPSRUWDQWIXQFWLRQRI(VHOHFWLQLVSURPRWLQJQHXWURSKLO DWWDFKPHQWWRWKHHQGRWKHOLDOFHOOVXUIDFH([SUHVVLRQRI(VHOHFWLQUHTXLUHVGHQRYR SURWHLQV\QWKHVLV+HQFHPD[LPDOH[SUHVVLRQLVUHDFKHGDIWHUVHYHUDOKRXUV

9RQ :LOOHEUDQG IDFWRU DQRWKHU PDUNHU RI HQGRWKHOLDO FHOO LQYROYHPHQW LV D ODUJH JO\FRSURWHLQV\QWKHVL]HGLQWKHYDVFXODUHQGRWKHOLXP(QGRWKHOLDOFHOOVVWRUHY:)LQ WKH:HLEHO3DODGHERGLHVLQWKHIRUPRIXQXVXDOO\ODUJHY:)PXOWLPHUV7KHIXQFWLRQ RI Y:) FRPSULVHV DGKHVLRQ RI SODWHOHWV WR H[SRVHG VXEHQGRWKHOLXP DQG SODWHOHW DJJUHJDWLRQIRUPLQJWKHEDVLVIRUWKHKHPRVWDWLFSOXJ+HQFHORZSODVPDOHYHOVRI Y:)FDQFDXVHEOHHGLQJ,QDGGLWLRQWRLWVIXQFWLRQY:)ELQGVDQGFDUULHVIDFWRU9,,, SURWHFWLQJLWIURPUDSLGUHPRYDOIURPWKHFLUFXODWLRQ

&KDSWHU  7KHDLPRIWKLVZRUNZDVWRLQYHVWLJDWHHQGRWKHOLDOFHOOG\VIXQFWLRQLQUHODWLRQWR EOHHGLQJLQSDWLHQWVVXIIHULQJIURPVHYHUHOHSWRVSLURVLVXVLQJWZRHQGRWKHOLDOVSHFLÀF PDUNHUVV(VHOHFWLQDQGY:) 3DWLHQWVDQGFRQWUROV

&RQVHFXWLYH FDVHV RI VHYHUH OHSWRVSLURVLV ZHUH LQFOXGHG IURP )HEUXDU\  WLOO 6HSWHPEHUDWWKH'U.DULDGLKRVSLWDO6HPDUDQJ,QGRQHVLD6HYHUHOHSWRVSLURVLV ZDVGHÀQHGDVKRVSLWDOL]HGSDWLHQWVZLWKDKLJKFOLQLFDOVXVSLFLRQRIOHSWRVSLURVLV SUHVHQWLQJ ZLWK DW OHDVW RQH RI WKH IROORZLQJ V\PSWRPV RU VLJQV MDXQGLFH UHQDO IDLOXUH WKURPERF\WRSHQLD DQGRU EOHHGLQJ DQG D SRVLWLYH /HSWR7HN 'UL'RW DVVD\ %LRPpULHX[ :H GHÀQHG EOHHGLQJ DV WKH VSRQWDQHRXV RFFXUUHQFH RI SHWHFKLDH HFFK\PRVHV HSLVWD[LV JXP EOHHGLQJ KDHPDWXULD PHODHQD KDHPDWHPHVLV KDHPRSW\VLVDQGRURWKHU6HSVLVZDVGHÀQHGXVLQJVWDQGDUGVHSVLVFULWHULD7KLV ZDVDVWDWLFFODVVLÀFDWLRQVFRUHGRQDGPLVVLRQSURJUHVVLRQIURPHJVHSVLVWRVHYHUH VHSVLVZLWKLQGD\VZDVQRWWDNHQLQWRDFFRXQW$IWHUZULWWHQLQIRUPHGFRQVHQWZDV JLYHQEORRGVDPSOHVZHUHWDNHQRQDGPLVVLRQDQGGXULQJIROORZXSDWGD\ DQG&LWUDWHGEORRGZDVZRUNHGXSLPPHGLDWHO\DQGDOLTXRWVZHUHVWRUHGDWƒ& XQWLOIXUWKHUDQDO\VHV$VFRQWUROVKHDOWK\,QGRQHVLDQYROXQWHHUVZHUHWHVWHG7KH PHGLFDOHWKLFVFRPPLWWHHVRIWKH'U.DULDGLKRVSLWDODQGWKH6ORWHUYDDUWKRVSLWDO ERWKDSSURYHGWKHVWXG\SURWRFRO 0HDVXUHPHQWVDQG$VVD\V

&OLQLFDO GLDJQRVLV RI OHSWRVSLURVLV ZDV FRQÀUPHG E\ WKH PLFURVFRSLF DJJOXWLQDWLRQ WHVW0$7)RUWKH0$7DSDQHORIVHURYDUVZDVXVHGSDWKRJHQLFVHURYDUVDQG QRQSDWKRJHQLFVHURYDUV$WLWUHRI•RQDVLQJOHVDPSOHVHURFRQYHUVLRQRUD IRXUIROGRUKLJKHULQFUHDVHRIWKHWLWUHLQSDLUHGVDPSOHVRUDWLWUH•LQDVLQJOH VDPSOHIURPHDUO\GHFHDVHGSDWLHQWVZHUHFRQVLGHUHGWREHSRVLWLYH %RWKHQGRWKHOLDOPDUNHUVV(VHOHFWLQ5 '6\VWHPV0LQQHDSROLV0186$DQGY:) DQWLERGLHVIURP'DNR*ORVWUXS'HQPDUNZHUHGHWHUPLQHGE\(/,6$

0$7(5,$/6$1'0(7+2'6

/HSWRVSLURVLVDQGHQGRWKHOLXP



6WDWLVWLFDODQDO\VLV

3DWLHQW FKDUDFWHULVWLFV DUH SUHVHQWHG DV PHGLDQV ZLWK FRUUHVSRQGLQJ LQWHUTXDUWLOH UDQJHV,45PHDQVZLWKVWDQGDUGGHYLDWLRQVRUDVQXPEHUVZLWKSHUFHQWDJHVZKHQ DSSURSULDWH &RQWLQXRXV YDULDEOHV ZHUH VWDWLVWLFDOO\ HYDOXDWHG XVLQJ WKH 6WXGHQWV WWHVWRUDQDO\VHVRIYDULDQFHRQHZD\$129$$VVRFLDWLRQVZHUHH[SUHVVHGDVRGGV UDWLRV25DQGLQFDVHRIGLFKRWRPRXVGDWDFDOFXODWHGE\FURVVWDEXODWLRQ$OOWHVW ZHUHWDLOHGZLWKWKHαVHWWR$OODQDO\VHVZHUHGRQHXVLQJ6366YHUVLRQ &KLFDJR,OOLQRLV 3DWLHQWV )LIW\WZRSDWLHQWVZHUHLQFOXGHGLQWKHVWXG\RIZKLFKPDOHV7KHPHGLDQ DJHZDV,45\HDUV)RXUWHHQSDWLHQWVGLHGGXULQJDGPLVVLRQ7KH PHGLDQ WLPH IURP DGPLVVLRQ WR GHDWK ZDV  GD\V %OHHGLQJ ZDV DSSDUHQW LQ   VXEMHFWV RI WKHVH  VXUYLYHG DQG  GLHG GLIIHUHQFH QRW VLJQLÀFDQW :H UHFRJQL]HGSHWHFKLDHQ HFFK\PRVHVQ HSLVWD[LVQ PHODHQDQ  KDHPDWHPHVLVQ DQGKDHPDWXULDQ 2QDGPLVVLRQSDWLHQWVZHUHVWUDWLÀHG DVQRQVHSWLFDVVHSWLFDQGDVVHYHUHVHSWLF6WDWLVWLFDOO\EOHHGLQJZDVHTXDOO\ GLVWULEXWHG DPRQJ WKH QRQVHSWLF VHSWLF DQG VHYHUH VHSWLF SDWLHQWV 7KH PHGLDQ SODVPD FUHDWLQLQH DQG ELOLUXELQ OHYHOV ZHUH  PJGO ,45  DQG  PJ GO,45UHVSHFWLYHO\/LYHUHQ]\PHVZHUHRQO\PLOGO\HOHYDWHG$6$78O $/$78O7KURPERF\WRSHQLDSODWHOHWV”[_{/ZDVUHFRJQL]HGLQ} VXEMHFWV 6ROXEOH(VHOHFWLQDQGY:)DUHQRWDVVRFLDWHGZLWKEOHHGLQJ 6ROXEOH(VHOHFWLQPHDQQJPO6'DQGY:)PHDQ6'OHYHOV LQVHYHUHOHSWRVSLURVLVSDWLHQWVZHUHVWURQJO\HOHYDWHGRQDGPLVVLRQ7KHFRQWUROV GLVSOD\HGVLJQLÀFDQWORZHUPHDQYDOXHVV(VHOHFWLQQJPO6'DQGY:) 6'RQDOOWLPHSRLQWVÀJXUH%RWKHQGRWKHOLDOPDUNHUVGHFUHDVHGJUDGXDOO\ GXULQJ IROORZ XS EXW GLG QRW UHDFK QRUPDO YDOXHV RQ GD\  RI IROORZ XS :KHQ

5(68/76

&KDSWHU



FRPSDULQJ WKH VXEJURXS RI SDWLHQWV ZLWK Q  DQG ZLWKRXW Q  KHPRUUKDJLF PDQLIHVWDWLRQVRQDGPLVVLRQQRVLJQLÀFDQWGLIIHUHQFHZDVREVHUYHGLQV(VHOHFWLQ QJPOYVQJPOS RUY:)YVS OHYHOVVHHÀJXUH $% )LJXUH$3ODVPDOHYHOVRIVROXEOH(VHOHFWLQLQSDWLHQWVZLWKVHYHUHOHSWRVSLURVLVRYHUWLPH )LJXUH%3ODVPDOHYHOVRIY:)LQSDWLHQWVZLWKVHYHUHOHSWRVSLURVLVRYHUWLPH 6ROXEOH(VHOHFWLQDQGY:)SODVPDOHYHOVRYHUWLPHLQSDWLHQWVVXIIHULQJIURPVHYHUHOHSWRVSLURVLV Q 5HVXOWVDUHSUHVHQWHGDVPHDQVZLWKHUURUEDUVLQGLFDWLQJWKHVWDQGDUGHUURURIWKH PHDQ7KHYDOXHVGHQRWHGLQWKHEDUVLQGLFDWHWKHQXPEHURIDYDLODEOHVDPSOHV SYDOXH VLJQLÀFDQWGLIIHUHQFHIURPFRQWUROV      &RQWUROV     

/HSWRVSLURVLVDQGHQGRWKHOLXP



)LJXUH$%6ROXEOH(VHOHFWLQDQGY:)SODVPDOHYHOVLQOHSWRVSLURVLVSDWLHQWVZLWKDQG ZLWKRXWKDHPRUUKDJLFPDQLIHVWDWLRQV

6FDWWHU SORWV VKRZ SODVPD OHYHOV V(VHOHFWLQ DQG Y:) LQ OHSWRVSLURVLV SDWLHQWV ZLWK % DQG ZLWKRXWQ%EOHHGLQJPDQLIHVWDWLRQVRQDGPLVVLRQ+RUL]RQWDOOLQHLQGLFDWHVWKHPHDQ (QGRWKHOLDOFHOOPDUNHUVDUHQRWDVVRFLDWHGZLWKPRUWDOLW\DQGGLVHDVHVHYHULW\ 1H[WZHDQDO\]HGWKHVXEJURXSVXUYLYRUVDQGQRQVXUYLYRUV7KHPHDQFRQFHQWUDWLRQ FLUFXODWLQJV(VHOHFWLQLQWKHVXUYLYRUVZDVQJPO6'DQGLQWKHQRQVXUYLYRUV QJPO6'3ODVPDOHYHOVY:)ZHUHLQWKHVXUYLYRUV6'DQGLQQRQ VXUYLYRUV6'1RVLJQLÀFDQWGLIIHUHQFHLQV(VHOHFWLQRUY:)OHYHOVEHWZHHQ WKHVHJURXSVZDVIRXQG7KHFRQWUROVVKRZHGVLJQLÀFDQWORZHUV(VHOHFWLQPHDQ QJPO6'SDQGY:)PHDQ6'SOHYHOVFRPSDUHGWR ERWKVXUYLYRUVDQGGHFHDVHG,QUHJDUGWRGLVHDVHVHYHULW\ZHFRPSDUHGQRQVHSWLF VHSWLFDQGVHYHUHVHSWLFSDWLHQWVRQDGPLVVLRQ0HDQV(VHOHFWLQOHYHOVZHUHQJ PO6'QJPO6'DQGQJPO6'UHVSHFWLYHO\0HDQY:)OHYHOV ZHUH6'6'DQG6'7KHGLIIHUHQFHVEHWZHHQ QRQVHSWLFVHSWLFDQGVHYHUHVHSWLFSDWLHQWVZHUHQRWVLJQLÀFDQW % _Q%      V( 6 HO HFW LQ Q J P O % _Q%      Y: ) DQ WLJ HQ  

&KDSWHU



7KLVVWXG\LQYHVWLJDWHGWKHSDWWHUQVRIWKHHQGRWKHOLDOVSHFLÀFPDUNHUVV(VHOHFWLQ DQG Y:) LQ UHODWLRQ WR EOHHGLQJ LQ SDWLHQWV ZLWK VHYHUH OHSWRVSLURVLV &OHDUO\ V( VHOHFWLQ DQG Y:) ZHUH KLJKO\ H[SUHVVHG DQG FLUFXODWLQJ LQ SDWLHQWV ZLWK VHYHUH OHSWRVSLURVLVUHÁHFWLQJHQGRWKHOLDOFHOOG\VIXQFWLRQ+RZHYHUQRDVVRFLDWLRQZLWK EOHHGLQJZDVREVHUYHG %OHHGLQJFDQEHFDXVHGE\G\VIXQFWLRQRISULPDU\KHPRVWDWLFSDWKZD\VWKDWLQFOXGH SODWHOHWDFWLYDWLRQDGKHVLRQDQGDJJUHJDWLRQ9RQ:LOOHEUDQGIDFWRULVFUXFLDOIRU SODWHOHWDGKHVLRQDSURFHVVSULPDULO\PHGLDWHGE\WKHELQGLQJRISODWHOHWVXUIDFH UHFHSWRU*3,E,;9FRPSOH[WRY:)LQWKHVXEHQGRWKHOLDOPDWUL[/RZOHYHOVRI Y:)ZLOOFDXVHEOHHGLQJDVLVREVHUYHGLQSDWLHQWVVXIIHULQJIURPYRQ:LOOHEUDQG·V GLVHDVH,QWKHFXUUHQWZRUNEOHHGLQJZDVQRWWKHUHVXOWRIUHGXFHGOHYHOVRIY:) $OWKRXJKDGHFUHDVLQJWUHQGZDVREVHUYHGGXULQJIROORZXSRQGD\Y:)OHYHOV ZHUHVWLOOHOHYDWHGFRPSDUHGWRWKHFRQWUROV:HGLGQRWÀQGVLJQLÀFDQWO\GLIIHUHQW Y:)OHYHOVLQWKHGHFHDVHGRULQWKHVLFNHVWJURXSV(OHYDWHGOHYHOVRIY:)KDYHEHHQ REVHUYHGLQVHYHUDOLQÁDPPDWRU\GLVHDVHVWDWHVLQFOXGLQJVHSVLVDQGVHSWLFVKRFN 'DWDWKDWFRUUHODWHSODVPDOHYHOVRIY:)ZLWKVHYHULW\RILQÁDPPDWLRQDQG SDWLHQWRXWFRPHDUHLQFRQVLVWHQWLQWKHOLWHUDWXUH

8QGHU SK\VLRORJLFDO FRQGLWLRQV WKH HQGRWKHOLXP KDV DQWLFRDJXODQW SURSHUWLHV DQG SUHYHQWV SODWHOHW DJJUHJDWLRQ DV ZHOO DV WKH DGKHUHQFH DQG PLJUDWLRQ RI EORRG FHOOV GXH WR ORZ H[SUHVVLRQ RI DGKHVLRQ PROHFXOHV VXFK DV (VHOHFWLQ (QGRWKHOLDO FHOOV ORVH WKHLU DQWLFRDJXODQW SURSHUWLHV ZKHQ VWLPXODWHG E\ F\WRNLQHV RU RWKHU LQÁDPPDWRU\PHGLDWRUV7KLVWUDQVIRUPDWLRQWRDSURFRDJXODQWVXUIDFHLVFRQVLGHUHG WRSOD\DSURPLQHQWUROHLQDOOWKUHHPDMRUSDWKRJHQHWLFSDWKZD\VDVVRFLDWHGZLWK FRDJXORSDWK\LQVHSVLVWLVVXHIDFWRU7)PHGLDWHGWKURPELQJHQHUDWLRQLPSDLUHG DQWLFRDJXODQW SDWKZD\V DQG EORFNHG ÀEULQRO\VLV  $FWLYDWHG HQGRWKHOLXP FDQ FDXVHDG\VEDODQFHLQWKHLJQLWLRQRIWKHSODVPDWLFFRDJXODWLRQSDWKZD\VZKLFKFDQ OHDG WR ERWK WKURPERVLV DQG EOHHGLQJ +LJK OHYHOV RI (VHOHFWLQ ZHUH REVHUYHG LQ WKHSUHVHQWVWXG\UHÁHFWLQJHQGRWKHOLDOFHOODFWLYDWLRQRUGDPDJH6HYHUDOVWXGLHV KDYH LQGLFDWHG WKDW V(VHOHFWLQ LVHOHYDWHG GXULQJ VHSWLF FRQGLWLRQV DQG WKDW KLJK OHYHOVDUHDVVRFLDWHGZLWKSRRUFOLQLFDORXWFRPH+RZHYHUZHVKRZHGHOHYDWHG

',6&866,21

/HSWRVSLURVLVDQGHQGRWKHOLXP



V(VHOHFWLQUHJDUGOHVVRIGLVHDVHVHYHULW\EOHHGLQJRURXWFRPH0RUHVWXGLHVDUH ZDUUDQWHGWRHOXFLGDWHSODVPDWLFFRDJXODWLRQGLVRUGHUVLQOHSWRVSLURVLV

'DWD RQ WKH LQWHUDFWLRQ EHWZHHQ WKH HQGRWKHOLDO FHOO DQG /HSWRVSLUD DUH VFDUFH /HSWRVSLUHVZHUHVKRZQWRLQGXFHHQGRWKHOLDOFHOODGKHVLYHQHVVIRUQHXWURSKLOVLQDQ H[SHULPHQWDOPRGHOXVLQJFXOWXUHGKXPDQXPELOLFDOYHLQHQGRWKHOLDOFHOOV+89(& DQG LQWDFW RU VRQLFDWHG /HSWRVSLUD  %ORFNLQJ RI (VHOHFWLQ DEURJDWHG WKH REVHUYHGOHXNRF\WHDGKHUHQFH/HSWRVSLUDOSHSWLGRJO\FDQEXWQRWOHSWRVSLUDO/36 DFWLYHO\LQGXFHGWKHREVHUYHGHQGRWKHOLDOFHOODGKHVLYHQHVVIRUQHXWURSKLOV9LHLUDHW DOUHSRUWHGH[SUHVVLRQRI(VHOHFWLQDQG,&$0E\+89(&ZKHQGLUHFWO\VWLPXODWHG ZLWKWKHOHSWRVSLUDOSURWHLQ/,&LQDGRVHGHSHQGDQWPDWWHU3DWKRORJLFDO VWXGLHVVXJJHVWWKDWWKHKHPRUUKDJLFSKHQRPHQDLQOHSWRVSLURVLVSDWLHQWVDUHGXHWR FDSLOODU\ZDOOGDPDJH2QHFRXOGVSHFXODWHWKDW/HSWRVSLUDPLJKWEHDEOHWR GDPDJHHQGRWKHOLDOFHOOPHPEUDQHVGLUHFWO\RULQGLUHFWO\E\WKHLUJUDQXODUSURGXFW ZKHQGHJUDGHG,QGHHGLWKDVEHHQVKRZQWKDWSDWKRJHQLF/HSWRVSLUDFRQWDLQGLIIHUHQW JHQHVHQFRGLQJIRUSURWHDVHVDQGRWKHUSURGXFWVWKDWFDQFDXVHKRVWFHOOPHPEUDQH GHJUDGDWLRQOLNHVSKLQJRP\HOLQDVHVDQGSKRVSKROLSDVHV6HYHUDOLVVXHVRIWKH SUHVHQWVWXG\PHULWIXUWKHUFRPPHQW&XUUHQWWHFKQLTXHVDUHQRWDEOHWRGLVWLQJXLVK EHWZHHQHQGRWKHOLDOGDPDJHDQGDFWLYDWLRQ6ROXEOH(VHOHFWLQKDVLWVSK\VLRORJLFDO DFWLYLW\RQWKHHQGRWKHOLDOFHOOVXUIDFHZKHUHDVY:)PHGLDWHVDGKHVLRQRISODWHOHWV WRVLWHVRIYDVFXODUGDPDJHDQGLVLPSRUWDQWIRUSODWHOHWDJJUHJDWLRQE\ELQGLQJWKH *3 ,,E,,,D SODWHOHW UHFHSWRU +RZHYHU ERWK V(VHOHFWLQ DQG Y:) DUH UHOHDVHG E\ SURLQÁDPPDWRU\PHGLDWRUVVXFKDVHQGRWR[LQ,QWUDYHQRXVDGPLQLVWUDWLRQRI HQGRWR[LQLQWRKXPDQVFDXVHGDGRVHGHSHQGHQWLQFUHDVHRIV(VHOHFWLQHVWDEOLVKLQJ LWVUROHDVDTXDQWLWDWLYHPDUNHURILQÁDPPDWLRQLQGXFHGHQGRWKHOLDODFWLYDWLRQ 6HFRQGO\ RQO\ SDWLHQWV ZLWK VHYHUH OHSWRVSLURVLV ZHUH HQUROOHG LQ WKH VWXG\7KLV PLJKWH[SODLQZK\ZHGLGQRWÀQGDGLIIHUHQFHEHWZHHQVXUYLYRUVDQGQRQVXUYLYRUV RQDGPLVVLRQ,QDSUHYLRXVVWXG\V(VHOHFWLQZDVVKRZQWREHHOHYDWHGPHDQ QJPO LQ 7KDL SDWLHQWV ZLWK PLOG OHSWRVSLURVLV  7KHVH OHYHOV ZHUH KLJKHU DOEHLWQRWVLJQLÀFDQWO\FRPSDUHGWRSDWLHQWVSUHVHQWLQJZLWKPXULQHW\SKXVVFUXE W\SKXVW\SKRLGGHQJXHIHYHURUXQFRPSOLFDWHGPDODULDEXWORZHUWKHQRXUUHVXOWV )XWXUH VWXGLHV VKRXOG LQYHVWLJDWH WKH UROH RI HQGRWKHOLDO FHOOV LQ PLOG DQG VHYHUH OHSWRVSLURVLV/DVWWKHQXPEHURISDWLHQWVVWXGLHGZDVOLPLWHGDQGWKHUHIRUHFDXWLRQ VKRXOGEHXVHGZKHQLQWHUSUHWLQJWKHVHGDWD

&KDSWHU  ,QFRQFOXVLRQZHKDYHGHPRQVWUDWHGWKDWPDUNHUVRIHQGRWKHOLDOFHOODFWLYDWLRQDUH VWURQJO\HOHYDWHGLQVHYHUHOHSWRVSLURVLVEXWZHUHQRWDVVRFLDWHGZLWKEOHHGLQJ1R GLIIHUHQFHLQHOHYDWLRQRIWKHVHPDUNHUVZDVIRXQGEHWZHHQWKHVXUYLYRUVDQGQRQ VXUYLYRUV0RUHVWXGLHVDUHQHHGHGWRHVWDEOLVKWKHSUHFLVHUROHRIWKHHQGRWKHOLDO FHOOLQWKHSDWKRSK\VLRORJ\RIOHSWRVSLURVLV $FNQRZOHGJHPHQWV :HJUDWHIXOO\WKDQN60+)DUDG]DQGSHUVRQQHO&(%,256HPDUDQJ,QGRQHVLDDQG WKHUHVLGHQWVRIWKHGHSDUWPHQWRI,QWHUQDO0HGLFLQH'U.DULDGLKRVSLWDO6HPDUDQJ ,QGRQHVLDIRUWKHLUKHOSDQGDVVLVWDQFHGXULQJWKHVWXG\

/HSWRVSLURVLVDQGHQGRWKHOLXP    %KDUWL$51DOO\-(5LFDOGL-10DWWKLDV0$'LD]00/RYHWW0$HWDO/HSWRVSLURVLVD ]RRQRWLFGLVHDVHRIJOREDOLPSRUWDQFH/DQFHW,QIHFW'LV'HFHPEHU   0F%ULGH$-$WKDQD]LR'$5HLV0*.R$,/HSWRVSLURVLV&XUU2SLQ,QIHFW'LV 2FWREHU

  $UHDQ 90 7KH SDWKRORJLF DQDWRP\ DQG SDWKRJHQHVLV RI IDWDO KXPDQ OHSWRVSLURVLV :HLO·VGLVHDVH$P-3DWKRO$SULO   :DJHQDDU-)*RULV0*6DNXQGDUQR06*DVHP0+0DLUXKX$7.UXLIGH0'HWDO :KDWUROHGRFRDJXODWLRQGLVRUGHUVSOD\LQWKHSDWKRJHQHVLVRIOHSWRVSLURVLV"7URS0HG ,QW+HDOWK-DQXDU\   .HOOHU770DLUXKX$7.UXLIGH0'.OHLQ6.*HUGHV9(WHQ&+HWDO,QIHFWLRQVDQG HQGRWKHOLDOFHOOV&DUGLRYDVF5HV2FWREHU

  %ODQQ $' $PLUDO - 0F&ROOXP &1 3URJQRVWLF YDOXH RI LQFUHDVHG VROXEOH WKURPERPRGXOLQDQGLQFUHDVHGVROXEOH(VHOHFWLQLQLVFKDHPLFKHDUWGLVHDVH(XU- +DHPDWRO$XJXVW

  /HYL0&DWHWHQ+3ROOYDQGHU7(QGRWKHOLXPLQWHUIDFHEHWZHHQFRDJXODWLRQDQG LQÁDPPDWLRQ&ULW&DUH0HG0D\6XSSO66

  $PHULFDQ &ROOHJH RI &KHVW 3K\VLFLDQV6RFLHW\ RI &ULWLFDO &DUH 0HGLFLQH$PHULFDQ &ROOHJHRI&KHVW3K\VLFLDQV6RFLHW\RI&ULWLFDO&DUH0HGLFLQH&RQVHQVXV&RQIHUHQFH GHÀQLWLRQV IRU VHSVLV DQG RUJDQ IDLOXUH DQG JXLGHOLQHV IRU WKH XVH RI LQQRYDWLYH WKHUDSLHVLQVHSVLV&ULW&DUH0HG-XQH   &OHPHWVRQ.-3ODWHOHW*3,E9,;FRPSOH[7KURPE+DHPRVW-XO\   .D\DO6-DLV-3$JXLQL1&KDXGLHUH-/DEURXVVH-(OHYDWHGFLUFXODWLQJ(VHOHFWLQ LQWHUFHOOXODUDGKHVLRQPROHFXOHDQGYRQ:LOOHEUDQGIDFWRULQSDWLHQWVZLWKVHYHUH LQIHFWLRQ$P-5HVSLU&ULW&DUH0HG0DUFK3W   5XELQ'%:LHQHU.URQLVK-30XUUD\-)*UHHQ'57XUQHU-/XFH-0HWDO(OHYDWHG YRQ:LOOHEUDQGIDFWRUDQWLJHQLVDQHDUO\SODVPDSUHGLFWRURIDFXWHOXQJLQMXU\LQ QRQSXOPRQDU\VHSVLVV\QGURPH-&OLQ,QYHVW$XJXVW   5HLQKDUW.%D\HU2%UXQNKRUVW)0HLVQHU00DUNHUVRIHQGRWKHOLDOGDPDJHLQRUJDQ G\VIXQFWLRQDQGVHSVLV&ULW&DUH0HG0D\6XSSO66   5HLQKDUW.%D\HU2%UXQNKRUVW)0HLVQHU00DUNHUVRIHQGRWKHOLDOGDPDJHLQRUJDQ G\VIXQFWLRQDQGVHSVLV&ULW&DUH0HG0D\6XSSO66   'REULQD$1DUGRQ(9HFLOH(&LQFR03DWULDUFD3/HSWRVSLUDLFWHURKHPRUUKDJLDHDQG OHSWRVSLUHSHSWLGROJ\FDQVLQGXFHHQGRWKHOLDOFHOODGKHVLYHQHVVIRUSRO\PRUSKRQXFOHDU OHXNRF\WHV,QIHFW,PPXQ$XJXVW   9LHLUD0/'·$WUL/36FKDWWQHU0+DEDUWD$0%DUERVD$6GH0RUDLV=0HWDO$QRYHO OHSWRVSLUDO SURWHLQ LQFUHDVHV ,&$0 DQG (VHOHFWLQ H[SUHVVLRQ LQ KXPDQ XPELOLFDO YHLQHQGRWKHOLDOFHOOV)(060LFURELRO/HWW1RYHPEHU

  $UHDQ 90 7KH SDWKRORJLF DQDWRP\ DQG SDWKRJHQHVLV RI IDWDO KXPDQ OHSWRVSLURVLV :HLO·VGLVHDVH$P-3DWKRO$SULO

  1LFRGHPR$&'XDUWH0,$OYHV9$7DNDNXUD&)6DQWRV571LFRGHPR(//XQJOHVLRQV LQ KXPDQ OHSWRVSLURVLV PLFURVFRSLF LPPXQRKLVWRFKHPLFDO DQG XOWUDVWUXFWXUDO IHDWXUHVUHODWHGWRWKURPERF\WRSHQLD$P-7URS0HG+\J)HEUXDU\   1DVFLPHQWR$/ .R$, 0DUWLQV ($ 0RQWHLUR9LWRUHOOR &% +R 3/ +DDNH '$ HW DO

&RPSDUDWLYHJHQRPLFVRIWZR/HSWRVSLUDLQWHUURJDQVVHURYDUVUHYHDOVQRYHOLQVLJKWV LQWRSK\VLRORJ\DQGSDWKRJHQHVLV-%DFWHULRO$SULO   .XKQV'%$OYRUG:**DOOLQ-,,QFUHDVHGFLUFXODWLQJF\WRNLQHVF\WRNLQHDQWDJRQLVWV DQG(VHOHFWLQDIWHULQWUDYHQRXVDGPLQLVWUDWLRQRIHQGRWR[LQLQKXPDQV-,QIHFW'LV -DQXDU\

5()(5(1&(6

&KDSWHU



  6FKRUHU$( 0ROGRZ &) 5LFN 0( ,QWHUOHXNLQ  RU HQGRWR[LQ LQFUHDVHV WKH UHOHDVH RI YRQ :LOOHEUDQG IDFWRU IURP KXPDQ HQGRWKHOLDO FHOOV %U - +DHPDWRO  2FWREHU   .XKQV'%$OYRUG:**DOOLQ-,,QFUHDVHGFLUFXODWLQJF\WRNLQHVF\WRNLQHDQWDJRQLVWV DQG(VHOHFWLQDIWHULQWUDYHQRXVDGPLQLVWUDWLRQRIHQGRWR[LQLQKXPDQV-,QIHFW'LV -DQXDU\   3DULV'+-HQMDURHQ.%ODFNVHOO6'3KHWVRXYDQK5:XWKLHNDQXQ91HZWRQ31HWDO 'LIIHUHQWLDOSDWWHUQVRIHQGRWKHOLDODQGOHXFRF\WHDFWLYDWLRQLQ¶W\SKXVOLNH·LOOQHVVHV LQ/DRVDQG7KDLODQG&OLQ([S,PPXQRO-XO\